Title
Efficacy of contrast-enhanced EUS for lymphadenopathy: a
prospective multicenter pilot study (with videos)( 内容と審査の
要旨(Summary) )
Author(s)
吉田, 健作
Report No.(Doctoral
Degree)
博士(医学) 甲第1112号
Issue Date
2019-11-20
Type
博士論文
Version
none
URL
http://hdl.handle.net/20.500.12099/79130
※この資料の著作権は、各資料の著者・学協会・出版社等に帰属します。Ặ ྡ 㸦 ᮏ ⡠ 㸧 ྜྷ ⏣ స 㸦ᒱ㜧┴㸧 Ꮫ ࡢ ✀ 㢮 ༤ ኈ㸦་Ꮫ㸧 Ꮫ ᤵ ␒ ྕ ⏥➨ ྕ Ꮫ ᤵ ᪥ ௧ඖᖺ ᭶ ᪥ Ꮫ ᤵ せ ௳ Ꮫつ๎➨㸲᮲➨㸯㡯ヱᙜ
Ꮫ ㄽ ᩥ 㢟 ┠ Efficacy of contrast-enhanced EUS for lymphadenopathy: a prospective multicenter pilot study (with videos)
ᑂ ᰝ ጤ ဨ 㸦ᰝ㸧ᩍᤵ ᏹஅ
㸦ᰝ㸧ᩍᤵ ➉ෆ ಖ ᩍᤵ ᳃⏣ ᾈஅ
ㄽ ᩥ ෆ ᐜ ࡢ せ ᪨ ࠙⥴ゝࠚ
⦪㝸ෆ࣭⭡⭍ෆࣜࣥࣃ⠇⭘ࡢṇ☜࡞㚷ูデ᩿ࡣ㸪㐺ษ࡞⒪᪉㔪ࡢỴᐃ࠾࠸࡚ᴟࡵ࡚㔜せ࡛࠶
ࡿࠋᾘ⟶ෆࡽኚ㏆᥋ࡍࡿ㉸㡢Ἴෆど㙾㸦Endoscopic ultrasonography: EUS㸧ࡣ㸪㧗࠸✵㛫
ศゎ⬟ᇶ࡙࠸ࡓほᐹࢆྍ⬟ࡍࡿࡓࡵ㸪ᾘ⟶࿘ᅖ⭘ࣜࣥࣃ⠇ࡢ᳨ฟ࠾ࡅࡿඃࢀࡓ᳨ᰝἲ࡛࠶
ࡿࠋ≉㸪➨2 ୡ௦㐀ᙳࢆ⏝ࡋࡓ㐀ᙳ㉸㡢Ἴෆど㙾㸦Contrast-enhanced EUS㸸CE-EUS㸧ࡣ㸪
ኚෆࡢ⾑ὶࢆࣜࣝࢱ࣒ホ౯ࡍࡿࡇࡀྍ⬟࡛࠶ࡾ㸪ࡑࡢᛂ⏝ࡀᮇᚅࡉࢀ࡚࠸ࡿࠋ㏆ᖺ㸪
CE-EUS ⾜ࡢ Time intensity curve㸦TIC㸧ࢆ⏝࠸ࡓ⾑ὶࡢᐃ㔞ⓗホ౯ࡀ㸪⭘⒆ᛶኚࡢ㚷ูデ᩿
࠾࠸࡚᭷⏝࡛࠶ࡿྍ⬟ᛶࡀሗ࿌ࡉࢀ࡚࠸ࡿࡀ㸪⭘ࣜࣥࣃ⠇ࡢ㚷ูデ᩿ᑐࡍࡿ CE-EUS ࡢ᭷⏝ᛶ
