短期間にEMRを繰り返した胃上部Ⅱb型早期癌の1例

Type Ⅱb Early Gastric Cancer in the Upper Body of the Stomach which Was Successively Repeated to do EMR in a Short Period, Report of a Case

要旨　われわれは，体上部小彎のⅡb病変に対し，短期間にEMRを繰り返し，癌の遺残に対する治療を行った症例を経験した．患者は59歳，男性．他医の胃内視鏡検診で体上部小彎の粘膜不整部（小発赤斑）を指摘され，生検で腺癌を認められ当院へ紹介されたが，当院での内視鏡下生検で癌の同定ができず，経過観察とした．その後，体上部小彎の小発赤のⅡb病変に対してEMR-L法で粘膜切除を行った．m癌であったが切除標本の口側断端(＋)となり，5日後，追加EMR（EMRC）を施行した．m癌が認められ，再構築上，後壁側の癌遺残の可能性が考えられたため，4日後に再追加EMRを施行，更に，前回までのEMR潰瘍との間のbridgeにエタノール局注し，ヒータープローブで焼灼した．治療後3年5か月経過したが再発はみられていない．本症例から学びえた問題点は，①分化型Ⅱb病変の病巣範囲同定の困難性，②生検診断の困難性と限界，③胃上部など癌存在部位によるEMRの困難性で，これらにつき考察を加えた．

　We describe a case in which, to treat the remnants of the cancer, EMR procedures were performed successively in a short period of time to resect a type Ⅱb lesion located in the lesser curvature of the upper body of the stomach. The patient was a 59-year-old man. A mucosal irregularity (small red patch) in the lesser curvature of the upper body was identified by gastroscopy performed at another clinic, and the patient was referred to this hospital after biopsy disclosed adenocarcinoma. An endoscopic biopsy performed at this hospital failed to identify the cancer, and a decision was made to monitor the patient's course. Subsequently, mucosal resection by EMR-L was performed for a type Ⅱb lesion, a small area of redness in the lesser curvature of the upper body. Histopathologically, the lesion was diagnosed as a mucosal cancer, but the proximal end of the resected specimen was(+), so an additional EMR (EMRC) procedure was performed five days later. A mucosal cancer was identified, and, after reconstruction of these specimens, since there was a possibility of a cancer remnant remaining on the posterior wall a further EMR procedure was performed four days later, and the bridge between the previous ulcers and the one removed during the 3rd EMR was treated with local ethanol injection and cauterized with a heater probe. Three years and five months have now elapsed since treatment with no sign of recurrence. The lessons to be learned from this case include (1) the difficulty of identifying the extent of the focus for a differentiated type Ⅱb lesion, (2) the difficulty and limits of diagnosis by biopsy, and (3) difficulties in performing EMR due to the site of the lesion, such as the upper body of the stomach. In this paper, we describe the present case and further discuss these problems.