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━━ Background. Pulmonary pleomorphic carcinoma, a rare form of poorly differentiated carcinoma, has sarcomatoid components, including spindle cells and giant cells. Making a definite pathological diagnosis is difficult using transbronchial biopsied specimens. Case. A 73-year-old man was admitted to our hospital with a fever and abdominal pain. Computed tomography showed a mass shadow in the left upper lobe of the lung and multiple masses in the small intestine. A bronchoscopic biopsy of the lung mass revealed poorly differentiated carcinoma. An endoscopic biopsy of the abdominal tumors revealed poorly differentiated carcinoma in the small intestine. Immunostaining confirmed that the lung lesion was the primary cancer site. Because of the high risk of ileus and perforation, partial resection of the small intestine was performed. Surgery revealed three metastases in the small intestine, one of which showed penetration and invasion of the transverse colon and invasion to the urinary bladder and abdominal wall. A histopathological analysis showed that the metastases in the small intestine had sarcomatous components, consisted of spindle cells and giant cells, and poorly differentiated carcinoma cells, which confirmed the diagnosis of pulmonary pleomorphic carcinoma. Conclusion. In this case, it was difficult to diagnose this patient based on a transbronchial tumor biopsy of the primary site alone. Pulmonary pleomorphic carcinoma should be considered in the differential diagnosis in the cases with a persistent antibiotic-resistant fever and gastrointestinal metastasis with an increase in the levels of inflammatory markers. Resection of the metastasis is necessary before the patient develops a severe condition. (JJLC. 2015;55:176-182) KEY WORDS━━ Primary lung cancer, Pulmonary pleomorphic carcinoma, Small intestine metastasis Reprints: Kyoko Gocho, Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Ota-ku, Tokyo 143-8541, Japan (e-mail: kyokogocho@med.toho-u.ac.jp). Received January 7, 2015; accepted May 21, 2015. 要旨━━背景.肺多形癌は紡錘形細胞または巨細胞か らなる肉腫様成分を含む稀な低分化な癌で,診断に難渋 することが多く,その予後は不良である.症例.73 歳男 性.発熱を主訴に近医を受診し,左上葉の腫瘤と腹部腫 瘤を指摘され当院に紹介された.左上葉腫瘤に対して経 気管支的肺生検を行い,癌腫が証明されたが,組織型の 確定は困難であった.さらに腹部腫瘤は小腸内視鏡生検 にて低分化癌と診断され,免疫染色パターンから肺原発 が疑われた.腸閉塞や穿孔を来す危険性が高いと判断し, 小腸切除を行った.手術所見では計 3か所に小腸腫瘍を 認め,うち 1か所は既に横行結腸に穿通し,さらに空腸 動脈浸潤,腹壁・膀胱浸潤も伴っていた.腫瘍は,紡錐 形細胞,巨細胞を特徴とする肉腫様成分とともに低分化 な上皮性腫瘍を混じた多形癌であった.結論.本症例は 東邦大学医療センター大森病院 1呼吸器内科,2消化器外科,3病理 診断科. 別刷請求先:後町杏子,東邦大学医療センター大森病院呼吸器 内科,〒143-8541 東京都大田区大森西 6-11-1 (e-mail: kyokogocho @med.toho-u.ac.jp). 受付日:2015 年 1 月 7 日,採択日:2015 年 5 月 21 日. (肺癌.2015;55:176-182) 2015 The Japan Lung Cancer Society Pulmonary Pleomorphic Carcinoma with Small Intestine Metastasis―Gocho et al Japanese Journal of Lung Cancer―Vol 55, No 3, Jun 20, 2015―www.haigan.gr.jp 177 Table 1. Laboratory Data on Admission <Biochemistry> <Hematology> <Tumor markers> CRP 6.6 (0.0-0.2) mg/dl RBC 3.74×106/μl CEA 3.4 ng/ml Na 137 mM Hb 10.5 (14.0-17.0) g/dl SLX 44.3 (<38) U/ml K 3.9 mM PLT 40.9×104/μl s-IL2R 2010 (220-530) U/ml Cl 102 mM WBC 16.1 (4.0-9.0)×103/μl TP 6.9 g/dl BASO 0.0% <Others> ALB 3.0 (3.8-5.1) g/dl EOSINO 5.0% Procalcitonin 0.188 ng/ml UN 16 mg/dl LYMPHO 13.0% β-D glucan 10.5 (<20) pg/ml Cre 0.95 g/dl MONO 5.5% Aspergillus Ag (-) GOT 9 IU/l NEUT 76.5% T-spot (-) GPT 11 IU/l G-CSF 49.4 (4.7-18.1>_) pg/ml LDH 115 IU/l <Coagulation> IL-6 21.4 (4.0>_ ) pg/ml ALP 190 IU/l PT 13.9 sec. γ-GTP 27 IU/l APTT 25.2 sec. FPG 124 (75-116) mg/dl HbA1c (NGSP) 6.9 (4.2-6.2)% 原発巣の肺生検組織のみでは診断が困難であった.抗生 剤不応性の遷延性発熱,炎症反応の上昇を伴った消化管 転移を認める症例の鑑別には肺多形癌を考慮すべきで, 病状が重篤化する前に積極的に転移病巣の切除を検討す べきである. 索引用語━━原発性肺癌,肺多形癌,小腸転移

A Suspected Case of Pulmonary Pleomorphic Carcinoma Diagnosed by Resected Small Intestine Metastasis