조기위암 내시경 진단의 pearls and pitfalls total gastrectomy: Advanced gastric carcinoma...
Transcript of 조기위암 내시경 진단의 pearls and pitfalls total gastrectomy: Advanced gastric carcinoma...
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조기위암 내시경 진단의 pearls and pitfalls
성균관대학교 의과대학 내과 이준행
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위암 내시경 진단의 순서
보만 4형 진행성 위암?
다른 진행성 위암?
조기위암?
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증례 1 - 보만 4형 진행성 위암
성균관대학교 의과대학 내과 이준행
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보만 4형 진행성 위암 (F/55, 2013)
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Stomach, total gastrectomy:
Advanced gastric carcinoma
1. Location : upper third, middle third, lower third, Center at fundus, body, and greater
curvature
2. Gross type : Borrmann type IV
3. Histologic type : tubular adenocarcinoma, poorly (poorly cohesive) differentiated
4. Histologic type by Lauren : diffuse
5. Size : 20x18 cm
6. Depth of invasion : invades serosa (pT4a)
7. Resection margin: free from carcinoma
8. Lymph node metastasis : no metastasis in 31 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : present
12. Peritoneal cytology : negative
13. AJCC stage by 7th edition: T4a N0
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1년 전
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2년 전
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1년 전에 진단할 수 있었을까?
1년 전
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보만 4형 진행성 위암 (M/49, 2015) - Initially peritoneal seeding (+)
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1년 전
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2년 전
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1년 전
1년 전에 진단할 수 있었을까?
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주름은 두꺼워지고 골짜기는 얕아진다
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Shoulder by shoulder
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정상과 비정상의 경계
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Antral type
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Remnant stomach s/p STG due to AGC (5 years ago) Colon involvement
잔위 보만 4형 진행성 위암
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AGC B-IV (F/25) - 마지막 내시경: 3개월 & 6개월 전
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내시경에서 잘펴지지 않는 소견이나 조직검사에서 암 (-). CT 찍고 의뢰됨
• 2016년 3월 17일 외래 방문: "Multiple erosion & submucosal lesions on body, 송기를 하여도 expansion 잘 안됨. Fundus에도 elongated mass양상 Bx: CG with granulation tissue" 소견으로 의뢰됨
• 3월 17일. 당일 내시경 검사 시행. 이준행 교수가 오후 시술을 끝낸 후 내시경 결과를 확인하고 환자에게 연락하여 다음 날 외래로 오시게 함
• 3월 18일 외래에서 조직검사에서 암이 나오지 않더라도 수술이 필요한 상황임을 설명함. 당일 입원
• 3월 19일 외과 전과. Bx: 암 (-) • 3월 20일 total gastrectomy
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증례 2 – 선종
성균관대학교 의과대학 내과 이준행
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상황 1 (기회 1)
• 2013년 10월
• 외부 내시경 조직검사
에서 atypical gland로
재생검 권유됨.
• 외부 사진 없음
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상황 2 (기회 2)
• 2014년 2월
외부 내시경 조직검사
에서 고도 선종
• 2014년 3월
이준행 외래에서 ESD
권유됨
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상황 3 (불필요한 재검)
• 2014년 3월 (같은 달)
• 다른 곳에서 내시경
재검을 받았는데 염증
으로만 나와 경과관찰
권유됨
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상황 4 (기회 3. 아쉬운 선택)
• 2014년 6월
• 같은 곳에서 내시경
재검을 받았는데 저도
선종으로 나옴
• ESD 혹은 추적관찰 논
의 후 추적관찰 선택
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상황 5 (때 늦은 시도)
• 2014년 8월
• 우연히 지인 내과 의
사와 이야기 하던 중
치료를 권유받음
• 이준행 즉시 ESD 시행
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Early gastric carcinoma
1. Location : antrum, lesser curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, poorly (solid type) differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 14 mm (2) vertical diameter, 10 mm
6. Depth of invasion : invades submucosa, (depth of sm invasion : 1900 ㎛) (pT1b)
7. Resection margin : involved deep resection margin by carcinoma with cauterized artifacts,
safety margin : distal 11 mm, proximal 10 mm, anterior 12 mm, posterior 16 mm, deep 0
mm (sm only)
8. Lymphatic invasion : present (+++)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent
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Diagnostic group classifications before and after the treatment
ESD or surgery
LGD HGD AI-EGC EI-EGC BEI-EGC AGC
Pre-treatment diagnostic groups
LGD HGD AI-EGC EI-EGC BEI-EGC AGC
Post-treatment diagnostic groups
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Post-treatment analysis of EI-EGCs (2012)
LGD 1
HGD 12
AI-EGC 67
EI-EGC 31
BEI-EGC AGC
ESD 111
LGD HGD AI-EGC EI-EGC 111
BEI-EGC AGC
Lee JH. Surg Endosc 2016;30:3987-93
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Pre-treatment analysis of AI-EGCs (2012)
LGD HGD AI-EGC
396 EI-EGC BEI-EGC AGC
ESD 355
LGD 1
HGD 4
AI-EGC 229
EI-EGC 67
BEI-EGC 53
AGC 1
Lee JH. Surg Endosc 2016;30:3987-93
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Discrepancy between pre- and post-treatment diagnosis, SMC (2012)
Lee JH. Surg Endosc 2016;30:3987-93
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Villous adenoma with high grade dysplasia, 4.0x3.6cm
Surgery was done before ESD era.
