内容紹介
Summary
A 73-year-old woman had a history of medication, including methotrexate for rheumatoid arthritis, for 5 years. She had chronic epigastralgia for 2 weeks and found to have multiple submucosal tumors on upper gastrointestinal endoscopy in another hospital. She had a strong abdominal pain thereafter and diagnosed as having gastrointestinal perforation on the basis of CT scans. Abdominal examination revealed disseminated peritonitis, and emergency laparoscopic surgery was performed on the day of admission. A 1 cm perforation of the ileum was identified, and a 5 cm mass of the mesentery near the perforation was also identified. Small bowel partial resection, including both lesions, was performed. From the intraoperative findings, methotrexate-associated lymphoproliferative disorders(MTX-LPD)was suspected, and methotrexate was discontinued after the surgery. At a later date, the pathological result from both the surgical specimen and upper gastrointestinal endoscopy was diffuse large B cell lymphoma(DLBCL). CT scan, PET-CT scan, and upper gastrointestinal endoscopy were performed 1-2 months after surgery, and no tumor was identified. Currently, 6 months after the surgery, the patient is still alive without any progression of the lymphoma.
要旨
症例は73歳,女性。5年前より関節リウマチに対しメトトレキサート(MTX)を含めた抗リウマチ薬を投薬中である。2週間前からの心窩部痛を認めていた。他院での上部消化管内視鏡検査では,胃内に多発する粘膜下腫瘍を認めていた。前日からの腹痛を主訴に前医を受診し,CT検査上free airを認め消化管穿孔の診断で当院救急搬送となった。来院時汎発性腹膜炎を呈しており,同日緊急手術を施行した。腹腔鏡下に観察すると回腸に1 cm大の穿孔,また近傍の腸間膜内に5 cm大の腫瘤様の硬結を触知し,両病変を含めた小腸部分切除術を施行した。他の腸間膜にも数cm大のリンパ節腫脹を認めた。経過から,MTX関連リンパ増殖性疾患(MTX-LPD)を疑い,MTXのみ休薬の方針とした。切除した小腸は上部消化管内視鏡検査の生検とともに,diffuse large B cell typeの悪性リンパ腫と診断された。術後1～2か月に施行したPET検査,CT検査,上部消化管内視鏡検査では腫瘍は消退しており,術後6か月の時点でも再発徴候を認めていない。
目次
A 73-year-old woman had a history of medication, including methotrexate for rheumatoid arthritis, for 5 years. She had chronic epigastralgia for 2 weeks and found to have multiple submucosal tumors on upper gastrointestinal endoscopy in another hospital. She had a strong abdominal pain thereafter and diagnosed as having gastrointestinal perforation on the basis of CT scans. Abdominal examination revealed disseminated peritonitis, and emergency laparoscopic surgery was performed on the day of admission. A 1 cm perforation of the ileum was identified, and a 5 cm mass of the mesentery near the perforation was also identified. Small bowel partial resection, including both lesions, was performed. From the intraoperative findings, methotrexate-associated lymphoproliferative disorders(MTX-LPD)was suspected, and methotrexate was discontinued after the surgery. At a later date, the pathological result from both the surgical specimen and upper gastrointestinal endoscopy was diffuse large B cell lymphoma(DLBCL). CT scan, PET-CT scan, and upper gastrointestinal endoscopy were performed 1-2 months after surgery, and no tumor was identified. Currently, 6 months after the surgery, the patient is still alive without any progression of the lymphoma.
要旨
症例は73歳,女性。5年前より関節リウマチに対しメトトレキサート(MTX)を含めた抗リウマチ薬を投薬中である。2週間前からの心窩部痛を認めていた。他院での上部消化管内視鏡検査では,胃内に多発する粘膜下腫瘍を認めていた。前日からの腹痛を主訴に前医を受診し,CT検査上free airを認め消化管穿孔の診断で当院救急搬送となった。来院時汎発性腹膜炎を呈しており,同日緊急手術を施行した。腹腔鏡下に観察すると回腸に1 cm大の穿孔,また近傍の腸間膜内に5 cm大の腫瘤様の硬結を触知し,両病変を含めた小腸部分切除術を施行した。他の腸間膜にも数cm大のリンパ節腫脹を認めた。経過から,MTX関連リンパ増殖性疾患(MTX-LPD)を疑い,MTXのみ休薬の方針とした。切除した小腸は上部消化管内視鏡検査の生検とともに,diffuse large B cell typeの悪性リンパ腫と診断された。術後1～2か月に施行したPET検査,CT検査,上部消化管内視鏡検査では腫瘍は消退しており,術後6か月の時点でも再発徴候を認めていない。