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EndoTODAY ³»½Ã°æ ±³½Ç


[À§ ¼±Á¾/ÀÌÇü¼º (gastric adenoma/dysplasia)] - ðû

2017³â 4¿ù 15ÀÏ ¼øõ¸¸³»½Ã°æ¼¼¹Ì³ª

1) Á¤ÀÇ

2) º´¸®ÇÐÀû Áø´Ü

3) °íµµ/Àúµµ µî±Þ ºÐ·ù

4) ³»½Ã°æ Áø´Ü

5) ÀÓ»óÀû ÀÇÀÇ

6) Ä¡·á

7) °íµµ¼±Á¾ ³»½Ã°æ Ä¡·á ÈÄ ¾ÏÀ¸·Î Áø´ÜµÈ Áõ·Ê

8) Àúµµ¼±Á¾ ³»½Ã°æ Ä¡·á ÈÄ ¾ÏÀ¸·Î Áø´ÜµÈ Áõ·Ê

9) 2014 Konkuk symposium lecture on adenoma

10) FAQ - °íµµÀÌÇü¼ºÀº ÀüÀÌ °¡´É¼ºÀÌ ¾ø½À´Ï±î?

11) References


1. What is adenoma and dysplasia? ¼±Á¾Àº ¹«¾ùÀÌ°í ÀÌÇü¼ºÀº ¹«¾ùÀΰ¡

Doland ÀÇÇлçÀü¿¡¼­ dysplasia(ÀÌÇü¼º)´Â ¡°abnormality of development; in pathology, alteration in size, shape, and organization of adult cells¡±·Î, adenoma(¼±Á¾)´Â ¡°a benign epithelial tumor in which the cells form recognizable glandular structures or in which the cells are derived from glandular epithelium¡±À¸·Î Á¤Àǵǰí ÀÖ´Ù.

¼­±¸¿¡¼­´Â À§ ÀÌÇü¼º (gastric dysplasia)À» flat/depressed dysplasia¿Í elevated dysplasia·Î ³ª´©´Âµ¥ elevated dysplasia¸¸À» adenoma·Î ºÎ¸¥´Ù. ÀϺ»°ú ¿ì¸®³ª¶ó¿¡¼­´Â dysplasia¸¦ adenoma¿Í °ÅÀÇ °°Àº ¶æÀ¸·Î ¿©±ä´Ù. µû¶ó¼­ ÀϺ»°ú ¿ì¸®³ª¶ó¿¡¼­´Â flat/depressed adenoma¿Í elevated adenoma°¡ ¸ðµÎ °¡´ÉÇÏ´Ù.

¼­¾ç¿¡¼­´Â À¶±âÇü dysplasia¸¸ ¼±Á¾À̶ó°í ºÎ¸£Áö¸¸ ¿ì¸®´Â À¶±âÇü dysplasia¿Í ÇÔ¸ôÇü dysplasia¸¦ ¸ðµÎ ¼±Á¾À̶ó°í ºÎ¸¥´Ù. Áï ¿ì¸®³ª¶ó¿Í ÀϺ»¿¡¼­´Â "gastric dysplasia = gastric adenoma"ÀÌ´Ù.

ÃÖ±Ù À§ÀÇ ¾Ï°ú ÀÌÇü¼º¿¡ ´ëÇÑ º´¸®ÇÐÀÚµéÀÇ Æò°¡°¡ ¼­±¸¿Í ÀϺ»¿¡¼­ ÇöÀúÇÑ Â÷À̸¦ º¸Àδٴ Á¡ÀÌ ¹àÇôÁö°í, À̸¦ ±Øº¹Çϱâ À§ÇÑ ´Ù¾çÇÑ ³ë·ÂÀÌ ÁøÇàµÇ°í ÀÖ´Ù. ±×·¯³ª °ÅÀÇ 1-2³â¸¶´Ù »õ·Î¿î ºÐ·ù¹ýÀÌ Á¦½ÃµÇ°í ÀÖÀ¸¸ç, ±×¿¡ ´ëÇÑ Æò°¡°¡ Á¤È®ÇÏ°Ô ÀÌ·ç¾îÁöÁö ¸øÇÔÀ¸·Î½á È¥¶õÀ» ºÎäÁúÇÏ°í ÀÖ´Ù. ƯÈ÷ °ú°Å¿¡´Â °æ°ú°üÂû¹Û¿¡ ÇÒ ¼ö ¾ø¾ú´ø ÀÌÇü¼º º´¼Ò¿¡ ´ëÇÑ ³»½Ã°æ Ä¡·á°¡ µµÀԵǸ鼭, ºÐ·ù ¹× °³³äÅëÀÏÀÇ Çʿ伺ÀÌ ´õ¿í Áõ´ëµÇ°í ÀÖ´Ù.

°¡Àå È¥¶õ½º·¯¿î °ÍÀº Revised Vienna ºÐ·ùÀÌ´Ù. ÀÌ´Â ´ëÀå¿¡¼­´Â Àû´çÇÒÁö ¸ð¸£Áö¸¸ À§¿¡¼­´Â ÀüÇô Ÿ´çÇÏÁö ¾Ê´Ù. Àؾî¹ö¸®´Â °ÍÀÌ ³´´Ù°í »ý°¢µÈ´Ù.

Revised Vienna´Â Àؾî¹ö¸®ÀÚ.

* Âü°í: EndoTODAY Opinion difference between Korea and Japan on gastric adenoma


2. Pathologic diagnosis. ¼±Á¾/ÀÌÇü¼ºÀÇ º´¸®ÇÐÀû Áø´Ü

ÀϹÝÀûÀ¸·Î À§¿¡¼­ÀÇ ÀÌÇü¼ºÀº À§»óÇÇ ÀÌÇü¼º(gastric epithelial dysplasia)À» ÁöĪÇÑ´Ù. À§»óÇÇ ÀÌ¿ÜÀÇ ¼¼Æ÷¿¡¼­µµ ÀÌÇü¼ºÀÌ ¹ß»ýÇÒ ¼ö Àִµ¥, ÀÌ¿Í °°Àº °æ¿ì´Â ±¸Ã¼ÀûÀ¸·Î ¼¼Æ÷ÀÇ ±â¿øÀ» ¹àÇôÁÖ´Â °ÍÀÌ ÀϹÝÀûÀÌ´Ù (¿¹: enterochromaffin-like dysplasia).

ÀÌÇü¼º°ú ±¸ºÐÇϱ⠾î·Á¿î °³³äÀÌ ¼±Á¾ÀÌ´Ù. ¼­±¸¿¡¼­´Â À§ÀÇ ÀÌÇü¼ºÀ» ÆíÆòÇÑ ÀÌÇü¼º(flat dysplasia)°ú ¿ëÁ¾Çü ÀÌÇü¼º(polypoid dysplasia)À¸·Î ±¸ºÐÇÏ¿© ¿ëÁ¾ÇüÀÇ µ¹ÃâµÈ ÀÌÇü¼º¸¸À» ¼±Á¾À¸·Î ±¹ÇÑÇÏ¿© ºÎ¸£±âµµ ÇÑ´Ù. ±×·¯³ª ÀϹÝÀûÀ¸·Î´Â À§ÀÇ ÀÌÇü¼º°ú ¼±Á¾À» È¥¿ëÇÏ¿© »ç¿ëÇÏ°í ÀÖ°í, °æ¿ì¿¡ µû¶ó¼­´Â adenoma/dysplasia¿Í °°ÀÌ ÇÔ²² ±â¼úÇÔÀ¸·Î½á È¥¼±À» ÇÇÇÏ°íÀÚ ½ÃµµµÇ±âµµ ÇÑ´Ù.

ÀÌÇü¼ºÀÇ º´¸®ÇÐÀûÀΠƯ¡Àº ¾Æ·¡¿Í °°´Ù.

Microscopic characteristics of gastric epithelial dysplasia
1) Cellular atypia
- nuclear pleomorphism
- hyperchromasia
- nuclear stratification
- increased N/P ratio
- sometimes increased cytoplasmic basophilia
- loss of cellular and nuclear polarity
2) Abnormal differentiation
- lack or reduced numbers of goblet cells and Paneth cells in the metaplastic intestinal epithelium
- reduction, alteration or disappearance of secretory products from the gastric epithelium
3) Disorganized mucosal architecture
- irregularity of crypt structure
- back-to-back gland formation
- budding and branching of crypts
- intraluminal and surface papillary growth


Á¶Á÷ÇÐÀûÀ¸·Î ÀÌÇü¼º°ú ºñ½ÁÇÑ °ÍÀÌ regenerating atypiaÀε¥, ÀÌ´Â À§Á¡¸· ¼Õ»ó¿¡ ´ëÇÑ Á¤»óÀûÀÎ Àç»ý¹ÝÀÀÀÇ Çϳª·Î °£ÁֵǴ °ÍÀ¸·Î ¹Ýµå½Ã ±¸ºÐµÇ¾î¾ß ÇÑ´Ù.

¼¼»óÀº analogueÀÌ´Ù. ¸ðµç °ÍÀ» digital·Î ³ª´©·Á´Â °æÁ÷¼ºÀÌ ¹®Á¦¸¦ º¹ÀâÇÏ°Ô ÇÑ´Ù. ¾Ö¸ÅÇÑ °ÍÀº ¾Ö¸ÅÇÏ´Ù°í ¸»ÇÏ´Â °ÍÀÌ ³´´Ù.


¾Æ·¡´Â Á¶Á÷°Ë»ç¿¡¼­ Àúµµ¼±Á¾À¸·Î ³ª¿Â ȯÀÚÀÔ´Ï´Ù. ³»½Ã°æÀ¸·Î´Â Àúµµ ¼±Á¾ÀÎÁö metaplastic noduleÀÎÁö °ÅÀÇ ±¸ºÐÀÌ ¾î·Æ½À´Ï´Ù.


3. Grading and classification. °íµµ/Àúµµ µî±Þ ºÐ·ù

º´¸®ÇÐÀûÀ¸·Î´Â ´ÙÀ½°ú °°Àº ±âÁØÀÌ »ç¿ëµÇ°í ÀÖ½À´Ï´Ù.

ÀϺ»¿¡¼­ ºñÁ¤»óÀûÀÎ À§»óÇÇ º´º¯¿¡ ´ëÇÑ ÃÖÃÊÀÇ Á¶Á÷ÇÐÀûÀÎ ±âÁØÀº 1996³â Nakamura¿¡ ÀÇÇÏ¿© Á¦½ÃµÇ¾úÀ¸¸ç, ÀÌÈÄ 1971³â Nagayo¿¡ ÀÇÇÏ¿© 5°³ÀÇ ±×·ìÀ¸·Î ºÐ·ùµÈ ÀÌÈÄ, 1985³â Japanese Research Society for Gastric Cancer (JRSGC)¿¡ ÀÇÇÏ¿© ¾à°£ ¼öÁ¤µÇ¾î ÇöÀç¿¡ À̸£°í ÀÖ´Ù.

ÀϺ»¿¡¼­ »ç¿ëµÇ°í ÀÖ´Â 5 ±×·ì ºÐ·ùÀÇ °¡Àå Å« ¹®Á¦Á¡Àº ¡°°æ°è¼ºº´º¯¡±À¸·Î ÁöĪµÇ´Â 3±ºÀÇ ¹üÀ§°¡ ³Ê¹« ³Ð´Ù´Â Á¡Àε¥, ¾Æ·¡¿¡¼­ ¾ð±ÞµÇ´Â Vienna ºÐ·ùÀÇ category 2¿Í 3 ¹× 4¿¡ °ÉÄ¡´Â ±¤¹üÀ§ÇÑ ¿µ¿ªÀÇ º´º¯ÀÌ 3±º¿¡ Æ÷Ç﵃ ¼ö ÀÖ´Ù.

ÀÌ·¯ÇÑ ÇÑ°èÁ¡¿¡µµ ºÒ±¸ÇÏ°í 5 ±×·ì ºÐ·ù´Â À§³»½Ã°æ Á¶Á÷°Ë»çÀÇ °á°ú¸¦ °£ÆíÇÏ°Ô Ç¥ÇöÇÏ´Â ¹æ½ÄÀ¸·Î ÀÌÇصǰí ÀÖ°í, °¢ ±×·ì¿¡ µû¸¥ Ä¡·á¹æħÀ» ºñ±³Àû ¸íÈ®ÇÏ°Ô Á¤ÇÒ ¼ö ÀÖÀ¸¹Ç·Î ÀϺ»¿¡¼­´Â ¸Å¿ì ±¤¹üÀ§ÇÏ°Ô ÀÌ¿ëµÇ°í ÀÖ´Ù. ¶ÇÇÑ ¼­¾ç°ú ÀϺ»ÀÇ º´¸®ÇÐÀÚ°£ÀÇ °ßÇظ¦ ÀÏÄ¡½ÃÅ°±â À§ÇÑ ³ë·ÂÀÎ Vienna ºÐ·ù¿Í Padova ºÐ·ùµµ ±âº»ÀûÀ¸·Î´Â ÀϺ»ÀÇ 5 ±×·ì ºÐ·ù¹ý¿¡ ±âÃÊÇÏ°í Àֱ⠶§¹®¿¡ ±× ¿µÇâ·ÂÀº ¸Å¿ì Å©´Ù°í »ý°¢µÈ´Ù.

Vienna ºÐ·ù¿Í ´Ù¸¥ ºÐ·ùÀÇ ºñ±³

À§¾ÏÀÇ Áø´Ü¿¡ À־ ÀϺ»°ú ¼­±¸ÀÇ º´¸®ÇÐÀÚ°£ÀÇ °ßÇØ´Â ¸Å¿ì Â÷ÀÌ°¡ Å©´Ù. ÀϺ»¿¡¼­´Â º´º¯ÀÇ ±¸Á¶¿Í ¼¼Æ÷ÇÐÀû Ư¡¿¡ µû¶ó À§¾ÏÀ» Áø´ÜÇÏÁö¸¸ ¼­¾ç¿¡¼­´Â ħÀ±ÀÇ Áõ°Å°¡ ÀÖÀ» ¶§¿¡¸¸ À§¾ÏÀ¸·Î Áø´ÜÇÑ´Ù. µû¶ó¼­ ¼­±¸¿¡¼­ÀÇ °íµµÀÌÇü¼ºÀÇ ´ëºÎºÐ°ú ÀúµµÀÌÇü¼ºÀÇ ÀϺΰ¡ ÀϺ»¿¡¼­´Â À§¾ÏÀ¸·Î Áø´ÜÀÌ µÇ°í ÀÖ´Ù. ¶ÇÇÑ ÀϺ»¿¡¼­ÀÇ ¼±Á¾Àº ¼­¾ç¿¡¼­ÀÇ ÀÌÇü¼º°ú´Â ¾à°£ ´Ù¸¥ ¿ë¾î·Î¼­ ³»½Ã°æ ȤÀº À°¾È¼Ò°ß°ú´Â ¹«°üÇϸç, ¿ÀÈ÷·Á ¼­±¸¿¡¼­ÀÇ ÀúµµÀÌÇü¼º¿¡ °¡±î¿î °³³äÀÌ´Ù. µû¶ó¼­ ÀϺ»¿¡¼­´Â ÇÔ¸ôÇü ¼±Á¾À̶ó´Â Áø´ÜÀÌ °¡´ÉÇÏ´Ù. ÀÌ¿¡ ¹ÝÇÏ¿© ¼­¾ç¿¡¼­´Â ÀϹÝÀûÀ¸·Î À¶±âÇüÀÇ ÀÌÇü¼º¸¸À» ¼±Á¾À̶ó°í ºÎ¸£°í ÀÖ´Ù.

ÀÌ¿Í °°Àº µ¿¼­¾çÀÇ Â÷ÀÌ¿¡ ´ëÇÑ ¹®Á¦Á¦±â´Â ÁÖ·Î Schlemper¿¡ ÀÇÇÏ¿© ÀÌ·ç¾îÁ³´Ù. SchlemperÀÇ ÁÖµµÇÏ¿¡ 1996³â µ¿°æ¿¡¼­ ±¹Á¦È¸ÀÇ°¡ ¿­·ÈÀ¸¸ç, ±× °á°ú°¡ 1997³â ¡°Differences in diagnostic criteria for gastric carcinoma between Japanese and western pathologists¡±¶ó´Â Á¦¸ñÀ¸·Î LancetÁö¿¡ óÀ½À¸·Î ½Ç¸®¸é¼­ ±¹Á¦ÀûÀÎ ÁÖ¸ñÀ» ¹Þ°Ô µÇ¾ú´Ù.

