胃隆起性病変の診断,および,鑑別診断のX線学的研究 : とくに,X線検査の基礎となる肉眼形態の分析も含めて
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One hundred and ninety-three elevated and protruded lesions of the stomach, including polyp, intramural tumor, Type I and IIa early cancer, advanced cancer of Borrmann Type I , localized thickning of the mucosa, and etc. were made the object of a comparative study on their morphological characteristics of the gross specimens and X-ray appearances. I Pathological Findings of the Gross Specimens (a) The relations between the maximum diameters (horizontal axis) and the heights (vertical axis) of all lesions tabulate into as follows. Polyps are distributed to some extent along the vertical axis on the table, and Type IIa early cancer and the localized thickning of mucosa along the horizontal axis, mostly limiting their heights within 5 mm. Intramural tumors situate in between the two zones occupied by polyps, and Type IIa early cancer and localized thickning of the mucosa. Advanced cancer of Borrmann Type I and Type I early cancer are distributed on the area more than 30mm in maximum diameter, except for 3 lesions. (b) According to the gross characteristics of all lesions, their face-on appearances are classified into following seven types; (1) non-specific type, (2) round type, (3) oval type, (4) irregular, flowerbed-shaped type, (5) irregularly granulated type, (6) cauliflower- and cabbage-shaped type, (7) massive type: and their profile appearances are classified into nine types; (1) minutely elevated type, (2) flat polypoid type, (3) flowerbed-shaped type, (4) smoothly elevated type, (5) hemispherical type, (6) subpedunculated type, (7) pedunculated type, (8) cauliflower- and cabbage-shaped type, (9) massive type. (c) While 76.9% of single polyps are adenomatous, the ratio between adenomatous and hyperplastic polyps in multiple lesions is found to be nearly equal. In contrast to the high percentages (90.0%) of hyperplastic polyps whose maximum diameter is less than 10mm, only 47.4% of adenomatous polyps were found to have the maximum diameter in less than 10mm. In Type I early cancer percentage of singular lesions is 66.7%, including 77.8% of cabbage-shaped and massive types of them, being their maximum diameter more than 30mm. (d) Review of the literature describing the sizes of the intramural tumors shows that aberrent pancreas, eosinophilic granuloma, parasitic granuloma, and lipoma are contained in the group of lesions less than 30mm in maximum diameter. When a intramural lesion has the size more than 31 mm in maximum diameter, fibroma, neurogenic tumor, tumors arising from blood vessels and leiomyoma are suggested. In Type IIa early cancer and localized thickning of the mucosa which show minutely elevated type, flat polypoid type and smoothly elevated type their maximum diameters are limited in less than 30mm. On the other hand, 66.7% of Type Ila early cancer and 50.0% of localized thickning of the mucosa which are classified into flowerbed-shaped type have the maximum diameter more than 30 mm. II X-Ray Diagnosis of Elevated and Protruded Lesions (a) The term, "demonstrability" in this paper is employed based on the following definition. Demonstrability = (Number of film on which lesion is demonstrated)/(Total number of film used to demonstrate the lesion) No difference can be observed in the demonstrability between single and multiple polyps on any portion of the stomach by compression method, and those on the posterior gastric wall by double contrast method. The difference in the demonstrability by the two methods becomes apparent, when to demonstrate polyps on the anterior gastric wall. In demonstrating intramural tumors by double contrast method its effectiveness can not be judged easily, because not only the size and height of the lesion, but also its location and shape have fairly important influences on the demonstrability by the method. Generally speaking, it is easier to demonstrate the lesions of hemispherical type than those of smoothly elevated type; and the lesions on the posterior wall and lesser curvature than those on the anterior wall and greater curvature. There is a considerable difference in the demonstrability of Type IIa early cancers with the use of double contrast method. Its demonstrability depends on their shape classified above. Minutely elevated type shows a demonstrating difficulty by this method, due to their extremely low heights. Flowerbed-shaped type are fairly easily demonstrated, because of their superficial nodularity and large maximum diameter. Divergent results can be obtained in the demonstration of flat polypoid as well as smoothly elevated type. (b) While many sessile lesions, including polyp, Type I early cancer, advanced cancer of Borrmann Type I leave only their face-on appearances on X-ray films, their percentages being 73.7%, 78.0% and 60.7% respectively, 59.0% of pedunculated lesions show only profile appearances. Most cauliflower- and cabbage-shaped types show either face-on (27.3%) or profile appearances (63.6%). In massive type both face-on and profile appearances can be obtained in 40.0% of them. In intramural tumors either face-on (70.6%) or profile appearances (23.5%) can be obtained. In Type IIa early cancer and localized thickning of the mucosa 84.8% of them show only face-on appearances. This may be because they are too low in height to be demonstrated satisfactorily as a profile view on X-ray films. III Differential Diagnosis Combination of the face-on and profile appearances which are obtained by the analysis of gross pathology indicates the existence of following five groups of elevated and protruded lesions suggesting malignancy. (1) flat polypoid type, oval in face-on view (2) flat polypoid type with central depression and oval in face-on view (3) flowerbed-shaped type with a irregular surface (4) cauliflower- and cabbage-shaped type (5) massive type Histological study revealed that 82.0% of them are malignant. It may be concluded that detailed analysis of the five groups mentioned above lead to the differentiation of malignancy of elevated and protruded lesions of the stomach.
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