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Stomach and Intestine(Tokyo) Volume 40, Issue 5 （April 2005）

胃と腸 40巻5号（2005年4月発行）

Japanese English

今月の主題切開・剥離法（ESD）時代の胃癌術前診断

主題

切開・剥離法（ESD）に必要な胃癌術前診断―超音波内視鏡診断―リンパ節転移診断を含めて Is Endoscopic Ultrasonography (EUS) Needed for Deciding the Indication for Endoscopic Submucosal Dissection (ESD) of Early Gastric Carcinoma?―The Significance of Diagnosis of the Invasive Depth and Lymphnode Metastasis of Gastric Carcinoma by EUS 中村常哉 ¹ , 田近正洋 ¹ , 河合宏紀 ¹ , 横井太紀雄 ² , 谷田部恭 ³ , 中村栄男 ³ Tsuneya Nakamura ¹ , Masahiro Tajika ¹ , Hiroki Kawai ¹ , Takio Yokoi ² , Yasushi Yatabe ³ ¹愛知県がんセンター中央病院内視鏡部 ²愛知医科大学病理部 ³愛知県がんセンター中央病院遺伝子病理診断部 ¹Department of Endoscopy, Aichi Cancer Center Hospital ²Division of Pathology, Aichi Medical University Hospital ³Department of Pathology and Molecular Diagnosis, Aichi Cancer Center Hospital キーワード：胃癌深達度診断 , 超音波内視鏡 , リンパ節転移 , 切開・剥離法 , ESD Keyword: 胃癌深達度診断 , 超音波内視鏡 , リンパ節転移 , 切開・剥離法 , ESD pp.779-790

発行日 2005年4月25日 Published Date 2005/4/25

DOI https://doi.org/10.11477/mf.1403100111

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要旨　内視鏡切除を実施した胃癌症例のEUSの深達度診断能は86％(31/36)であり，外科切除を合わせた胃癌症例275例ではm77％，sm60％，mp以深85％，全体で73％であった．内視鏡切除の適応拡大病変に対するEUSの意義は，2cmを超えるUL(－)の分化型M癌や2cm以下のUL(－)未分化型M癌ではtype I(第3層に変化のないtype)の病変であることの診断に，3cm以下のUL(＋)分化型M癌では潰瘍の深さの評価にある．type UL(UL-III，UL-IVの潰瘍を表すtype)の病変に対するESDは穿孔のリスクを考慮すべきである．sm₁のEUS所見は，第3層の上層にbudding様に浸潤しているものである．胃癌に対するEUSのリンパ節転移診断能は感度54％・特異度93％・正診率81％と，感度が低いことが問題である．EUSの診断能の特徴を知った上で，内視鏡切除の適応拡大病変の術前評価にEUSを利用すべきと考える．

　Accuracy of EUS for determining the invasive depth in cases of gastric carcinoma resected by EMR was 86 ％ (31/36).

　Accuracy of EUS was 77 ％ in mucosal invasion, 60 ％ in submucosal invasion and was 85 ％ in proper muscle layer or more invasion in the analysis of 275 gastric carcinoma cases resected by EMR and surgery.

　We think that EUS is significant in gastric carcinoma cases in which the lesion is not included in the clinical practice guidelines for EMR.

　1 ) When the lesion is 2 cm or more in size, without ulceration, limited in the mucosa and is a well to moderately differentiated adenocarcinoma in histology, and when the third hyperechoic layer is unaffected.

　2 ) When the lesion is 3 cm or less in size, with ulceration, limited in the mucosa and is a well to moderately differentiated adenocarcinoma in histology, the depth of tissue defect of ulceration should be evaluated by EUS. Attention concerning perforation should be paid in ESD of early gastric carcinoma when EUS reveals that the lesion has an ulcer whose tissue defect within itself is the proper muscle or more.

　3 ) When the finding of EUS of slight submucosal invasion is budding-like growth from the second hypoechoic layer to the third hyperechoic layer.

　In other diagnostic aspects of EUS, diagnostic ability of EUS for lymphnode metastasis was 54 ％ in sensitivity, 93 ％ in specificity and 81 ％ in accuracy. The existence of false negative cases should be resolved.

　After we understand the diagnostic ability of EUS, we should use it when deciding the indication for ESD in early gastric carcinoma beyond the clinical practice guidelines for the use of EMR.