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Stomach and Intestine(Tokyo) Volume 50, Issue 4 （April 2015）

胃と腸 50巻4号（2015年4月発行）

Japanese English

今月の主題早期大腸癌内視鏡治療後の中・長期経過

主題研究

内視鏡摘除後大腸T1（SM）癌の転移･再発に関する多施設共同研究─大腸癌研究会プロジェクト研究の結果から Questionnaire Survey regarding Metastasis and Recurrence after Endoscopic Resection for T1（SM）Carcinomas：Results from JSCCR Project Research 斉藤裕輔 ¹ , 岡志郎 ² , 田中信治 ² , 斎藤豊 ³ , 池松弘朗 ⁴ , 五十嵐正広 ⁵ , 和田祥城 ⁶ , 工藤進英 ⁷ , 小林清典 ⁸ , 井上雄志 ⁹ , 浦岡俊夫 ¹⁰ , 飯石浩康 ¹¹ , 山野泰穂 ¹² , 鶴田修 ¹³ , 永田信二 ¹⁴ , 蔵原晃一 ¹⁵ , 山口裕一郎 ¹⁶ , 佐野寧 ¹⁷ , 樫田博史 ¹⁸ , 堀松高博 ¹⁹ , 斎藤彰一 ²⁰ , 上野秀樹 ²¹ , 石黒めぐみ ²² , 石川秀樹 ²³ , 味岡洋一 ²⁴ , 大倉康男 ²⁵ , 藤盛孝博 ²⁶ , 渡邉聡明 ²⁷ , 杉原健一 ²² Yusuke Saitoh ¹ , Shiro Oka ² , Shinji Tanaka ² , Yutaka Saito ³ , Hiroaki Ikematsu ⁴ , Masahiro Igarashi ⁵ , Yoshiki Wada ⁶ , Shin-ei Kudo ⁷ , Kiyonori Kobayashi ⁸ , Yuji Inoue ⁹ , Toshio Uraoka ¹⁰ , Hiroyasu Iishi ¹¹ , Hiro-o Yamano ¹² , Osamu Tsuruta ¹³ , Shinji Nagata ¹⁴ , Koichi Kurahara ¹⁵ , Yuichiro Yamaguchi ¹⁶ , Yasushi Sano ¹⁷ , Hiroshi Kashida ¹⁸ , Takahiro Horimatsu ¹⁹ , Shoichi Saitou ²⁰ , Hideki Ueno ²¹ , Megumi Ishiguro ²² , Hideki Ishikawa ²³ , Yoichi Ajioka ²⁴ , Yasuo Ohkura ²⁵ , Takahiro Fujimori ²⁶ , Toshiaki Watanabe ²⁷ , Kenichi Sugihara ²² ¹市立旭川病院消化器病センター ²広島大学病院内視鏡診療科 ³国立がん研究センター中央病院内視鏡科 ⁴国立がん研究センター東病院内視鏡科 ⁵がん研有明病院内視鏡診療部 ⁶東京医科歯科大学医学部附属病院光学医療診療部 ⁷昭和大学横浜市北部病院消化器センター ⁸北里大学病院消化器内科 ⁹東京女子医科大学消化器病センター ¹⁰慶應義塾大学医学部腫瘍センター低侵襲療法研究開発部門 ¹¹大阪府立成人病センター消化管内科 ¹²秋田赤十字病院消化器病センター ¹³久留米大学医学部内科学講座消化器内科部門 ¹⁴広島市立安佐市民病院内視鏡内科 ¹⁵松山赤十字病院胃腸センター ¹⁶静岡県立静岡がんセンター内視鏡科 ¹⁷佐野病院消化器センター内科 ¹⁸近畿大学医学部内科学講座（消化器内科部門） ¹⁹京都大学医学研究科消化器内科 ²⁰東京慈恵会医科大学内視鏡科 ²¹防衛医科大学校外科学講座 ²²東京医科歯科大学腫瘍外科学分野 ²³京都府立医科大学大学院医学研究科分子標的癌予防医学 ²⁴新潟大学大学院医歯学総合研究科分子・診断病理学分野 ²⁵杏林大学医学部病理学教室 ²⁶神綱病院病理診断センター ²⁷東京大学腫瘍外科 ¹Digestive Disease Center, Asahikawa City Hospital, Asahikawa, Japan ²Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan ³Endoscopy Division, National Cancer Center Hospital, Tokyo ⁴Department of Gastroenterology Endoscopy Division, National Cancer Center Hospital East, Kashiwa, Japan ⁵Department of Gastroenterology, Cancer Institute Hospital of JFCR, Tokyo ⁶Department of Endoscopy, Tokyo Medical and Dental University, Tokyo ⁷Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan ⁸Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan ⁹Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo ¹⁰Division for Research and Development of Minor Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo ¹¹Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan ¹²Department of Gastroenterology, Akita Red Cross Hospital, Akita, Japan ¹³Division of Gastroenterology, Department of Medicine, Kurume University, Kurume, Japan ¹⁴Department of Endoscopy, Hiroshima City Asa Hospital, Hiroshima, Japan ¹⁵Division of Gastroenterology, Matsuyama Red Cross Hospital, Matsuyama, Japan ¹⁶Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan ¹⁷Endoscopy Division, Gastrointestinal Center, Sano Hospital, Kobe, Japan ¹⁸Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kinki University Faculty of Medicine, Osakasayama, Japan ¹⁹Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan ²⁰Department of Endoscopy, The Jikei University School of Medicine, Tokyo ²¹Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Japan ²²Department of Surgical Oncology, Tokyo Medical and Dental University, Tokyo ²³Department of Molecular-Targeting Cancer Prevention, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan ²⁴Department of Molecular and Diagnostic Pathology, Niigata University, Graduate School of Medical and Dental Sciences, Niigata, Japan ²⁵Department of Pathology, Kyorin University School of Medicine, Tokyo ²⁶Diagnostic Pathology Center, Shinko Hospital, Kobe, Japan ²⁷Department of Surgical Oncology, The University of Tokyo, Tokyo キーワード：大腸T1（SM）癌 , 内視鏡摘除 , 追加外科手術 , salvage治療 Keyword: 大腸T1（SM）癌 , 内視鏡摘除 , 追加外科手術 , salvage治療 pp.448-456

