高齢者早期胃癌に対するEMR/ESDの適応拡大

Expanded Indication of EMR/ESD for Early Gastric Cancer in the Elderly

要旨●早期胃癌のESD適応は外科手術例と同等の治療成績が得られる病変とガイドラインで定義されてきた．胃癌Stage I外科手術後の全生存率と疾患特異的生存率は80歳以上で乖離してくることから，高齢者では病変側の因子だけでなく，年齢，併存疾患，全身状態，手術侵襲や術後QOL低下などの患者因子を総合的に考慮する必要がある．SM1胃癌に対しESDを施行した検討では，R0切除率が高く，eCura systemからみたリンパ節再発リスクは7%程度のものが多く占めた．本研究において，CCIとサルコペニア関連因子であるPMIが高齢者胃癌ESD治療後の予後に関連する独立した因子として抽出された．以上より，CCIやPMIなど患者因子をもとに一部の高齢者においてはSM1胃癌へもESDの適応拡大が考えられる．今後の前向き研究で高齢者ESDに関するエビデンスを構築する必要がある．

　The indications of ESD（endoscopic submucosal dissection）for early gastric cancer are the lesions that provide equivalent treatment outcomes to surgery. A nationwide study revealed that an increasing gap existed between the overall survival rate and disease-specific survival rate following stage 1 gastric cancer surgery in the elderly. So, not only the disease factors but also the patient's factors should be considered comprehensively among the earlier mentioned elderly. In this study, the R0 resection of ESD has achieved a high rate in SM1 gastric cancer, with the risk of lymph node recurrence by the eCura system estimated at about 7% in most cases. Moreover, the independent factors of prognosis in the elderly following ESD for gastric cancer were CCI and sarcopenia-related factor PMI. Therefore, the indications of ESD in the elderly may also be applicable to SM1 gastric cancer, especially in patients who are unlikely to expect long-term prognosis based on CCI and PMI. To establish an indication of gastric ESD limited to the elderly, a further prospective study should be conducted.