ࡘ࠸࡚ࡣ౫↛ࡋ࡚᫂࡞Ⅼࡀከࡃ㸪ࡼࡃ᳨ウࡉࢀ࡚࠸࡞࠸ࠋᮏ◊✲࡛ࡣ㸪⭘ࣜࣥࣃ⠇ࡢⰋᝏᛶ
㚷ูデ᩿࠾ࡅࡿCE-EUS ࡢᐃᛶⓗ࠾ࡼࡧᐃ㔞ⓗホ౯ࡢ᭷⏝ᛶࡘ࠸᳨࡚ウࡋࡓࠋ
࠙ᑐ㇟᪉ἲࠚ
2016 ᖺ 9 ᭶ࡽ 2018 ᖺ 3 ᭶ࡲ࡛㸪ᒱ㜧Ꮫ་Ꮫ㒊㝃ᒓ㝔ࢆྵࡴ㛵㐃 3 タ࡛⦪㝸ෆ࣭⭡⭍
ෆࣜࣥࣃ⠇⭘ᑐࡋ࡚㉸㡢Ἴෆど㙾ୗ✸่྾ᘬ㔪⏕᳨㸦EUS-guided fine needle aspiration㸸EUS-FNA㸧ࢆணᐃࡉࢀࡓࢆ๓ྥࡁⓏ㘓ࡋホ౯ࡋࡓࠋB-mode EUS ࡛ࡣ㸪᪤ሗᇶ࡙࠸࡚⭘⒆ᚄӍ 10mm㸪ᙧ㸪ቃ⏺᫂░㸪ෆ㒊࢚ࢥ࣮ࣃࢱ࣮ࣥࡀᆒ୍࡞ప࢚ࢥ࣮ኚࢆᝏᛶᐃ⩏ࡋࡓࠋCE-EUS ࡢ ᐃᛶⓗホ౯ࡣ㸪⭘ࣜࣥࣃ⠇ࡢ㐀ᙳࣃࢱ࣮ࣥࢆ hypervascular with homogeneous㸪hypervascular with heterogeneous㸪hypovascular with heterogeneous ࡢ 3 ࡘศ㢮ࡋ⾜ࡗࡓࠋCE-EUS ࡢᐃ㔞ⓗ
ホ౯ࡣ TIC ࢆ⏝࠸࡚⾜࠸㸪㐀ᙳ㛤ጞᚋ 60 ⛊㛫࠾ࡅࡿ⭘ࣜࣥࣃ⠇ෆࡢ࢚ࢥ࣮㍤ᗘࡢ᭱㍤ᗘ್ 㸦dB㸧㸪᭱㍤ᗘ್฿㐩ࡲ࡛ࡢ㛫㸦s㸧㸪࣮࣋ࢫࣛࣥ㍤ᗘ್᭱㍤ᗘ್ࡢᕪ㸦dB㸧㸪᭱㍤ᗘ್ ࡽ60 ⛊ᚋࡲ࡛ࡢῶ⾶㏿ᗘ㸦dB/s㸧ࡘ࠸࡚ ᐃࡋࡓࠋ᭱⤊⌮デ᩿ࡣ EUS-FNA ࡛ᚓࡽࢀࡓ᳨య ࡲࡓࡣᡭ⾡᳨య࡛⾜࠸㸪CE-EUS ࡢᐃᛶⓗ࠾ࡼࡧᐃ㔞ⓗホ౯ࡀ⭘ࣜࣥࣃ⠇ࡢⰋᝏᛶデ᩿᭷⏝࡛ ࠶ࡿ᳨ウࡋࡓࠋ ࠙⤖ᯝࠚ ⮫ᗋヨ㦂ྠពࢆᚓࡽࢀࡓ118 ࡢ࠺ࡕ㸪㐺᱁ᇶ‽ࢆ‶ࡓࡍ 100 ࢆⓏ㘓ࡋࡓࠋ᭱⤊デ᩿ࡣᝏᛶ㸸 70 㸦ᝏᛶࣜࣥࣃ⭘㸸34 㸪⭢⒴㸸24 㸪⭢⒴௨እࡢ⒴㸸9 㸪⚄⤒ෆศἪ⒴㸸2 㸪⚄⤒ෆศἪ ⭘⒆㸸1 㸧㸪Ⰻᛶ㸸30 㸦ᛂᛶࣜࣥࣃ⠇⅖㸸18 㸪ࢧࣝࢥࢻ࣮ࢩࢫ㸸10 㸪⤖᰾ᛶࣜࣥࣃ⠇ ⅖㸸1 㸪㠀⤖᰾ᛶᢠ㓟⳦㸸1 㸧࡛࠶ࡗࡓࠋB-mode EUS ࡛ࡣⰋᝏᛶデ᩿࠾ࡅࡿឤᗘ㸪≉␗ᗘ㸪 ṇデ⋡ࡣࡑࢀࡒࢀ 77㸣㸪17㸣㸪59㸣࡛࠶ࡗࡓࠋCE-EUS ࡼࡿᐃᛶⓗホ౯࡛ heterogeneous
