胃と腸50巻13号

2015年12月発行

今月の主題 大腸鋸歯状病変の取り扱い 主題

大腸鋸歯状病変の経過と取り扱い─積極的に摘除すべきと考える立場に基づいた大腸鋸歯状病変の内視鏡診断

著者： 山階武¹² 竹内洋司¹ 長井健悟¹³ 松井芙美¹⁴ 伊藤貴史¹⁵ 松浦倫子¹ 藤井基嗣¹⁶ 鼻岡昇¹ 山本幸子¹ 東野晃治¹ 上堂文也¹ 石原立¹ 冨田裕彦⁷ 飯石浩康¹

所属機関： ¹大阪府立成人病センター消化管内科 ²大阪赤十字病院消化器内科 ³大阪大学大学院医学系研究科消化器内科学 ⁴関西医科大学消化器肝臓内科 ⁵帯広厚生病院消化器内科 ⁶ふじい消化器内科・内視鏡クリニック ⁷大阪府立成人病センター病理細胞診断科

ページ範囲：P.1667 - P.1675

要旨●近年，通常の大腸腺腫からの発癌とは異なる大腸鋸歯状病変，特にSSA/Pからの発癌経路が報告され，摘除対象として他のポリープとの鑑別が重要となってきている．筆者らの施設ではSSA/Pからの発癌予防，および正確なSSA/Pの組織学的診断に基づく大腸癌発癌のリスク層別化のために，SSA/Pが疑わしい病変を積極的に摘除している．そこでSSA/Pを放置することなく摘除するために感度の高いNBI併用拡大観察所見を前向きに検討した．NICE Type 1と分類された大腸ポリープにおいて腺窩開口部の開大所見（ECO），拡張分岐した血管所見（TBV）のSSA/Pに対する診断能（感度，特異度，正診率）はそれぞれ98％，60％，75％と良好であった．NBI併用拡大観察を用いてSSA/Pが疑わしい病変を拾い上げることにより，大腸癌の前癌病変，および併発する大腸癌発癌リスクの層別化因子と考えられるSSA/Pを効率的に鑑別し摘除できる可能性が示された．

参考文献

1）Colorectal cancer statistics. World Cancer Research Fund International. http://www.wcrf.org/int/cancer-facts-figures/data- specific-cancers/colorectal-cancer-statistics

2）The global burden of disease：2004 update. World Health Organization. http://www.who.int/healthinfo/global_burden_dis ease/GBD_report_2004update_full.pdf

3）国立がん研究センターがん対策情報センター．がん情報サービス．がんの統計'14. http://ganjoho.jp/data/reg_stat/statistics/brochure/2014/cancer_statistics_2014.pdf

4）Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic alterations during colorectal-tumor development. N Engl J Med 319：525-532, 1988

5）Leggett B, Whitehall V. Role of the serrated pathway in colorectal cancer pathogenesis. Gastroenterology 138：2088-2100, 2010

6）Snover DC. Update on the serrated pathway to colorectal carcinoma. Hum Pathol 42：1-10, 2011

7）Longacre TA, Fenoglio-Preiser CM. Mixed hyperplastic adenomatous polyps/serrated adenomas. A distinct form of colorectal neoplasia. Am J Surg Pathol 14：524-537, 1990

8）Snover DC, Ahnen DJ, Burt RW, et al. Serrated polyps of the colon and rectum and serrated polyposis. In WHO Classif tumours Dig Syst, 4th ed. IARC, Lyon, 2010

9）Sweetser S, Smyrk TC, Sinicrope F. Serrated colon polyps as precursors to colorectal cancer. Clin Gastroenterol Hepatol 11：760-767, 2013

10）斎藤彰一，池上雅博，小野雅史，他．Serrated adenomaおよびMixed hyperplastic adenomatous polypの臨床病理学的検討．Gastroenterol Endosc 40：12-21, 1998

11）佐野寧，加藤茂治，目良清美，他．大腸の鋸歯状腺腫を診る─表面構造からみた大腸鋸歯状腺腫の質的診断の限界．消内視鏡 25：12, 2000

12）Torlakovic E, Skovlund E, Snover DC, et al. Morphologic reappraisal of serrated colorectal polyps. Am J Surg Pathol 27：65-81, 2003

13）Jass JR. Classification of colorectal cancer based on correlation of clinical, morphological and molecular features. Histopathology 50：113-130, 2007

14）Samowitz WS, Albertsen H, Herrick J, et al. Evaluation of a large, population-based sample supports a CpG island methylator phenotype in colon cancer. Gastroenterology 129：837-845, 2005

15）Torlakovic EE, Gomez JD, Driman DK, et al. Sessile Serrated Adenoma（SSA）vs. Traditional Serrated Adenoma（TSA）. Am J Surg Pathol 32：21-29, 2008

16）Lash RH, Genta RM, Schuler CM. Sessile serrated adenomas：prevalence of dysplasia and carcinoma in 2,139 patients. J Clin Pathol 63：681-686, 2010

