噴門部陥凹型早期胃癌の見つけ出し診断―内視鏡的立場から

Endoscopic Detection of Superficial Depressed Type Early Gastric Cancer at the Cardia

要旨　噴門部陥凹型早期胃癌の診断は従来から困難で，特にEGJ近傍の小さいⅡcの報告は少ない．癌研病院外科で1978～1987年の10年間に切除した胃上部陥凹型早期癌111例中にEGJから2cm以内にとどまるⅡc（噴門部Ⅱc）はわずかに4例（5.6％）であった．4例中2例は単発病変であったが，他の2例は胃下部のⅡcの術前精査中に噴門部Ⅱcが発見された．4例のⅡcの肉眼的形態は，小彎径に比して前後径が大きくて，小彎に直角の方向に細長い拡がりを示し，組織型は全例分化型腺癌で，潰瘍性病変を認めなかった．4例の発見契機は1例がⅡc＋Ⅱaの形態でsmの浸潤を示し，X線検査で発見されたが，他の3例は内視鏡検査で噴門直下に発赤を示すびらんとしてチェックされた．1例は直視鏡によるJターンの観察で発見され，1例はGTFの反転写真でチェックされ，残りの1例は側視鏡のダウンによる観察で発見された．噴門部Ⅱcの発見は内視鏡的立場から，噴門直下の発赤したびらん性病変に注目すべきであろう．

　Diagnosis of superficial depressed early gastric cancer at the Cardia has been difficult with only a few reports on small Ⅱc type cancer near the esophagogastric junction (EGJ).

　We experienced only four cases (5.6%) of Ⅱc cancer within 2 cm from the EGJ (cardiac Ⅱc) among 111 cases of depressed early cancer in the upper part of the stomach resected in the past ten years (1978-1987) at the Surgical Department, Cancer Institute Hospital.

　Two of these four cases were solitary lesions. In the other two cases, cardiac Ⅱc type lesions were coincidentally detected during pre-operative examination for Ⅱc type lesion in the lower part of the stomach.

　Macroscopically, Ⅱc type lesions in these four cases extended targentially to the lesser curvature with longer anteroposterior diameter than that along the lesser curvature. Histologically, all cases were well differentiated adenocarcinoma with no ulcer formation. Clues for case finding included Ⅱc ＋ Ⅱa with sm invasion detected radiographically in one case and erosion with redness just below the Cardia detected endoscopically in three cases. In the latex three cases, J-turn observation with forward-viewing gastroscope, reverse film (by GTF) observation, and down observation with sideviewing gastroscope were the procedures leading us to the definitive diagnosis, respectively.

　Thus, from the endoscopical viewpoint, erosive lesion with redness just below the Cardia should always prompt us to entertain the possibility of depressed early cancer in this area.