enhancement pattern ࢆᝏᛶᐃ⩏ࡍࡿឤᗘ㸪≉␗ᗘ㸪ṇデ⋡ࡣࡑࢀࡒࢀ 67㸣㸪87㸣㸪73㸣࡛࠶ ࡗࡓࠋTIC ゎᯒࡣ homogeneous enhancement heterogeneous enhancement ᑐࡋู࡚ࠎ⾜ ࡋ㸪heterogeneous enhancement ࡛ࡣ᭷ពᕪࢆㄆࡵ࡞ࡗࡓࡀ㸪homogeneous enhancement ࠾ ࠸࡚㸪ῶ⾶㏿ᗘࡣᝏᛶ࡛᭷ព㏿ࡗࡓ㸦P = 0.0011㸧ࠋReceiver Operating Characteristic ゎᯒࡢ ⤖ᯝ㸪ᝏᛶࢆᝏᛶデ᩿ࡍࡿῶ⾶㏿ᗘࡢ㐺ษ࡞cut-off ࡣ 0.149 dB/s ࡛࠶ࡗࡓ㸦area under the curve㸸 0.77㸧ࠋTIC ゎᯒ࡛ᚓࡽࢀࡓྠ cut-off ࢆ⏝࠸ࡓ homogeneous enhancement ᑐࡍࡿᐃ㔞ⓗホ౯ࡢ
ឤᗘ㸪≉␗ᗘ㸪ṇデ⋡ࡣࡑࢀࡒࢀ65㸣㸪89㸣㸪81㸣࡛࠶ࡗࡓࠋCE-EUS ࡢᐃᛶⓗホ౯ᐃ㔞ⓗホ౯
ࢆ⤌ࡳྜࢃࡏࡿ㸪ᝏᛶࡢデ᩿࠾ࡅࡿឤᗘ㸪≉␗ᗘ㸪ṇデ⋡ࡣࡑࢀࡒࢀ 89㸣㸪77㸣㸪85㸣ᨵၿ
ࡋࡓࠋCE-EUS ࡢᐃᛶⓗ࠾ࡼࡧᐃ㔞ⓗホ౯ࢆ⤌ࡳྜࢃࡏࡓṇデ⋡ࡣ㸪B-mode EUS ༢⊂㸦P < 0.0001㸧
ࡸCE-EUS ࠾ࡅࡿᐃᛶⓗホ౯༢⊂㸦P = 0.0362㸧ẚ㍑ࡋ࡚᭷ពⰋዲ࡛࠶ࡗࡓࠋ ࠙⪃ᐹࠚ ⦪ 㝸 ෆ ࣭ ⭡ ⭍ ෆ ࣜ ࣥ ࣃ ⠇ ⭘ ࡢ Ⰻ ᝏ ᛶ 㚷 ู ࠾ ࡅ ࡿ CE-EUS ࡢ ᐃ ᛶ ⓗ ホ ౯ ࠾ ࠸ ࡚ 㸪 heterogeneous enhancement ࢆᝏᛶᐃ⩏ࡋ᳨࡚ウࡍࡿឤᗘ㸪≉␗ᗘ㸪ṇデ⋡ࡣࡑࢀࡒࢀ 67㸣㸪 87㸣㸪73㸣࡛࠶ࡾ㸪≉ឤᗘࡀప࠸⤖ᯝ࡞ࡗࡓࠋࡇࢀࡣ㸪ᝏᛶࣜࣥࣃ⭘ࡢ⣙༙ᩘࡀ homogeneous enhancement ࢆ♧ࡍࡇ㉳ᅉࡋ࡚࠾ࡾ㸪CE-EUS ࡢᐃᛶⓗホ౯ࡢࡳ࡛ࡣⰋᝏᛶ㚷ู࠾ࡅࡿデ᩿ ⬟ࡣ㝈ᐃⓗ࡛࠶ࡿ⪃࠼ࡽࢀࡓࠋᮏ◊✲࡛ࡣᐃ㔞ⓗホ౯ࡶ⾜࠸㸪homogeneous enhancement ࠾࠸ ࡚ᝏᛶ࡛ࡣ᭱㍤ᗘ್ࡽ60 ⛊ᚋࡲ࡛ࡢῶ⾶㏿ᗘࡀ᭷ព㏿ࡃ㸪ࡉࡽᐃᛶⓗホ౯ᐃ㔞ⓗホ౯ࢆ ⤌ࡳྜࢃࡏࡿࡇ࡛㸪CE-EUS