ÀÌÈÄ 1998³â Vienna¿¡¼­ ¿­¸° World Congress of Gastroenterology¿¡¼­ consensus¸¦ ¸¸µé±â À§ÇÑ È¸ÀÇ°¡ ¿­·ÈÀ¸¸ç ±× °á°ú Vienna ºÐ·ù°¡ Á¦¾ÈµÇ¾ú°í ÇöÀç±îÁö °¡Àå ³Î¸® ÀÌ¿ëµÇ°í ÀÖ´Ù. 1998³â ÀÌÅ»¸®¾ÆÀÇ Padova¿¡¼­µµ consensus¸¦ À§ÇÑ È¸ÀÇ°¡ ¿­·ÈÀ¸¸ç ±× °á°ú Padova ºÐ·ù°¡ Á¦¾ÈµÇ¾ú´Âµ¥, Vienna ºÐ·ù¿¡ ºñÇÏ¿© ÀÌ¿ëµÇ´Â ºóµµ´Â ³·Àº µí ÇÏ´Ù. Padova ºÐ·ù¿¡¼­ÀÇ category´Â JRSGCÀÇ ±×·ì°ú °ÅÀÇ ´ëµîÇÑ °ÍÀ¸·Î, Padova ºÐ·ù´Â ÀϺ»ÀÇ °³³äÀ» ¼­¾ç¿¡¼­ °ÅÀÇ º¯ÇüÇÏÁö ¾Ê°í ¹Þ¾ÆµéÀÎ °ÍÀ¸·Î ÀÌÇØÇصµ ¹«¹æÇÒ Á¤µµ·Î À¯»çÇÏ´Ù.

Vienna ºÐ·ùÀÇ Á¦¾È¿¡ Âü¿©ÇÏ¿´´ø ÀϺΠ¿¬±¸ÀÚµéÀÌ 2000³â È«Äá¿¡¼­ ¿­¸° 11ȸ Asian Pacific Congress of Gastroenterology¿¡¼­ Vienna ºÐ·ù¸¦ ´Ù¼Ò º¯Çü½ÃŲ »õ·Î¿î ºÐ·ù¹ýÀ» Á¦¾ÈÇÏ¿´´Ù (¡°revised Vienna classification¡±). Vienna ºÐ·ù°¡ ¹ßÇ¥µÈ ÀÌÈÄ¿¡µµ ¼­¾ç°ú ÀϺ»¿¡¼­ º´¸®ÇÐÀûÀÎ Áø´Ü¿¡ Áö¼ÓÀûÀÎ Â÷ÀÌÁ¡ÀÌ ³ëÃâµÇ¾ú´Âµ¥, À̵éÀº high-grade adenoma/dysplasia¿Í intramucosal carcinoma¸¦ ÇÑ ±×·ìÀ¸·Î ¹­À½À¸·Î¼­ µ¿¼­¾çÀÇ Â÷À̸¦ ¾ø¾Ö°íÀÚ ÇÏ¿´´Ù. ±×·¯³ª ÀÌÇü¼º°ú ¾ÏÀ» ÇϳªÀÇ ±×·ìÀ¸·Î ¹­´Â´Ù´Â °ÍÀº ±âÁ¸ÀÇ °³³äÀ¸·Î´Â ¹Þ¾ÆµéÀ̱⠾î·Á¿î °ÍÀ¸·Î revised Vienna classificationÀÌ ³Î¸® »ç¿ëµÇÁö ¸øÇÏ°í ÀÖ´Â ÀÌÀ¯¶ó°í »ý°¢µÈ´Ù.

¾Æ·¡´Â ESD ÈÄ Àúµµ ¼±Á¾À¸·Î Æǵ¶µÈ Áõ·ÊµéÀÔ´Ï´Ù.

adenoma with low grade dysplasia

adenoma with low grade dysplasia

¾Æ·¡´Â 16mm °íµµ¼±Á¾ÀÔ´Ï´Ù.


4. Endoscopic diagnosis. ¼±Á¾/ÀÌÇü¼ºÀÇ ³»½Ã°æ Áø´Ü

Elevated type adenoma with pseudodepression (ESD pathology: 10 mm low grade dysplasia)

Elevated type adenoma

Elevated type adenoma

80¼¼ ¿©¼º. ¿ì¿¬È÷ ¹ß°ßµÈ Àúµµ¼±Á¾Àε¥ ¾î¶°ÇÑ Ä¡·á¸¦ ÃßõÇÒ °ÍÀΰ¡? °æ°ú°üÂû, ¼ÒÀÛ¼ú, ÀýÁ¦¼ú???

Á¶Á÷°Ë»ç¿¡¼­ adenoma with high grade dysplasia¿´À¸³ª EMR ÈÄ À§¾ÏÀ¸·Î Áø´ÜÀÌ ¹Ù²ï ¿¹

Depressed type adenoma. ¼­¾ç¿¡¼­´Â adenoma¶ó°í ºÎ¸£Áö ¾Ê´Â´Ù. flat/depressed typeÀÇ º´º¯µé ¼­¾ç¿¡¼­´Â dysplasia¶ó°í ºÎ¸¥´Ù.

6mm Àúµµ ¼±Á¾

¸ð¾çÀ» º¸°í ¾ÏÀÏ ¼öµµ ÀÖ°Ú´Ù »ý°¢ÇÏ¿´°í ESD °á°ú¸¦ È®ÀÎÇÏ¿´´Âµ¥ ÀÇ¿Ü·Î 1.4 cm Àúµµ ¼±Á¾À¸·Î ³ª¿ÔÀ½.

°íµµ¼±Á¾Àº µÇ°Ú´Ù ½Í¾ú´Âµ¥ Àúµµ¼±Á¾À¸·Î ³ª¿Ô½À´Ï´Ù.
Stomach, endoscopic submucosal dissection:
Tubular adenoma with low grade dysplasia
1. Location : angle, lesser curvature
2. Gross type : elevated
3. Size of adenoma : (1) longest diameter, 32 mm (2) vertical diameter, 17 mm
4. Resection margin : negative resection margins(N)

20¹Ð¸® °íµµ¼±Á¾ (ESD was done.)

Ÿ ÀÇ·á±â°ü¿¡¼­ ³»½Ã°æ ¹× Á¶Á÷°Ë»ç·Î Áø´ÜµÈ ¼±Á¾À̳ª Á¶±âÀ§¾Ï ȯÀÚÀÇ ³»½Ã°æ Ä¡·á Àü ³»½Ã°æ Àç°ËÀÌ ÇÊ¿äÇÒ±î¿ä? ù ³»½Ã°æ »çÁøÀ» °ËÅäÇÏ¿© °Ë»ç°¡ ÀûÀýÈ÷ ÀÌ·ç¾îÁ³°í º´¼Ò¿¡ ´ëÇÑ ¸íÈ®ÇÑ »çÁøÀÌ ÀÖÀ¸¸é Àç°ËÇÏÁö ¾Ê°í Áï½Ã ½Ã¼úÀ» ÇÕ´Ï´Ù. ±× °úÁ¤ Áß Á¾Á¾ Ãß°¡ º´º¯ÀÌ ¹ß°ßµË´Ï´Ù. ´ÙÇེ·´°Ô ù º´¼Ò¿Í Ãß°¡ º´¼Ò°¡ ¸Å¿ì °¡±î¿ì¸é ÇѲ¨¹ø¿¡ ÀýÁ¦Çϱ⵵ ÇÕ´Ï´Ù. °íµµ¼±Á¾À¸·Î ÀÇ·ÚµÈ È¯ÀÚÀÔ´Ï´Ù. ESD¸¦ Çϱâ Á÷Àü Ãß°¡ º´¼Ò¸¦ ¹ß°ßÇÏ¿´´Âµ¥, µÎ º´¼ÒÀÇ À§Ä¡°¡ ¸Å¿ì °¡±î¿ö ÇѲ¨¹ø¿¡ Ä¡·áÇÏ¿´°í ÃÖÁ¾ º´¸®°á°úµµ Àß ³ª¿Ô½À´Ï´Ù. "Tubular adenoma with high grade dysplasia. (1) 14 x 13 mm, (2) 10 x 8 mm, negative resection margins." ±×·±µ¥ óÀ½ »çÁøÀ» ÀÚ¼¼È÷ »ìÆ캸´Ï µÎ¹ø° º´¼Ò°¡ Èñ¹ÌÇÏ°Ô º¸¿´½À´Ï´Ù (³ë¶õ Á¡¼± È­»ìÇ¥). ¾Æ·¡ Áõ·Êµµ °ÅÀÇ µ¿ÀÏÇÑ °æ¿ì¿´½À´Ï´Ù. [2017-9-10]

°¡±îÀÌ ÀÖ´Â ¼±Á¾ µÎ°³¸¦ ÇѲ¨¹ø¿¡ Ä¡·á

¼±Á¾ ´Ü°è¸¦ Áö³ª À§¾ÏÀÌ µÇ´Â ºÎºÐÀÌ Àüü À§¾ÏÀÇ ¸î %ÀÎÁö ¸íÈ®ÇÏÁö ¾Ê½À´Ï´Ù. ºÐÈ­Çü À§¾ÏÀÇ ´ëºÎºÐÀÌ ¼±Á¾ ´Ü°è¸¦ °ÅÄ¥ °ÍÀ¸·Î ÃßÁ¤ÇÏ°í ÀÖÀ» »ÓÀÔ´Ï´Ù. ¹®Á¦´Â ¼±Á¾ÀÇ ÀÚ¿¬»ç°¡ ¸íÈ®ÇÏÁö ¾Ê´Ù´Â °ÍÀÔ´Ï´Ù. 11³â Àü adenoma with LGD·Î Áø´ÜµÇ¾ú°í, ³»½Ã°æ Ä¡·á¸¦ ±ÇÇßÀ¸³ª ȯÀÚ´Â ÃßÀû°üÂûÀ» ¿øÇϼ̰í, ´ë°­ 2³â °£°ÝÀ¸·Î ¸î ¹ø Á¶Á÷°Ë»ç¿¡¼­ °è¼Ö LGD·Î ³ª¿Ô´Ù°¡ 11³â ° Á¶Á÷°Ë»ç¿¡¼­ HGD·Î ³ª¿Ô½À´Ï´Ù. ESD¸¦ Çß½À´Ï´Ù. ºÐ¸í õõÈ÷ º¯ÇÏ´Â ¼±Á¾ÀÌ ÀÖ½À´Ï´Ù.
LC of mid antrum, ESD: Tubular adenoma with high grade dysplasia
1. Location : antrum, lesser curvature
2. Gross type : elevated
3. Size of adenoma : (1) longest diameter, 30 mm (2) vertical diameter, 15 mm
4. Resection margin : negative resection margins(N)

84¼¼ ³²¼ºÀÇ °ËÁø ³»½Ã°æ¿¡¼­ ¹ß°ßµÈ º´¼Ò¸¦ ESD·Î Ä¡·áÇß½À´Ï´Ù. 84¼¼¿¡¼­ °ËÁøÀÌ ÇÊ¿äÇÑÁö´Â Àǹ®ÀÌÁö¸¸ ÀÏ´Ü ¹ß°ßµÈ º´¼Ò´Â Ä¡·áÇÏÁö ¾ÊÀ» ¼ö ¾ø´Â °ÍÀÌ Çö½ÇÀÔ´Ï´Ù.
ESD: Tubular adenoma with high grade dysplasia
1. Location : mid body, lesser curvature
2. Gross type : elevated
3. Size of adenoma : (1) longest diameter, 30 mm (2) vertical diameter, 27 mm
4. Resection margin : negative resection margins(N)


ESD: Tubular adenoma with high grade dysplasia
1. Location : antrum, lesser curvature
2. Gross type : elevated
3. Size of adenoma : (1) longest diameter, 25 mm (2) vertical diameter, 24 mm
4. Resection margin : negative resection margins(N)

¿©ÀÚ 80¼¼ Àúµµ¼±Á¾ÀÔ´Ï´Ù. ¾î¶»°Ô Ä¡·áÇϽðڽÀ´Ï±î? Àú´Â ¼ÒÀÛ¼úÀ» ÃßõÇÏ¿´½À´Ï´Ù.

¿ÜºÎ Á¶Á÷°Ë»ç¿¡¼­ 'Áߵ ÀÌÇü¼º'À̶ó ÀÇ·ÚµÈ ºÐÀÔ´Ï´Ù. ºÒ±ÔÄ¢ÇÑ ÇÔ¸ôÇü º´¼ÒÀ̹ǷΠÀ§¾ÏÀÇ °¡´É¼ºµµ ÀÖ°Ú´Ù ½Í¾ú½À´Ï´Ù. ESD¸¦ ÇÏ¿´´Âµ¥ ÀÇ¿Ü·Î Àúµµ ¼±Á¾À¸·Î ³ª¿Ô½À´Ï´Ù. ¾Ë´Ù°¡µµ ¸ð¸¦ °ÍÀÌ ¼±Á¾ÀÔ´Ï´Ù. (ÁÂÃø ³»½Ã°æ »çÁøÀº contrast°¡ ³Ê¹« °­ÇÕ´Ï´Ù. ³»½Ã°æ ½Ã½ºÅÛÀÇ enhancement¸¦ ³·Ãç¾ß ÇÕ´Ï´Ù. Contrast°¡ °­Çϸé ÀÏ°ß Àß º¸ÀÌ´Â °Í °°Áö¸¸ subtleÇÑ »öÁ¶ º¯È­´Â ´Ù ³õÄ£´Ù°í º¸¸é µË´Ï´Ù. Àû´çÇÑ °ÍÀÌ ÃÖ¼±ÀÔ´Ï´Ù.)
ESD: adenoma with low grade dysplasia
1. Location : antrum, greater curvature
2. Gross type : elevated
3. Size of adenoma : (1) longest diameter, 18 mm (2) vertical diameter, 13 mm
4. Resection margin : negative resection margins(N)

À¶±âÇü ¼±Á¾. Near Focus·Î °üÂûÇÑ ÈÄ ESDÇÑ Àúµµ ¼±Á¾. À¶±â°¡ ¸ðµÎ ¼±Á¾Àº ¾Æ´Ï¾úÀ½


5. Clinical significance. ¼±Á¾/ÀÌÇü¼ºÀÇ ÀÓ»óÀû ÀÇÀÇ

¿ì¸®³ª¶ó¿¡¼­ À§ dysplasia´Â ¸Å¿ì ¸¹ÀÌ Áø´ÜµÇ°í ÀÖ½À´Ï´Ù (2018³â 18,717¸í, ½ÉÆò¿ø).

ÀÌÇü¼ºÀÇ ¿¹ÈÄ ¹× ÀÓ»óÀû ÀÇÀÇ¿¡ ´ëÇÑ Á¶¸ÁÀ» À§Çؼ­´Â ÀÌÇü¼ºÀÇ Á¶Á÷ÇÐÀûÀÎ Áø´Ü°ú ºÐ·ù¹ýÀÌ ¸íÈ®ÇÏ¿©¾ß ÇÑ´Ù. ±×·¯³ª, ¾Õ¼­ ¾ð±ÞÇÑ ¹Ù¿Í °°ÀÌ ÀÌÇü¼ºÀÇ º´¸®ÇÐÀû ºÐ·ùü°è°¡ ÃÖ±Ù±îÁöµµ °è¼ÓÇؼ­ º¯ÇüµÇ°í ÀÖÀ¸¹Ç·Î ±âÁ¸ÀÇ ¿¬±¸°á°ú¸¦ ÇöÀçÀÇ Ä¡·á¹æħ¿¡ ºÎÇÕÇϵµ·Ï ´Ù½Ã Çؼ®ÇÏ´Â ÀÏÀº ¸Å¿ì ¾î·Á¿î °úÁ¦°¡ µÇ°í ÀÖ´Ù.

