今日の臨床サポート

リンパ節腫大

著者: 萩原將太郎 筑波大学附属水戸地域医療教育センター

監修: 徳田安春 一般社団法人 群星沖縄臨床研修センター

著者校正/監修レビュー済:2021/07/07
患者向け説明資料

概要・推奨   

  1. 30歳未満のリンパ節腫脹は、多くは良性で自然軽快するものが多い。しかし、中高年者のリンパ節腫脹に対しては悪性腫瘍を念頭に生検を前提に精査することが推奨される(推奨度2)。
  1. リンパ節生検は、確定診断におけるゴールドスタンダードである。したがって、リンパ節腫大で悪性腫瘍が疑われる患者にはリンパ節生検を行うことが推奨される(推奨度2)。
  1. 有痛性リンパ節腫脹は感染または炎症性であることが多い。しかし、痛みの有無のみで良性・悪性を判断してはならない。有痛性リンパ節腫脹で悪性疾患を除外することは推奨しない(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
萩原將太郎 : 研究費・助成金など(セルジーン株式会社)[2021年]
監修:徳田安春 : 特に申告事項無し[2021年]

改訂のポイント:
  1. Virchowリンパ節について追記した。
  1. 悪性腫瘍を考えるべき所見について追記した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. リンパ節腫脹は日常診療で出合うことの多い症状であるが、別の主訴で受診した患者の診察過程でみつかることも多い。
  1. 原因疾患は炎症性と悪性腫瘍に分けられる。若年者では炎症性疾患が比較的多いが、中高年者では悪性腫瘍の割合が高い。
 
  1. リンパ節の身体診察はルーチンに行うことが推奨される(推奨度2)。
  1. リンパ節腫脹は、別の主訴で受診した患者に対する診察過程でみつかることも多い。1つの観察研究では、リンパ節腫脹が見いだされた56%の患者は、ほかの主訴で受診していた[1]。よって、日常診療における身体診察においてリンパ節のスクリーニングを行うことを推奨する。
 
  1. 30歳未満のリンパ節腫脹は、多くは良性で自然軽快するものが多い。しかし、中高年者のリンパ節腫脹に対しては悪性腫瘍を念頭に生検を前提に精査することが推奨される(推奨度2)。
  1. リンパ節腫大の鑑別には年齢の要素が大きなウエートを占める。ある観察研究では30歳未満のリンパ節腫大の約80%は感染あるいは炎症性であったが、50歳以上では60%が悪性疾患であった[2]。よって、中高年者のリンパ節腫大では、安易に経過観察せず、適切な画像診断を行い、生検を積極的に考慮すべきである。
問診・診察のポイント  
  1. 病歴、薬歴、全身性か局在性か、皮疹や発熱など随伴症状、リンパ節腫大の部位、大きさと硬さ、周囲の組織との癒着の有無が鑑別に重要である。

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文献 

著者: O I Linet, C Metzler
雑誌名: Postgrad Med. 1977 Oct;62(4):210-3.
Abstract/Text
PMID 909851  Postgrad Med. 1977 Oct;62(4):210-3.
著者: Y Lee, R Terry, R J Lukes
雑誌名: J Surg Oncol. 1980;14(1):53-60.
Abstract/Text This is a retrospective and all inclusive study of 925 patients who had isolated lymph node biopsies for diagnosis from 1973 to 1977. Overall, 60% of the nodes had benign lesions, 28% carcinoma, and 12% lymphoma. The comparable figures for abdominal nodal biopsies were 63%, 33% and 4%; for intrathoracic nodes, 73%, 26% and 1%; for peripheral nodes, 56%, 29% and 15%. Detailed distribution according to specific site of nodal biopsy, histological subtypes, age, and sex of patients are presented. Statistically, age is the most important factor useful in estimating the probability of whether the lymphadenopathy is due to a benign or malignant process.

