膀胱自然破裂を起こした巨大膀胱肉腫様癌の1例

Abstract

60歳女.多発性筋炎に対してステロイド療法を約25年前より受けていた.今回, 肉眼的血尿, 下腹部痛を主訴とした.入院時検査にて高度の炎症反応を, 腹部超音波にて膀胱内に径8cmの内部不均一な腫瘤を認めた.腹部単純X線にて遊離ガス像を認め, 腹部単純CTにて膀胱内に内部不均一な腫瘤と膀胱前壁の欠損を認めた.腹膜炎と診断し, 膀胱破裂の疑いで緊急開腹すると, 膀胱前壁は大きく欠損して腹腔内破裂の状態であった.膀胱内に手拳大の腫瘍と全体的な膀胱粘膜の壊死を認め, 膀胱全摘術を施行した.また, 膀胱癌の浸潤を疑い, 回腸・S状結腸を部分切除し, 回腸瘻およびS状結腸瘻を造設した.腫瘍は組織学的に, spindle cellが束状に密に錯綜増生しており, 巨大な核を有する細胞や多核細胞への移行像も認め, 膀胱肉腫様癌と診断した.腫瘍は筋層深部まで浸潤し, 頂部から前壁にかけて全層壊死した附近が破裂部位と考えられた.術後6ヵ月に多発性肝・肺・骨転移を来たして全身状態が悪化し, 術後約11ヵ月に癌死した

A 60-year-old woman has been on steroids under the diagnosis of polymyositis for 25 years. She was referred to our hospital complaining of asymptomatic macroscopic hematuria and lower abdominal pain. Physical examination revealed abdominal tenderness and rigidity. We suspected peritonitis because of free air image on the abdominal roentogenogram. The computed tomographic (CT) scan demonstrated an 8 cm solid mass in the bladder and defect of anterior wall of urinary bladder. Then we performed total cystectomy with cutaneous ureterostomy and partial resection of ileum as an emergency operation. Macroscopically, intra-peritoneal bladder rupture and severe adhesion of necrotic bladder dome wall to ileum were recognized and the tumor 8 cm in diameter existed in posterior wall of urinary bladder. Microscopic examination showed sarcomatoid carcinoma with spindle cell component and no invasion to ileum was recognized. Multiple lung, liver and bone metastasis appeared 6 months after the operation. She died of cancer 11 months after the operation.