転移陽性が疑われる胃粘膜内癌の治療方針―縮小手術を含めて

Treatment Plan for Mucosal Cancer of the Stomach with Lymph Node Metastasis: Adding Discussion for Limited Surgery

要旨　単発性胃粘膜内癌（M癌）1,337例についてリンパ節転移の実態，縮小手術の遠隔成績，合併症，死因などにつき検討した．リンパ節転移陽性例は2.0％（27例）であり，分化型1.4％，未分化型3.5％であった．未分化型は大きさにかかわらず，SM浸潤が高率であった．内視鏡治療の適応にならないM癌に対しては機能を温存する縮小手術が標準術式となっており，切除範囲やリンパ節郭清の縮小，網囊や大網の温存，神経温存など機能温存することによってQOL向上を目指している．単発性早期胃癌における他病死を除いた遠隔成績（5生率/10生率）は（98.1％/96.3％）と良好であった．術後合併症は6.5％であり，うちM癌では在院死が3例（0.2％）存在した．死因は原病死10例，他癌死34例，他病死124例，不明死9例であり，高齢者の遠隔成績は不良であった．以上より，高齢者に対する内視鏡治療の適応拡大は考慮すべきであるが，未分化型に対しては慎重な態度が必要である．また，縮小手術後の再発例を経験しており，術式選択は胃癌治療ガイドラインを参考に適応を厳密にすべきである．

　The actual condition of lymph node metastasis, long survival after limited surgery, postoperative complications and causes of death were evaluated in 1,337 patients with mucosal gastric cancer (MGC). The frequency of positive lymph nodes was 2.0％ (27 patients), 1.4％ in the differentiated type and 3.5％ in the undifferentiated type, respectively. The submucosal invasion rate was high, regardless of size in undifferentiated cancer lesions. For most of MGC, limited surgery preserving function of the stomach is a standard procedure. In order to improve the quality of patient life, we select limited surgery and reduce the range of lymph node dissection, preserve a bursa, an omentum, and a vagal nerve. Except for other causes of death, 5-year and 10-year-survival rate was 98.1％ and 96.3％, respectively. The percentage of postoperative complications was 6.5％ in early gastric cancer and, in MGC, that of hospital death was 0.2％ (3 patients). As for the cause of death, there were 10 cases of cancer death, 34 cases of other malignancies, 124 cases of other causes of death, and 9 cases of death due to unknown causes. The survival rate of aged patients was poor. In conclusion, the indication of endoscopic treatment for aged patients should be extended, but that for undifferentiated adenocarcinoma should be observed carefully and strictly. We encountered recurrence after limited surgery, showing that selection of the procedure of limited surgery should be make carefully according to the treatment guidelines.