PMID 7382513  J Surg Oncol. 1980;14(1):53-60.
著者: D Ben-Yehuda, A Polliack, E Okon, Y Sherman, S Fields, P Lebenshart, H Lotan, E Libson
雑誌名: J Clin Oncol. 1996 Sep;14(9):2431-4.
Abstract/Text PURPOSE: In an initial evaluation of 1,500 computed tomography (CT)-guided core-needle biopsies performed at our institute during the period from 1989 to 1994, we encountered 100 patients with the diagnosis of lymphoma. Here, we review the clinical impact of 109 image-guided needle biopsies in these 100 patients with non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD).
PATIENTS AND METHODS: NHL was diagnosed in 71 patients, and 29 had HD. Among the NHL patients, 17 (24%) had proven lymphoma diagnosed before the biopsy was performed; in 54 (76%) core-needle biopsy was performed as the first diagnostic procedure. Of 29 HD patients, nine (31%) were already established cases of HD, and in 20 (69%) core-needle biopsy was the first diagnostic procedure attempted. Most of the biopsies were performed under CT control using a 20- or 18-gauge Turner biopsy needle.
RESULTS: Eighty-six patients received therapy based on the results of the needle biopsy alone. Fourteen patients received therapy after undergoing surgical biopsy for a suspected diagnosis of lymphoma, which could not be established with certainty on the basis of an earlier core-needle biopsy alone. In 78% of the patients, the needle biopsy saved a further surgical procedure that may have been difficult to perform because of the primary location of the tumor.
CONCLUSION: From our experience in this study, image-guided core-needle biopsies provide sufficient information for the diagnosis of and subsequent therapeutic decision to treat most cases of lymphoma.

PMID 8926505  J Clin Oncol. 1996 Sep;14(9):2431-4.
著者: H J Steinkamp, M Cornehl, N Hosten, W Pegios, T Vogl, R Felix
雑誌名: Br J Radiol. 1995 Mar;68(807):266-70.
Abstract/Text The purpose of this study was to evaluate short- and long-axis diameters of enlarged cervical lymph nodes with ultrasonography and to determine whether the long-to-short axis (l/s) ratio is a valid diagnostic parameter in the differentiation between benign and malignant nodal disease. 730 enlarged cervical lymph nodes in 285 patients were examined with ultrasound. The short- and the long-axis diameters of each enlarged node were measured and the l/s ratio calculated. Definite diagnoses of the nodes were obtained by histological examination following neck dissection. 95% of enlarged cervical nodes shown on ultrasound to have a l/s ratio of more than 2 were correctly diagnosed as benign. Nodes presenting with a more circular shape and a l/s ratio of less than 2 were diagnosed correctly as metastases with 95% accuracy. The l/s ratio of lymph nodes thus provides an excellent criterion for differentiation between benign and malignant enlargement in cervical lymphadenopathy.

PMID 7735765  Br J Radiol. 1995 Mar;68(807):266-70.
著者: T M Habermann, D P Steensma
雑誌名: Mayo Clin Proc. 2000 Jul;75(7):723-32. doi: 10.4065/75.7.723.
Abstract/Text Lymphadenopathy can occur in any age group, in symptomatic or asymptomatic patients, and in a single site or at multiple sites. Lymphadenopathy is associated with numerous disorders. An abnormal lymph node may be observed or palpated by the patient, found by a health care worker, or discovered through radiologic evaluation. Lymphadenopathy may be a part of a complex case presentation, or the clinical cause may be straightforward. Patients with potentially curable malignant disorders may have lymphadenopathy as the first sign of their disease. This review of lymphadenopathy summarizes general considerations, discusses which patients might be considered for biopsy, reviews which nodes are most likely to be diagnostic, outlines initial diagnostic considerations on a region-by-region basis, and reviews a broad differential diagnosis for adenopathy.

PMID 10907389  Mayo Clin Proc. 2000 Jul;75(7):723-32. doi: 10.4065/75.・・・
著者: M L Ghirardelli, V Jemos, P G Gobbi
雑誌名: Haematologica. 1999 Mar;84(3):242-7.
Abstract/Text BACKGROUND AND OBJECTIVE: How to reach the correct diagnosis of a lymph node enlargement is still a problem which strongly challenges the knowledge and experience of the clinician. Organized and specifically oriented literature on the right sequential steps and the logical criteria that should guide this diagnostic approach is still lacking.
METHODS: The authors have tried to exploit available knowledge and their personal experience by correlating a large body of information regarding size, physical characteristics, anatomical location of enlarged lymph nodes, and the possible epidemiological, environmental, occupational and clinical categorization of this condition.
RESULTS AND CONCLUSIONS: It was intended that such material would have constituted the basis of a hypothetic decision-making tree, but this was impossible because of the lack of epidemiological investigation and registry data. Nevertheless, we present this preparatory work here in order to stimulate the interest of concerned readers and because of its possible direct usefulness in hematologic practice.

