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Stomach and Intestine(Tokyo) Volume 51, Issue 12 （November 2016）

胃と腸 51巻12号（2016年11月発行）

Japanese English

早期胃癌研究会症例

NBI併用拡大観察が有用であったBrunner腺由来の十二指腸癌の1例 Duodenal Adenocarcinoma Originating from Brunner's Glands Observed Using Magnifying Endoscopy with Narrow Band Imaging, Report of a Case 原田英 ¹ , 蔵原晃一 ¹ , 大城由美 ² , 八板弘樹 ¹ , 長末智寛 ¹ , 久能宜昭 ¹ , 亀田昌司 ¹ , 田中貴英 ¹ , 岩崎一秀 ¹ , 浦岡正義 ³ , 渕上忠彦 ¹ Akira Harada ¹ , Koichi Kurahara ¹ , Yumi Oshiro ² , Hiroki Yaita ¹ , Tomohiro Nagasue ¹ , Nobuaki Kuno ¹ , Masashi Kameda ¹ , Takahide Tanaka ¹ , Kazuhide Iwasaki ¹ , Masayoshi Uraoka ³ , Tadahiko Fuchigami ¹ ¹松山赤十字病院胃腸センター ²松山赤十字病院病理診断科 ³浦岡胃腸クリニック ¹Division of Gastroenterology, Matsuyama Red-cross Hospital, Matsuyama, Japan ²Department of Pathology, Matsuyama Red-cross Hospital, Matsuyama, Japan ³Uraoka Gastroenterology Clinic, Matsuyama, Japan キーワード： Brunner腺 , 十二指腸癌 , 胃腺窩上皮化生 , NBI拡大観察 , ESD Keyword: Brunner腺 , 十二指腸癌 , 胃腺窩上皮化生 , NBI拡大観察 , ESD pp.1617-1625

発行日 2016年11月25日 Published Date 2016/11/25

DOI https://doi.org/10.11477/mf.1403200774

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要旨●患者は60歳代，男性．上部消化管内視鏡検査で，十二指腸球部に，頂部に陥凹を伴う径約10mm大の粘膜下腫瘍様隆起を認めた．NBI併用拡大観察では，陥凹面内部に腺管構造の消失と微小血管の異常を認め，陥凹周囲の病変表面には胃腺窩上皮パターンの領域を認めた．超音波内視鏡検査で病変は第2層を中心に内部に囊胞を伴うやや低エコー領域として描出され，第3層は保たれていた.粘膜内にとどまる悪性病変と考え，診断的治療目的でESDを施行した．病理組織学的に病変内部に高度異型腺管の増生を認め，周囲にBrunner腺腫や過形成への移行がみられたため，Brunner腺より発生し粘膜下腫瘍様の形態を示したBrunner腺由来の十二指腸癌と診断した．病変の表面には，陥凹に一致して癌の露出を認め，その周囲の病変表層にMUC5AC陽性の胃腺窩上皮化生領域を認めた．近年，Brunner腺過形成や過誤腫の病変表層に胃腺窩上皮が多くみられることが報告されているが，本例では癌が露出した陥凹面周囲の病変表層に胃腺窩上皮化生の領域を認めた．本例の術前診断において，NBI併用拡大観察は陥凹面の評価と胃腺窩上皮化生の存在診断に有用であった．

　A 68-year-old man was found to have a submucosal tumor（SMT）measuring approximately 10mm by creating a depression on the top of the first part of the duodenum during esophagogastroduodenoscopy. Magnifying endoscopy with narrow-band imaging showed no surface and irregular vascular patterns in the depression and an area of gastric foveolar metaplasia around the depression. Endoscopic ultrasonography detected the tumor as a low echo area that had a cyst, mainly in the second layer, with no abnormal findings in the third layer. Based on these findings, we assessed that the tumor was malignant and intramucosal and treated the patient with endoscopic submucosal dissection.

　Histological examination of the resected specimen revealed an atypical shift wherein hyperplasic Brunner's glands and Brunner's glands adenoma went to adenocarcinoma in the tumor ; therefore, we diagnosed that the SMT was duodenal adenocarcinoma originating from Brunner's glands. We found that on the surface of the tumor, the exposure of the carcinoma was just in the depression and MUC5AC was positive in the gastric foveolar metaplasia area.

　In recent years, it has been reported that gastric foveolar metaplasia is often found the surface of hyperplasic Brunner's glands and Brunner's gland adenoma, and in our case this area was found around the depression in the exposed part of the carcinoma. In our case, magnifying endoscopy with narrow-band imaging was useful in the assessment of the depression and observation of gastric foveolar metaplasia before treatment.