発行日 2015年4月25日 Published Date 2015/4/25

DOI https://doi.org/10.11477/mf.1403200211

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要旨●大腸癌治療ガイドラインにおける大腸T1（SM）癌内視鏡摘除後の追加腸切除考慮基準は妥当であるが，追加腸切除がover surgeryとなっているという問題点がある．その理由は，追加腸切除を行わずに経過をみて転移や再発を来した際に，salvage治療による予後の改善が可能かどうかが不明なためである．本研究は大腸T1癌に対して内視鏡摘除単独あるいは内視鏡摘除＋追加外科手術を行い，経過観察中に転移・再発した症例の臨床経過と生命予後，およびsalvage治療の有効性を明らかにすることを目的とした．内視鏡摘除を行った大腸T1癌のうち，2001〜2008年の間に再発した病変に，後向きアンケート調査を行った．その結果，（1）内視鏡摘除単独または追加外科手術を施行した例において，2001〜2008年の間の再発は101例であり，男性62例，女性39例と男性で多く，初回治療時の平均年齢は64.7歳であった．発生部位は結腸52例，直腸48例と結腸に多く，肉眼型は隆起型68例，表面型25例と隆起型が多く，平均腫瘍径は22.1mmであった．再発様式はリンパ節転移再発21例，遠隔転移再発45例，SM層以深の局所再発が35例であった．（2）他病死6例，予後不明5例を除いた経過観察例90例中，原病死は54例（60.0％）であり，再発例における50％生存期間は39か月と，その予後は不良であった．（3）90例において初回内視鏡摘除からの累積生存率は初回内視鏡摘除後の追加外科手術の有無で有意差は認めなかった．（4）リンパ節再発，遠隔転移再発，SM層以深の局所再発，いずれの再発様式においても，その予後は不良であった．（5）再発後の平均生存期間は手術施行例で，非施行例に比較して長かった．また，再発例90例における生存例36例中31例は，追加外科手術施行例であった．（6）リンパ節転移危険因子数が少ない例では局所再発が多く，リンパ節転移危険因子数の多い例で遠隔転移が多くみられたが，有意な差は認められなかった．結論として（1）内視鏡治療後に再発を来した例では90例中54例（60.0％）が原病死しており，その予後は不良であった．（2）大腸T1癌内視鏡治療後の再発例において，外科切除可能例では外科切除不能例に比較して生存率の向上，平均生存期間の延長が得られた．

　The recommendation for consideration of additional surgery after endoscopic resection for colorectal T1（SM）carcinomas is evaluated to be appropriate by Japan Society for Cancer of the Colon and Rectum（JSCCR）guidelines for the treatment of colorectal cancer ; however, additional surgery is still controversial as over surgery. This is because it is still unclear whether salvage therapy improves the prognosis when relapse or metastasis occur during the follow-up without additional surgery after endoscopic resection. The aim of this project was to elucidate the prognosis and the effectiveness of the salvage therapy in patients with relapse or metastasis during the follow-up after endoscopic resection alone or endoscopic resection with additional surgery. A retrospective questionnaire survey was performed and the results were analyzed for relapse cases during the period of 2001-2008. Results : 1）The number of cases dealt with during the period of 2001-2008, after endoscopic resection alone and with additional surgery were 101. The study comprised 62 males and 39 females whose average age at the initial endoscopic resection was 64.7 years. The location of endoscopic resection was the colon in 51 cases and rectum in 48 cases, macroscopic type was 68 cases of the polypoid type and 25 cases of flat and depressed type. The average size of the lesion was 22.1mm. As for the relapse pattern, cases of lymph node metastasis were 21, those of distant metastases were 45, and those of local recurrences in the deeper part of the submucosal layer were 35. 2）Excluding 6 cases of death due to other diseases and 5 cases of unknown prognosis, deaths due to cancer were seen in 54 cases（60%）among 90 follow-up relapse cases ; for 50% of these, the survival period was 39 months. Thus, prognosis was poor in the relapse cases. 3）In the 90 follow-up cases, there was no significant difference in the cumulative survival ratio between cases of endoscopic resection alone and those of endoscopic resection with additional surgery. 4）Prognosis was poor, regardless of the relapse pattern of lymph node metastasis, distant metastasis, and local recurrence of the deeper part of the submucosal layer. 5）The average survival period after relapse was significantly longer in patients with surgery for the relapsed disease compared with that in patients without surgery. The 36 survival cases reported included patients with surgery for the relapsed disease. 6）. Local recurrence was the popular relapse pattern in cases with low risk factors for lymph node metastasis and in those with distant metastasis with high risk factors for lymph node metastasis ; however, no significant difference was seen. Conclusion : As the prognosis was poor in relapse patients after endoscopic resection for T1 cancers, regardless of the relapse pattern, patients with risk factors for lymph node metastasis should be cautiously evaluated for follow-up after endoscopic resection without additional surgery.