PMID 10189390  Haematologica. 1999 Mar;84(3):242-7.
著者: Andrew W Bazemore, Douglas R Smucker
雑誌名: Am Fam Physician. 2002 Dec 1;66(11):2103-10.
Abstract/Text The majority of patients presenting with peripheral lymphadenopathy have easily identifiable causes that are benign or self-limited. Among primary care patients presenting with lymphadenopathy, the prevalence of malignancy has been estimated to be as low as 1.1 percent. The critical challenge for the primary care physician is to identify which cases are secondary to malignancies or other serious conditions. Key risk factors for malignancy include older age, firm, fixed nodal character, duration of greater than two weeks, and supraclavicular location. Knowledge of these risk factors is critical to determining the management of unexplained lymphadenopathy. In addition, a complete exposure history, review of associated symptoms, and a thorough regional examination help determine whether lymphadenopathy is of benign or malignant origin. Unexplained lymphadenopathy without signs or symptoms of serious disease or malignancy can be observed for one month, after which specific testing or biopsy should be performed. While modern hematopathologic technologies have improved the diagnostic yields of fine-needle aspiration, excisional biopsy remains the initial diagnostic procedure of choice. The overall evaluation of lymphadenopathy, with a focus on findings suggestive of malignancy, as well as an approach to the patient with unexplained lymphadenopathy, will be reviewed.

PMID 12484692  Am Fam Physician. 2002 Dec 1;66(11):2103-10.
著者: A J Leibman, M B Kossoff
雑誌名: AJR Am J Roentgenol. 1992 Sep;159(3):493-5. doi: 10.2214/ajr.159.3.1503012.
Abstract/Text OBJECTIVE: The purpose of this study was to determine the value of mammography in detecting occult carcinoma in patients with axillary adenopathy and normal breasts on physical examination.
MATERIALS AND METHODS: We analyzed the results of mammography performed in 17 patients; all women had palpable axillary lymphadenopathy of unknown origin and all had normal breasts on physical examination.
RESULTS: In 10 of the 17 patients, mammographic findings were abnormal. The mammographic finding of axillary adenopathy in seven patients was inconsequential because the nodes were evident on physical examination. Three patients had abnormal mammographic findings that were potentially significant, including one with a poorly defined mass suggestive of breast carcinoma, one with a subcutaneous nodule, and one with parenchymal breast edema. Two of 17 patients had an occult breast cancer. In only one of the patients was the cancer detected on mammography. The other patient had undergone prior left mastectomy and was thought to have metastases to the right axilla from the contralateral breast. Mammographic findings in this latter patient were normal.
CONCLUSION: While occult breast carcinoma was relatively common in our series (two of 17 patients), the ability to detect the tumor with mammography was disappointing (one of two patients). This may be explained by the fact that one postmastectomy patient with occult carcinoma had metastatic disease to the contralateral axilla and a normal remaining breast, which was pathologically confirmed at mastectomy. Our experience suggests that mammography is valuable in patients with normal breasts on physical examination who have primary carcinoma involving ipsilateral axillary lymph nodes. The procedure should be included in the diagnostic evaluation of patients with axillary adenopathy in order to detect the unusual case of occult breast carcinoma.

