胃癌EMR後の遺残再発における外科的治療の適応と成績

The Suitability and Results of Surgical Operations in Case of Recurrence of Cancers that Have Already been Treated with Endoscopic Mucosal Resection

要旨　外科手術可能な症例ではEMR後の経過観察中に癌遺残が確認された場合，外科治療との接点をどこに置くのかは常に見据えておく必要があり，この観点から，EMR後の遺残再発例に対する外科的治療の適応や成績について検討した．対象は1986年1月から1998年3月までの260例285病変で平均観察期間は38.2か月であった．経過観察中，遺残再発を確認した例は35例35病変（12.3％，35/285）で，再EMRが可能だったものは23例あり，再EMRが不能な12例に対しては外科手術を行った．EMR後1年以内の再発累計が35例中27例（77.1％）に認められ，経過観察を1年間は厳重に行うことが重要と考えられた．外科治療となった要因として，遺残再発部は潰瘍瘢痕上にあるため，部位的にEMRが困難なもの7例，局注しても病変部の挙上が悪く技術的に不能なもの2例，癌遺残を告げると患者自身が手術を希望したもの1例，不十分なinformed consentの面が存在したと考えられるもの2例などがあった．外科手術標本の病理結果は，速やかに手術したものは全例深達度mでありly(－)，v(－)かつリンパ節転移も認めなかった．しかし，医師側の外科手術への対応の遅れが原因でsm癌や進行癌に進行したものがあり，informed consentのあり方に問題が残った．

　The management of recurrent cancer, recognized at the follow-up examination after EMR (endoscopic mucosal resection), is very important for the patients because they are operable cases. In this paper, we discussed the reason why we have used surgical therapy for recurrent cancer, on our analysis of the pathological findings of the resected specimens. 260 cases with 285 lesions were followed up after EMR and 35 cases with 35 lesions (12.5%) out of them were recurrent at the site of resection. 77.1% of the recurrent cancers were diagnosed within one year after EMR, so it is in this period that careful fllow-up endoscopic observation should be made. The therapy used for these recurrent cancers was re-EMR for 23 cases and surgical operation for 12 cases. The factors that prevented re-EMR were mainly the location of the cancers and fibrous changes of the submucosa. Among the operated cases, 10 cases which were operated on immediately at the time of diagnosing the recurrence cancerous invasion limited to the mucosa was recognized but lymph node metastasis was not observed. On the other hand, invasion of the submucosa and the serosa along with lymph node metastasis was identified in two cases which were operated on after re-EMR treatment and laser therapy repeated several times.

　Our conclusion is that surgical operation as soon as possible should be the treatment of choice for operable cases of cancer that still remain after re-EMR.