17）長谷川申，鶴田修，河野弘志，他．大腸鋸歯状病変の内視鏡診断─通常内視鏡所見を中心に．胃と腸 46：394-404, 2011

18）Nishihara R, Wu K, Lochhead P, et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 369：1095-1105, 2013

19）Sawhney MS, Farrar WD, Gudiseva S, et al. Microsatellite instability in interval colon cancers. Gastroenterology 131：1700-1705, 2006

20）Arain MA, Sawhney M, Sheikh S, et al. CIMP status of interval colon cancers：another piece to the puzzle. Am J Gastroenterol 105：1189-1195, 2010

21）Singh S, Singh PP, Murad MH, et al. Prevalence, risk factors, and outcomes of interval colorectal cancers：a systematic review and meta-analysis. Am J Gastroenterol 109：1375-1389, 2014

22）Robertson DJ, Lieberman DA, Winawer SJ, et al. Colorectal cancers soon after colonoscopy：a pooled multicohort analysis. Gut 63：949-956, 2014

23）Pohl H, Srivastava A, Bensen SP, et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection（CARE）study. Gastroenterology 144：74-80, 2013

24）Farrar WD, Sawhney MS, Nelson DB, et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 4：1259-1264, 2006

25）Patai A V, Molnár B, Tulassay Z, et al. Serrated pathway：alternative route to colorectal cancer. World J Gastroenterol 19：607-615, 2013

26）Ban S, Mitomi H, Horiguchi H, et al. Adenocarcinoma arising in small sessile serrated adenoma/polyp（SSA/P）of the colon：clinicopathological study of eight lesions. Pathol Int 64：123-132, 2014

27）Oono Y, Fu K, Nakamura H, et al. Progression of a sessile serrated adenoma to an early invasive cancer within 8 months. Dig Dis Sci 54：906-909, 2009

28）Ito T, Takeuchi Y, Hanaoka N, et al. Ten-millimeter advanced transverse colon cancer accompanied by a sessile serrated adenoma and/or polyp. Gastrointest Endosc 17:2015 [Epub ahead of print]

29）Schreiner MA, Weiss DG, Lieberman DA. Proximal and large hyperplastic and nondysplastic serrated polyps detected by colonoscopy are associated with neoplasia. Gastroenterology 139：1497-1502, 2010

30）Hiraoka S, Kato J, Fujiki S, et al. The presence of large serrated polyps increases risk for colorectal cancer. Gastroenterology 139：1503-1510, 2010

31）Li D, Jin C, McCulloch C, et al. Association of large serrated polyps with synchronous advanced colorectal neoplasia. Am J Gastroenterol 104：695-702, 2009

32）Holme Ø, Bretthauer M, Eide TJ, et al. Long-term risk of colorectal cancer in individuals with serrated polyps. Gut 64：929-936, 2015

33）Hewett DG, Kaltenbach T, Sano Y, et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology 143：599-607, 2012

34）Wallace MB. Not so NICE to be serrated. Gastrointest Endosc 78：911-912, 2013

35）Kimura T, Yamamoto E, Yamano HO, et al. A novel pit pattern identifies the precursor of colorectal cancer derived from sessile serrated adenoma. Am J Gastroenterol 107：460-469, 2012

36）Uraoka T, Higashi R, Horii J, et al. Prospective evaluation of endoscopic criteria characteristic of sessile serrated adenomas/polyps. J Gastroenterol 50：555-563, 2015

37）Hazewinkel Y, López-Cerón M, East JE, et al. Endoscopic features of sessile serrated adenomas：validation by international experts using high-resolution white-light endoscopy and narrow-band imaging. Gastrointest Endosc 77：916-924, 2013

38）Yamashina T, Uedo N. Diagnosis of sessile serrated adenoma/polyp with magnifying narrow band imaging. J Gastroenterol Hepatol 27：48-48, 2012

39）八尾隆史，菅井有，岩下明德，他．大腸SSA/Pの病理組織学的特徴と診断基準─大腸癌研究会プロジェクト研究から．胃と腸 46：442-448, 2011

40）Rex DK, Ahnen DJ, Baron JA, et al. Serrated lesions of the colorectum：review and recommendations from an expert panel. Am J Gastroenterol 107：1315-1329, 2012

41）Dekker E, Dinis-ribeiro M, Ferlitsch M, et al. Post-polypectomy colonoscopy surveillance：European Society of Gastrointestinal Endoscopy（ESGE）Guideline. pp842−851, 2013

42）日本消化器病学会（編）．大腸ポリープ診療ガイドライン．南江堂，2014

43）Sano W, Sano Y, Iwatate M, et al. Prospective evaluation of the proportion of sessile serrated adenoma/polyps in endoscopically diagnosed colorectal polyps with hyperplastic features. Endosc Int Open. 2015 [Epub ahead of print]