長期観察および内視鏡的切除例からみた胃腺腫の治療方針―積極的に治療する立場から

Treatment Strategy for Gastric Adenoma Based on Cases with Long-term Follow-up and Endoscopic Resection―from the Point of View of Active Resection

要旨　胃腺腫に対する内視鏡的治療の意義について臨床的検討を行った．対象とした症例は，当院にて発見された胃腺腫1,121例のうち，内視鏡的切除(以下ER)が施行された118例を対象に病変の大きさ，内視鏡所見の変化および病理組織学的所見について検討した．ERが施行された118例のうち，腺腫例が75例，腺腫内癌と診断された症例は43例であった．病変の最大径と病理組織所見の関係では，10mm以下の症例では，腺腫内癌の症例は28％であったが，11～20mmでは49％，21mm以上では23％と，腫瘍径と癌の合併頻度に相関はなかった．内視鏡所見の変化は，腺腫例では形態的変化がなかった症例は79％であった．増大例は9％であり，隆起の表面に陥凹を伴った症例は5％，発赤陥凹例は5％であった．一方，癌合併例では，形態変化のなかった症例は65％であった．増大例は12％，陥凹を伴った症例は9％，発赤陥凹例は7％であり，癌合併例で腫瘍の増大や発赤・陥凹を伴う頻度が高かった．生検による病理組織所見とERの病理組織所見を比較検討した結果，ER前の生検による腺腫および腺腫内癌の正診率は71％であった．正確な診断と治療を行うには，total biopsyという観点から，積極的に内視鏡的切除を行うべきであると考えている．

　The significance of endoscopic treatment for gastric adenoma was clinically investigated. Of 1,121 cases with gastric adenoma found in our hospital,118 cases that underwent endoscopic resection (ER) were examined under the aspects of size, changes in endoscopic findings, and pathohistology. In 118 ER cases, there were 75 cases of adenoma and 43 of cancer in adenoma. When the association was examined between pathohistology and the maximum diameter of the lesion, cancer in adenoma was found in 28％ of 10mm or smaller,49％ of 11 to 20mm, and 23％ of 21mm or larger tumors. There was no association between the tumor size and cancer occurrence. In 79％ of adenoma cases, no morphological change was observed endoscopically. Enlargement, the appearance of irregular surface, and redness with depression were observed in 9％, 5％, and 5％, respectively. On the other hand, in cases with cancer, no morphological change was observed in 65％ of them. Enlargement, the appearance of irregular surface, and redness with depression were found in 12％, 9％, and 7％, respectively. Enlargement of the tumor and changes with redness and depression occurred more frequently in cases with cancer.

　When pathohistology was compared between biopsy samples and specimens obtained by ER, there was 1％ of discrepancy in cases with adenoma. On the other hand, in cases with cancer, discrepancy was found in 77％. In all the cases with adenoma and cancer in adenoma, the diagnostic accuracy was 71％. When cases with cancer in adenoma were examined from the aspects of endoscopic findings and pathohistology, tumors 20mm or larger in size, with increased nodularity, and with redness and depression were not accompanied by cancer as frequently as previously reported, and tumors 10mm or smaller in size accounted for 28％ of cancer in adenoma, but endoscopic findings were often similar to those of adenoma. In addition, the diagnostic accuracy by biopsy was as low as 23％. Therefore, from the point of view of total biopsy, it would be reasonable to actively perform ER for correct diagnosis and treatment.