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Tubular adenoma, elevated type, 4x3.5cm, negative RM
A majority of gastric adenoma is treated by ESD or EMR.
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ESD for adenoma with LGD - Final pathology: adenoma with LGD, 1.4x1.2cm
6 years later
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Consider ER for LGD, 2cm or more & don’t have pale discoloration
Kim YJ, Lee YC (Yonsei U). Endoscopy 2010;42:620–626
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Small, flat, and pale adenoma with low grade dysplasia is treated by ablation.
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증례 3 – Atypia / atypical glands
성균관대학교 의과대학 내과 이준행
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“5년 전 위내시경 검사부터 조직검사에서 gastritis 와 atypia가 번갈아 나오던 병변으로 이번 검사시 EGC IIc 의심되어 의뢰”
11 months before ESD
Papillary adenoca (M/D) 7 x 6 mm Resection margin (-) SM invasion : 1900 ㎛ Venous invasion : present
5 weeks before ESD
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Atypia at biopsy (2004-2010, SMCHPC)
a few atypical gland (reactive regenerating gland)
atypical regenerative epithelium
atypical foveolar glands (regenerating)
atypical gland (regenerating atypia)
atypical gland (reactive regenerating atypia )
atypical glands (reactive change of regenerating gland)
atypical regenerating glands
atypical regenerative foveolar epithelium
focal atypical cells (reactive regenerating atypia)
atypical glands (regenerating atypia)
focal atypical glands (reactive change)
focal atypical glands (regenerating atypia)
focal regenerating atypia
regenerating atypia
regenerating epithelial atypia
focal atypical glands (regenerating atypia )
focal atypical glands (regenerating gland)
focal atypical regenerative glands
regenerative atypia
regenerating foveolar epithelium with mild atypia
regenerative foveolar epithelium with moderate atypia
Atypical cell / glands
Regenerating Atypia (n=71, 57%)
Atypia (n=54, 43%)
Atypia
Regenerating Atypia
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Final pathological diagnosis
Mean follow-up (day) 351.02 ± 532.53 (range 11~2600)
Mean follow-up (day) 1153.15 ± 805.04 (range 49~3191)
Cancer 67%
Adenoma 12%
Adenoma 7% Cancer
15%
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Atypia at biopsy (2004-2010, SMCHPC)
• 비정형 세포군(atypia)의 추적 내시경에서 위암이 67%, 선종
이 12%가 진단되었다. 재생 변화를 동반한 비정형 세포군
(regenerating atypia)의 추적 내시경에서 위암이 15%, 선종이
7% 진단되었다.
• Atypia의 병리소견에서 regenerative change가 보이는 경우
암발생률이 낮은 경향을 보였다.
• 표면의 발적이나 자연출혈 등 내시경소견이 동반되는 경우 최
종적으로 위암으로 진단될 확률이 높았다.
• 암의 85%가 1년 이내에 진단되었으나 15%는 그보다 늦게 진
단되었다.
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비전형적 샘 재검: 미분화조직형 위암
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Atypical cells로 오심. 많이 좋아짐 - 외부슬라이드 재판독: 암. 조직검사 재검: 암
비록 많이 좋아져 보이지만 이번 조직 검사에서도 암으로 나왔습니다.
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Early gastric carcinoma
1. Location : lower third, center at body and lesser curvature
2. Gross type : EGC type IIc and IIa
3. Histologic type : tubular adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 3.9x2.5 cm
6. Depth of invasion : invades mucosa (muscularis mucosae) (pT1a)
7. Resection margin: free from carcinoma
safety margin: proximal 3.5 cm, distal 6.3 cm
8. LN: no metastasis in 65 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 7th edition: pT1a N0
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Regenerating atypia. 어떻게 하시겠습니까?
첫 조직검사: H. pylori-chronic gastritis, active, with intestinal metaplasia (complete type), erosion and regenerating atypia
제균치료 후 조직검사 (2달 후): Tubular adenocarcinoma, well differentiated (foveolar-type)
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ESD for EGC (W/D, 17mm, LP암)
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Atypical glands with regenerative change - 육안 소견 의거 ESD 시행. 8밀리 고도선종으로 결론
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4년 간 follow up loss 되었다가 위암 진단
H. pylori - associated chronic active gastritis, moderate with intestinal metaplasia, ulcer and atypical glands, suggestive of regenerative atypia. (The possibility of dysplasia cannot be excluded with certainty. Follow up is recommended.)
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어떻게 설명할 것인가? (1/2)
• 비전형적 세포(atypia)는 세포의 모양이 비전형적, 즉 정상이
아니라는 뜻입니다. 여기에는 많은 원인이 있습니다. 좋은 것
부터 나쁜 것까지 상당히 다양합니다.
