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[Noncurative ESD. ºÒ¿ÏÀüÀýÁ¦. SPS e-Cura system] - ðû

2022³â KGCA °¡À̵å¶óÀο¡¼­ ESD ½Ã¼ú ÈÄ ¼ö¼ú ¿©ºÎ °áÁ¤¿¡ ´ëÇÑ flowchart

2018³â JGCA °¡À̵å¶óÀο¡¼­ ¸²ÇÁÀý ÀüÀÌ À§Çèµµ Æò°¡

1. Surgery Prediction System (SPS)°ú e-Cura system

2. Management of non-curative endoscopic resection of EGC at SMC

3. ¼ö¼úÇÏÁö ¾Ê°í °æ°ú°üÂû ÇÏ´ø Áß cancer progressionÀ» º¸ÀÎ °æ¿ì - 5 cases, SMC experience

4. ESD ÈÄ ¼ö¼úÇÑ È¯ÀÚ¿¡¼­ ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ¾ú´ø °æ¿ì

5. ESD ÈÄ ¼ö¼úÇÑ È¯ÀÚ¿¡¼­ local residual tumor°¡ ÀÖ¾ú´ø °æ¿ì

6. Non-curative resection ȯÀÚÀÇ outcome - ±¹³» ³í¹®

7. Noncurative resection ȯÀÚÀÇ outcome - ÀϺ» ³í¹®

8. Noncurative resection ȯÀÚÀÇ eCure scoring systemÀÇ °³¹ß °úÁ¤ÀÇ ¿©·¯ ÀÚ·áµé

9. Áõ·Ê - ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ°¡ ¼ö¼úÀ» ¾È ÇÏ¿´À» ¶§

10. FAQs

11. References


1. Surgery Prediction System (SPS)°ú e-Cura system

Á¶±âÀ§¾Ï ESD ÈÄ ¾à 15%¿¡¼­ ¼ö¼úÀÌ ÇÊ¿äÇÑ °á°ú°¡ ³ª¿É´Ï´Ù. ESD Àü ¼ö¼úÀÌ ÇÊ¿äÇÒ È®·üÀ» ¿¹ÃøÇÒ ¼ö ÀÖÀ¸¸é Ä¡·á °èȹÀ» ÀâÀ» ¶§ µµ¿òÀÌ µÉ °ÍÀÔ´Ï´Ù. »ï¼º¼­¿ïº´¿øÀÇ ÀڷḦ ºÐ¼®ÇÏ¿© Surgery Prediction System (SPS)À» ¸¸µé¾ú½À´Ï´Ù. (Q and A)

À§¿Í °°Àº ºñÀ²·Î ¼ö¼úÀÌ ÇÊ¿äÇÑ º´¸® °á°ú°¡ ³ª¿À¸é ¼ö¼úÀ» ±ÇÇÕ´Ï´Ù. ÀÌ ¶§ Âü°íÇÒ ¼ö ÀÖ´Â ³»¿ëÀÌ ÀϺ»¿¡¼­ Á¦¾ÈµÈ e-Cura systemÀÔ´Ï´Ù. e-Cura C-2¿¡ ÇØ´çÇÏ¸é ¼ö¼úÀ» ±ÇÇÕ´Ï´Ù. e-Cura C-2¸¦ ¸²ÇÁÀý ÀüÀÌ À§Çèµµ¿¡ µû¶ó high risk, intermediated risk, low risk·Î ³ª´©´Âµ¥ ¼ö¼úÀ» ÁÖÀúÇÏ´Â °í·É ȯÀÚ¿¡¼­ Âü°íÇÒ ¼ö ÀÖ´Â ÀÚ·á¶ó°í »ý°¢ÇÕ´Ï´Ù.

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Á¤È®ÇÑ ºñ±³ µ¥ÀÌÅÍ´Â ¾Æ´Õ´Ï´Ù¸¸... ESD ºÒ¿ÏÀüÀýÁ¦°¡ ³ª¿Â »óȲ¿¡¼­ ¿ì¸® ȯÀÚµéÀÌ ¼ö¼ú¹Þ´Â ºñÀ²Àº ÀϺ» ȯÀÚµéÀÌ ¼ö¼ú¹Þ´Â ºñÀ²º¸´Ù ³ô´Ù´Â ´À³¦ÀÔ´Ï´Ù. ÀϺ»Àº °í·É ȯÀÚ°¡ ¸¹±â ¶§¹®¿¡ ¼ö¼ú·üÀÌ ´õ ³·À» °Í °°±â´Â ÇÕ´Ï´Ù. ¿ì¸®³ª¶ó´Â Áú°ü¸® Â÷¿ø¿¡¼­ ²À ¼ö¼úÀ» Çϵµ·Ï ±ÇÇϴ ȤÀº °­Á¦ÇÏ´Â ±âÁØÀÌ À־ ¼ö¼ú·üÀÌ ³ô¾ÆÁö´Â °æÇâÀÌ ÀÖ½À´Ï´Ù.

2022³â Æò°¡ Ç׸ñ


2. Management of non-curative endoscopic resection of EGC at SMC - 2015³â 4¿ù 4ÀÏ À§¾ÏÇÐȸ (KINGCA) ¹ßÇ¥ Àü¹®

This is the immediate endoscopic outcome. The rate of non-curative resection is 16.7%.

There are two subgroups in non-curative resection. One is lateral margin positive only group, and the other is cases with risk of lymph node metastasis. Lateral margin positive cases were excluded in this study, because most of them are treated by additional endoscopy. In cases with risk of lymph node metastasis, 70% were operated, and 30% were observed without surgery. The main reason of observation is patient¡¯s refusal to surgery.

When we compared the two groups, patients in the observation group were older and have more cardiovascular diseases, and have higher Charlson comorbidity score¡¦

And have bigger tumor. The rate of lymphovascular invasion was higher in the surgery group.

In the surgery group, 11 have lymph node metastasis, which means 5.7%. Patients with lymph node metastasis were older. To our surprise, the rate of lymph node metastasis was not different by the tumor size, depth of invasion, histological differentiation, and lymphovascular invasion in the endoscopically resected specimen. So, basically we found no predictor of lymph node metastasis in this analysis.

Rate of progression into the advanced cancers were different between 2 groups. Five advanced cancers were found in the observation group, and only one metastatic disease was found in the surgery group. This difference - 6.3% versus 0.5% - was statistically significant.

This is the summary of six cases with documented progression of gastric cancer. As you can see, all cases have submucosal invasion of more than 200 micrometer and all have evidence of endolymphatic invasion.

The next two slides are the main findings of this study. We compared the overall survival by some factors. As you can see in the figures, age less than 65, low Charlson score, and additional surgery were related with longer survival.

In the Cox proportional hazard model, additional surgery was the only significant independent factor related to the longer survival. So surgery was beneficial for patients with non-curative resection after ESD.

This is the initial endoscopy of the six cases. Some are elevated, some are depressed, and some are flat. There is no uniform characteristics.

Ladies and gentlemen. I¡¯d like to conclude my presentation by saying that progression to advanced stage in non-curative resection without surgery is at least 6.3% within 40 months. In this setting, additional surgery confers a survival benefit and should be positively considered.


3. ¼ö¼úÇÏÁö ¾Ê°í °æ°ú°üÂû ÇÏ´ø Áß cancer progressionÀ» º¸ÀÎ °æ¿ì (5 cases, SMC experience)

From now on, I¡¯d like to show you some of the interesting cases. The patient refused surgery, and multiple hepatic metastasis developed 28 months later.

The next case is very similar.

Advanced gastric cancer was found 38 months later. Subtotal gastrectomy with lymph node dissection was done. Depth of invasion was subserosal layer and one lymph node was involved. However, peritoneal seeding was found during the follow up.

