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Stomach and Intestine(Tokyo) Volume 50, Issue 12 （November 2015）

胃と腸 50巻12号（2015年11月発行）

Japanese English

今月の主題胃底腺型胃癌

主題症例

漿膜下層に脈管侵襲を認めた進行胃底腺型胃癌の1例 Advanced Stage of Gastric Adenocarcinoma of Fundic Gland Type with Venous Invasion in the Subserosa, Repot of a Case 上尾哲也 ¹ , 米増博俊 ² , 石田哲也 ¹ , 岩城堅太郎 ³ , 八尾建史 ⁴ , 八尾隆史 ⁵ , 福田昌英 ¹ , 柳井優香 ¹ , 都甲和美 ¹ , 占部正喜 ¹ , 垣迫陽子 ² , 永松秀康 ¹ , 成田竜一 ¹ , 若杉健三 ³ , 村上和成 ⁶ Tetsuya Ueo ¹ , Hirotoshi Yonemasu ² , Tetsuya Ishida ¹ , Kentaro Iwaki ³ , Kenshi Yao ⁴ , Takashi Yao ⁵ , Masahide Fukuda ¹ , Yuka Yanai ¹ , Kazumi Togo ¹ , Masaki Urabe ¹ , Yoko Kakisako ² , Hideyasu Nagamatsu ¹ , Ryuichi Narita ¹ , Kenzo Wakasugi ³ , Kazunari Murakami ⁶ ¹大分赤十字病院消化器内科 ²大分赤十字病院病理診断科 ³大分赤十字病院外科 ⁴福岡大学筑紫病院内視鏡部 ⁵順天堂大学大学院医学研究科人体病理病態学 ⁶大分大学医学部附属病院消化器内科 ¹Department of Gastroenterology, Oita Red Cross Hospital, Oita, Japan ²Department of Pathology, Oita Red Cross Hospital, Oita, Japan ³Department of Surgery, Oita Red Cross Hospital Oita, Japan ⁴Department of Endoscopy, Fukuoka University Chikushi Hospital, Chikushino, Japan ⁵Department of Human Pathology, Juntendo University Graduate School of Medicine, Tokyo ⁶Department of Gastroenterology, Oita University Hospital, Yufu, Japan キーワード：胃底腺型胃癌 , 脈管侵襲 , 進行胃癌 , NBI Keyword: 胃底腺型胃癌 , 脈管侵襲 , 進行胃癌 , NBI pp.1566-1572

発行日 2015年11月25日 Published Date 2015/11/25

DOI https://doi.org/10.11477/mf.1403200473

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要旨●患者は62歳，男性．検診目的に施行した上部消化管内視鏡検査で胃癌の診断を受け，精査加療目的に入院となった．通常光観察で胃体下部小彎後壁寄りに20mm大の陥凹型病変を認めた．H. pyloriは陰性であったが，背景粘膜は萎縮化生性変化を認め，H. pylori自然消退例の可能性が示唆された．NBI拡大観察を用いたVS classification systemでirregular microvascular pattern plus relatively regular microsurface pattern with a demarcation lineと診断し，粘膜下層浅層までの浸潤にとどまった分化型早期胃癌0-IIc型と判断した．ESDによる一括切除を施行し，胃底腺に類似した腫瘍腺管から成る高分化型腺癌の所見を認めた．免疫染色にてpepsinogen Iが陽性かつ胃型の粘液形質発現を認め，胃底腺型胃癌と診断した．腫瘍細胞は予想外に陥凹局面の外側にまで進展を認めた．また，脈管侵襲が目立ってみられたため，腹腔鏡下胃全摘術およびD2郭清を追加施行した．その結果，漿膜下組織への脈管侵襲が確認された．最終的にT3N0M0，Stage IIAの進行胃癌であった．

　A 62-year-old Japanese man was referred to our institution for gastric cancer treatment. Endoscopic examination revealed a depressed lesion approximately 20mm in size at the lesser curvature of the lower gastric body. All Helicobacter pylori（H. pylori）tests were negative ; however, atrophic mucosa with intestinal metaplasia suggested spontaneous eradication of H. pylori. According to the VS（vessel plus surface）classification, magnifying endoscopy with narrow-band imaging showed an irregular microvascular pattern in addtion to a relatively regular microsurface pattern with a demarcation line. We suspected this lesion to be an early stage type 0-IIc differentiated adenocarcinoma that was either limited to the mucosa or had minimal invasion into the submucosa. En bloc endoscopic submucosal dissection revealed a well-differentiated adenocarcinoma mimicking fundic gland cells, which were positive for pepsinogen-1 and, hence, classified as a gastric mucin phenotype. These findings were consistent with a GA-FG（gastric adenocarcinoma of fundic gland type）. Unexpectedly, cancer cells were extensively spread beyond the area of depression. Because massive lymphovenous invasions were observed, a total gastrectomy with lymph node dissection was performed. Consequently, subserosal venous invasion has occurred with cancer cells. The final pathological stage was noted as IIA（T3N0M0）.