ÀÌÇü¼º¿¡ ´ëÇÑ ³»½Ã°æ Á¡¸·ÀýÁ¦¼úÀ» ½ÃÇàÇÑ ÈÄ ÀýÁ¦µÈ º´º¯¿¡ ´ëÇÑ Á¶Á÷ÇÐÀû °Ë»ç°á°ú¿Í ½Ã¼ú Àü Á¶Á÷°Ë»ç °á°ú¸¦ ºñ±³ÇÑ ¿©·¯ ¿¬±¸ÀÇ °á°úµéÀ» »ìÆ캸¸é ÀÌÇü¼º¿¡ ´ëÇÑ Ä¡·á¿øÄ¢À» ¼¼¿ì´Âµ¥ µµ¿òÀÌ µÈ´Ù.

º» ±³½Ç¿¡¼­ ³»½Ã°æ Á¡¸·ÀýÁ¦¼úÀ» ½ÃÇàÇÑ È¯ÀÚÀÇ ½Ã¼ú Àü Á¶Á÷°Ë»ç °á°ú¿Í ½Ã¼ú ÈÄ Á¡¸·ÀýÁ¦¼ú º´¸®°á°ú¸¦ ºñ±³ÇØ º¸¾ÒÀ» ¶§, ÀúµµÀÌÇü¼ºÀÇ 1.0%¿¡¼­ ½Ã¼ú ÈÄ À§¾ÏÀ¸·Î Áø´ÜÀÌ ¹Ù²î¾ú°í °íµµÀÌÇü¼ºÀÇ 31.8%¿¡¼­ À§¾ÏÀ¸·Î Áø´ÜÀÌ ¹Ù²î¾ú´Ù. Á¶Á÷°Ë»çºÎÅÍ ³»½Ã°æ Á¡¸·ÀýÁ¦¼ú°£ÀÇ ±â°£ÀÌ Âª±â ¶§¹®¿¡ °íµµÀÌÇü¼ºÀÌ À§¾ÏÀ¸·Î ÁøÇàÇÏ¿´´Ù°í »ý°¢Çϱ⠺¸´Ù´Â óÀ½ºÎÅÍ À§¾ÏÀÌ ÀÖ¾úÀ¸³ª Á¶Á÷°Ë»ç ¼Ò°ß¸¸À¸·Î À§¾ÏÀ» Áø´ÜµÇÁö ¸øÇÏ¿´´ø °ÍÀ¸·Î ÆǴܵȴÙ. ÃÖ±Ù¿¡´Â ÀÌÇü¼º¿¡ ´ëÇÑ Á¶Á÷°Ë»çÀÇ Æǵ¶ ¿¹°¡ Áõ°¡Çϸ鼭 °íµµÀÌÇü¼ºÀÌ ³»½Ã°æ Á¡¸·ÀýÁ¦¼ú ÈÄ À§¾ÏÀ¸·Î Áø´ÜÀÌ º¯°æµÇ´Â °æ¿ì°¡ °¨¼ÒÇÏ°í ÀÖ´Ù.

±Ë¾çÀ» µ¿¹ÝÇÑ Àúµµ¼±Á¾ ??? --> °á±¹ ESD ÈÄ 3 cm °íµµ¼±Á¾ + 1 cm ¾ÏÀ¸·Î È®ÀεǾú½À´Ï´Ù. Á¶Á÷°Ë»ç°¡ Àúµµ¼±Á¾ÀÌ´õ¶óµµ ¸ð¾çÀÌ ÀÌ»óÇÏ¸é ¾ÏÀ» »ý°¢ÇØ¾ß ÇÕ´Ï´Ù.


[2019-11] ³»½Ã°æÇÐȸ¿¡¼­ ¹ßÇ¥µÈ Æ÷½ºÅÍ - Clinical outcomes of endoscopic resection for LGD and HGD on gastric pretreatment biopsy: Korea ESD Study Group

Introduction: Some cases of gastric low-grade dysplasias (LGDs) and high-grade dysplasias (HGDs) on forceps biopsy (FB) are diagnosed as gastric cancer (GC) after endoscopic resection (ER). This study aims to evaluate the clinical outcomes of ER for gastric LGD and HGD on pretreatment FB and factors predicting the pathologic upstage to GC. Patients and Methods: Patients who underwent ER for LGD and HGD on pretreatment FB from March 2005 to February 2018 in 14 hospitals in South Korea were enrolled, and medical records for the patients were reviewed retrospectively. Results: 2150 LGD and 1534 HGD diagnosed by pretreatment FB were enrolled. 589 cases of 2150 LGDs (27.4%) were diagnosed with GC after ER. Helicobacter pylori infection, smoking history, tumor location in middle third of stomach, tumor size > 10 mm, depressed lesion, and ulceration significantly predicted GC. 1129 cases of 1534 HGD (72.7%) were diagnosed with GC after ER. previous history of GC, Helicobacter pylori Infection, smoking history, tumor location in upper third of stomach, tumor size > 10 mm, depressed lesion and ulceration were significantly associated with GC. As the number of risk factors predicting GC increased in both LGD and HGD on pretreatment FB, the rate of upstage diagnosis to GC after ER increased. Conclusions; A substantial proportion of LGD and HGD on pretreatment FB were diagnosed as GC after ER. Accurate ER such as endoscopic submucosal dissection (ESD) should be recommended in cases of LGD and HGD with factors predicting pathologic upstage to GC.


[À§¾Ï 505 - ¼±Á¾ ESD ÈÄ À§¾ÏÀ¸·Î Áø´ÜÀÌ ¹Ù²ï Áõ·Ê]

¿ì¿¬È÷ ½ÃÇàÇÑ °ËÁø ³»½Ã°æ¿¡¼­ ÀüÁ¤ºÎ ´ë¸¸ÀÇ ¼±Á¾ÀÌ ¹ß°ßµÇ¾ú½À´Ï´Ù. ÀÇ·Ú Àü Á¶Á÷°Ë»ç Æǵ¶Àº "atypical gland proliferation , favoring adenoma, low grade dysplasia"¿´À¸¸ç ÀÇ·Ú ÈÄ ¿ÜºÎ½½¶óÀ̵å ÀçÆǵ¶ °á°ú´Â "adenoma, focal high grade dysplasia"¿´½À´Ï´Ù. Ç¥ÇöÀº ¾à°£ ´Ù¸£Áö¸¸ ³»¿ëÀº °ÅÀÇ ºñ½ÁÇÏ´Ù°í ÇÒ ¼ö ÀÖ½À´Ï´Ù. ¿ÜºÎ º´¸® ¼±»ý´ÔÀÇ Æǵ¶À» ÀÇ¿ªÇϸé 'Àúµµ ¼±Á¾Àε¥ gland°¡ ¾à°£ atypicalÇÏ´Ù (= Àúµµ ¼±Á¾ Ä¡°í´Â ¾à°£ ½ÉÇÏ´Ù)' Á¤µµ°¡ µÉ °ÍÀÌ°í, º» º´¿ø º´¸® ¼±»ý´ÔÀÇ Æǵ¶Àº '°íµµ ¼±Á¾Àε¥ focalÇÏ´Ù (= °íµµ ¼±Á¾ Ä¡°í´Â ¾à°£ ¾äÀüÇÏ´Ù)' Á¤µµÀÔ´Ï´Ù. µÎ ºÐ ¸ðµÎ Àúµµ ¼±Á¾°ú °íµµ ¼±Á¾ÀÇ Áß°£ ¾Æ´Ñ°¡ Á¤µµÀÇ Æǵ¶À» ÁֽŠ°ÍÀÔ´Ï´Ù.

Àúµµ ¼±Á¾ ESD ÈÄ À§¾ÏÀ¸·Î Áø´ÜÀÌ ¹Ù²î´Â °æ¿ì´Â 5-10%ÀÔ´Ï´Ù. °íµµ ¼±Á¾ ESD ÈÄ À§¾ÏÀ¸·Î Áø´ÜÀÌ ¹Ù²î´Â °æ¿ì´Â 33%-50%ÀÔ´Ï´Ù (EndoTODAY Diagnostic group classification). Àúµµ ¼±Á¾°ú °íµµ¼±Á¾ÀÇ Áß°£ Á¤µµ¶ó¸é ESD ÈÄ ¾ÏÀ¸·Î Áø´ÜÀÌ ¹Ù²ð °¡´É¼ºµµ ÀÌ Áß°£ ¾îµðÂëÀÏ °ÍÀÔ´Ï´Ù. ´ë·« 20% Á¤µµ?

ÀüüÀûÀ¸·Î 6.9% (141/2,041)°¡ down-grade µÇ°í 15.9% (324/2,041)°¡ up-grade µÇ¾ú½À´Ï´Ù. Diagnostic group classificationÀÌ ±×·¸°Ô ¹Ù²î¾ú´Ù´Â ÀǹÌÀÔ´Ï´Ù. (Lee JH. Surg Endosc 2016)

ESD¸¦ ½ÃÇàÇÏ¿´°í °á°ú´Â ¾Æ·¡¿Í °°¾Ò½À´Ï´Ù.


Stomach, endoscopic submucosal dissection:
. Early gastric carcinoma
1. Location : antrum, greater curvature
2. Gross type : EGC type IIa
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 11 mm (2) vertical diameter, 10 mm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 10 mm, proximal 10 mm, anterior 8 mm, posterior 16 mm
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

°ú°Å 4¹Ú 5ÀÏ CP(clinical pathway)·Î ½Ã¼úÇÒ ¶§¿¡´Â Åð¿ø Àü º´¸®°á°ú°¡ ³ª¿Ô½À´Ï´Ù. Á¤ºÎÀÇ ÀÔ¿ø±â´Ü ´ÜÃà ¾Ð·ÂÀ¸·Î ÀÎÇÏ¿© CP¸¦ 3¹Ú 4ÀÏ·Î ¹Ù²Û Èķδ Åð¿ø Àü º´¸®°á°ú°¡ ³ª¿ÀÁö ¾Ê±â ¶§¹®¿¡ ¿Ü·¡¿¡¼­ ¼³¸íÀ» ÇÏ°í ÀÖ½À´Ï´Ù. Àú´Â ¾Æ·¡¿Í °°ÀÌ ¼³¸íÇÏ¿´½À´Ï´Ù. »çÀü¿¡ ¾Ï °¡´É¼ºÀ» ÃæºÐÈ÷ ¾Ë·Áµå·È±â ¶§¹®¿¡ ȯÀÚ°¡ Å©°Ô ³î¶ó´Â ÀÏÀº °ÅÀÇ ¾ø½À´Ï´Ù.


6. Treatment. ¼±Á¾/ÀÌÇü¼ºÀÇ Ä¡·á

À§ ¼±Á¾/ÀÌÇü¼º(adenoma/dysplasi)¿¡ ´ëÇÑ Ä¡·á¹æ¹ý Áß °¡Àå Àû±ØÀûÀÎ ¹æ¹ýÀº À§ÀýÁ¦¼úÀÌÁö¸¸ ÃÖ±Ù¿¡´Â °ÅÀÇ »ç¿ëµÇ´Â ¿¹°¡ ¾øÀ¸¸ç, ´ëºÎºÐ ³»½Ã°æÀ» ÀÌ¿ëÇÑ Ä¡·á°¡ ÀÌ¿ëµÇ°í ÀÖ½À´Ï´Ù. À§¾ÏÀÇ °æ¿ì¿¡ ³»½Ã°æÁ¡¸·ÀýÁ¦¼úÀº ºñ·Ï Àå±â°£ÀÇ ÃßÀû°üÂû ¼ºÀûÀÌ ºÎÁ·ÇÏ°í ½Ã¼úÀÚ¸¶´Ù °¢±â ´Ù¸¥ Ä¡·á¹æ¹ýÀÌ »ç¿ëµÇ°í ÀÖ´Ù´Â ÇÑ°è´Â ÀÖÀ¸³ª, ÀûÀÀÁõÀ» ¸¸Á·ÇÏ´Â ÀϺΠÁ¶±âÀ§¾ÏÀÇ ±ÙÄ¡Àû Ä¡·á¹ýÀÇ Çϳª·Î ÀÎÁ¤µÇ°í ÀÖ½À´Ï´Ù.

ƯÈ÷ ³»½Ã°æÁ¡¸·ÇÏÀýÁ¦¼ú(ESD: endoscopic submucosal dissection) ¹æ¹ýÀÌ µµÀԵǸ鼭, °ú°Åº¸´Ù´Â ÈξÀ Å« º´º¯¿¡ ´ëÇÑ ÀÏ°ýÀýÁ¦°¡ °¡´ÉÇØÁö¸é¼­ ³»½Ã°æÄ¡·áÀÇ ÀûÀÀÁõÀ» ³ÐÇô°¡´Â Ãß¼¼ÀÔ´Ï´Ù. ÀÌÇü¼ºÀÇ °æ¿ì¿¡´Â ¾î¶°ÇÑ ³»½Ã°æ Ä¡·á¹ýÀÌ ÃÖ¼±ÀÇ ¹æ¹ýÀÎÁö¿¡ ´ëÇÑ ÅëÀÏµÈ ÀÇ°ßÀÌ ¾øÀ¸³ª, ³»½Ã°æ Ä¡·áÀÇ ÀûÀÀÁõÀÌ µÇ´Â À§¾Ï°ú °íµµÀÌÇü¼ºÀÇ »ý¹°ÇÐÀûÀΠƯ¼ºÀÌ Å©°Ô ´Ù¸£Áö ¾Ê´Ù´Â °üÁ¡¿¡¼­ µ¿ÀÏÇÑ Ä¡·á¹ýÀ» Àû¿ëÇÏ´Â °ÍÀÌ ÀϹÝÀûÀÔ´Ï´Ù. ±×·¯³ª, ÀÌÇü¼º¿¡ ´ëÇÑ ³»½Ã°æÄ¡·á¿¡ À־ ¾ÆÁ÷±îÁö ÇØ°áµÇ¾î¾ß ÇÒ ¸¹Àº °úÁ¦°¡ ³²¾ÆÀÖ½À´Ï´Ù.

(1) °íµµÀÌÇü¼º¿¡ ´ëÇؼ­ ³»½Ã°æÄ¡·á¸¦ ½ÃµµÇÏ´Â °ÍÀº ÀϹÝÀûÀ¸·Î ÀÎÁ¤µÇ°í ÀÖÀ¸³ª, ÀúµµÀÌÇü¼ºµµ Àû±ØÀûÀ¸·Î Ä¡·á¸¦ ÇÒ °ÍÀÎÁö ȤÀº À§ÇèÀÎÀÚ¸¦ µ¿¹ÝÇÑ ÀúµµÀÌÇü¼º¸¸À» ¼±ÅÃÀûÀ¸·Î Ä¡·áÇÒ °ÍÀÎÁö¿¡ ´ëÇÑ ³íÀÇ°¡ Áö¼ÓµÇ°í ÀÖ½À´Ï´Ù. 2014³â ¸®ºä(°Ç±¹´ë À̼±¿µ)¿¡¼­ ¾ð±ÞµÈ ¹Ù ÀÖµíÀÌ ¿ì¸®³ª¶ó¿Í ÀϺ»ÀÇ º´¸®ÇÐÀû Áø´Ü±âÁØ Â÷ÀÌ¿¡ µû¸¥ È¥¶õÀÌ »ó´çÇÕ´Ï´Ù. ÀÌ À̽´°¡ Á¦±âµÈ °ÍÀÌ 20³âÀÌ ³Ñ¾úÁö¸¸ ¾ÆÁ÷µµ °ÅÀÇ Á¼ÇôÁöÁö ¾ÊÀº °Í °°½À´Ï´Ù. ¿ì¸®³ª¶ó¿¡¼­´Â ¿ì¸®³ª¶ó º´¸®ÀÇ»çÀÇ ±âÁØ¿¡ µû¶ó Ä¡·á¹ýÀ» ¼±ÅÃÇÒ ¼ö ¹Û¿¡ ¾ø´Ù°í »ý°¢ÇÕ´Ï´Ù.

°í·É ȯÀÚ¿¡¼­ Àúµµ ¼±Á¾ÀÌ°í ³»½Ã°æ ¼Ò°ßÀÌ À¶±âÇüÀÌ°í paleÇÑ °æ¿ì´Â Á¶½É½º·´°Ô °æ°ú°üÂûÀ» ÇÒ ¼ö ÀÖ´Ù°í »ý°¢ÇÕ´Ï´Ù. ¹°·Ð ¼ÒÀÛ¼ú·Î °£´ÜÈ÷ Ä¡·áÇÒ ¼ö Àֱ⵵ ÇÏÁö¸¸...

15³â ÀÌ»ó °æ°ú°üÂû ÁßÀÎ Àúµµ ¼±Á¾. ¸ð¾çÀÌ Á¶±Ý ¹Ù²ï °ÍÀº ÀæÀº Á¶Á÷°Ë»ç ¶§¹®Àº ¾Æ´Ñ°¡ ÃßÁ¤µÇ¾ú½À´Ï´Ù.

(2) ¼ÒÀÛ¼ú: ¼±Á¾¿¡ ´ëÇÑ Ç¥ÁØÀûÀÎ Ä¡·á¹ýÀÇ ³»½Ã°æ ÀýÁ¦¼úÀÌÁö¸¸ °£È¤ ³»½Ã°æ ¼ÒÀÛ¼úµµ »ç¿ëµÇ°í ÀÖ½À´Ï´Ù. ±×·¯³ª Ä¡·á¹ý ¼±ÅÃÀÇ ±âÁØÀº ¿©ÀüÈ÷ ºÒ¸íÈ®ÇÕ´Ï´Ù. ¼ÒÀÛ¼úÀº ÀýÁ¦¼ú¿¡ ºñÇÏ¿© ºñ±³Àû ¾ÈÀüÇϸç, ÀÔ¿øÀ» ÇÏÁö ¾Ê°í ¿Ü·¡¿¡¼­ ½ÃÇàÇϱ⵵ Çϸç, ¾Æ¸£°ï ÇöóÁ ÀÀ°í¼ÒÀÛ¼úÀ̶ó´Â ±â¼úÀûÀÎ ³­À̵µ°¡ ³ôÁö ¾ÊÀº ¹æ¹ýÀ̹ǷΠÃÖ±Ù ±× ÀÌ¿ë ºóµµ°¡ Áõ°¡ÇÏ°í ÀÖ½À´Ï´Ù. ±×·¯³ª ¼ÒÀÛ¼úÀº Ä¡·áÇÑ º´º¯¿¡ ´ëÇÑ ¿ÏÀüÇÑ Á¶Á÷ÇÐÀûÀÎ °ËÅä°¡ ºÒ°¡´ÉÇϸç, ƯÈ÷ ¾Æ¸£°ï ÀÀ°í ¼ÒÀÛ¼úÀÇ °æ¿ì ±âÁ¸ÀÇ Àü±âÀÀ°í¼ÒÀÛ¼úÀ̳ª ·¹ÀÌÀú¼ÒÀÛ¼ú¿¡ ºñÇÏ¿© Á¶Á÷ÀÌ Æı«µÇ´Â ±íÀÌ°¡ ¾è´Ù´Â ´ÜÁ¡µµ ÀÖÀ¸¹Ç·Î, À§ÇèÀÎÀÚ°¡ ¾ø´Â ÀúµµÀÌÇü¼º ÀÌ¿ÜÀÇ °íµµÀÌÇü¼º¿¡ ´ëÇÑ ¼ÒÀÛ¼úÀº ´Ù¼Ò À§ÇèÇÏ´Ù°í »ý°¢ÇÕ´Ï´Ù.

Àúµµ ¼±Á¾À» ÀýÁ¦ÇÑ ÈÄ °íµµ¼±Á¾À¸·Î ¹Ù²î´Â ¿¹°¡ ÀÖ½À´Ï´Ù. ±×·¯³ª ÀÛ°í ÇϾé°í ³³ÀÛÇÏ°í ±Ë¾çÀÌ ¾ø´Â Àúµµ¼±Á¾ÀÌ ½Ã¼ú ÈÄ °íµµ¼±Á¾À¸·Î ¹Ù²î´Â ¿¹´Â °ÅÀÇ ¾ø½À´Ï´Ù. ÀÛ°í ÇϾé°í ³³ÀÛÇÏ°í ±Ë¾çÀÌ ¾ø´Â Àúµµ¼±Á¾¿¡ ´ëÇÏ¿© APC ablationÀ» ÇÒ ¼ö ÀÖ´Ù°í »ý°¢ÇÕ´Ï´Ù.

ÀÌ Á¤µµ Àúµµ ¼±Á¾ÀÌ¸é ¼ÒÀÛ¼ú·Î Ä¡·áÇÏ°í ÀÖ½À´Ï´Ù.

APC ablation for gastric low grade adenoma (½Ã¼ú Àå¸éÀ» serial·Î º¸½Ã·Á¸é ±×¸²À» Ŭ¸¯Çϼ¼¿ä.)

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¼ÒÀÛ¼ú(APC ablation)Àº ÈçÈ÷ °£´ÜÇÑ Ä¡·á·Î °£ÁֵǴ °æÇâÀÌ ÀÖ½À´Ï´Ù. ´ëºÎºÐ ¿Ü·¡ ±â¹ÝÀ¸·Î Ä¡·á°¡ µË´Ï´Ù. ±×·¯³ª µå¹°°Ô ÃâÇ÷À» ÇÏ´Â °æ¿ì°¡ ÀÖ½À´Ï´Ù. »ý°¢º¸´Ù mucosal destructionÀÌ Å©°í ±í±â ¶§¹®ÀÔ´Ï´Ù. Local controlÀº Àß µÈ´Ù´Â ÀǹÌÀ̱⵵ ÇÕ´Ï´Ù¸¸... µû¶ó¼­ ½Ã¼úÀ» Çϱâ Àü¿¡´Â ´Ã ÃâÇ÷ À§ÇèÀ» ¼³¸íÇØ¾ß ÇÕ´Ï´Ù.

APC ÈÄ delayed bleedingÀ» º¸ÀÎ Áõ·Ê

2022³â Gut and Liver Áö¿¡ ¾Æ»êº´¿ø¿¡¼­ APC ÈÄ ÃâÇ÷ÀÇ ¹ß»ý·üÀ» ºÐ¼®ÇÑ º¸°í°¡ ÀÖ¾ú½À´Ï´Ù (Gut Liver 2022). ÃâÇ÷·üÀº 2.4%¿´½À´Ï´Ù. Ç×Ç÷ÀüÁ¦ Åõ¾à À¯¹«¿Í ÃâÇ÷·ü »çÀÌ¿¡´Â À¯ÀÇÇÑ »ó°ü°ü°è°¡ ¾ø¾ú½À´Ï´Ù. ÀûÀýÈ÷ ²÷¾ú±â ¶§¹®À¸·Î ÃßÁ¤µË´Ï´Ù.

APC ÈÄ ÃâÇ÷ ½ÃÁ¡

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À§¾ÏÀ̳ª À§¼±Á¾ÀÌ ÀÖ´Â ºÐ¿¡¼­ ´ëÀå¾ÏÀ̳ª ´ëÀå ¼±Á¾µµ Àß »ý±ä´Ù°í ÇÕ´Ï´Ù. µû¶ó¼­ ¾ÆÁ÷ °Ë»ç¸¦ ¹ÞÁö ¾ÊÀ¸¼Ì´Ù¸é ´ëÀå³»½Ã°æ °Ë»ç¸¦ ²À ¹Þ¾Æº¸½Ê½Ã¿ä.

(3) ÀýÁ¦¼ú: À§¼±Á¾ Áß Á¶Á÷ÇüÀÌ °íµµ ¼±Á¾ÀÌ°í³ª Àúµµ ¼±Á¾ÀÌ¶óµµ Å©±â°¡ Å« °æ¿ì, ÇÔ¸ôºÎ°¡ ÀÖ´Â °æ¿ì µî¿¡¼­´Â ÀýÁ¦¼úÀÌ ½ÃÇàµÇ°í ÀÖ½À´Ï´Ù. ESD°¡ °¡Àå ÁÁÀº ¹æ¹ýÀÌÁö¸¸ Á¦µµÀûÀÎ ÀÌÀ¯·Î EMRÀÌ ½ÃÇàµÇ±âµµ ÇÕ´Ï´Ù. Àú¾ß ¹°·Ð ESD¸¦ ¼±È£ÇÏ°í ÀÖ½À´Ï´Ù.

Stomach: Posterior wall of low body, ESD: Tubular adenoma with low grade dysplasia
1. Location : low body, posterior wall
2. Gross type : elevated
3. Size of adenoma : (1) longest diameter, 9 mm (2) vertical diameter, 8 mm
4. Resection margin : negative resection margins(N)

Àúµµ¼±Á¾ÀÌ¶óµµ Å©¸é ÀýÁ¦¼ú·Î Ä¡·áÇØ¾ß ÇÕ´Ï´Ù.

°íµµ¼±Á¾Àº Å©±â¿Í ¹«°üÇÏ°Ô ¿ì¼±ÀûÀ¸·Î ÀýÁ¦¼úÀ» ¼±ÅÃÇÏ´Â °ÍÀÌ ¾ÈÀüÇÕ´Ï´Ù.

°íµµ¼±Á¾ ³»½Ã°æÄ¡·á¸¦ °í·ÁÇϴ ȯÀÚ¿¡ ´ëÇÑ ¾î¶² ±³¼ö´ÔÀÇ ¼³¸í¼­ (2018). ¾ÏÀ¸·Î Áø´ÜÀÌ upgrade µÉ È®·ü, ¼ö¼úÀÌ ÇÊ¿äÇÏ´Ù´Â °á°ú°¡ ³ª¿Ã È®·ü, À̼Ҽº º´¼ÒÀÇ À§Çè¿¡ ´ëÇÑ ¼³¸íÀÌ Àß µÇ¾î ÀÖ½À´Ï´Ù.

¸¸¼º½ÅºÎÀüÀ¸·Î Åõ¼® ÁßÀΠȯÀÚÀÇ KT workup µµÁß ¹ß°ßµÈ °íµµ¼±Á¾¿¡ ´ëÇÑ ESD.
Stomach, endoscopic submucosal dissection:
Tubular adenoma with high grade dysplasia
1. Location : prepyloric antrum, posterior wall
2. Gross type : depressed
3. Size of adenoma : (1) longest diameter, 12 mm (2) vertical diameter, 5 mm
4. Resection margin : negative resection margins(N)

À§¾Ï ÀǽÉÀ¸·Î Á¶Á÷°Ë»ç¸¦ ÇÏ¿© °íµµ¼±Á¾ÀÌ ³ª¿ÔÀ½. EUS¿¡¼­ SM invasion Àǽɵȴٰí ÇÏ¿© ÃÑ 4¹øÀÇ Á¶Á÷°Ë»ç¸¦ ÇÏ¿´´Âµ¥ ¾ÏÀ¸·Î ³ª¿ÀÁö ¾Ê¾Æ Áø´Ü¸ñÀûÀÇ ESD°¡ ±ÇÀ¯µÇ¾î ÀÇ·ÚµÊ. ¾Æ·¡ »çÁø°ú °°ÀÌ ½Ã¼úÇÏ¿´À½. (2018³â, ¿©ÀÚ 60¼¼)


ESD: Tubular adenoma with high grade dysplasia
1. Location : body, anterior wall-lesser curvature
2. Gross type : flat
3. Size of adenoma : (1) longest diameter, 16 mm (2) vertical diameter, 14 mm
4. Resection margin : negative resection margins(N)

ÀÛÀº À¶±âÇü º´¼ÒÀε¥ Á¶Á÷°Ë»ç¿¡¼­ high grade dysplasia·Î ³ª¿Í ESD¸¦ ÇÏ¿´°í 6mm HGD·Î ÃÖÁ¾ °á·Ð (¾Æ·¡ º´¸® »çÁø ÂüÁ¶)

(4) ¾Ï Ä¡·áÀÇ ÀϹÝÀûÀÎ ¿øÄ¢¿¡ µû¶ó Á¶±âÀ§¾ÏÀÇ °æ¿ì¿¡´Â ´Ù¼Ò°£ÀÇ À§Ç輺ÀÌ ÀÖ´Ù°í ÇÏ´õ¶óµµ ÀÏ°ýÀýÁ¦¸¦ À§ÇÏ¿© ³ë·ÂÇÏ´Â °ÍÀº Á¤´çÈ­µÉ ¼ö ÀÖ½À´Ï´Ù. µû¶ó¼­ Á¶±âÀ§¾Ï ȯÀÚ¿¡¼­´Â ³»½Ã°æÁ¡¸·ÇÏÀýÁ¦¼ú(ESD)°ú °°Àº Àû±ØÀûÀÎ Ä¡·á¸¦ ÅëÇÏ¿© ÃæºÐÇÑ ÀýÁ¦¿¬À» È®º¸Çϸ鼭 ÀÏ°ýÀýÁ¦¸¦ ÇÒ ¼ö ÀÖ´Â ½Ã¼ú¹ýÀÌ ³Î¸® ÀÌ¿ëµÇ°í ÀÖ½À´Ï´Ù. ±×·¯³ª Á¶Á÷ÇÐÀûÀ¸·Î ¾ÏÀ¸·Î È®ÀεÇÁö ¾ÊÀº ÀÌÇü¼º º´º¯¿¡ ´ëÇؼ­µµ Á¶±âÀ§¾ÏÀÇ Ä¡·á¿¡ »ç¿ëµÇ´Â ¸ðµç ¹æ¹ýÀÌ µ¿ÀÏÇÏ°Ô Àû¿ëµÇ¾î¾ß ÇÏ´ÂÁö´Â ¸íÈ®ÇÏÁö ¾Ê½À´Ï´Ù. ESD °æÇèÀÌ ¸¹Àº ½Ã¼úÀÚ´Â ºñ±³Àû ÀÛÀº ¼±Á¾µµ ESD·Î Ä¡·áÇÏ´Â °æÇâÀÌ°í, ESD ÃʽÉÀÚ´Â Á¶±Ý Å« º´¼Òµµ EMR·Î Ä¡·áÇÏ´Â µî ½Ã¼úÀÚÀÇ °æÇè¿¡ µû¸¥ Ä¡·á¹æ¹ý ¼±Åÿ¡ Â÷ÀÌ°¡ ÀÖ½À´Ï´Ù. Àú´Â ÀÇ»çµéÀÌ ÀÚ½ÅÀÇ °æÇè°ú ½Ä°ßÀ» ¹ÙÅÁÀ¸·Î ÃÖ¼±ÀÇ Ä¡·á¹ýÀ» ¼±ÅÃÇϵµ·Ï À¶Å뼺À» ÀÎÁ¤ÇÏ´Â °ÍÀÌ ÁÁÀ» °ÍÀ¸·Î »ý°¢ÇÕ´Ï´Ù. 2018³â ¸» °³Á¤µÈ ESD ±âÁØ¿¡¼­´Â 1.5cm ÀÌÇÏÀÇ ¼±Á¾¿¡ ´ëÇÑ ESD°¡ ÀÎÁ¤µÇÁö ¾Ê°í ÀÖ½À´Ï´Ù. ÀÇ»çÀÇ Ä¡·á¹ý ¼±Åà ¹üÀ§¸¦ Å©°Ô À§Ãà½ÃÅ°°í ÀÖ´Â ÁÁÁö ¾ÊÀº ±âÁØÀ̹ǷΠ´çÀå º¯°æµÇ¾î¾ß ÇÕ´Ï´Ù. 1.5cm ÀÌÇÏÀÇ ¼±Á¾ ESD ÈÄ Á¶±âÀ§¾ÏÀ¸·Î ³ª¿Â °æ¿ì´Â ÀûÁö ¾ÊÀ¸¸ç, ±× Áß ÀϺδ ù Á¶Á÷°Ë»ç¿¡¼­ Àúµµ ¼±Á¾À̾ú½À´Ï´Ù (¾Æ·¡ Áõ·Ê ÂüÁ¶). 2018³â ¸» °³Á¤µÈ ±âÁØ¿¡ µû¶ó EMR·Î Ä¡·áÇÏ¿´´õ¶ó¸é ´Ù¼Ò Ä¡·á°¡ ºÒÃæºÐÇÏ¿´À» °¡´É¼ºÀÌ ÀÖ½À´Ï´Ù.

Àúµµ ¼±Á¾ ESD ÈÄ Á¶±âÀ§¾Ï ¿ÏÀüÀýÁ¦·Î ³ª¿È.
Stomach, endoscopic submucosal dissection:
Early gastric carcinoma
1. Location : proximal antrum, postero-greater curvature
2. Gross type : EGC type IIa
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 10 mm (2) vertical diameter, 8 mm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin : free from carcinoma(N) - safety margin : distal 6 mm, proximal 5 mm, anterior 8 mm, posterior 8 mm
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

(5) ±¹³»¿¡¼­´Â ³»½Ã°æ°Ë»ç°¡ Àú·ÅÇÏ°í °Ç°­°ËÁøÀÌ Æø ³Ð°Ô ½ÃÇàµÇ°í Àֱ⠶§¹®¿¡ °ÇÁø¼¾ÅÍ ¹× ÀÏÂ÷ÀÇ·á±â°ü¿¡¼­ ³»½Ã°æ°Ë»ç¸¦ ÅëÇÏ¿© ÀÌÇü¼ºÀÌ Áø´ÜµÇ´Â °æ¿ì°¡ ´Ã°í ÀÖ½À´Ï´Ù. ±×·¯³ª ´ëºÎºÐÀÇ ÀÌÇü¼ºÀº ÀÛÀº À¶±â¼º ȤÀº ÇÔ¸ô¼º º´º¯À̹ǷÎ, ù °Ë»ç½ÃÀÇ ÀÚ¼¼ÇÑ Á¤º¸°¡ Àü´ÞµÇÁö ¾ÊÀ¸¸é ´Ù½Ã ½ÃÇàÇÑ ³»½Ã°æ °Ë»ç¿¡¼­ Á¤È®ÇÑ º´¼ÒÀÇ À§Ä¡¸¦ ãÁö ¸øÇÏ´Â °æ¿ì°¡ ¹ß»ýÇÒ ¼ö ÀÖ½À´Ï´Ù. ÀÌÇü¼ºÀÇ Ä¡·á¸¦ À§ÇÏ¿© ÀǷڵǾúÀ¸³ª º´¼Ò¸¦ ãÁö ¸øÇÑ °æ¿ì¿¡ indigocarmine°ú °°Àº »ö¼Ò¸¦ »ìÆ÷ÇÏ¸é µµ¿òÀÌ µÈ´Ù´Â ÁÖÀåµµ ÀÖÀ¸³ª, ¸¸¼ºÀ§Ã༺ À§¿°¿¡ ÀÇÇÏ¿© Ç¥¸éÀÌ ÆòźÇÏÁö ¾ÊÀº À§¿¡¼­ À°¾ÈÀûÀ¸·Î ÀÚ¼¼È÷ °üÂûÇÏ¿© ¹ß°ßµÇÁö ¾Ê¾Ò´ø ÀÌÇü¼º ºÎÀ§¸¦ »ö¼ÒÀÇ µµ¿òÀ» ¹Þ¾Æ¼­ ¹ß°ßÇÏ´Â °ÍÀº ¸Å¿ì ¾î·Á¿î ÀÏÀÔ´Ï´Ù. µû¶ó¼­ ÀÌÇü¼ºÀÇ È¿°úÀûÀÎ ³»½Ã°æÄ¡·á¸¦ À§Çؼ­´Â ù ³»½Ã°æ °Ë»ç¿¡¼­ ¹ß°ßµÈ º´¼ÒÀÇ À§Ä¡, Å©±â, ¸ð¾çÀ» Á¤È®È÷ ±â·ÏÇÏ´Â ½À°üÀÌ ÇÊ¿äÇϸç, ȯÀÚ¸¦ ÀÇ·ÚÇÒ ¶§¿¡´Â °¡±ÞÀû ¿µ»óÁ¤º¸¿Í ÇÔ²² ÀÚ¼¼ÇÑ ÀڷḦ ÇÔ²² º¸³»±â À§ÇÑ ³ë·ÂÀÌ ÇÊ¿äÇÕ´Ï´Ù.

(6) ³»½Ã°æ ½Ã¼úÀÇ¿Í º´¸®ÀÇ»ç¿ÍÀÇ È°¹ßÇÑ ÀÇ°ß±³È¯µµ Áß¿äÇÑ °úÁ¦ÀÇ ÇϳªÀÔ´Ï´Ù. ¼­·ÎÀÇ ´«³ôÀ̸¦ ¸ÂÃß·Á´Â ´Ù¾çÇÑ ½Ãµµ¿¡µµ ºÒ±¸ÇÏ°í ¾ÆÁ÷µµ ¼­±¸¿Í ÀϺ»ÀÇ º´¸®ÇÐÀÚµéÀÌ µ¿ÀÏÇÑ ±âÁØÀ¸·Î À§¾Ï°ú ÀÌÇü¼ºÀÇ Áø´ÜÀ» ³»¸®°í ÀÖÁö ¸øÇÏ´Ù´Â Æò°¡°¡ ÀϹÝÀûÀÔ´Ï´Ù. ±¹³»¿¡¼­µµ ÀÌ¿Í ºñ½ÁÇÑ Æò°¡°¡ ÀÌ·ç¾îÁø´Ù¸é ȯÀÚÀÇ Áø´Ü°ú Ä¡·á¿¡ Å©°Ô µµ¿òÀÌ µÉ °ÍÀ¸·Î »ý°¢µÈ´Ù. ³»½Ã°æ ÀÇ»ç´Â º´¸® ¼Ò°ß¿¡ ´ëÇÏ¿© ¾î´À Á¤µµÀÇ ÀÌÇØ°¡ ÀÖ¾î¾ß ÇÕ´Ï´Ù (EndoTODAY À§Àå°ü º´¸®).


7. Cancer after ESD for adenoma with high grade dysplasia


½Ã¼ú Àü Á¶Á÷°Ë»ç: °íµµ¼±Á¾
Stomach, ESD :
Early gastric carcinoma
1. Location : proximal antrum, lesser curvature
2. Gross type : EGC type IIa+IIc
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 52 mm (2) vertical diameter, 19 mm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin : free from carcinoma(N); safety margin : distal 9 mm, proximal 9 mm, anterior 8 mm, posterior 10 mm, deep 1800 §­
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

À§¾Ï 643
Cardia, ESD: Early gastric carcinoma
1. Location : cardia, lesser curvature
2. Gross type : EGC type IIb
3. Histologic type : tubular adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 20 mm (2) vertical diameter, 13 mm
6. Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 6 mm, proximal 2 mm, anterior 10 mm, posterior 12 mm, deep 900 §­
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

°íµµ ¼±Á¾À¸·Î ESD ÈÄ Á¶±âÀ§¾Ï ¿ÏÀüÀýÁ¦·Î ³ª¿È.
- Histologic type : tubular adenocarcinoma, moderately differentiated
- Size : 1.6x0.7x0.05 cm
- Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
- Resection margin: free from carcinoma (safety margin: distal 1.2 cm, proximal 1 cm, anterior 1.4 cm, posterior 1.4 cm)
- Lymphatic invasion : not identified
- Venous invasion : not identified

High grade dysplasia¶ó´Â Á¶Á÷°Ë»ç °á°ú·Î ÀÇ·ÚµÈ È¯ÀÚÀÔ´Ï´Ù. Olympus ³»½Ã°æÀ̾ú½À´Ï´Ù. ±×·¯³ª ÇÔ¸ôÇü º´¼ÒÀÇ Å©±â¿Í °æ°è¸¦ »ìÆ캸¾ÒÀ» ¶§ À§¾ÏÀÇ °¡´É¼ºÀÌ ³ô´Ù°í ÆǴܵǾú½À´Ï´Ù.
ESD¸¦ ½ÃÇàÇÏ¿´½À´Ï´Ù. Pentax ³»½Ã°æÀ̾ú½À´Ï´Ù.
ESD: Early gastric carcinoma
1. Location : antrum, lesser curvature-posterior 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, 20 mm (2) vertical diameter, 15 mm
6. Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 7 mm, proximal 9 mm, anterior 8 mm, posterior 24 mm, deep 800 §­
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent
13. Associated finding: Gastritis cystica

°íµµ¼±Á¾À¸·Î ÀǷڵǾî ESD ÇÏ¿´°í 4mm LP ¾ÏÀ¸·Î ³ª¿È

À§ ȯÀÚÀÇ º´¸®

À§ ȯÀÚÀÇ º´¸®


8. Cancer after ESD for adenoma with low grade dysplasia

°Ç°­°ËÁø¿¡¼­ ¿ì¿¬È÷ ¹ß°ßµÈ r/o EGC¿¡ ´ëÇÏ¿© Á¶Á÷°Ë»ç¸¦ ½ÃÇàÇÏ¿© adenoma with low grade dysplasia°¡ ³ª¿Ô°í 1´Þ ÈÄ ÃßÀû³»½Ã°æ Á¶Á÷°Ë»ç¿¡¼­ À§¾ÏÀ¸·Î ³ª¿Í ÀÇ·ÚµÈ È¯ÀÚÀÔ´Ï´Ù. º´¼Ò´Â ÀüÁ¤ºÎ ¼Ò¸¸ÀÇ angle Á÷ÇϺο¡ À§Ä¡ÇÏ°í ÀÖ¾ú°í ESD¸¦ ½ÃÇàÇÏ¿© complete resectionÀ̶ó´Â º´¸® °á°ú¸¦ ¾ò¾ú½À´Ï´Ù.

À°¾È¼Ò°ß¿¡¼­ À§¾ÏÀÌ ÀǽɵǾú°í Á¶Á÷°Ë»ç¿¡¼­ adenoma°¡ ³ª¿Â °æ¿ì¿¡´Â (1) short-term follow upÀ» Çϰųª (2) ³»½Ã°æÀû ÀýÁ¦¼úÀ» ½ÃÇàÇÒ ¼ö ÀÖ½À´Ï´Ù. Short-term follow up¿¡¼­ ¾ÏÀÌ ³ª¿À¸é Áø´ÜÀÌ ³¡³ªÁö¸¸, ¾ÏÀÌ ³ª¿ÀÁö ¾Ê´Â °æ¿ì´Â Ä¡·á¹æħ °áÁ¤ÀÌ ¸ðÈ£ÇØÁú ¼ö ÀÖ½À´Ï´Ù. µû¶ó¼­ Àú´Â ¾Ö¸ÅÇÑ °á°ú°¡ ³ª¿Ã ¼ö ÀÖ´Â short-term follow-upº¸´Ù´Â º¸´Ù È®½ÇÇÏ°Ô Á¶Á÷Áø´ÜÀ» ÇÒ ¼ö ÀÖ´Â ³»½Ã°æÀýÁ¦¼úÀ» ¼±È£ÇÏ´Â ÆíÀÔ´Ï´Ù. ¸ðµç ¼±Á¾À» ESDÇÒ ÇÊ¿ä´Â ¾øÁö¸¸ À°¾È¼Ò°ß»ó Á¶±âÀ§¾ÏÀÌ ÀǽɵǴ °æ¿ì¿¡´Â ESD¸¦ ½ÃÇàÇÒ ¼ö ÀÖ´Ù°í ¿©°ÜÁý´Ï´Ù.

°íµµ ¼±Á¾ ESD ÈÄ ¾ÏÀ¸·Î ³ª¿À´Â °æ¿ì´Â ¿ö³« ¸¹¾Æ¼­ (33-50%), Àúµµ ¼±Á¾ ESD ÈÄ ¾ÏÀ¸·Î ³ª¿Â °æ¿ì¸¦ Áß½ÉÀ¸·Î ¸î Áõ·Ê¸¦ ¼Ò°³ÇÕ´Ï´Ù.

Àúµµ ¼±Á¾ ESD ÈÄ Á¶±âÀ§¾Ï ¿ÏÀüÀýÁ¦·Î ³ª¿È.
ESD: Early gastric carcinoma
1. Location : antrum, greater curvature
2. Gross type : EGC type IIa
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 10 mm (2) vertical diameter, 6 mm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 12 mm, proximal 12 mm, anterior 14 mm, posterior 12 mm, deep 500 §­
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

Àúµµ ¼±Á¾À¸·Î ÀÇ·ÚµÈ ºÐÀÔ´Ï´Ù. ºñ·Ï ¿ÜºÎ »çÁøÀÌ ¸Å¿ì Èñ¹ÌÇßÁö¸¸, À°¾È¼Ò°ßÀÌ À¶±â + ÇÔ¸ôÇüÀ¸·Î ½É»óÄ¡ ¾Ê´Ù°í ÆǴܵǾú½À´Ï´Ù. ESD ÇÏ¿´°í ¿ª½Ã ¾ÏÀ¸·Î ³ª¿Ô½À´Ï´Ù.
ESD: Early gastric carcinoma
1. Location : angle
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 18 mm (2) vertical diameter, 7 mm
6. Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 17 mm, proximal 7 mm, anterior 10 mm, posterior 12 mm, deep 1500 §­
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

Àúµµ ¼±Á¾ ESD ÈÄ ¼ö¼úÀÌ ÇÊ¿äÇÑ À§¾ÏÀ¸·Î ÆÇÁ¤µÊ.
Stomach, endoscopic submucosal dissection:
Early gastric carcinoma
1. Location : low body, posterior wall
2. Gross type : EGC type IIa
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 36 mm (2) vertical diameter, 22 mm
6. Depth of invasion : invades submucosa, (depth of sm invasion :800 §­) (pT1b)
7. Resection margin : safety margin : distal 2 mm, proximal 5 mm, anterior 2 mm, posterior 2 mm, deep < 50 §­
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

Àúµµ ¼±Á¾ ESD ÈÄ ¼ö¼úÀÌ ÇÊ¿äÇÑ À§¾ÏÀ¸·Î ÆÇÁ¤µÊ (2016)
Stomach, ESD: Early gastric carcinoma
1. Location : low body, lesser curvature
2. Gross type : EGC type IIa
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 24 mm (2) vertical diameter, 14 mm
6. Depth of invasion : invades submucosa, (depth of sm invasion : 750 §­) (pT1b)
7. Resection margin : free from carcinoma(N); safety margin : distal 7 mm, proximal 5 mm, anterior 12 mm, posterior 4 mm, deep 150 §­
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent


¼±Á¾¿¡ ´ëÇÑ conventional endoscopic resection ÈÄ ¾ÏÀÌ ³ª¿À´Â °æ¿ì°¡ Á¦¹ý ¸¹½À´Ï´Ù. ÀûÁö ¾ÊÀº °æ¿ì¿¡ resection marginÀÌ ÃæºÐÇÏÁö ¸øÇÏ¿© 'óÀ½ºÎÅÍ ESD¸¦ Çß´õ¶ó¸é ´õ ÁÁ¾ÒÀ»ÅÙµ¥'¶ó°í ÈÄȸÇÏ°Ô µË´Ï´Ù. 2020³â ÇöÀç 1.5cmÀÌ ¾È µÇ´Â ¼±Á¾¿¡¼­´Â ESD¸¦ ÇÒ ¼ö ¾ø±â ¶§¹®¿¡ conventional EMRÀÌ ½ÃÇàµÇ´Â °æ¿ì°¡ ¸¹½À´Ï´Ù. ¼ú±â»óÀÇ ¾î·Á¿ò ¶§¹®ÀÎ °æ¿ìµµ ¾øÁö ¾ÊÁö¸¸... ȯÀÚ¸¦ À§ÇÑ ÃÖ¼±ÀÇ Áø·á¸¦ ÇÒ ¼ö Àִ ȯ°æÀ» ¸¸µé°í ½Í½À´Ï´Ù.

¼±Á¾¿¡ ´ëÇÑ inject and cut ¹æ¹ýÀÇ EMR ÈÄ SM invasionÀÌ ÀÖ´Â cancerÀÌ°í resection marginÀÌ ÃæºÐÇÏÁö ¾Ê´Ù°í ÀÇ·ÚµÈ È¯ÀÚÀÔ´Ï´Ù.


Outside slide reading: EMR; ADENOCARCINOMA, MODERATELY DIFFERENTIATED, arising from tubular adenoma
1. Location : body (according to outside report)
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, 8 mm (2) vertical diameter, 6 mm (according to outside report)
6. Depth of invasion : invades submucosa, (depth of sm invasion : 300 §­) (pT1b)
7. Resection margin : free from carcinoma(N) safety margin : closest lateral, 0.2 mm (in given specimen), deep, 80-90§­
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

³»½Ã°æ ÃßÀû°Ë»ç¸¦ ÇÏ¿´°í suspected high grade dysplasia°¡ ³ª¿Í ESD¸¦ ÇÒ ¼ö ¹Û¿¡ ¾ø¾ú½À´Ï´Ù. Fibrotic scar ¶§¹®¿¡ ÀÌ·± °æ¿ìÀÇ ESD´Â ¸¸¸¸Ä¡ ¾Ê½À´Ï´Ù.

Á¶Á÷°Ë»ç ¼±Á¾ÀÌ¶óµµ Á¶±ÝÀÌ¶óµµ Àǽɽº·¯¿ì¸é Å©±â¿Í ¹«°üÇÏ°Ô ESD¸¦ ÇÒ ¼ö ÀÖ°Ô µÇ¾úÀ¸¸é ÁÁ°Ú½À´Ï´Ù (2020-2-11. ÀÌÁØÇà)


[Àúµµ ¼±Á¾À¸·Î ÀǷڵǾúÀ¸³ª ¿ÜºÎ ½½¶óÀ̵å ÀçÆǵ¶¿¡¼­ °íµµ¼±Á¾ÀÌ°í ¾ÏÀÇ½ÉµÈ´Ù°í ³ª¿Í ESD¸¦ ÇÏ¿´°í Á¡¸·¾ÏÀ¸·Î ÃÖÁ¾ È®ÀÎµÈ Áõ·Ê]

¿ÜºÎ ½½¶óÀ̵å ÀçÆǵ¶: Atypical glands, high grade dysplasia versus tubular adenocarcinoma, well differentiated. ESD is recommended.


9. 2014 Konkuk symposium lecture on adenoma (LJH)

There are no generally accepted definitions of dysplasia and adenoma of the stomach. Dysplasia is best defined as an unequivocal neoplastic epithelial alteration. Detailed histological findings of gastric dysplasias have been described in many literatures. However, endoscopic or gross findings of gastric dysplasia need to be studied in more detail. Macroscopically, two types of dysplasias are recognized: elevated dysplasia and flat/depressed dysplasia.

Definition for adenoma is somewhat confusing. In the western countries, adenomas mean elevated or nodular lesions with dysplasia in histology, so only elevated type of dysplasias are considered as adenomas. In the eastern countries, however, both elevated and flat/depressed types of dysplasia are considered as adenomas. Actually, the terms dysplasia and adenoma are thought to be the same thing in the clinical practice. The difference is who prefers what. Usually, pathologists prefer dysplasia, and endoscopists prefer adenoma.

Dysplasias are graded as either high grade or low grade. So, adenomas (= dysplasias) can be divided as adenoma with low grade dysplasia (LGD) and adenoma with high grade dysplasia (HGD). In Korean pathologists' tradition, adenoma usually means adenoma with LGD.

In Korea, gastric adenomas with HGD are usually treated by endoscopic resection. In the final pathology for the resected specimen, 1/3 to 1/2 of adenomas with HGD are upgraded as cancer. Therapeutic approach for adenomas with HGD should be the same for early gastric cancers within absolute indications for endoscopic submucosal dissection (ESD).

Situations for gastric adenomas with LGD are quite different. After endoscopic resection of adenoma with LGD, the risk of histological upgrading is relatively small. About 10-20% of adenomas with LGD are upgraded to adenoma with HGD and 5-10% are upgraded to early gastric cancers. So, the clinical options for adenomas with LGD can be resection (EMR or ESD), ablation, and observation. In the lecture, some data regarding the advantages and disadvantages of each treatment options will be discussed.


We need to start from the definition of dysplasia. What is dysplasia? Most simply, it is an unequivocal neoplastic transformation.

There are three important histological characteristics for gastric dysplasia. They are disorganized mucosal architecture, abnormal differentiation, and cellular atypia.

Based on those three characteristics, a lot of grading schemes have been proposed. Isn¡¯t it confusing?

Recently, dysplasias are histologically divided into two groups, low grade dysplasia and high grade dysplasia.

Endoscopically, dysplasias can be divided into elevated dysplasias and flat/depressed dysplasias.

What is the relationship between dysplasia and adenoma? Definition of adenoma is somewhat confusing. In the western countries, adenomas mean elevated or nodular lesions with dysplasia in histology, so only elevated type dysplasias are considered as adenomas. In the eastern countries, however, both elevated and flat/depressed dysplasias are considered as adenomas. Actually, the two terms dysplasia and adenoma are thought to be the same thing in the clinical practice. The difference is who prefers what. Usually, pathologists prefer dysplasia, and endoscopists prefer adenoma.

Dysplasias are graded as either high grade or low grade. So, adenomas (= dysplasias) can be divided as adenoma with low grade dysplasia (LGD) and adenoma with high grade dysplasia (HGD). In Korean pathologists' tradition, adenoma usually means adenoma with LGD.

Ideally, there should be no difference in the histological diagnosis of adenoma and cancer, because everybody is using the Vienna classification. However, it¡¯s not so simple.

The concept of cancer may be different between countries. In Japan, structural and cytological features are important. In the western countries and in Korea, evidence of invasion is much more important. Actually, we think that most cases of HGD in the western system and Korea, as well as some LGD, become carcinoma in the Japanese system.

This is a famous study comparing the pathological diagnosis of gastric neoplasm between western countries and Japan. About half of the cases were adenomas by the western point of view. However, only 7 percent were adenomas by Japanese doctors. There is a huge difference. Korean pathologists seem to be close to western doctors in the diagnosis of gastric adenomas.

This is my understanding of this confusing situation. Three blocks are adenoma with LGD, adenoma with HGD and EGC in Korea. The next three blocks are diagnoses in Japan. So, most cases of adenoma with HGD in Korea may be EGCs in Japan.

Professor Sun Young Lee at Konkuk University discussed this dilemma in the recent editorial. Most cases of low grade dysplasias are endoscopically resected in Korea, but observation is frequently chosen in Japan. High grade dysplasias are endoscopically resected not only in Korea but also in Japan. But the diagnosis is different.

The natural history of adenoma is not clear yet. In this old study, the low grade adenomas progressed to cancer in 15% in 10 years.

Excluding palliative surgeries, we have endoscopically or surgically treated more than seventeen hundred gastric cancers in 2012 at Samsung Medical Center. Among them, 72% were early gastric cancers. In early gastric cancers, cases within absolute indications were 25%. There were 263 cases of gastric adenomas in a single year.

This is an example of endoscopically treated adenoma with low grade dysplasia.

Almost the same thing except that it was an adenoma with high grade dysplasia.

I performed ESD for a small depressed adenoma with LGD.

However, the final ESD pathology was adenocarcinoma.

It¡¯s another example of gastric cancer with initial biopsy of adenoma. In this case, the initial biopsy was adenoma with low grade dysplasia.

In this old report from my institution, 7 out of 22 adenomas with HGD were actually carcinomas in the endoscopically resected specimen.

We reviewed the discrepancy between pre-treatment diagnostic groups and post-treatment diagnostic groups. As you can see in this complicated slide, the rate of discrepancy is more than expected. For adenoma with LGD, about 34 percents were upgraded as high grade dysplasias or cancers. For adenomas with HGD, 34 percents were upgraded as cancers.

This is a personal communication. About 1/3 to half of cases with high grade dysplasia are upgraded into cancers at Samsung Medical Center, Gangnam Severance Hospital, and Asan Medical Center.

In this report from Yonsei University, 51 out of 273 endoscopically resected low grade adenomas were upgraded into either HGD or adenocarcinoma. They evaluated the risk factors for upgrading, and recommended endoscopic resection for larger lesions and lesions without white discoloration

So, small pale flat elevated low graded adenomas can be easily treated by ablation therapy using argon plasma coagulation.

Ladies and gentlemen. I¡¯d like to conclude my short presentation. For adenomas with HGD, endoscopic resection, preferably ESD, is recommended. For adenomas with LGD, endoscopic resection is preferred for larger lesions or lesions with central depression. Ablation is an easy and effective treatment for small pale flat/elevated adenomas with LGD.


[FAQ]

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³¯¸¶´Ù º¸³»Áֽô ¿£µµÅõµ¥ÀÌ °¨»çÇÕ´Ï´Ù. PW/antrum º´¼ÒÀ̸ç EGC°¡ ³ª¿Ã °ÍÀ¸·Î ¿¹»óÇߴµ¥ Á¶Á÷°Ë»ç´Â tubular adenoma ¿´½À´Ï´Ù.

* Stomach, antrum, posterior wall, endoscopic biopsy ; Suggestive of tubular adenoma, focal high grade dysplasia, (see note) with
1. Erosion.
2. Focally back to back or fused pattern.
3. Combined regenerated atypia.

* Microscopic findings by Sydney system ;
1. Neutrophils : absent
2. Mononuclear cells : moderate
3. Atrophy : absent
4. Intestinal metaplasia : mild
5. H.pylori : absent in Giemsa stain

* Note : Endoscopic mucosal resection is recommended for excluding higher grade lesion.

Á¶Á÷°Ë»ç¿¡¼­ focal high grade dysplasia°¡ ÀÖ¾ú°í ¶Ç ÀúÀÇ ³»½Ã°æ ¼Ò°ßÀÌ EGC¿´±â ¶§¹®¿¡ Àα٠´ëÇк´¿øÀ¸·Î ÀÇ·ÚÇß½À´Ï´Ù. ±×ÂÊ¿¡¼­ ÀúÈñ Á¶Á÷½½¶óÀ̵å reviewÇØ ÁֽŠ°á°ú¿Í ³»½Ã°æ Á¶Á÷°Ë»ç Àç°Ë °á°ú´Â ´ÙÀ½°ú °°¾Ò½À´Ï´Ù.

ÀúÈñ ½½¶óÀ̵å ÀçÆǵ¶: Stomach, antrum, posterior wall, endoscopic biopsy: Tubular adenoma with low grade dysplasia.

Àα٠´ëÇк´¿ø Á¶Á÷°Ë»ç Àç°Ë: Stomach, posterior wall of antrum, endoscopic biopsy: Tubular adenoma with low grade dysplasia (Immunoexpression of tumor: MUC5AC: weakly positive)

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ÀÌ·¸°Ô ¼³¸íÇÑ´Ù¸é ¾î¶»°Ú½À´Ï±î? "À§¾Ï Àǽɺ´¼Ò°¡ ÀÖ¾ú½À´Ï´Ù. ±×·±µ¥ Á¶Á÷°Ë»ç °á°ú´Â ¾Ï Àü´Ü°èÀÎ ¼±Á¾À¸·Î ³ª¿Ô½À´Ï´Ù. Á¶Á÷°Ë»ç´Â ºÎºÐ °Ë»çÀÔ´Ï´Ù. Àüü¸¦ »ìÆ캸¸é ¾ÏÀÏ ¼ö ÀÖ½À´Ï´Ù. µû¶ó¼­ ³»½Ã°æ ÀýÁ¦¼úÀÌ ÇÊ¿äÇÒ °Í °°½À´Ï´Ù. ¼±Á¾À» ³»½Ã°æÀ¸·Î ÀýÁ¦Çϸé 5-33%¿¡¼­ ¾ÏÀ¸·Î ³ª¿É´Ï´Ù. »ó±Þ ÀÇ·á±â°üÀ» ÃßõÇÏ°Ú½À´Ï´Ù. ³»½Ã°æ °á°úÁö, ³»½Ã°æ »çÁø, Á¶Á÷°Ë»ç °á°úÁö, Á¶Á÷°Ë»ç À¯¸® ½½¶óÀ̵å, ±×¸®°í ¼Ò°ß¼­¸¦ ì°Üµå¸³´Ï´Ù. ÁÁÀº °á°ú ¹Ù¶ó°Ú½À´Ï´Ù."

P.S. ¸é¿ªÇü±¤¿°»ö°Ë»ç´Â º´¸®°ú Àǻ簡 ÇÊ¿ä¿¡ µû¶ó Ãß°¡ÇÏ°í ±× °á°ú¸¦ °í·ÁÇÏ¿© ÃÖÁ¾ º´¸® Áø´ÜÀ» ³À´Ï´Ù. ´ëºÎºÐÀÇ °æ¿ì ÀÓ»óÀǻ簡 ¸é¿ªÇü±¤¿°»ö°Ë»ç °á°ú¸¦ µû·Î È®ÀÎÇÒ ÇÊ¿ä´Â ¾ø½À´Ï´Ù.


[2017-4-15 ¼øõ¸¸³»½Ã°æ¼¼¹Ì³ª. Áú¹®]

¿ÜºÎ½½¶óÀ̵å ÀçÆǵ¶ÀÇ Á߿伺À» °­Á¶Çϼ̴µ¥¿ä... À¯¸® ½½¶óÀ̵尡 ¾Æ´Ñ paraffin blockÀ» ¿äûÇÏ´Â °æ¿ì°¡ ÀÚÁÖ ÀÖ´ÂÁö¿ä.

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´ëºÎºÐ ¿ÜºÎ À¯¸® ½½¶óÀ̵å·Î ³¡³»°í ÀÖ½À´Ï´Ù. Paraffin blockÀº ¸²ÇÁÁ¾°ú °°Àº Ư¼öÇÑ °æ¿ì¿¡ ¿äûÇϱ⵵ ÇÕ´Ï´Ù¸¸ ¸Å¿ì µå¹® ÀÏÀÔ´Ï´Ù. Paraffin blockÀ» ÀÌ¿ëÇÑ Ãß°¡ °Ë»ç°¡ ÇÊ¿äÇÑ °æ¿ì´Â ´ëºÎºÐ º» º´¿ø ³»½Ã°æ Àç°Ë¿¡¼­ ¾òÀº Á¶Á÷À» ÀÌ¿ëÇÏ°í ÀÖ½À´Ï´Ù.


[2017-4-15 ¼øõ¸¸³»½Ã°æ¼¼¹Ì³ª. Áú¹®]

Ä¡·á Àü°ú Ä¡·á ÈÄ º´¸®Áø´ÜÀÇ Â÷ÀÌ¿¡ ´ëÇÏ¿© Àß ¼³¸íÇØ Á̴ּµ¥¿ä.... ±³¼ö´ÔÀº ¸ðµç ¼±Á¾À» ESD·Î Ä¡·áÇÏ°í °è½Ã´ÂÁö¿ä? Ȥ½Ã EMR-C¿Í °°Àº ÀüÅëÀûÀÎ ¹æ¹ýÀ¸·Î Ä¡·áÇÏ´Â °æ¿ì´Â ¾ø´ÂÁö ±Ã±ÝÇÕ´Ï´Ù.

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½Ã¼ú Àü Á¶Á÷°Ë»ç¿¡¼­ °íµµ ¼±Á¾À̾ú´ø °æ¿ì´Â Àû¾îµµ 1/3¿¡¼­ ½Ã¼ú ÈÄ ¾ÏÀ¸·Î Áø´ÜÀÌ ¹Ù²ò´Ï´Ù. µû¶ó¼­ ¿øÄ¢ÀûÀ¸·Î °íµµ ¼±Á¾Àº ¸ðµÎ ESD·Î Ä¡·áÇÏ°í ÀÖ½À´Ï´Ù. Àúµµ ¼±Á¾Àº less invasiveÇÑ Á¢±ÙÀÌ °¡´ÉÇÏ´Ù°í »ý°¢ÇÕ´Ï´Ù. ÀÛ°í, flatÇÏ°í paleÇÑ Àúµµ ¼±Á¾Àº ablationÀ¸·Î Ä¡·áÇÒ ¼ö ÀÖ½À´Ï´Ù. ±× ÀÌ¿Ü´Â ´ëºÎºÐ ÀýÁ¦¼úÀ» ¼±ÅÃÇÏ°í ÀÖ½À´Ï´Ù. ¹°·Ð ESD·Î Ä¡·áÇÏ´Â °æ¿ì°¡ ¸¹Áö¸¸ °æ¿ì¿¡ µû¶ó¼­´Â EMR-P, inject and cut°ú °°Àº º¸´Ù ÀüÅëÀûÀÎ ÀýÁ¦¼úÀ» »ç¿ëÇϱ⵵ ÇÕ´Ï´Ù.

ÀüüÀûÀ¸·Î 6.9% (141/2,041)°¡ down-grade µÇ°í 15.9% (324/2,041)°¡ up-grade µÇ¾ú½À´Ï´Ù. Diagnostic group classificationÀÌ ±×·¸°Ô ¹Ù²î¾ú´Ù´Â ÀǹÌÀÔ´Ï´Ù. (Lee JH. Surg Endosc 2016 / PDF)


[2017-4-15 ¼øõ¸¸³»½Ã°æ¼¼¹Ì³ª. Áú¹®]

¼±Á¾Àº Àúµµ¿Í °íµµ·Î ³ª´¹´Ï´Ù. ±×·±µ¥ °£È¤ Àúµµ, Áߵ (intermediate grade), °íµµ·Î ³ª´¶ º´¸® °á°úÁö¸¦ ¸¸³³´Ï´Ù. Áߵ (intermediate grade) ¼±Á¾Àº ¾î¶»°Ô Á¢±ÙÇÏ´Â °ÍÀÌ ÁÁ°Ú½À´Ï±î?

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º´¸® ÀÇ»çµéÀÇ Ç¥ÁØÈ­ ³ë·ÂÀÌ ºÎÁ·ÇÑ °ÍÀº Á¤¸» ½É°¢ÇÑ ¹®Á¦ÀÔ´Ï´Ù. Áߵ (intermediate grade) ¼±Á¾À¸·Î ÀÇ·ÚµÈ °æ¿ì ¿ÜºÎ ½½¶óÀ̵å ÀçÆǵ¶À» ÇÏ¸é ´ëºÎºÐ Àúµµ ¼±Á¾À¸·Î ³ª¿É´Ï´Ù. µû¶ó¼­ Àú´Â Áߵ ¼±Á¾Àº ÀÏ´Ü Àúµµ ¼±Á¾¿¡ ÁØÇÏ¿© Á¢±ÙÇÏ°í ÀÖ½À´Ï´Ù.


[2017-4-15 ¼øõ¸¸³»½Ã°æ¼¼¹Ì³ª. Áú¹®]

Ä¡·á Àü°ú Ä¡·á ÈÄ º´¸®Áø´Ü Â÷ÀÌÀÇ ¿øÀο¡ ´ëÇÏ¿© ¾î¶»°Ô »ý°¢ÇϽôÂÁö¿ä.

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¼±Á¾À̳ª ¾ÏÀ¸·Î ESD¸¦ ½ÃÇàÇÑ ÈÄ non-neoplastic pathology°¡ ³ª¿À¸é ¾à°£ ³­°¨ÇÕ´Ï´Ù. ±×·¯³ª µå¹® ÀÏÀº ¾Æ´Õ´Ï´Ù. 2015³â ¾ÆÁÖ´ë ³í¹®À» º¸¸é (Yang MJ. Endoscopy. 2015) Àúµµ ¼±Á¾ÀÇ °æ¿ì 6%, °íµµ ¼±Á¾À̳ª À§¾ÏÀÇ °æ¿ì 3%¿¡¼­ ESD ÈÄ non-neoplastic pathology°¡ ³ª¿À°í ÀÖ½À´Ï´Ù.

BiopsyLGDHGD or cancer
No neoplasia at ESD39 (5.5%)13 (2.7%)
Neoplasia at ESD664470

ÀÌ·¯ÇÑ ¿øÀÎÀº Å©°Ô ¼¼ °¡Áö·Î »ý°¢ÇÏ°í ÀÖ½À´Ï´Ù. (1) ÀÛÀº Á¾¾çÀº Á¶Á÷°Ë»ç·Î Á¦°ÅµÇ´Â °æ¿ì°¡ ÀÖ½À´Ï´Ù. (2) ÀýÁ¦¼ú ÈÄ Ç¥º»À» 2 mm °£°ÝÀ¸·Î Àß¶ó º´¸® specimenÀ» ¸¸µé±â ¶§¹®¿¡ 2 mm ÀÌÇÏÀÇ Á¾¾çÀº º´¸®ÇÐÀûÀ¸·Î ¹ß°ßÇÏÁö ¸øÇÒ ¼ö ÀÖ½À´Ï´Ù. (3) ³»½Ã°æ ÀýÁ¦ ´ç½Ã mislocalizationµµ °¡´ÉÇÕ´Ï´Ù.

ForcepÀ¸·Î ÀÛÀº Á¶Á÷À» ¾òÀº ¸çÄ¥ ÈÄ ³»½Ã°æÀ» ÇØ º¸¸é ÀÇ¿Ü·Î Å« ±Ë¾çÀÌ ¸¸µé¾îÁø °æ¿ì°¡ ÀÖ½À´Ï´Ù. Á¶Á÷°Ë»ç·Î »ó´çÈ÷ Å« º´¼Ò°¡ Á¦°ÅµÇ´Â ¼ö ÀÖ°Ú´Ù´Â »ý°¢ÀÔ´Ï´Ù. Mislocalization (Àü¹® ¿ë¾î·Î 'Çê¹ßÁú'À̶ó°í ÇÕ´Ï´Ù^^)Àº ¸Å¿ì µå¹® °Í °°½À´Ï´Ù.

* Âü°í: EndoTODAY Nonneoplastic pathology after ESD


[2019-8-7. ÀÌÁØÇà È¥À㸻] Á¶±â ÀºÅ𸦠°í¹ÎÇÕ´Ï´Ù. ³Ê¹« Èûµé¾î¼­.

70 years old lady visited my clinic due to an adenoma of the cardia involving at least 3/4 of the circumference, which was detected during the screening endoscopy. In the local hospital, endoscopic resction was tried but failed. Actually the procedure stopped in the middle of the marking step. Surgical treatment was recommended in that hospital. What's your option for this woman?

I decided to try endoscopic resection again, although the procedure would be very difficult. I gave full information about the advantages and disadvantages of the endoscopic treatment in this challenging situation.

Endoscopic resection (multiple piecemeal) followed by APC ablation was done. The procedure time was 42 minutes. PPI with oral steroid (4 weeks course) was given for the prevention of the stricture.

The final pathology was acceptable.

Tubulovillous adenoma with high grade dysplasia ;
1. Location : cardia
2. Gross type : elevated
3. Size of adenoma : (1) longest diameter, 24 mm (2) vertical diameter, 15 mm
4. Resection margin : involved distal resection margin by adenoma negative other resection margins

Endoscopic resection of the gastric neoplasms is getting more and more difficult for me, because easy cases are treated in the local clinic. Challenging cases are referred so often. It is time to think about early retirement.


[2019-9-3. ÀÌÁØÇà È¥À㸻]

Tubular adenoma¸¦ ´ë·Õ»ùÁ¾À̶ó°í ºÎ¸£³ªº¸´Ù.


[2020-5-30. ¾Öµ¶ÀÚ Áú¹®] °íµµÀÌÇü¼ºhigh grade dysplasiaÀº ÀüÀÌ °¡´É¼ºÀÌ ¾ø½À´Ï±î?

±³¼ö´Ô. High grade dysplasia ´Â °íÀÌÇü¼º Áï ¼¼Æ÷°¡ ²Ï º¯ÇüµÈ Á¾¾çÀÌ¶ó º¼¼ö ÀÖ´Ù°í ¾Ë°í ÀÖ½À´Ï´Ù¸¸ ÀÓ»ó¿¡¼­´Â ÀüÀÌ°¡´É¼ºÀÌ ¾ø´Ù°í º»´Ù. ÀÌ°Ô ¸Â´Â °Ç°¡¿ä?

[2020-5-31. ÀÌÁØÇà ´äº¯]

¿¹. ¿øÄ¢»ó ¸Â½À´Ï´Ù. High grade dysplasia´Â ¾ÆÁ÷ intraepithelial lesionÀÌ°í epithelial cellÀÇ basement membraneÀ» ħ¹üÇÏÁö ¾ÊÀº Á¼Àº ÀǹÌÀÇ non-invasive pathologyÀÔ´Ï´Ù. ÀüÀÌ °¡´É¼ºÀÌ ¾ø´Ù°í º¸´Â °ÍÀÌ ¸Â½À´Ï´Ù. ±×·¯³ª ¸î °¡Áö trickyÇÑ ¸éÀÌ ÀÖ½À´Ï´Ù.

1) º´¸®ÀÇ»çÀÇ inter-observer variationÀÔ´Ï´Ù. ¾î¶² º´¸®ÀÇ»ç´Â Á¶±Ý¸¸ ÀÌ»óÇÏ¸é ¾ÏÀ¸·Î Áø´ÜÇÏ°í, ¶Ç ´Ù¸¥ º´¸®ÀÇ»ç´Â ¿©°£Çؼ­´Â ¾ÏÀ¸·Î ºÎ¸£Áö ¾Ê½À´Ï´Ù. Inter-continental difference´Â Àß ¾Ë·ÁÁ® ÀÖ°í, inter-national differenceµµ ²Ï ¸í¹éÇÏÁö¸¸, ÇÑ ³ª¶ó ¾È¿¡¼­ÀÇ È¤Àº ÇÑ º´¿ø ¾È¿¡¼­ÀÇ inter-oberserver variationÀº ¾î´À Á¤µµ ½ÉÇÑÁö ¿©ÀüÈ÷ ºÒ¸íÈ®ÇÕ´Ï´Ù. °á±¹ ³ªÀÇ Á¶Á÷°Ë»ç sampleÀ» ´©°¡ Æǵ¶ÇÏ°í ÀÖ´ÂÁö, ±×ºÐÀÇ ¼ºÇâÀº ¾î¶²Áö ÆľÇÇÏ°í ÀÖ¾î¾ß ÇÕ´Ï´Ù. ±Ã±ÝÇϸé ÀüÈ­·Î »óÀÇÇÒ ¼ö ÀÖÀ» ¼öÁØÀÇ communicationÀÌ °¡´ÉÇØ¾ß ÇÕ´Ï´Ù. ´ëÇü º´¿ø¿¡¼­ ±Ù¹«ÇÏ°í ÀÖ´Â ÀÔÀå¿¡¼­ ¸»¾¸µå¸®¸é, Á¦°¡ ½ÃÇàÇÑ Á¶Á÷°Ë»ç¸¦ ¿©·¯ º´¸®Àǻ簡 Æǵ¶ÇÏ°í ÀÖ½À´Ï´Ù. ³»½Ã°æ ¼Ò°ß°ú º´¸® ¼Ò°ßÀÌ ÀÏÄ¡ÇÏÁö ¾ÊÀ» ¶§¿¡´Â ¿ì¼± ´©°¡ Æǵ¶Çϼ̴ÂÁö¸¦ È®ÀÎÇÏ°í ÀÖ½À´Ï´Ù.

2) Á¶Á÷°Ë»ç °á°ú¿Í ESD °á°ú´Â »ó´çÈ÷ ´Ù¸¨´Ï´Ù. Á¶Á÷°Ë»ç´Â ºÎºÐ °Ë»çÀÌ°í Áø´Ü °úÁ¤À̹ǷΠº´¸®ÀÇ»ç ÀÔÀå¿¡¼­´Â '¾Ï'À¸·Î ºÎ¸£±â ¾î·Á¿î »óȲÀÌ ¸¹½À´Ï´Ù. ¾Ï °°±â´Â Çѵ¥ ¾ÏÀ̶ó°í ´Ü¾ðÇϱ⠾î·Á¿î »óȲ ¸»ÀÔ´Ï´Ù. ±×·± °æ¿ì °íµµ ÀÌÇü¼ºÀ¸·Î º¸°íµÇ±âµµ ÇÕ´Ï´Ù. ESD °Ëü¿¡¼­´Â ¾Ï Áø´ÜÀÌ ½±½À´Ï´Ù. Àüü °Ë»çÀÌ°í ÀÏÂ÷ Ä¡·á¸¦ ¸¶Ä£ »óÅÂÀ̹ǷΠº´¸®ÀÇ»ç ÀÔÀå¿¡¼­´Â '¾Ï'À̶ó´Â Áø´ÜÀ» ºÙÀ̴µ¥ ½É¸®Àû ¾î·Á¿òÀÌ ´úÇÒ °ÍÀÔ´Ï´Ù.

Àú´Â ÀÌ À̽´(ESD ÀüÈÄ º´¸® °á°úÀÇ Â÷ÀÌ)¸¦ Diagnostic Group ClassificationÀ̶ó´Â °³³äÀ¸·Î Á¤¸®ÇÏ°í ÀÖ½À´Ï´Ù (Lee JH. Surg Endosc 2016).

Results: The study patients belonged to the following pretreatment diagnostic groups; LGDs in 162, HGDs in 164, AI-EGCs in 396, BAI-EGCs in 824, and AGCs in 495 cases. Posttreatment diagnostic groups were LGDs in 140, HGDs in 121, AI-EGCs in 322, BAI-EGCs in 947, AGCs in 505, and no residual tumor in 6 cases. In general, 6.9% (141/2,041) of cases were down-graded, and 15.9% (324/2,041) were up-graded. Thirty-four percent of pretreatment HGDs (56/164) were changed to cancers after endoscopic resection. Thirty-three percent of pretreatment AI-EGCs (131/396) were re-grouped as posttreatment BAI-EGCs.The additional surgery rate in each pretreatment group was 0.6% in LGD, 4.3% in HGD, 15.7% in AI-EGC, 23.6% in BAI-EGC among the patients with initial endoscopic resection (p < 0.01).

ÀüüÀûÀ¸·Î 6.9% (141/2,041)°¡ down-grade µÇ°í 15.9% (324/2,041)°¡ up-grade µÇ¾ú½À´Ï´Ù. Diagnostic group classificationÀÌ ±×·¸°Ô ¹Ù²î¾ú´Ù´Â ÀǹÌÀÔ´Ï´Ù.

°á±¹ ³»½Ã°æ Á¶Á÷°Ë»ç¿¡¼­ °íµµÀÌÇü¼ºÀ¸·Î ³ª¿Ô´Ù´Â °ÍÀ¸·Î´Â ÀüÇô ¾È½ÉÇÒ ¼ö ¾ø½À´Ï´Ù. ÃÖ¼ÒÇÑ ESD º´¸®¿¡¼­ ¾ÏÀÌ ¾Æ´Ñ °ÍÀ» È®ÀÎÇÑ ÈÄ ÀüÀÌ °¡´É¼ºÀÌ ¾ø´Ù°í ¸»ÇØ¾ß ÇÒ °Í °°½À´Ï´Ù.

3) º´¿ø°£ Â÷À̵µ Å©°í °³Àΰ£ Â÷À̵µ ¹«½ÃÇÒ ¼ö ¾ø´Â ¼öÁØÀÔ´Ï´Ù. 2014³â °Ç±¹´ëÇб³ ½ÉÆ÷Áö¾ö ¼±Á¾ °­ÀǸ¦ ÁغñÇϸ鼭 ÀúÈñ º´¿ø°ú ÁÖº¯ º´¿øÀÇ ½Ã¼ú ÀüÈÄ º´¸® upgrade(ESD Àü °íµµ¼±Á¾, ESD ÈÄ ¾Ï)ÀÇ ºñÀ²À» °£´ÜÈ÷ ¾Ë¾Æº» ¹Ù ÀÖ½À´Ï´Ù. Á¦ ¼Ò¼Ó º´¿øÀº 1/3 ¼öÁØÀ̾ú°í 1/2À» Á¶±Ý ³Ñ´Â ±â°üµµ ÀÖ¾ú½À´Ï´Ù. Àü±¹ÀûÀ¸·Î´Â ¾à 60% ÀüÈÄÀÎ °ÍÀ¸·Î ¾Ë°í ÀÖ½À´Ï´Ù. ÀÌ ¶ÇÇÑ Àڱ⠺´¸® ÀÇ»çÀÇ ¼ºÇâÀ» Àß ¾Ë¾Æ¾ß ÇÑ´Ù´Â °ÍÀ» º¸¿©ÁÖ´Â ÀÚ·áÀÔ´Ï´Ù.

This is a personal communication. About 1/3 to half of cases with high grade dysplasia are upgraded into cancers at Samsung Medical Center, Gangnam Severance Hospital, and Asan Medical Center.

4) ¸¶Áö¸·À¸·Î ¸Å¿ì °¡½¿¾ÆÆÍ´ø Áõ·Ê¸¦ ¼Ò°³ÇÕ´Ï´Ù. ESD ÈÄ extragastric recurrenceÀÇ ºñÀ²Àº ¸Å¿ì ³·½À´Ï´Ù. ±×·¯³ª 0%´Â ¾Æ´Õ´Ï´Ù. ¸Å¿ì ¸¹Àº ȯÀÚ¸¦ Ä¡·áÇÏ´Ùº¸¸é ¼Ò¼öÀÇ ¾ÈŸ±î¿î Áõ·ÊµéÀ» ¸¸³ª°Ô µË´Ï´Ù. ¾Æ·¡ ȯÀÚ°¡ ±×·± °æ¿ìÀÔ´Ï´Ù.

Á¶Á÷°Ë»ç¿¡¼­ °íµµÀÌÇü¼ºÀ¸·Î ÀǷڵǾú°í, ESDÀ» ÇÏ¿´°í, 38mmÀÇ lamina propria ¾ÏÀ¸·Î ³ª¿Ô°í, Å©±â ÀÌ¿ÜÀÇ ´Ù¸¥ risk factor´Â ¾ø¾ú°í, Á¤±âÀûÀ¸·Î ÃßÀû°Ë»ç¸¦ ÇÏ¿´À½¿¡µµ ºÒ±¸ÇÏ°í ESD ÈÄ multiple hepatic metastasis°¡ ¹ß»ýÇÏ¿´½À´Ï´Ù. 9°³¿ù Àü ³»½Ã°æ°ú CT´Â Á¤»óÀ̾ú´Âµ¥µµ ¸»ÀÔ´Ï´Ù.

ESD 5³â ÈÄ multiple metastasis. Initial ESD pathology: M/D adenocarcinoma, 38x22mm, lamina propria, RM (-), L/V (-/-)

5) °íµµÀÌÇü¼ºÀº ÀüÀÌÇÏÁö ¾Ê´Â º´ÀÔ´Ï´Ù. °³³ä»ó ±×·¸´Ù´Â ¸»ÀÔ´Ï´Ù. ±×·¯³ª ¿©·¯ Á¶°ÇÀÌ ÇÊ¿äÇÕ´Ï´Ù. ESD ÈÄ °íµµÀÌÇü¼ºÀ¸·Î È®ÀÎµÈ È¯ÀÚ¿¡ ´ëÇؼ­´Â ³»½Ã°æ ÃßÀû°Ë»ç´Â ÇÏÁö¸¸ CT ÃßÀû°Ë»ç´Â ÇÏÁö ¾Ê°í ÀÖ½À´Ï´Ù (¹°·Ð °íµµÀÌÇü¼º ȯÀÚ¿¡¼­ CT ÃßÀû°Ë»ç¸¦ ÇÏ´Â º´¿øµµ ÀÖ½À´Ï´Ù). º´¸®ÇÐÀû under-estimation µÈ °æ¿ì¸¦ °í·ÁÇÏ¿© °íµµÀÌÇü¼º ȯÀÚ¿¡ ´ëÇؼ­ CTµµ ½ÃÇàÇÏ¿©¾ß ÇÑ´Ù´Â ÁÖÀåÀ» Àß ¾Ë°í ÀÖÀ¸³ª CT¸¦ ÇÑ´Ù°í ¸ðµç »óȲÀÌ ¾ÈÀüÇØÁö´Â °Íµµ ¾Æ´Õ´Ï´Ù. CT´Â º»ÁúÀûÀ¸·Î Ä¡·áÇÒ ¼ö ¾ø´Â Àç¹ßÀ» ¹ß°ßÇÏ´Â °Ë»ç ¾Æ´Õ´Ï±î... CT¿¡¼­ ¹¹°¡ ³ª¿À¸é ´ëºÎºÐ ÀÌ¹Ì ¾È ÁÁÀº »óȲÀÔ´Ï´Ù. (Regional node only·Î ³ª¿À´Â ´õ¿í µå¹® °æ¿ì Á¦¿Ü)

¿ä¾àÇÕ´Ï´Ù. ³»½Ã°æ Á¶Á÷°Ë»ç¿¡¼­ °íµµÀÌÇü¼ºÀ¸·Î ³ª¿Â °æ¿ì´Â ´ë·« Àý¹Ý Á¤µµ ¾ÏÀÔ´Ï´Ù. ESD ÈÄ °íµµÀÌÇü¼ºÀ¸·Î °á·ÐµÈ °æ¿ì´Â ÀüÀÌÇÏÁö ¾Ê½À´Ï´Ù. ¾ÆÁÖ ¾à°£ÀÇ ¿¹¿Ü´Â ÀÖÀ» ¼ö ÀÖ½À´Ï´Ù. ÀÇÇп¡¼­ ¿¹¿Ü°¡ ¾ø´Â °æ¿ì´Â ¾ø½À´Ï´Ù.


[2020-7-10] À§ ESD ÈÄ adenoma with HGD·Î ³ª¿Â ȯÀÚ°¡ ¿Ü·¡¿¡¼­ D37 Äڵ带 ÁÙ ¼ö Àִ°¡ ¹®ÀÇÇÏ¿© D13.1·Î ÇÏ°í ÀÖ´Ù°í ¼³¸íµå·È½À´Ï´Ù. ÄÚµå´Â ´äÀÌ ¾ø½À´Ï´Ù. °ü°ø¼­¸¶´Ù ´Ù¸£°í º´¿ø¸¶´Ù ´Ù¸¨´Ï´Ù. ³ª´Â ³» styleÀ» ÀÏ°ü¼º ÀÖ°Ô À¯ÁöÇÏ´Â °ÍÀÌ ´äÀÔ´Ï´Ù. ȯÀÚ¿¡ ÀßÇص帰´Ù°í Äڵ带 º¯°æÇϰųª Æò¼Ò ¾È ¾²´ø Äڵ带 ¾²¸é ȯÀÚ¿¡°Ô ÇØ°¡ µÇ´Â °æ¿ì°¡ ´ëºÎºÐÀÔ´Ï´Ù. ȯÀÚ¿¡°Ô ÇØ°¡ µÇÁö ¾Ê´õ¶óµµ ÀÇ»ç º»Àο¡°Ô ÇØ°¡ µË´Ï´Ù. ±×³É ÃÊÁöÀÏ°ü ÇսôÙ.

* Âü°í: EndoTODAY ÄÚµå


[2021-12-4. ¾Öµ¶ÀÚ Áú¹®] low-grade(moderate) dysplasia

±³¼ö´Ô ¾È³çÇϽʴϱî? ·ÎÄ®¿¡¼­ ³»½Ã°æÇÏ´Â ÀÇ»çÀÔ´Ï´Ù. ´ëÀå ¿ëÁ¾ÀýÁ¦¼úÀ» ÇßÀ»¶§, Tubular adenoma with low-grade(moderate) dysplasia ¶ó°í ³ª¿À´Â °æ¿ì°¡ °¡²û ÀÖ½À´Ï´Ù. ÀÌ·¸°Ô ³ª¿À¸é Á» ½Å°æÀÌ ¾²ÀÔ´Ï´Ù. ?

Low-grade(moderate) dysplasia ´Â low grade dysplasia ¿Í ´Þ¸® ¾î¶² ÀÓ»óÀûÀÎ ÀÇ¹Ì ¹× ¿¹ÈÄ Â÷ÀÌ°¡ ÀÖ´Â ¼Ò°ßÀÎÁö ±Ã±ÝÇÕ´Ï´Ù. º´¸®¼±»ý´Ô²² ¹®Àǵ帮´Ï, ¿¾³¯¿¡´Â 3´Ü°è ºÐ·ù¹ýÀ̾ú´Ù°¡ 2´Ü°è ºÐ·ù¹ýÀ¸·Î º¯°æµÇ¾ú´Ù°í ¸»¾¸ÇϽðí, 3´Ü°èÀ϶§ÀÇ moderate °¡ 2´Ü°è¿¡¼­´Â mild °¡ µÇ¾ú´Ù°í ¸»¾¸Çϼ̽À´Ï´Ù. 3´Ü°è ºÐ·ù¹ýÀÇ moderate °¡ 2´Ü°è ºÐ·ù¹ý¿¡¼­´Â mild°¡ µÈ°ÍÀº ÀÓ»óÀû ÀÇÀÇ ¹× ¿¹ÈÄ°¡ mild¿Í ºñ½ÁÇϱ⠶§¹®¿¡ Å©°Ô ½Å°æ¾µ ÇÊ¿ä°¡ ¾ø±â ¶§¹®¿¡ ±×·¸°Ô º¯°æµÈ°ÍÀ¸·Î Çؼ®Çصµ µÇ´ÂÁö¿ä?

¿ëÁ¾ÀýÁ¦ÈÄ low-grade(moderate) dysplasia ¶ó°í ³ª¿À¸é, ½Å°æÀÌ ¸¹ÀÌ ¾²ÀÔ´Ï´Ù. ¿ÏÀüÀýÁ¦µÇ¾úÀ»Áö °ÆÁ¤µµ µÇ°í¿ä. Ȥ½Ã º´¸® ¼±»ý´ÔÀÇ ¼ºÇâ¿¡ µû¶ó¼­ low-grade(moderate) dysplasia ¶ó°í °á°ú ³»Áö ¾Ê°í, º°ÀÇ¹Ì ¾ø´Ù°íº¸°í ±×³É low-grade dysplasia ·Î ³»´Â º´¸®¼±»ý´Ôµµ ÀÖÁö ¾ÊÀ»±î »ý°¢µµ µì´Ï´Ù. ?

±×³É º´¸®ÀûÀ¸·Î Á» Â÷ÀÌ ÀÖÁö¸¸, ÀÓ»óÀû ÀǹÌ, ¿¹ÈÄ´Â ±×³É low grade ¿Í º° Â÷ÀÌ ¾ø´Ù°í ºÁµµ µÇ´ÂÁö¿ä? ¾Æ´Ï¸é high gradeµÇ±â Á÷Àü ´Ü°èÀÌ´Ï ÁÖÀÇÇØ¾ß µÈ´Ù ÀÌ·¸°Ô »ý°¢ÇØ¾ß ÇÒ¸¥Áö¿ä? ?

°ü·Ã Á¤º¸¸¦ ¾Ë ¼ö ¾ø¾î¼­ ¹Ù»Ú½Å ±³¼ö´Ô²² ¹®Àǵ帮°Ô µÇ¾ú½À´Ï´Ù. Æò¼Ò ¿£µµÅõµ¥ÀÌ·Î ¸¹Àº °¡¸£Ä§À» Áּż­ ¹è¿ï¼ö ÀÖ´Â ±âȸ¸¦ Áּż­ Ç×»ó °¨»çµå¸³´Ï´Ù.

[2021-12-4. ÀÌÁØÇà ´äº¯]

EndoTODAY À§¼±Á¾¿¡¼­ °íµµ/Àúµµ µî±Þ ºÐ·ù¿¡ ´ëÇÏ¿© ³íÇÑ ¹Ù ÀÖ½À´Ï´Ù¸¸ ÀÌ»óÀûÀÎ ¾ÈÀº ¾ø´Ù°í »ý°¢ÇÕ´Ï´Ù. ±Ùº»ÀûÀ¸·Î interobserver variationÀÌ »ó´çÇÑ »óȲ¿¡¼­ 2´Ü°è·Î ³ª´©´ø 3´Ü°è·Î ³ª´©´ø ³ª¸§ÀÇ ¹®Á¦°¡ ÀÖÀ¸¹Ç·Î ±×³ª¸¶ °üÂûÀÚ°£ Â÷ÀÌ°¡ ÀûÀº 2´Ü°è µî±Þ ±¸ºÐ¹ýÀÌ Ã¤ÅÃµÈ °ÍÀ¸·Î ÀÌÇØÇÏ°í ÀÖ½À´Ï´Ù.

Çö»óÀº analogueÀε¥ Çؼ®Àº digitalÀÌ´Ï ¾Ö¸ÅÇÑ °æ¿ì°¡ ¾øÀ» ¼ö ¾øÀ¸¸ç ±× °á°ú low-grade(moderate) dysplasia¶ó´Â ¸ðÈ£ÇÑ °á°úÁö°¡ ³ª¿Â´Ù°í »ý°¢µË´Ï´Ù. º¹ÀâÇÏ°Ô »ý°¢ÇÏ¿© ȯÀÚ °³Àκ°·Î ÃÖÀûÈ­µÈ ¼³¸íÀ» ÇÏ´õ¶óµµ ±×´ÙÁö Á¤È®ÇÏÁö ¾ÊÀº °ÍÀº ¸¶Âù°¡ÁöÀ̹ǷΠÃÖ´ëÇÑ ´Ü¼øÇÏ°Ô Á¢±ÙÇÏ´Â °ÍÀÌ ¾î¶»°Ú½À´Ï±î? Àú´Â ±×³É low grade dysplasia¿¡ ÁØÇÏ¿© ¼³¸íÇÒ °Í °°½À´Ï´Ù.

¿ä¾àÇϸé, low-grade(moderate) dysplasia = low grade dysplasia·Î º¸´Â °ÍÀÌ ÁÁ°Ú½À´Ï´Ù. Keep it simple!

[2022-4-18. YouTube Áú¹®]

¾È³çÇϼ¼¿ä ±³¼ö´Ô ´Ù¸§ÀÌ ¾Æ´Ï¶ó ¿©Â庸°í ½ÍÀº °Ô ÀÖ½À´Ï´Ù. º¸Åë À§¿¡¼­ ¹ß»ýµÇ´Â dysplasia ´Â ÇÙ Å©±â¿Í ¸ð¾çÀÌ ´Ù¾çÇÑ pleomorphismÀ» ¸¹ÀÌ ¶ç°í ÀÖ³ª¿ä? Low grade ¿Í high grade ¸¦ ±¸ºÐÇϴ ôµµ°¡ ¼¼Æ÷, ÇÙÀÇ ´ÙÇü¼ºÀ¸·Î ±¸ºÐÇϴ°Ŷó°í ¹è¿ü¾ú´Âµ¥ ¸Â´Â°ÇÁö ¸ð¸£°Ú½À´Ï´Ù.

[2022-4-19. ÀÌÁØÇà ´äº¯]

DysplasiaÀÇ µî±Þ ±¸ºÐ ±âÁØÀº ´Ù¾çÇÏ°í ¾à°£ ÁÖ°üÀûÀÏ ¼ö ÀÖ½À´Ï´Ù. Àú´Â ¾Æ·¡¿Í °°Àº ÀڷḦ Âü°íÇÏ°í ÀÖ½À´Ï´Ù. º´¸®°ú Àǻ簡 ¾Æ´Ñ ÀÔÀå¿¡¼­ °¡Àå Áß¿äÇÏ°Ô »ý°¢ÇÏ´Â °ÍÀº nuclear stratificationÀÔ´Ï´Ù. ºñÀü¹®°¡ÀÇ ÀÔÀå¿¡¼­ ÇÙÀÇ Å©±â°¡ »óÇǼ¼Æ÷ÀÇ Àý¹Ý ÀÌÇÏÀ̸é Àúµµ, Àý¹Ý ÀÌ»óÀÌ¸é °íµµ·Î »ý°¢ÇÏ°í ÀÖ½À´Ï´Ù.


[References]

1) À§ÀÌÇü¼ºÀÇ Áø´Ü°ú Ä¡·á (text, PDF)

2) [Lecture note] Gastric adenoma: to resect, ablate, or not (2014-7-12. 2014 International Hub in Advanced Endoscopy at Konkuk University)

3) Lee SY. Gastric adenoma with low-grade dysplasia: two countries, two outcomes. Dig Dis Sci 2014 (PDF 0.2 M)

4) Shin-Fan Kuan. Pathology of gastric neoplasms (Available in the Internet, PDF 2.0 M)

5) A representative case of ESD (biopsy: adenoma, ESD: EGC) (in Korean)

6) ¾î¶² Àúµµ ¼±Á¾ ȯÀÚ (70´ë) º¸È£ÀÚÀÇ Áú¹®¿¡ ´äÇÏ¿´½À´Ï´Ù.



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