¼ö¼úÇÏÁö ¾Ê°í °æ°ú°üÂû Áß progressionÀ» º¸ÀÎ 5¸íÀÇ »çÁøÀÔ´Ï´Ù. ¿ìÃø ÇÏ´Ü ¹Ú½º´Â ¼ö¼úÇÏ¿´À½¿¡µµ ºÒ±¸ÇÏ°í multiple metastasis·Î recurÇÑ È¯ÀÚÀÔ´Ï´Ù. ÀÌµé ¸ðµÎ ESD candidate ¼±Á¤ °úÁ¤¿¡¼­ ´Ù¼Ò ¿å½ÉÀ» ºÎ·È´ø °æ¿ì¶ó°í »ý°¢µË´Ï´Ù.


4. ESD ÈÄ ¼ö¼úÇÑ È¯ÀÚ¿¡¼­ ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ¾ú´ø °æ¿ì (SMC experience, ±èÀº¶õ ¿¬±¸)

Á¶±âÀ§¾Ï ³»½Ã°æ Ä¡·á ÈÄ ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ¿¡¼­ ¼ö¼ú ÈÄ ¸²ÇÁÀý ÀüÀÌ°¡ È®ÀεǴ °æ¿ì´Â 10% ³»¿ÜÀÔ´Ï´Ù (Kim ER. Br J Surg 2015). ÀúÈñ ±â°ü¿¡¼­´Â ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ 274¸í Áß 194¸í(70.8%)¿¡¼­ ¼ö¼úÀ» ½ÃÇàÇÏ¿© local residual cancer°¡ ÀÖ¾ú´ø ȯÀÚ°¡ 10¸í (5.2%), ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ¾ú´ø ȯÀÚ°¡ 11¸í(5.7%)À̾ú½À´Ï´Ù. ¾Æ·¡´Â ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ´ø 11¿¹ÀÇ »çÁøÀÔ´Ï´Ù.


[Ãß°¡ Áõ·Ê]

Á¶±âÀ§¾Ï ³»½Ã°æ Ä¡·á ÈÄ ¾à 10-15% ȯÀÚ´Â ¼ö¼úÀÌ ÇÊ¿äÇÏ´Ù´Â °á°ú°¡ ³ª¿É´Ï´Ù. ¼ö¼úÀ» ÇØ¾ß ÇÕ´Ï´Ù. ÀϺο¡¼­ ÀÌ¹Ì ¸²ÇÁÀý ÀüÀÌ·Î ³ª¿À±â ¶§¹®ÀÔ´Ï´Ù.

ÇÑ º´¿ø¿¡¼­ ESD Ä¡·á¸¦ ¹Þ±â·Î ÇÑ È¯ÀÚ¿´´Âµ¥, ±× º´¿ø °£È£»ç°¡ Æľ÷À» ÇÏ´Â ¹Ù¶÷¿¡ Ä¡·á¸¦ ¹ÞÁö ¸øÇÏ°í Àú¸¦ ãÀº ȯÀÚ¿´½À´Ï´Ù. ½Ã¼ú Àü Á¶Á÷°Ë»ç´Â moderately differentiated adenocarcinoma¿´½À´Ï´Ù. ESD¸¦ Çß½À´Ï´Ù.


ESD: Early gastric carcinoma
1. Location : low body, greater curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, poorly differentiated
4. Histologic type by Lauren : diffuse
5. Size of carcinoma : (1) longest diameter, 10 mm (2) vertical diameter, 8 mm
6. Depth of invasion : invades submucosa, (depth of sm invasion : 800§­) (pT1b)
7. Resection margin : free from carcinoma(N), safety margin : distal 12 mm, proximal 12 mm, anterior 12 mm, posterior 16 mm, deep 50 §­
8. Lymphatic invasion : present
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

¾Æ·¡¿Í °°ÀÌ ¼³¸íÇÏ°í ¼ö¼úÀ» ±ÇÇÏ¿´½À´Ï´Ù.

4¹ø ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ¾ú½À´Ï´Ù. ¼ö¼úÀÌ ÇÊ¿äÇÏ´Ù°í ³ª¿À¸é ¼ö¼úÀ» ÇÑ´Ù. ³¡.

Stomach, subtotal gastrectomy: Status post endoscopic submucosal dissection
Post ESD scar. No residual tumor
1) Location: cannot be determined (no residual tumor)
2) Gross type: cannot be determined (no residual tumor)
3) Histologic type: cannot be determined (no residual tumor)
4) Histologic type by Lauren: cannot be determined (no residual tumor)
5) Size: cannot be determined (no residual tumor)
6) Depth of invasion: cannot be determined (no residual tumor)
7) Resection margin: free from carcinoma
8) Lymph node metastasis : metastasis to 1 out of 32 regional lymph nodes (pN1) (1/32: "3", 0/4; "4", 1/7; "5", 0/0; "6", 0/3; "7", 0/4; "9", 0/7; "8a", 0/3; "11p", 0/2; "12a", 0/2; "4sb", 0/0; "1", 0/0)
9) Lymphatic invasion: not identified
10) Venous invasion: not identified
11) Perineural invasion: not identified
12) AJCC stage by 8th edition (ESD+subtotally gastrectomy): pT1b N1

¸ðµÎ ´Ù ¿Ü¿ï ¼ö ¾øÁö¸¸, 1ºÎÅÍ 7¹ø±îÁöÀÇ ¸²ÇÁÀý À§Ä¡¿Í À̸§À» ¾Ë°í ÀÖÀ¸¸é ¿©·¯¸ð·Î µµ¿òÀÌ µË´Ï´Ù. »ý°¢º¸´Ù ¾î·ÆÁö ¾Ê½À´Ï´Ù. Á¿ì ¦(pair)À¸·Î µÇ¾î ÀÖÀ¸´Ï±î.


5. ESD ÈÄ ¼ö¼úÇÑ È¯ÀÚ¿¡¼­ local residual tumor°¡ ÀÖ¾ú´ø °æ¿ì (SMC experience, ±èÀº¶õ ¿¬±¸)

¾Õ¼­ ¾ð±Þµå¸° ¹Ù¿Í °°ÀÌ Á¶±âÀ§¾Ï ³»½Ã°æ Ä¡·á ÈÄ ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ¿¡¼­ ¼ö¼ú ÈÄ ¸²ÇÁÀý ÀüÀÌ°¡ È®ÀεǴ °æ¿ì´Â 10% ³»¿ÜÀÔ´Ï´Ù. °ð ³í¹®À¸·Î ¹ßÇ¥µÉ ¿¹Á¤ÀÔ´Ï´Ù¸¸, ÀúÈñ ±â°ü¿¡¼­´Â ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ 274¸í Áß 194¸í(70.8%)¿¡¼­ ¼ö¼úÀ» ½ÃÇàÇÏ¿© local residual cancer°¡ ÀÖ¾ú´ø ȯÀÚ°¡ 10¸í (5.2%), ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ¾ú´ø ȯÀÚ°¡ 11¸í(5.7%)À̾ú½À´Ï´Ù. ¾Æ·¡´Â local residual cancer°¡ ÀÖ´ø 10¿¹ÀÇ »çÁøÀÔ´Ï´Ù.


6. Non-curative resection ȯÀÚÀÇ outcome (±¹³» ³í¹®)

1) 2012³â ¾Æ»êº´¿ø (Ahn JY. Endoscopy 2012)

Noncurative resection Áß undifferentiated-type 48¸íÀ» Á¦¿ÜÇÑ differentiated-type 285¸í Áß 126¸í(44.2%)¿¡¼­ Ãß°¡Ä¡·á°¡ ½ÃÇàµÇ¾ú°í 159¸í(55.8%)Àº °æ°ú°üÂûÀ» ÇÏ¿´½À´Ï´Ù.

°æ°ú´Â ´Ù¾çÇÏ¿´½À´Ï´Ù. À§¾ÏÀ¸·Î »ç¸ÁÇÑ »ç¶÷Àº ¼¼¸íÀ̾ú½À´Ï´Ù. ÀÌ ¼¼¸í¿¡ ´ëÇÑ »çÁøÀÌ ÀÖ¾ú´õ¶ó¸é Âü ÁÁ¾ÒÀ»ÅÙµ¥ ¹«Ã´ ¾Æ½¬¿ü½À´Ï´Ù.

