表層拡大型早期胃癌症例に内視鏡的粘膜切除を行った1例

Superficially Spreading Type of Early Gastric Cancer, Treated by Endoscopic Mucosal Resection, Report of a Case

要旨　患者は77歳，女性．慢性気管支炎で外来通院中であったが，胃体上部後壁に3cm大のⅡa集簇型の早期胃癌が発見されたため，内視鏡による分割切除と高周波凝固焼灼による治療を行った．この8か月後，1cm大のⅡa型の局所再発を認めたが再度の内視鏡的粘膜切除（EMR）が可能であった．更に9か月後に，それまで認識されていなかった広範に表層拡大を示すⅡa集簇型の病変が胃体中部後壁から胃角にかけて認められた．そこで，分割切除の手技を用いて内視鏡的に認識しうる病変を可能な限り切除し，更に遺残病変に対しては高周波凝固による焼灼術を徹底的に行うことにより，病変の完全消失が得られた．表層拡大型病変は本来は手術適応であるが，本症例は手術リスクが大きいため内視鏡的治療を選択し奏効した．

　A 77-year-old woman, with a history of chronic bronchitis, was referred to our clinic because of early gastric cancer of IIa aggregated type. Multiple endoscopic piecemeal mucosal resection and additional electrocauterization therapy was performed, and the biopsy of this lesion came to be negative for malignancy. Eight months later, local recurrence of IIa type cancer, 1 cm in diameter, was noted. Again, endoscopic mucosal resection was tried and was successful. After another nine months had passed, extension of the superficially spreading lesion was noted, for the first time, at the posterior wall of the middle body to the angulus. At this time, surgical therapy was considered because the lesion was too wide to cut off by endoscopic mucosal resection. However endoscopic therapy was again chosen, because of the high operative risk to the patient, such as high age and chronic bronchitis. Endoscopic piecemeal mucosal resection with additional electrocauterization therapy was performed extensively to remove the residual cancerous lesion. After the multiple electrocauterization therapy, the lesion became a huge open ulcer, but the biopsy of the lesion was negative. The follow-up of this lesion revealed rapid healing of the artificial ulcer without any complication and no longterm local recurrence.

　Usually, superficially spreading lesion is difficult to treat by endoscopic therapy, and should be treated by operation. However, for the high risk patients such as high age or severe cardiopulmonary disease, we should consider endoscopic therapy.