Colitic cancer-サーベイランスと外科治療  [in Japanese] COLITIC CANCER-SURVEILLANCE & SURGERY  [in Japanese]

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    • 藤井 久男 FUJII Hisao
    • 奈良県立医科大学 中央内視鏡・超音波部 Department of Endoscopy & Ultrasound, Nara Medical University


欧米では比較的古くから炎症性腸疾患が大腸癌の高リスク群であることが知られていたが,わが国においても患者数が漸増し,長期経過例が増えてくるにつれ臨床上大きな問題となってきた.潰瘍性大腸炎(UC)については,発症から8~10年経過後の全大腸炎型と左側大腸炎を対象に,癌またはdysplasiaを早期に発見する目的で,サーベイランスプログラムが提唱されている.欧米では炎症のある粘膜を背景とした平坦なdysplasiaは内視鏡で発見しがたいとして,30個を超える生検を行うrandom biopsyが行われてきた.しかし,拡大色素内視鏡によりdysplasia/cancerを認識できる可能性が増してきたので,疑わしき病変を選択的に狙撃生検する方法が検討されている.サーベイランスの結果,high-grade dysplasia(HGD)やdysplasia-associated lesion or mass(DALM)が発見されれば大腸切除が勧められるが,low-grade dysplasia(LGD)の対処については意見が分かれており,消化器病医の理解もまだ不十分である.  外科治療は大腸を亜全摘し,回腸嚢を作成して,肛門管上縁もしくは歯状線部で吻合する自然肛門温存術(IPAA)が広く行われ,成績も満足すべきものである.しかし,IPAA後にも少数例ながらdysplasia/cancerが報告されており,大腸切除後も定期検診を続けるべきである.早期癌の予後は一般の大腸癌と変わらず良好なので患者のみならず臨床医の啓発がサーベイランスを成功に導く鍵になる.

In western countries, it has been well known that inflammatory bowel disease is a high risk group for colorectal cancer. In Japan, it has become a major clinical problem as the number of patients with ulcerative colitis (UC) increased gradually and the long-standing cases in-creased. In order to detect early colitis cancer dysplasia, several surveillance programs for patients with long-standing extensive UC have been proposed. Because it is endoscopically difficult to find out the "flat" dysplasia against the inflammatory mucosa, a series of more than 30 random biopsies is recommended. However, because magnifying chromoendoscopy has enhanced the ability to visually identify dysplasia/cancer, targeted biopsy, an alternate method of sampling doubtful lesions selectively has been discussed. Although colectomy is generally recommended in case that high-grade dysplasia or DALM (dysplasia associated lesion or mass) is detected as a result of the surveillance, controversy exists as to the proper management of low-grade dysplasia, and gastroenterologists may not fully understand the ramifications involved. Restorative proctocolectomies, subtotal colectomy and ileal-pouch anal anastomoses (IPAA) are widely each performed on surgery-candidates, and operative results are satisfac-tory. However, a few cases of dysplasia/cancer after IPAA were reported and, therefore, annual follow-up should be continued after colectomy. Prognosis of the early colitic cancer seems to be as good as ordinary colorectal cancer, hence enlightenment of the physicians as well as the patients may be a key to bringing the surveillance to successful completion.



    GASTROENTEROLOGICAL ENDOSCOPY 50(8), 1699-1710, 2008-08-20 

    Japan Gastroenterological Endoscopy Society

References:  90

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