ࡼࡿⰋᝏᛶ㚷ู࠾ࡅࡿឤᗘ㸪≉␗ᗘ㸪ṇデ⋡ࡀࡑࢀࡒࢀ 89㸣㸪 77㸣㸪85㸣ࡲ࡛ᨵၿࡍࡿࡇࡀ᫂ࡽ࡞ࡗࡓࠋࡇࢀࡽࡢ◊✲⤖ᯝࡣ㸪CE-EUS ࡼࡿᐃᛶⓗホ౯ ᐃ㔞ⓗホ౯ࢆ⤌ࡳྜࢃࡏࡿࡇ࡛㸪B-mode EUS ẚ㍑ࡋ࡚ᝏᛶࡢ㚷ู࠾࠸࡚㧗࠸デ᩿⬟ࡀᚓ ࡽࢀࡿࡇࢆ♧ࡍࡶࡢ࡛࠶ࡿࠋ≉⭘ࣜࣥࣃ⠇ࢆከᩘㄆࡵࡿ࡛ࡣ㸪ᝏᛶࡢṇデࢆᚓࡿࡓࡵࡢ EUS-FNA ࡢᑐ㇟ኚࢆ㑅ᢥࡍࡿࡇ㏞࠺ሙྜࡀ࠶ࡿࡀ㸪CE-EUS ࡼࡿᐃᛶⓗ࠾ࡼࡧᐃ㔞ⓗホ ౯ࡣ㸪ࡑࡢ㑅ᢥࡢ⿵ຓ᭷⏝࡞ྍ⬟ᛶࡀ࠶ࡿࠋ ࠙⤖ㄽࠚ ⦪㝸ෆ࣭⭡⭍ෆࣜࣥࣃ⠇⭘ᑐࡍࡿCE-EUS ࡢᐃᛶⓗホ౯࠾ࡅࡿⰋᝏᛶ㚷ูࡢṇデ⋡ࡣ㸪73㸣 ẚ㍑ⓗⰋዲ࡞⤖ᯝ࡛࠶ࡗࡓࡀ㸪ᐃᛶⓗホ౯ᐃ㔞ⓗホ౯ࢆ⤌ࡳྜࢃࡏࡿࡇ࡛ྠṇデ⋡ࡣ 85㸣 ୖ᪼ࡋࡓࠋ⦪㝸ෆ࣭⭡⭍ෆࣜࣥࣃ⠇⭘ࡢデ᩿࠾࠸࡚ CE-EUS ࡼࡿᐃᛶⓗ࠾ࡼࡧᐃ㔞ⓗホ౯ࢆ ⏝࠸ࡿࡇࡣ㸪㏻ᖖࡢEUS ࡸ EUS-FNA ࡢ⿵ຓⓗデ᩿ࡋ࡚᭷⏝࡞ྍ⬟ᛶࡀ࠶ࡿࠋ ㄽ ᩥ ᑂ ᰝ ࡢ ⤖ ᯝ ࡢ せ ᪨ ⏦ㄳ⪅ ྜྷ⏣స ࡣ⦪㝸ෆ࣭⭡⭍ෆࣜࣥࣃ⠇⭘ᑐࡋ࡚㉸㡢Ἴෆど㙾ୗ✸่྾ᘬ㔪⏕᳨㸦
EUS-FNA㸧ࢆ⾜ࡗࡓ ᑐࡋ࡚㸪ᚑ᮶ࡢ B-mode EUS ຍ࠼࡚㸪㐀ᙳ㉸㡢Ἴෆど㙾㸦CE-EUS㸧ࡼ ࡿᐃᛶホ౯㸪time intensity curve㸦TIC㸧ࢆ⏝࠸ࡓ⾑ὶࡢᐃ㔞ⓗホ౯ࢆే⏝ࡍࡿࡇࡼࡗ࡚㸪Ⰻᛶ ᝏᛶࡢ㚷ูデ᩿⬟ࡀྥୖࡍࡿࡇࢆ♧ࡋࡓࠋᮏ◊✲⤖ᯝࡼࡾ㸪」ᩘࡢࣜࣥࣃ⠇⭘ࢆ᭷ࡍࡿ࠾ ࠸࡚㸪ࡼࡾ㝧ᛶ⋡ࡢ㧗࠸ࣜࣥࣃ⠇ᑐࡋ࡚㑅ᢥⓗ⏕᳨ࢆ⾜࠺ࡇࡀྍ⬟࡞ࡿࠋ௨ୖࡼࡾᮏ◊✲ࡣ ᾘჾែᏛࡢ㐍Ṍᑡ࡞ࡽࡎᐤࡍࡿࡶࡢ⪃࠼ࡽࢀࡿࠋ
㹙ㄽᩥබ⾲ㄅ㹛
Kensaku Yoshida, Takuji Iwashita, Shinya Uemura, Naoki Mita, Keisuke Iwata, Tsuyoshi Mukai, Ichiro Yasuda, Masahito Shimizu
Efficacy of contrast-enhanced EUS for lymphadenopathy: a prospective multicenter pilot study (with videos).