¿¹»óµÈ ÀÏÀÔ´Ï´Ù¸¸ lymphovascular invasionÀÌ ÀÖÀ¸¸é ¿¹ÈÄ´Â ³ª»¦½À´Ï´Ù.


2) 2014³â ¿øÀڷº´¿ø (Noh GY. Surg Endosc 2015)

Àüü ESD Áß ¾ÏÀÌ 61.5%ÀΠȯÀÚ±ºÀÔ´Ï´Ù. 655¿¹ Áß 83¿¹(12.7%)¿¡¼­ lymphovascular invasion ȤÀº posotive vertical marginÀ̾ú½À´Ï´Ù. Deep SM invasionÀ̳ª undifferentiated typeÀÌ ¾î´À Á¤µµ¿´´ÂÁö ÀÚ·á°¡ ¾ø¾î¼­ curative resection rate´Â ¾Ë ¼ö ¾ø½À´Ï´Ù. LV invasionÀ̳ª positive vertical marginÀ¸·Î ÀÎÇÏ¿© ¸í¹éÈ÷ ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ 83¸í Áß 45¸í(54.2%)ÀÌ ¼ö¼úÀ» ¹Þ¾Ò½À´Ï´Ù. ¼ö¼úÇÑ È¯ÀÚ Áß 7¸í(15.6%)¿¡¼­ ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ¾ú½À´Ï´Ù.

Three (6.7 %) of the 45 patients in the surgical group exhibited recurrence. Table 3 shows the characteristics of the 3 patients. All 3 patients exhibited deep submucosal (SM) invasion of more than 0.5 mm and a positive vertical margin after ESD, with one of the patients exhibiting accompanying lymphovascular invasion. All had undergone subtotal gastrectomy, and recurrences were detected at 12.0, 12.8, and 25.0 months during the close surveillance period after surgery.

À§¾Ï ESD ÈÄ ¼ö¼úÀ» ÇÑ È¯ÀÚ°¡ °£È¤ Àç¹ßÀ» º¸ÀÏ ¼ö ÀÖ½À´Ï´Ù. ¿øÀڷº´¿ø¿¡¼­´Â 3¸í(¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ´ø »ç¶÷ Áß 1¸í, ¸²ÇÁÀý ÀüÀÌ°¡ ¾ø´ø »ç¶÷ Áß 2¸í)¿¡¼­ Àç¹ßÀÌ ÀÖ¾ú½À´Ï´Ù. ESD ÈÄ ¼ö¼úÇÑ È¯ÀÚÀÇ Àç¹ß·üÀÌ 6.7%¿´½À´Ï´Ù.


3) 2015³â »ï¼º¼­¿ïº´¿ø (Kim ER. Br J Surg 2015)

There are two subgroups in non-curative resection. One is lateral margin positive only group, and the other is cases with risk of lymph node metastasis. Lateral margin positive cases were excluded in this study, because most of them are treated by additional endoscopy. In cases with risk of lymph node metastasis, 70% were operated, and 30% were observed without surgery. The main reason of observation is patient¡¯s refusal to surgery.

When we compared the two groups, patients in the observation group were older and have more cardiovascular diseases, and have higher Charlson comorbidity score¡¦

And have bigger tumor. The rate of lymphovascular invasion was higher in the surgery group.

In the surgery group, 11 have lymph node metastasis, which means 5.7%. Patients with lymph node metastasis were older. To our surprise, the rate of lymph node metastasis was not different by the tumor size, depth of invasion, histological differentiation, and lymphovascular invasion in the endoscopically resected specimen. So, basically we found no predictor of lymph node metastasis in this analysis.

Rate of progression into the advanced cancers were different between 2 groups. Five advanced cancers were found in the observation group, and only one metastatic disease was found in the surgery group. This difference - 6.3% versus 0.5% - was statistically significant.

This is the summary of six cases with documented progression of gastric cancer. As you can see, all cases have submucosal invasion of more than 200 micrometer and all have evidence of endolymphatic invasion.

ESD ÈÄ ¼ö¼ú±îÁö Çߴµ¥µµ Àç¹ßÇÑ È¯ÀÚ°¡ ÇÑ ºÐ °è¼Ì½À´Ï´Ù. óÀ½ºÎÅÍ '´Ù¼Ò ¹«¸®´Ù' ½ÍÀº ȯÀÚ¿¡¼­ ¼ö¼ú ÈÄ Àç¹ßÀ» ÇÏ´Â °Í °°½À´Ï´Ù. ESD ÀûÀÀÁõÀ» Àß ÁöÅ°´Â °ÍÀÌ ÃÖ¼±ÀÇ ¹æÃ¥ ¾Æ´Ñ°¡ »ý°¢ÇÕ´Ï´Ù.


4) 2016³â ¼øõÇâ´ëÇб³ ºÎõº´¿ø (Han JP. Surg Endosc 2016).

Non-curative resection Áõ·Ê¸¦ 4±ºÀ¸·Î ³ª´©¾ú´Âµ¥ 3±º°ú 4±ºÀÇ local recur À§ÇèÀÌ ³ô¾Ò½À´Ï´Ù.

Of 152 non-curative resections, 46 (30.3 %) were stratified as Group 1 (incomplete resection and met the ESD criteria), 31 (20.4 %) as Group 2 (complete resection and exceeded the ESD criteria), 41 (27.0 %) as Group 3 (incomplete resection and exceeded the ESD criteria), and 34 (22.4 %) as Group 4 (lymphovascular invasion regardless of complete resection).
Group 3 [odds ratio (OR) 3.991; p = 0.015] and Group 4 (OR 4.487; p = 0.014) had higher rates of local recurrence after non-curative resection. In those high-risk groups, endoscopic surveillance without additional treatment detected significantly more local recurrence than in those receiving additional treatment (p = 0.029).

Non-curative 152¸í Áß 35¸í(23.0%)´Â follow-up loss µÇ¾ú°í, 14¸í(9.2%)Àº Ãß°¡ ³»½Ã°æÄ¡·á¸¦ ¹Þ¾ÒÀ¸¸ç, 40¸í(26.3%)Àº rescue surgery¸¦ ¹Þ¾Ò½À´Ï´Ù. ÈçÈ÷ rescue surgeryÀÇ definite indicationÀ¸·Î »ý°¢µÇ´Â Group 2, 3, 4 ȯÀÚ Áß ÀÚ·á¼öÁýÀÌ °¡´ÉÇÑ 76¸í Áß ¼ö¼úÀº 38¸í(50.0%), Ãß°¡³»½Ã°æ Ä¡·á´Â 4¸í(5.3%), surveillance´Â 34¸í(44.7%)À̾ú½À´Ï´Ù.

ÃßÀû°üÂû ¼ºÀûÀº ¾Æ·¡ Ç¥¿Í °°¾Ò½À´Ï´Ù. Cancer-related death°¡ ÃßÀû°üÂû 34¸í Áß 3¸í(8.9%)À̾ú½À´Ï´Ù. ÀÌ Á¤µµÀÇ cancer-related death´Â ¼ö¼úÀÌ ²À ÇÊ¿äÇÑ È¯ÀÚ¿¡¼­ ¼ö¼úÀ» ÇÏÁö ¾ÊÀ¸¸é 5 year survival rate°¡ 10% Á¤µµ ³·¾ÆÁø´Ù´Â »ï¼º¼­¿ïº´¿øÀÇ °á°ú¿Í ºñ½ÁÇÑ ¼öÁØÀÔ´Ï´Ù.

★ ESD´Â ÀûÀÀÁõÀÌ ¾Æ´Ï¸é ¾Æ¹«¸® ȯÀÚ°¡ ¿øÇصµ ÇÏ¸é ¾ÈµÇ´Â ±×·± ½Ã¼úÀÔ´Ï´Ù.


