EMR後の遺残癌にEMRを4回施行した胃角部Ⅱa型癌の1例

EMR Performed Four Times for Residual Ⅱa Cancer of the Gastric Angle, Report of a Case

要旨　患者は67歳，男性．胃角小彎の径2cmのⅡaに内視鏡的切除（EMR）が行われた．切除標本の組織所見はtub2，m，断端(＋)で，EMR後の遺残癌に，2年間にわたり追加EMRを4回施行したが，切除が不十分で，EMRによる胃角部狭窄のため，遺残癌のEMRが不能になり，胃切除を施行した．切除標本の組織所見は胃角小彎にEMRのUl-Ⅲの瘢痕があって，その幽門側後壁に10×10mmのtub2が粘膜内にあって，一部smに浸潤していたが，リンパ節転移陰性であった．EMR後の遺残癌に対する治療をEMR深達度，占拠部位から検討した．EMR深達度がm，sm₁では，幽門前庭部の遺残癌には追加EMRで根治可能であるが，胃角および胃体部では追加EMRが不的確な場合には，局所切除を考慮すべきであろう．本例もEMR後の遺残癌に早期に局所切除が行われるべきであったと考えられた．

　A 67-year-old man, was diagnosed endoscopically as having Ⅱa type early gastric cancer, 2 cm in size, on the lesser curvature of the gastric angle. Endoscopic mucosal resection (EMR) was performed. The resected specimen showed tubular adenocarcinoma (tub2), limited to the mucosa, but the surgical margin was positive. On account of this, additional EMR was carried out four times for residual cancer during a two-year period, but specimens of EMR were insufficient, and shrinking of the angle occurred due to the repeated EMR. Because of this, EMR of the residual cancer became impossile. Finally, distal gastrectomy was performed. Resected material contained residual cancer, 10×10 mm in size, partly invading the submucosa, and the neighboring ulcerscar due to EMR, but there was no lymph node metastasis.

　The discussion of the treatments for residual cancer after EMR concerned the relation of location and depth of invasion of the EMR specimen. In cases of EMR, with depth of invasion m, sm₁, additional EMR is possible for cases located in the antrum, but in cases located at the gastric angle and body, local resection should be considered when additional EMR is unsuitable. In cases of residual cancer after EMR when further EMR is considered unsuitable, early local resection should be performed.