PMID 1503012  AJR Am J Roentgenol. 1992 Sep;159(3):493-5. doi: 10.221・・・
著者: G A Pangalis, T P Vassilakopoulos, V A Boussiotis, P Fessas
雑誌名: Semin Oncol. 1993 Dec;20(6):570-82.
Abstract/Text
PMID 8296196  Semin Oncol. 1993 Dec;20(6):570-82.
著者: C D Selby, H S Marcus, P J Toghill
雑誌名: J R Coll Physicians Lond. 1992 Apr;26(2):159-61.
Abstract/Text Few doctors routinely examine the epitrochlear glands as part of their physical examination of a patient. No palpable epitrochlear nodes were detected in 140 healthy subjects, but palpable epitrochlear nodes were present in 27% of 184 patients with diseases in which lymphadenopathy occurs. Whilst epitrochlear nodes are commonly enlarged in specific acute, subacute, and chronic infections, they are not enlarged in the mild, transient, non-specific febrile illnesses with cervical lymphadenopathy of children and young adults. Enlarged epitrochlear glands provide a useful discriminatory sign in the diagnosis of glandular fever. Enlargement of these nodes is common in most of the lymphoproliferative disorders except Hodgkin's disease. In rheumatoid arthritis their palpability indicates activity of hand joints. The examination of epitrochlear nodes should form part of the routine physical assessment of any ill patient.

PMID 1588523  J R Coll Physicians Lond. 1992 Apr;26(2):159-61.
著者: Tehillah S Menes, Jacob Schachter, Adam P Steinmetz, Ruth Hardoff, Haim Gutman
雑誌名: Arch Surg. 2004 Sep;139(9):1002-6. doi: 10.1001/archsurg.139.9.1002.
Abstract/Text UNLABELLED: Hypotheses Melanoma of the distal lower extremity may drain to the popliteal basin. Drainage pathways and retrieval of the popliteal sentinel nodes may affect patient outcome.
DESIGN: Retrospective analysis of popliteal involvement in patients with stage IB or higher melanoma, operated on from August 1, 1993, to July 31, 2003.
SETTING: Tertiary referral, university-affiliated medical center.
PATIENTS: One hundred six melanoma patients who underwent combined lymphoscintigraphy and blue dye-guided sentinel node biopsy, radical popliteal dissection, or both.
MAIN OUTCOME MEASURES: Incidence and patterns of drainage to popliteal nodes; effect on staging and outcome.
RESULTS: Lymphoscintigraphy (n = 8) and physical examination (n = 2) identified 10 cases (9%) of draining to the popliteal basin, with concurrent drainage to the groin. Three distinct drainage patterns were identified, with different popliteal node locations. Seven of 8 popliteal sentinel nodes were retrieved, 1 of which was metastatic with no groin metastasis. Two patients had synchronous palpable popliteal and groin metastases and underwent radical groin and popliteal dissection. All 3 patients with popliteal metastases relapsed early with synchronous systemic and in-transit disease. One of 7 patients with negative sentinel nodes is alive with in-transit disease; all others are disease free.
CONCLUSIONS: According to this series, the popliteal basin is the site of first drainage in about 9% of patients, with concurrent drainage to the groin. The 3 distinct patterns of drainage to the popliteal region and the presence of isolated popliteal metastases may affect the surgical treatment. Therefore, drainage to popliteal sentinel nodes and the pattern of this drainage should be noted in all distal lower extremity melanomas.

PMID 15381621  Arch Surg. 2004 Sep;139(9):1002-6. doi: 10.1001/archsur・・・
著者: E Hanna, J Wanamaker, D Adelstein, R Tubbs, P Lavertu
雑誌名: Arch Otolaryngol Head Neck Surg. 1997 Dec;123(12):1318-23.
Abstract/Text BACKGROUND: Extranodal non-Hodgkin lymphoma (NHL) of the head and neck is a relatively uncommon disease. Over the last 3 decades, a variety of systems, including the Rappaport, Luke-Collins, and Working Formulation classifications, have been used to classify extranodal NHLs of the head and neck. Most studies have included a relatively small number of patients, used different modalities of therapy, and did not include all head and neck sites. These limitations make comparisons between different studies and drawing any conclusions difficult.
OBJECTIVES: To describe in a uniform fashion a relatively large number of patients with extranodal NHL of the head and neck treated at the same institution, using only the most current classification system and to describe the clinical features, behavior, and outcome of this relatively uncommon, but potentially curable disease.
DESIGN: A retrospective study of 98 patients with extranodal NHL of the head and neck. All patients were reclassified according to the Working Formulation system (regardless of the time of diagnosis) in order to uniformly define the clinical course of this disease in the head and neck.
SETTING: A tertiary care referral center.
RESULTS AND CONCLUSIONS: The sinonasal tract was the most commonly involved site (25%). If the nasopharynx (16%), tonsil (12%), and base of tongue (8%) are grouped together, this combined site (Waldeyer ring) becomes the most common site of disease (36%). Patients with tonsillar lymphoma had a 20% incidence of associated gastrointestinal involvement. Approximately 50% of the patients had associated nodal disease, and only 20% had systemic or B symptoms. Three fourths of the patients had stage I or II disease, and approximately two thirds had intermediate-grade lymphoma. Radiation therapy was the primary modality of therapy for localized disease (stages I and II), especially for low-grade lymphomas. Combination chemotherapy with or without radiation was used for more advanced disease and for intermediate- and high-grade lymphomas. Surgery was limited to establishing the diagnosis. Two thirds of the patients had a remission after initial therapy. Two thirds of these patients had no further relapse. Three fourths of the patients with relapse after initial remission died of their disease. The overall and disease-free survival rates for all patients were 60% and 50%, respectively. Outcome of therapy was related to stage and histologic grade. Patients with lymphomas of high histopathologic grade and recurrent and recurrent and disseminated disease had the poorest prognosis.