5) 2018³â ±¹³» ´Ù±â°ü (Kim SG. Gut Liver 2018)

2010³â°ú 2011³â »çÀÌ ±¹³» ´Ù±â°ü¿¡¼­ µî·ÏµÈ cohortÀÇ 5³â ÃßÀû °á°úÀÔ´Ï´Ù. ´ëºÎºÐ ¿¹»óÇÏ¿´´ø °á°ú¿´´Âµ¥ Á¦°¡ °ü½ÉÀÖ°Ô º» °ÍÀº ¾Æ·¡ µÎ point¿´½À´Ï´Ù.

Non-curative resection¿¡¼­´Â ¼ö¼úÀÌ ¿øÄ¢ÀÔ´Ï´Ù. ±×·¯³ª ½ÇÁ¦·Î ¼ö¼ú¹Þ´Â ȯÀÚ´Â Àý¹Ý¿¡ ºÒ°úÇÕ´Ï´Ù.

ºñ´Ü non-curative resection ȯÀÚ±º¸¸ ¾Æ´Ï¶ó curative resection ȯÀÚ±º¿¡¼­µµ distant metastasis°¡ ¹ß»ýÇÕ´Ï´Ù.


7. Noncurative resection ȯÀÚÀÇ outcome (ÀϺ» ³í¹®)

1) 2010³â µ¿°æ¾Ï¼¾ÅÍ

Elderly¸¦ ´ë»óÀ¸·Î ÇÑ ¿¬±¸¿´±â ¶§¹®ÀÎÁö ¼ö¼ú±º°ú ºñ¼ö¼ú±ºÀÇ Â÷ÀÌ°¡ ÇöÀúÇÏ¿´½À´Ï´Ù.


2) 2016³â ÀϺ» Toranomon º´¿ø (Hoteya S. Digestion 2016)

Noncurative resection 165¿¹¸¦ ºÐ¼®ÇÏ¿´½À´Ï´Ù. Lymphovascular invasion ¾ç»óÀ» ESD indication group¿¡ µû¶ó ³ª´« Á¡ÀÌ Èï¹Ì·Î¿ü½À´Ï´Ù.

Surgery group (Group S)°ú follow up group (Group F)ÀÇ ºñ±³ÀÔ´Ï´Ù.


3) 2016³â Iwate Medical School (Toya. GIE 2016)

Lymphatic positive¶óµµ deep resection marginÀÌ À½¼ºÀÌ°í SM2¸é ÃßÀû°üÂû ÇÒ ¼ö ÀÖ´Ù´Â ³»¿ëÀε¥... ´Ù¼Ò ¿ì·Á½º·´½À´Ï´Ù. Sample size°¡ ³Ê¹« À۱⵵ ÇÏ°í.

Surgery (group A) versus observation (group B)


4) 2016³â ÀϺ» ´Ù±â°ü ¿¬±¸ - 19°³ ±â°ü. ÈÄÇâÀû (Hatta W. J Gastroenterol 2016b)

RESULTS: Overall survival (OS) and disease-specific survival (DSS) were significantly higher in the radical surgery group than in the follow-up group (p < 0.001 and p = 0.012, respectively). However, the difference in 3-year DSS between the groups (99.4 vs. 98.7 %) was rather small compared with the difference in 3-year OS (96.7 vs. 84.0 %). LNM was found in 89 patients (8.4 %) in the radical surgery group. Lymphatic invasion was found to be an independent risk factor for recurrence in the follow-up group (hazard ratio 5.23; 95 % confidence interval 2.01-13.6; p = 0.001).

CONCLUSIONS: This multi-center study, representing the largest cohort to date, revealed a large discrepancy between OS and DSS in the two groups. Since follow-up with no additional treatment after ESD may be an acceptable option for patients at low risk, further risk stratification is needed for appropriate individualized treatment strategies.

Hatta W. J Gastroenterol 2016 ³í¹®ÀÇ ¸¶Áö¸·Àº ´ÙÀ½°ú °°¾Ò½À´Ï´Ù. "Although radical surgical resection is currently indicated for these patients, we suggest that follow-up with no additional treatment after ESD may be an acceptable option for patients at low risk. Consequently, further risk stratification is needed for appropriate individualized treatment strategies."


8. Noncurative resection ȯÀÚÀÇ eCure scoring systemÀÇ °³¹ß °úÁ¤ÀÇ ¿©·¯ ÀÚ·áµé

Gotoda ¼±»ý´Ô²²¼­ KINGCA 2016 °­ÀÇ¿¡¼­ ¼Ò°³ÇÑ eCura systemÀÔ´Ï´Ù (Am J Gastroenterol 2017). ´Ù¸¥ À§ÇèÀÎÀÚº¸´Ù lymphatic invasion¿¡ 3¹èÀÇ °¡ÁßÄ¡°¡ ÁÖ¾îÁ³½À´Ï´Ù.

Cancer-specific survival and cancer recurrence according to the risk category in the validation cohort. (Am J Gastroenterol 2017)

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9. Á¶±âÀ§¾Ï ¸²ÇÁÀý ÀüÀ̸¦ ¿¹ÃøÇϱâ À§ÇÑ nomogram - CD44v6 Æ÷ÇÔ (±¹¸³¾Ï¼¾ÅÍ)

±¹¸³¾Ï¼¾ÅÍ ¾ö¹æ¿ï, ±¹¸íö ¼±»ý´Ô ÆÀ¿¡¼­ ¸²ÇÁÀý ÀüÀÌ nomogramÀ» ¹ßÇ¥ÇÏ¿´½À´Ï´Ù (Eom BW. PLoS One 2016). ESD ÈÄ ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ¿¡¼­ º¸´Ù Á¤È®ÇÑ ¼ýÀÚ¸¦ Á¦½ÃÇϸç Ä¡·á °èȹÀ» ³íÇÒ ¼ö ÀÖ´Ù´Â Á¡¿¡¼­ À¯¿ëÇÏ´Ù°í »ý°¢µË´Ï´Ù.

In previous studies, the seven biomarkers were proved to be associated to lymph node metastasis in gastric cancer. However, in this study, E-cadherin, ¥á1 catenin, p53, EZH2 had no relationship with lymph node metastasis, and Annexin II and PRL-3 had little discrimination in the immunohistochemistry. CD44v6 was the only significant risk factor for lymph node metastasis, and its OR was very high similar to depth of invasion.


9. Áõ·Ê - ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ°¡ ¼ö¼úÀ» ¾È ÇÏ¿´À» ¶§

Á¶±â À§¾Ï ESD ÈÄ ¾à 15%¿¡¼­ ¼ö¼úÀÌ ÇÊ¿äÇÏ´Ù´Â °á°ú°¡ ³ª¿É´Ï´Ù. ¼ö¼úÀÌ ÇÊ¿äÇÑ »óȲ¿¡¼­´Â ¼ö¼úÀ» ÇÏ´Â °ÍÀÌ °¡Àå ÁÁÀº °á°ú¸¦ º¸ÀÔ´Ï´Ù. ±×·¯³ª °¡²û ȯÀÚµéÀÌ ¼ö¼úÀ» °ÅºÎÇÏ´Â °æ¿ì°¡ ÀÖ½À´Ï´Ù. Âü ³­°¨ÇÑ ÀÏÀÔ´Ï´Ù. °­Á¦·Î ¼ö¼ú½Ãų ¼öµµ ¾ø°í....

¾à 3³â ¹Ý Àü Ÿ ´ëÇк´¿ø¿¡¼­ À§¾Ï ESD ÈÄ ¼ö¼úÀ» ±ÇÀ¯¹Þ¾Ò´Âµ¥ ¼ö¼úÀ» °ÅºÎÇÏ¿´´ø ȯÀÚ°¡ ¸î ³â ÈÄ Àü½Å Àç¹ß ¼Ò°ß¿¡ ´ëÇÑ 2Â÷ ÀÇ°ßÀ» À§ÇÏ¿© Àú¸¦ ãÀ¸¼Ì½À´Ï´Ù. ¾ÈŸ±õÁö¸¸ µµ¸®°¡ ¾ø¾ú½À´Ï´Ù.

15³âÀü À§¾Ï ¼ö¼ú → ÀÜÀ§¾Ï ¹ß°ßµÇ¾î ESD. SM2, L (+)¿´À¸³ª ¼ö¼ú °ÅºÎ → 4³â ÈÄ ±¹¼ÒÀç¹ß ¹× °£ÀüÀÌ »óÅ ¹ß°ß
ESD: Early gastric carcinoma
1. Location : cardia, anterior wall
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 15 mm (2) vertical diameter, 14 mm
6. Depth of invasion : invades submucosa, (depth of sm invasion : 700 §­) (pT1b)
7. Resection margin : free from carcinoma(N), safety margin : distal 2 mm, proximal 1 mm, anterior 8 mm, posterior 8 mm, deep 200§­ (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

3³â ÀüÀÎ 2013³â Àα٠ÀÇ·á±â°ü¿¡¼­ ³»½Ã°æ ÀýÁ¦¼úÀ» ¹ÞÀ¸¼Ì´ø 60´ë ¿©¼ºÀÔ´Ï´Ù. ´ç½Ã º´¸®°á°ú´Â adenocarcinoma M/D (1.7cm) arising in tubular adenoma (HGD), invades submucosa (SM1, 0.5mm), RM (-), L/V/N (-) ¿´´Ù°í ÇÕ´Ï´Ù. º´¸® °á°ú¿¡ µû¸¥ Àç¹ß À§Çè¿¡ ´ëÇÏ¿© ¾î¶»°Ô ¼³¸íÀ» µéÀ¸¼Ì´ÂÁö, ¼ö¼úÀ» ±ÇÀ¯¹ÞÀ¸¼Ì´ÂÁö ¾Ë ¼ö ¾øÀ¸³ª ³»½Ã°æ Ä¡·á 3³â ÈÄ multiple bone painÀÌ ¹ß°ßµÇ¾î bone scan°ú CT °Ë»ç¸¦ ¹ÞÀ¸¼Ì´Âµ¥ ´Ù¹ß¼º Àç¹ß·Î µè°í 2Â÷ ÀÇ°ßÀ» À§ÇÏ¿© ¹æ¹®Çϼ̽À´Ï´Ù. ÃÖ±Ù ³»½Ã°æÀ» ¹ÞÀ¸½ÃÁö´Â ¾Ê¾Ò´Ù°í ÇÕ´Ï´Ù. ºñ·Ï ³»½Ã°æ Àç°ËÀº ¹ÞÁö ¾Ê¾ÒÀ¸³ª CT¿¡¼­ À§ ÁÖº¯ node°¡ ÇöÀúÈ÷ Ä¿Á® ÀÖ°í, ´Ù¹ß¼º °£ÀüÀ̸¦ µ¿¹ÝÇÏ°í ÀÖ´Â ¸ð½ÀÀÌ À§¾ÏÀÇ Àç¹ß·Î ÆǴܵǾú½À´Ï´Ù. ¾ÈŸ±î¿î Áõ·ÊÀε¥¿ä¡¦ ½Ã¼úÀÚÀÇ ÀÔÀå¿¡¼­´Â ´Ã Á¶½ÉÇÏ´Â ¼ö ¹Û¿¡ ¾ø´Ù´Â °ÍÀ», ò×ìÑÞÀÓâô¸Ù¤ÀÌÁö¸¸ °£È¤ Àç¹ß¿¹°¡ ÀÖ´Ù´Â °ÍÀ» Åë°¨ÇÏÁö ¾ÊÀ» ¼ö ¾ø½À´Ï´Ù.

¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ°¡ ¼ö¼úÀ» ¾È ÇÏ¿´À» ¶§ ¿©·¯ºÐÀº ¾î¶»°Ô ÇϽʴϱî? Àú´Â °­·ÂÈ÷ ´Ù½Ã Çѹø ÃßõÇÕ´Ï´Ù. Á¦ ¿Ü·¡ EMR ±â·Ï ÀϺθ¦ ¼Ò°³ÇÕ´Ï´Ù.

2016³â 2¿ù ½ÉÆò¿ø¿¡¼­ ESD ÈÄ ¼ö¼úÀÌ ÇÊ¿äÇÑ È¯ÀÚ°¡ ¼ö¼úÀ» ÇÏÁö ¾Ê¾ÒÀ» ¶§ ±× »çÀ¯¸¦ ¸íÈ®È÷ ¹àÈ÷Áö ¾ÊÀ¸¸é ÀûÁ¤ÇÏÁö ¾ÊÀº °ÍÀ¸·Î Æò°¡ÇÑ´Ù´Â ÁöħÀ» ³»·È½À´Ï´Ù. ¸»ÀÌ¾ß ¿Ç´Ù°í ÇÒ ¼ö ÀÖÁö¸¸ Ä¡·á°¡ ÀûÁ¤ÇÏ¿´´ÂÁö ¿©ºÎ°¡ ¾Æ´Ï¶ó ´ÜÁö ÀÔ¸À¿¡ ¸Â´Â Àǹ«±â·ÏÀÌ Àִ°¡ ¾ø´Â°¡·Î ÀûÁ¤¼º ¿©ºÎ¸¦ ÆÇÁ¤ÇÏ´Ù´Ï... ¸¶À½ÀÌ ÆíÄ¡ ¾Ê½À´Ï´Ù. °í·ÉÀÌ°í ¼è¾àÇÏ¿© ¼ö¼úÇÒ ¼ö ¾ø´Â »óȲµµ ÀÎÁ¤ÇØÁÖÁö ¾Ê´Â´Ù´Ï ÀÔÀÌ ¹ú¾îÁöÁö ¾Ê½À´Ï´Ù.

2019³â 1³â µ¿¾È »ï¼º¼­¿ïº´¿ø¿¡¼­ ESD ÈÄ º´¸®ÇÐÀû noncurative resectionÀ¸·Î ³ª¿Â ȯÀÚ 75¸í Áß 63¸íÀÌ ½ÇÁ¦·Î ¼ö¼úÀ» ¹ÞÀ¸¼Ì½À´Ï´Ù. 84%ÀÔ´Ï´Ù. ¼ö¼úÀÌ ÇÊ¿äÇѵ¥ ¼ö¼ú¹ÞÁö ¾ÊÀº ÀÌÀ¯´Â ȯÀÚ º»ÀÎÀÌ ¼ö¼úÀ» °ÅºÎÇÑ °æ¿ì°¡ 5°Ç, Àü½Å »óÅ·Π¼ö¼úÀ» ±ÇÇϱ⠾î·Á¿î °æ¿ì°¡ 4°Ç, follow up loss°¡ 3°ÇÀ̾ú½À´Ï´Ù.


[FAQ]

[2015-2-18. ¾Öµ¶ÀÚ Áú¹®]

±Ã±ÝÇÑ Á¡ÀÌ À־ Áú¹®µå¸³´Ï´Ù. M/58, µ¿¹ÝÁúȯ ¾øÀÌ °Ç°­ÇÑ È¯ÀÚ·Î ÀüÁ¤ºÎÀÇ EGC, IIc+IIa, 15x10mm with erosion º´º¯¿¡ ´ëÇØ ESD¸¦ ½ÃÇàÇß½À´Ï´Ù. º´¸® °á°ú´Â Adenoca, M/D, Lateral/Deep RM (-/-), Complete resection, LVI (-), Sm cancer, 700 um invasion À̾ú½À´Ï´Ù. ´Ù¸¥ º´¸® ¼Ò°ßÀÌ ¸ðµÎ ¾çÈ£ÇÑ ¼Ò°ßÀε¥, depth of invasionÀÌ 500umÀ» ³ÑÀ» ¶§ ¾î¶»°Ô Ãß°¡ Ä¡·á³ª ÃßÀûÀ» ±ÇÀ¯ÇÏ°í °è½Ã´ÂÁö ±Ã±ÝÇÕ´Ï´Ù. Ȥ½Ã ¿¹¿Ü¸¦ Àû¿ëÇϽô °æ¿ì°¡ ÀÖÀ¸½ÅÁö°¡ ƯÈ÷ ±Ã±ÝÇÕ´Ï´Ù. ¿øÄ¢ÀÌ ¾Æ´Ï¶ó, ½ÇÁ¦·Î ´Ù¸¥ ±³¼ö´ÔµéÀº ¾î¶»°Ô ÇÏ°í °è½Ã´ÂÁö, ¿¹¿Ü´Â ¾ø´ÂÁö°¡ °©Àڱ⠱ñÝÇØÁ³½À´Ï´Ù.

[2015-2-20. ÀÌÁØÇà ´äº¯]

SM 500 umÀ» ÃÊ°úÇÏ´Â Á¡¸·ÇÏħÀ±ÀÇ °æ¿ì´Â ¿¹¿Ü¾øÀÌ ¼ö¼úÀ» ±ÇÇÕ´Ï´Ù.

Àú´Â ´Ü¼øÇÑ °ÍÀ» ÁÁ¾ÆÇÕ´Ï´Ù. ¾ÆÁÖ ¼Ò¼öÀÇ ´Ü¼øÇÑ ¿øÄ¢À» ¿¹¿Ü¾øÀÌ Àû¿ëÇÏ´Â °ÍÀ» ÁÁ¾ÆÇÕ´Ï´Ù. »ç·Êº°·Î º¸¸é ¾Æ½¬¿î Á¡ÀÌ ¾øÁö ¾Ê°ÚÁö¸¸... ÀüüÀûÀ¸·Î º¸¸é ´Ü¼øÇÑ ¿øÄ¢À» ÁöÅ°´Â °ÍÀÌ À¯¸®Çϱ⠶§¹®ÀÔ´Ï´Ù. 550 um invasionÀ̶ó°í º¸°íµÈ °á°ú¸¦ ¹ÙÅÁÀ¸·Î ¼ö¼úÀ» ±ÇÇÑ Àûµµ ÀÖ½À´Ï´Ù.


[2015-2-25. ¾Öµ¶ÀÚ Áú¹®]

3-4³â Àü °£À̽ÄÀ» ¹ÞÀ¸½Ã°í À̹ø¿¡ À§¾ÏÀÌ ¹ß°ßµÇ¾î ESD¸¦ ÇÏ¿´À¸³ª SM invasion 500 um, lymphatic (++)ÀΠȯÀÚ¿¡ ´ëÇÏ¿© ¼ö¼úÀ» °í¹ÎÁßÀÔ´Ï´Ù.

[2015-2-25. ÀÌÁØÇà ´äº¯]

ÀÏÀü¿¡ ¼Ò°³µå¸° ¹Ù ÀÖÁö¸¸ ESD ÈÄ incomplete resection ÀÎ °æ¿ì¿¡ ¼ö¼úÇÏÁö ¾ÊÀº ȯÀÚ¿¡¼­ Á¾Á¾ ÀǹÌÀÖ´Â Àç¹ßÀÌ ¹ß°ßµÇ°í ÀÖ½À´Ï´Ù (¸µÅ©). µû¶ó¼­ ¼ö¼úÀ» ±ÇÇÏ´Â °ÍÀÌ Ç¥ÁØÀ̶ó°í »ý°¢ÇÕ´Ï´Ù.

½ÇÁ¦·Î ¼ö¼úÀ» ±ÇÇغ¸¸é, ´ë°­ 80-90%´Â ¼ö¼úÀ» ¹æÀ¸½Ã°í 10-20%´Â ¼ö¼úÀ» ¹ÞÁö ¾Ê½À´Ï´Ù. ÀúÈñ º´¿ø µ¥ÀÌŸ¸¦ º¸¸é 70% ȯÀÚ°¡ ¼ö¼úÀ» ¹Þ´Â °ÍÀ¸·Î µÇ¾î ÀÖÁö¸¸ (¸µÅ©) ÀÌ Áß¿¡¼­ ÀϺδ ³»°ú¿¡¼­ ¼ö¼úÀ» ±ÇÇÏÁö ¾ÊÀº ȯÀÚÀ̹ǷΠ½ÇÁ¦·Î´Â ¼ö¼úÀ» ±ÇÇϸé 80-90% ÀÌ»óÀÇ È¯ÀںеéÀº ¼ö¼úÀ» ¹Þ½À´Ï´Ù.

¹®Á¦´Â ¼ö¼úÇÏÁö ¾Ê´Â´Ù°í ´Ù Àç¹ßÇÏ´Â °ÍÀº ¾Æ´Ï¶ó´Â °ÍÀÔ´Ï´Ù. ´ë°­ survivalÀ» ±¸Çغ¸¸é ¼ö¼úÀÌ ÇÊ¿äÇѵ¥µµ ¼ö¼úÇÏÁö ¾ÊÀº °æ¿ìÀÇ 5³â »ýÁ¸À²Àº 80% Á¤µµÀÔ´Ï´Ù. ¹°·Ð µ¹¾Æ°¡½Å ºÐÀÌ ÀüºÎ ¾ÏÀ¸·Î µ¹¾Æ°¡½Å °ÍÀº ¾Æ´Õ´Ï´Ù (¸µÅ©). Àç¹ßÀ§ÇèÀ» ¿¹ÃøÇÏ´Â ¿©·¯ ÀÎÀÚ Áß depth of invasion°ú lymphatic invasionÀÌ Áß¿äÇÏ´Ù°í »ý°¢ÇÕ´Ï´Ù. ƯÈ÷ lymphatic invasionÀº ¸Å¿ì Áß¿äÇÕ´Ï´Ù. Àç¹ßÀÌ È®ÀÎµÈ È¯ÀÚÀÇ ´ëºÎºÐ¿¡¼­ lymphatic invasionÀÌ ÀÖ¾ú±â ¶§¹®ÀÔ´Ï´Ù (¸µÅ©).

¶Ç ´Ù¸¥ °í·ÁÁ¡Àº ¼ö¼úÇÑ´Ù°í ¸ðµÎ Àç¹ßÇÏÁö ¾Ê´Â °Íµµ ¾Æ´Ï¶ó´Â °ÍÀÔ´Ï´Ù. Áõ·Ê´Â ¸¹Áö ¾ÊÁö¸¸ ESD ÈÄ incomplete resectionÀ¸·Î ¼ö¼úÇÏÀ½¿¡µµ ºÒ±¸ÇÏ°í ´Ù¹ß¼º Àç¹ßÀ» º¸ÀÎ °æ¿ìµµ ÀÖ¾ú½À´Ï´Ù (¸µÅ©).

µû¶ó¼­ ¸¹Àº °ÍÀ» °í·ÁÇÏ¿© °áÁ¤ÇÒ ¼ö ¹Û¿¡ ¾ø´Ù°í »ý°¢µË´Ï´Ù. ȯÀÚÀÇ ¼±Åõµ Áß¿äÇÕ´Ï´Ù. ±×·¡µµ ¿©ÇÏÆ° ¼³¸íÀ» ÇÑ´Ù¸é ÀÌ·¸°Ô ÇÏ´Â °ÍÀÌ ÃÖ¼±ÀÌ ¾Æ´Ò±î ½Í½À´Ï´Ù.

"Á¶±âÀ§¾ÏÀ¸·Î ³ª¿Í 85% Á¤µµÀÇ Ãʱ⼺°ø·ü (³»½Ã°æÄ¡·á¸¸À¸·Î ÀÏÂ÷ Ä¡·á°¡ ³¡³ª´Â ºñÀ²)À» ¿¹ÃøÇÏ´Â »óȲ¿¡¼­ ³»½Ã°æÄ¡·á¸¦ ÇÏ¿´´Âµ¥, ¾Æ½±°Ôµµ ±× 85%¿¡ µéÁö ¸øÇÏ°í ¼ö¼úÀÌ ÇÊ¿äÇÑ 15%¿¡ ÇØ´çÇÏ´Â °á°ú°¡ ³ª¿Ô½À´Ï´Ù. Ç¥ÁØÄ¡·á´Â ¼ö¼úÀÔ´Ï´Ù. À§¸¦ 2/3Á¤µµ ÀýÁ¦¸¦ ÇÏ°í ÁÖº¯ ¸²ÇÁÀý±îÁö Ä¡·áÇÏ´Â °ÍÀε¥, Àç¹ß·üÀ» ³·Ãß´Â °¡Àå ÁÁÀº ¹æ¹ýÀÔ´Ï´Ù. ¹°·Ð ÀÛÁö ¾ÊÀº ¼ö¼úÀÔ´Ï´Ù. ¼ö¼ú¿¡ µû¸¥ À§Ç輺µµ °í·ÁÇØ¾ß ÇÕ´Ï´Ù. ƯÈ÷ ȯÀÚºÐÀÇ °æ¿ì´Â °ú°Å °£À̽ÄÀ» ¹Þ¾ÒÀ¸¹Ç·Î ¼ö¼úÀÇ °íÀ§Ç豺ÀÔ´Ï´Ù. ¼ö¼úÇÏÁö ¾Ê´Â °æ¿ì À§¾ÏÀÇ Àç¹ß·üÀº ¸íÈ®ÇÑ ÀÚ·á´Â ¾øÁö¸¸ ´ë°­ 20-30% Á¤µµÀÏ °ÍÀ¸·Î ÃßÁ¤ÇÏ°í ÀÖ½À´Ï´Ù.

Á¤´äÀÌ ÀÖÀ» ¼ö ¾ø´Â »óȲÀÔ´Ï´Ù. ȯÀÚºÐÀÇ ¼±ÅÃÀÌ Áß¿äÇÒ ¼ö ¹Û¿¡ ¾ø½À´Ï´Ù. ¸ðµç ÀÇÇÐÀû °áÁ¤ÀÇ ¿øÄ¢Àº ÇϳªÀÔ´Ï´Ù. " ÀÇ·áÁøÀº ȯÀÚ¿¡°Ô ÃÖ´ëÇÑ ÀÚ¼¼ÇÑ Á¤º¸¸¦ Á¦°øÇØ µå¸®°í ÃÖÁ¾ °áÁ¤Àº ȯÀÚÀÇ ÆÇ´Ü¿¡ µû¸¥´Ù"°¡ ±×°ÍÀÔ´Ï´Ù. ¸¸¾à Àú¿¡°Ô Çϳª¸¦ ¼±ÅÃÇ϶ó°í ÇϽŴٸé Àú´Â ¼ö¼úÀ» ±ÇÇÏ°Ú½À´Ï´Ù. ¹°·Ð Àǻ縶´Ù ´Ù¸¥ ¼±ÅÃÀ» ÇÒ ¼ö ÀÖ´Â »óȲÀ̶ó´Â °Íµµ ÀÌÇØÇÏ¿© Áֽñ⠹ٶø´Ï´Ù."


[2017-12-13. ÀÌÁØÇà È¥À㸻]

¼ö ³â Àü Á¶±âÀ§¾Ï ³»½Ã°æ Ä¡·á ÈÄ º´¸®ÇÐÀûÀ¸·Î deep SM invasion°ú lymphatic (+)·Î ¼ö¼ú¹ÞÀº ȯÀÚ°¡ ¿Ü·¡¿¡ ¿À¼Ì½À´Ï´Ù. ¹®µæ ¾Æ·¡ ±â»ç¸¦ º¸¿©Áֽø鼭 "±× ¶§ ¼ö¼úÇ϶ó°í µè°í ¹«Ã´ ¼Ó»óÇߴµ¥, Áö±Ý »ý°¢Çغ¸´Ï Âü Àß ÇÑ °áÁ¤À̾ú´ø °Í °°½À´Ï´Ù. °í¸¿½À´Ï´Ù."¶ó°í Çϼ̽À´Ï´Ù.

À§¾Ï(êÖäß)À» ³»½Ã°æÀ¸·Î Á¦°ÅÇßÀ» ¶§ 4³â ¾È¿¡ ¾ÏÀÌ Àç¹ßÇÒ È®·üÀÌ ¼ö¼ú·Î Á¦°ÅÇßÀ» ¶§¿¡ ºñÇØ 2¹è ÀÌ»ó ³ô´Ù´Â ¿¬±¸°á°ú°¡ ³ª¿Ô´Ù. ´ë±¸ °è¸í´ë µ¿»êº´¿ø ¼ÒÈ­±â³»°ú ¿¬±¸ÆÀÀº ³»½Ã°æ ½Ã¼úÀ» ¹ÞÀº À§¾Ï ȯÀÚ 514¸í°ú À§ ÀýÁ¦¼úÀ» ¹ÞÀº À§¾Ï ȯÀÚ 686¸íÀ» ¾à 4³â °£ ÃßÀû °üÂûÇß´Ù. ±× °á°ú, ³»½Ã°æÀ¸·Î À§¾ÏÀ» Á¦°ÅÇÑ È¯ÀÚÀÇ 2.4%°¡ °üÂû ±â°£ ³»¿¡ À§¾ÏÀ» ´Ù½Ã Áø´Ü¹Þ¾Æ Àç¼ö¼úÀ» ¹Þ¾Æ¾ß Çß´Ù. À§ ÀýÁ¦¼úÀÇ °æ¿ì 1.1%¿¡ ±×ÃÆ´Ù.

ÀÌ·± Àú·± »ý°¢ÀÌ µé¾ú½À´Ï´Ù. (1) ±×·¸°Ô ÀÚ¼¼È÷ ¼³¸íÇØ µå·Áµµ ½ÃÅ«µÕ ÇϽôõ´Ï È°ÀÚÈ­µÈ ±â»çÀÇ ÈûÀº ¸·°­Çϱ¸³ª... (2) Àç¹ß·üÀÌ ³ô´Ù´Â °ÍÀÇ Àǹ̸¦ ȯÀÚ´Â ¾î¶»°Ô ÆľÇÇÏ°í ÀÖÀ»±î? Àç¹ß·üÀÌ ³·Àº Ä¡·á°¡ ²À ÁÁÀº Ä¡·á°¡ ¾Æ´Ò ¼ö ÀÖ´Ù´Â °ÍÀ» ȯÀÚ´Â ÀÌÇØÇÒ ¼ö ÀÖÀ»±î? (3) ¸¸¾à Àç¹ß·üÀÌ 2%¶ó°í ÇÑ´Ù¸é ¼ö¼úÀ» ÇØ¾ß ÇÒÁö ¸»¾Æ¾ß ÇÒÁö reasonable ÇÏ°Ô °áÁ¤ÇÏ½Ç ¼ö ÀÖÀ»±î? (4) Àç¹ß·ü 2%¸¦ ¸·±â À§ÇÏ¿© Áö±Ý ¼ö¼úÀ» ÇÑ´Ù¸é ȯÀÚ´Â ¼ö¼ú¿¡ µû¸¥ mortality¿¡ ³ëÃâµÈ´Ù´Â °ÍÀ» ¾î¶»°Ô ¹Þ¾ÆµéÀ̽DZî? (5) Àç¹ßÇÏ¿© »ç¸ÁÇÑ´Ù¸é 5³â ÈÄÀÌ°í, ¼ö¼ú¹Þ´Ù Á×À¸¸é À̹ø ´ÞÀε¥, µÑ »çÀÌ¿¡¼­ ±ÕÇüµÈ °áÁ¤À» ³»¸®½Ç ¼ö ÀÖÀ»±î?

¾ð·Ð ÀÇ·áÁ¤º¸´Â Âü Çã¸ÁÇÏ´Ù°í »ý°¢ÇÕ´Ï´Ù. ³ª¸§ Á¤º¸¸¦ Á¦°øÇÏÁö¸¸ ¹Þ¾ÆµéÀÌ´Â »ç¶÷Àº Á¦¸Ú´ë·ÎÀÎ °ÍÀÌ ¾ð·Ð ÀÇ·áÁ¤º¸ÀÔ´Ï´Ù. Àǻ翡°Ô ÃæºÐÈ÷ ¼³¸íÇÒ ¼ö ÀÖ´Â ½Ã°£À» ¸¸µé¾î ÁÖ´Â °ÍÀÌ ¿ì¸®³ª¶óÀÇ ÀÇ·á¹ßÀü ¾Æ´Ñ°¡ »ý°¢ÇÕ´Ï´Ù. ÃÖ¼ÒÇÑ 15ºÐ Áø·á°¡ ÇÊ¿äÇÕ´Ï´Ù. ¿ÀÀü ¿Ü·¡ 12¸í ½Ã´ë¸¦ ±â´ëÇÕ´Ï´Ù.


[2022-9-2. Áú¹®]

Score°¡ ³ôÀº »ç¶÷¿¡¼­ ¼ö¼ú ÈÄ node ÀüÀ̳ª local residual tumorÀÇ È®·üÀÌ ³ôÀ» °Í °°½À´Ï´Ù. Score¿Í residual tumorÀÇ À¯¹«°£ »ó°ü°ü°è¸¦ ¾Ë°í ½Í½À´Ï´Ù.

[2022-9-2. ÀúÀÚ ´äº¯]

1. ¿¬±¸ ´ë»ó 3127 case Áß 445 case¿¡¼­ ¼ö¼úÀ» ÇÏ¿´½À´Ï´Ù (445/3127, 14.5%) ÀÌ Áß ¼ö¼ú ÈÄ residual lesionÀº 92 case¿¡¼­ (+), 353 case¿¡¼­ (-) ¿´½À´Ï´Ù. LN »óÅ´ 351¸í¿¡ ´ëÇؼ­¸¸ Á¤º¸¸¦ °¡Áö°í Àִµ¥ LN (+) = 24, LN (-) = 327 ÀÔ´Ï´Ù.

2. NC-ESD-RGÀ» Á¤ÀÇÇÒ ¶§ ¼ö¼úÀÌ ÇÊ¿äÇÑ °æ¿ì·Î Á¤ÀÇÇϸ鼭 curative resection/lateral margin involvement only/piecemeal resectionÀ» ÇÑ ±×·ìÀ¸·Î ¹­°í, ³ª¸ÓÁö »çÀ¯·Î NCRÀÌ µÈ °æ¿ì¸¦ NC-ESD-RG·Î Á¤ÀÇÇÏ¿´¾ú½À´Ï´Ù. µû¶ó¼­ lateral margin involvement³ª piecemeal resectionÀÎ °æ¿ì residual lesionÀÌ ¸¹À» ¼ö ¹Û¿¡ ¾øÀ¸¹Ç·Î NC-ESD-RG¿¡¼­ ¼ö¼ú ÈÄ residual lesionÀÌ ¸¹À» °ÍÀ¸·Î ±â´ëµÇÁö´Â ¾Ê°í, LN (+) ÀÎ °æ¿ì°¡ ¸¹À» °ÍÀ¸·Î ±â´ëÇغ¼ ¼ö ÀÖÀ» °Í °°½À´Ï´Ù.

3. ½ÇÁ¦·Î NC-ESD-RG vs curative/lateral/piecemeal ºñ±³ÇßÀ» ¶§ LN (+) rate´Â 21/278 (7.6%) vs 3/73 (4.1%)·Î NC-ESD-RG groupÀÌ ´õ ³ô¾ÒÁö¸¸ N ¼ö ºÎÁ·À¸·Î P = 0.435·Î À¯ÀÇÇÏÁö´Â ¾Ê¾Ò½À´Ï´Ù. ÇÑÆí ¸¶Âù°¡Áö·Î ºñ±³ÇßÀ» ¶§ residual lesion (+)Àº 64/380 (16.8%) vs 28/65 (43.1%) ·Î NC-ESD-RG groupÀÌ À¯ÀÇÇÏ°Ô ³·¾Ò½À´Ï´Ù.

4. Predictive model¿¡¼­ °è»êµÈ score¿Í LN ¶Ç´Â ¼ö¼ú ÈÄ residual lesion ¿©ºÎ¿ÍÀÇ ¿¬°ü¼ºÀ» Æò°¡Çغ¸±â À§Çؼ­ ³í¹®¿¡¼­ Á¦½ÃµÈ cutoff 5Á¡ ±âÁØÀ¸·Î »ìÆ캸¾Ò½À´Ï´Ù. 5Á¡ ÀÌ»ó vs ¹Ì¸¸ ºñ±³ÇßÀ» ¶§ LN (+) Àº 15/142 (10.6%) vs 9/209 (4.3%)·Î À¯ÀÇÇÏ°Ô predicted score 5Á¡ À̻󿡼­ ³ô¾Ò½À´Ï´Ù (P=0.023) Logistic regressionÀ» Çغ¸¾ÒÀ» ¶§¿¡´Â score 5Á¡ ÀÌ»óÀº ÀÌÇÏ¿¡ ºñÇÏ¿© LN(+)ÀÇ unadjusted ORÀÌ 2.63 (95% CI 1.12-6.18)·Î ³ªÅ¸³µ½À´Ï´Ù. ÇÑÆí score 5Á¡ ÀÌ»ó vs ¹Ì¸¸À¸·Î º¸¾ÒÀ» ¶§ ¼ö¼ú ÈÄ residual lesion (+) Àº 34/178 (19.1%) vs 58/267 (21.7%)·Î Â÷ÀÌ°¡ ¾ø¾ú½À´Ï´Ù (P = 0.503)

5. °ú°Å ÀÌ ³í¹® Á¦Ãâ½Ã diagnostic ESD¸¦ Çؼ­ LNM risk¸¦ Æò°¡ÇÏ´Â ¹æ¹ýÀÌ Àִµ¥ ±»ÀÌ pre-ESD variable·Î ¿Ö Æò°¡ÇØ¾ß ÇϳĴ ¸®ºä°¡ ¸¹¾Ò´ø °Í °°½À´Ï´Ù. ±×·¯³ª ÀÌ ³í¹®À» ÅëÇÏ¿© ȯÀÚ¿¡°Ô ESD ÈÄ¿¡ °á±¹ ¼ö¼úÀÌ ÇÊ¿äÇÏ°Ô µÉ È®·üÀÌ ¾ó¸¶³ª µÇ´ÂÁö ½Ã¼ú Àü¿¡ ¹Ì¸® ¾Ë·ÁÁÙ ¼ö ÀÖ´Ù´Â ÀåÁ¡ÀÌ ÀÖ´Ù´Â Á¡À» ¾îÇÊÇß¾ú½À´Ï´Ù. À§¿¡ ¾ð±Þµå¸° ¹Ù¿Í °°ÀÌ predicted score°¡ 5Á¡ ÀÌ»óÀ̸é LN risk°¡ À¯ÀÇÇÏ°Ô ³ô°Ô ³ª¿À´Â Á¡ÀÌ Èï¹Ì·Ó½À´Ï´Ù. ±×·±µ¥ ÀÌ°ÍÀº LNMÀ» outcomeÀ¸·Î ºÐ¼®ÇÑ scoring systemÀÌ ¾Æ´Ï¶ó´Â ¹®Á¦Á¡°ú, NC-ESD-RG¿¡ ´ëÇÑ AUCµµ 70% Á¤µµ¿´´Âµ¥ LNMÀ» outcomeÀ¸·Î ÇÑ´Ù¸é ÃæºÐÈ÷ AUC°¡ È®º¸µÉÁö°¡ °ÆÁ¤ÀÎ °Í °°½À´Ï´Ù.


[References]

1) Management of non-curative endoscopic resection of EGC at SMC - 2015³â 4¿ù 4ÀÏ À§¾ÏÇÐȸ (KINGCA) ¹ßÇ¥

2) [2021³â 3¿ù] ´ëÇѼÒÈ­±â³»½Ã°æÇÐȸ Áø·áÁöħTF - Áõ·Ê¸¦ ÅëÇÑ ÀÓ»óÁø·áÁöħ ÇнÀ

© ÀÏ¿ø³»½Ã°æ±³½Ç ¹Ù¸¥³»½Ã°æ¿¬±¸¼Ò ÀÌÁØÇà. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.