• 먼저 좋은 쪽을 보자면 단순한 위염 또는 위궤양 때문에 세포
의 모양이 비전형적(atypical)으로 변할 수 있습니다. 반대로
전암성 병소 또는 위암의 첫 조직검사에서 비전형적이라고 보
고되는 경우도 있습니다.
http://endotoday.com/manual/sulmyung.html#atypia
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어떻게 설명할 것인가? (2/2)
• 위염이나 궤양과 같은 비종양성이 1/3, 선종이나 위암과 같은
종양성이 2/3입니다. 외부 슬라이드 재판독과 내시경 재검을
권합니다. 첫 평가에서 큰 이상이 아닌 것으로 나와도 재검이
필요합니다.
• 계획 1. 외부슬라이드 재판독
• 계획 2. 내시경 조직검사 재검
• 계획 3. 내시경 치료 (ESD) 예약
http://endotoday.com/manual/sulmyung.html#atypia
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증례 4 – Blind area
성균관대학교 의과대학 내과 이준행
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들어가면서 위각 직상방 위체하부 후벽
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다시 살펴보았으나 일견 뚜렷하지 않음
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접근하며 공기를 많이 넣어보니…
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위암 의심하였으나 조직검사는 저도 선종
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ESD 하였고 역시 암으로 나옴
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1년 전 외부 사진을 살펴보았습니다.
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Blind area
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위체하부 후벽 위암 - AGC, mucinous adenocarcinoma 4.3x4.2 cm, invades serosaLN +(7/41)
6 months ago
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의외지만, 위각도 맹점일 수 있습니다.
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GC side of the fundus – a blind spot
1 2
Blind area
(1)
(2)
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AGC with spinal metastasis - 마지막 내시경: 4개월 전
4 개월 전 내시경
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전정부 ESD 후 추적관찰 하던 환자
1 year ago
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Fold 뒤에 숨어있는 용종
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Yao K. Ann Gastroenterol 2013
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Emura, et al. 2013. 사진 제공 이혁
E2, E3, A6, A7, U19…….?!
훈련을 통해서 마음속으로 코드화 하기
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내시경 관찰의 일반적인 순서 - ‘빠른 내시경보다는 바른 내시경’
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Yao K. Ann Gastroenterol 2013
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ESGE에서는 4장 요구 (2002)
1 2 3 4 20cm from IT GE junction Fundus & Cardia Mid-body
ESGE guideline, 2002
5 7 8 6 Angle Antrum Duodenal bulb 2nd part
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SMC 사진 촬영법
• 기본 개념: ESGE (2002) 지침의 2배
정도
• 식도 4장: 상부, 중부, 하부, EG
junction
• 십이지장 2장: 제1부, 제2부
• 위 8장: 근위부 4장, 원위부 4장
• 후두는 optional
• 병소가 발견되면 최소한 (1) 원경,
(2) 중간, (3) 근경, (4) 조직검사 직
후 사진을 남겨놓는다.
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The more the better가 아닙니다. 유의미한 사진을 찍읍시다.
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중요 소견은 여러장의 사진을 남기자
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조기위암 내시경 진단을 위한 tip
성균관대학교 의과대학 내과 이준행
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조기위암의 내시경 소견
• 조기 위암 초기 위암
• 조기 위암 작은 위암
• 조기위암 = superficial lesion
• 내시경 소견에 따라 치료방침이 달라진다.
• 조기위암의 내시경 분류는 40여년 전에 만들어진 것이다. (in vivo,
real-time, 내시경적 분류)
• 가능하면 단순한 형태로 분류한다.
• 자세한 글보다 좋은 사진이 정보가치가 높다.
• 크기에 대한 정확한 평가가 필수적이다.
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색조 변화에 유의합시다. - 위 fundus의 매우 작은 병소 (P/D)
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좀 더 넓지 않은지 주변을 살핍시다.
위각의 작은 함몰부 2개로 의뢰됨. 좌측 미란: adenoma with HGD 우측 미란: W/D adenocarcinoma
ESD 과정에서 위각부뿐만 아니라 위체하부 소만쪽으로 넓은 융기부가 연결되어 있음을 발견 Tubular adenocarcinoma, well differentiated, arising from adenoma 44 밀리 선종에 24 밀리 암(lamina propria)이 있는 것으로 나왔음.
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공기에 따라 이렇게 달라 보일 수 있습니다. - EGC, M/D, 5.3x5.1cm, LN (-)
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주름 변화에 유의합시다.
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Fold 연습 (1)
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Fold 연습 (2)
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첫 내시경 후 PPI (rabeprazole 20 mg daily) 복용 6일 후 재검시 모양이 변해 있음
6 days
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집으로 가져가는 메세지
• 보만 4형 진행성 위암이 가장 중요합니다.
• 선종은 암일 수 있습니다.
• Atypia 혹은 atypical gland는 내시경 소견에 따
라 접근해야 합니다.
• Blind area를 주의합시다.