PMID 9413361  Arch Otolaryngol Head Neck Surg. 1997 Dec;123(12):1318-・・・
著者: N Gopalakrishna Iyer, Anumeha Kumar, Iain J Nixon, Snehal G Patel, Ian Ganly, R Michael Tuttle, Jatin P Shah, Ashok R Shaha
雑誌名: Ann Surg. 2011 May;253(5):988-91. doi: 10.1097/SLA.0b013e31821219ca.
Abstract/Text OBJECTIVE: The objective of this study was to determine the incidence and significance of Delphian node (DN) metastasis in papillary thyroid cancer.
SUMMARY OF BACKGROUND DATA: Despite the historic association, the prognostic implications of thyroid cancer metastasis to the DN remain unclear.
METHODS: Retrospective analysis of 101 patients who underwent thyroid surgery from 2007 to 2009 for papillary thyroid cancer, and had their DN harvested ab initio. Of these, 25 had metastatic disease to the DN. DN status was correlated with clinical and pathologic factors including age, gender, tumor size, histologic variant, extra-thyroidal extension (ETE), and central and lateral nodal metastasis.
RESULTS: DN positivity was seen consequent to higher rates of ETE of the primary tumor (52% vs. 28%; P = 0.025) and is associated with further nodal metastases to the central (72% vs. 22%; P < 0.0001) and lateral (28% vs. 4%; P < 0.0001) neck compartments. DN positivity was also associated with heavier nodal burden, in terms of number of metastatic nodes (median 5 vs. 2 nodes; P = 0.005) and nodal size (median 1 cm vs. 0.5 cm; P = 0.03).
CONCLUSIONS: Metastatic involvement of the DN is often associated with ETE and increased incidence of metastatic disease to the central and lateral neck compartments. If the DN is positive on intraoperative frozen section, careful evaluation of the central and lateral nodal compartments is essential.

@ 2011 Lippincott Williams & Wilkins, Inc.
PMID 21372688  Ann Surg. 2011 May;253(5):988-91. doi: 10.1097/SLA.0b01・・・
著者: Mohannad Abu-Hilal, James S Newman
雑誌名: Am J Med Sci. 2009 Apr;337(4):271-3. doi: 10.1097/MAJ.0b013e3181954187.
Abstract/Text Sister Mary Joseph's nodule is referred to a metastatic lesion of the umbilicus originating from intra-abdominal or pelvic malignant disease. Metastases from other locations have been also reported. In 1949 the English surgeon Sir Hamilton Bailey coined this term after Sister Mary Joseph (1856-1939), a superintendent nurse at St. Mary's Hospital in Rochester, Minnesota, USA, who was the first to observe the association between the umbilical nodule and intra-abdominal malignancy. In this article, we discuss both the historical and clinical perspectives of Sister Mary Joseph's nodule.

PMID 19365173  Am J Med Sci. 2009 Apr;337(4):271-3. doi: 10.1097/MAJ.0・・・

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契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから