食道SM癌に対する治療成績―内視鏡切除の立場から

Clinical Outcome of Endoscopic Resection Associated with Adjuvant Treatment for SM Massive Esophageal Cancer

要旨　食道SM2以深癌の内視鏡治療（ER）を中心とした温存治療の可能性を探るため，1990～2010年までに当院で深達度pSM2以深食道癌と診断した手術症例119例，ER症例65例の合計184例を検討対象とした．手術症例では，脈管侵襲を98例，リンパ節転移を51例に認めた．脈管侵襲陰性21例は，全例がリンパ節転移を認めず，無再発であった．ER症例は，追加治療未施行が22例，うち耐術能を有する7例は全例，無再発生存で，脈管侵襲陰性，SM2浸潤部の距離や面積が小さい特徴を認めた．化学放射線療法（CRT）は27例で，耐術能を有する症例は11例であった．そのうち1例が照射範囲外のリンパ節再発で原病死となった．手術療法が16例で，うち2例にリンパ節転移を認めたが，全例が無再発生存中であった．ER症例65例中49例（75％）に温存治療を施行した．他病死を除いた5年生存率は，ER単独が89％，ER＋CRTが82％と良好で，特に脈管侵襲陰性11例は全例無再発生存であった．この結果から，SM2以深Stage I食道癌においてstep upとしてのERは有効であり，特に脈管侵襲陰性例では温存治療の可能性があることが示された．

　To clear the possibility of organ preserving treatment for SM massive esophageal cancer by ER（endoscopic resection）associated with adjuvant treatment, we studied the clinical outcome with 184 patients（surgery : 119 cases and ER : 65 cases）who had pathologically proved SM2 and SM3 esophageal cancer, in from 1990 to 2010. In 119 cases underwent esophagectomy, vascular permeation and lymph node metastasis were discovered in 98 cases and 51 cases, respectively. In 21 cases without vascular permeation, underwent esophagectomy, there were no lymph node metastasis and recurrence. In 65 cases underwent ER, no additional therapy was employed in 22 cases. In cases of ER alone, 7 cases, who were judged to be able to withstand surgery, had no recurrence. Vascular permeation was not noted and the depth and size of the tumor invaded submucosal layer tended to be small in 7 cases. In 27 cases underwent CRT（chemoradiotherapy）after ER, 11 cases were judged to be able to withstand surgery. One case became progression of the primary disease because of the recurrence of lymph node outside of the range of the irradiation. In 16 cases underwent esophagectomy after ER, in 2cases showed lymph node metastasis. However, all cases underwent esophagectomy had no recurrence. The organ preserving treatments were operated in 49（75％）out of 65 cases. A 5-year cause specific survival rates after ER alone and CRT after ER were 89％and 82％, respectively and they showed relatively good outcome. Especially, 11 cases without vascular permeation showed no recurrence and no progression diseases after organ preserving treatments. A step up strategy of ER for SM massive esophageal cancer is a useful method and shows the possibility of organ preserving treatment, especially in the cases without vascular permeation.