2）SSBEに発生したSM深部浸潤Barrett表在癌の1例

Superficial Barrett's Esophageal Carcinoma in SSBE, Which was pT1b-SM2 in Invasion Depth, Report of a Case

要旨　患者は80歳代，男性．4～5年前より逆流性食道炎にてPPIを内服中であったが，心窩部への違和感を主訴にEGDを施行し，SSBE右壁に径15mm大の発赤調隆起性病変を認めた．通常観察で緊満感・硬さを認めた．隆起部のNBI併用拡大内視鏡観察では，表面構造は不明瞭で血管の拡張，口径不同・走行不整は非常に目立ち，一部新生血管と考えられる太い血管が存在した．EUSでは，SM層の圧排・菲薄化を認め，深達度T1b-SM2と診断した．隆起口側平坦部では腺管密度の高いpit構造とnetwork血管，隆起肛門側陥凹部でも走行異常を伴う口径不同血管を認め，SCJに接する部位から肛門側は陥凹部まで進展する病変であった．CTでは，リンパ節転移を認めず，高齢・合併症を考慮し十分なインフォームドコンセントを行い，病変をESDにて切除した．病理診断はAe，26×14×2mm，adenocarcinoma（tub1，tub2＞por2）in SSBE，pSM2，ly0，v0，pHM0，pVM0．病変肛門側粘膜下層には食道固有腺を認め，内視鏡所見と切除標本との対比では進展範囲診断および深達度診断は一致していた．Barrett腺癌の診断には通常内視鏡観察に加え，酢酸撒布・NBI併用拡大内視鏡による範囲診断，EUSによる深達度診断が有用である．

　A male in his eighties undergoing conventional esophagoscopy due to epigastric discomfort was shown to have a reddish protruded lesion on the right wall of the SCJ（squamo-columnar junction）. The background mucosa of the tumor was diagnosed as short segment Barrett's esophagus by recognizing the lower end of palisade longitudinal vessels in the columnar-lined esophagus. Magnifying endoscopy with NBI（narrow band imaging）for the middle part of the tumor revealed the absence of surface pattern with irregular microvascular pattern（tortuous/bizarrely shaped without a network/irregular distribution and arrangement）. EUS（endoscopic ultrasonography, 20MHz）showed a hypoechoic mass lesion deeply invading the submucosal layer. The oral flat part and the anal depressed part of the tumor revealed fine network pattern with high density of pit and irregular microvascular pattern（tortuous/caliber change/heterogeneity in shape）, respectively. Because there was neither lymph node nor distant metastasis found on CT examination and because of the patient's high age, we performed ESD（endoscopic submucosal dissection）for the lesion in en-bloc fashion. Histopathologically, the tumor was diagnosed as 0-“Is”＋IIb＋IIc, an esophageal adenocarcinoma（tub1, tub2＞por2）in SSBE, ly0, v0, pSM2, pHM0, pVM0, with tumor size being 26×14×2 mm. Contrasting endoscopic findings and histopathological findings, both of them resulted in approximately the same diagnosis of delineation and depth of invasion, so it is useful to observe magnifying endoscopy with NBI or acetic acid and EUS for diagnosis of Barrett's carcinoma.