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EndoTODAY ³»½Ã°æ ±³½Ç


[Barrett adenocarcinoma. ¹Ù·¿½Äµµ¼±¾Ï]

1. Introduction

ÇϺνĵµ ¼±¾Ï¿¡¼­ ÁÖº¯¿¡ ¹Ù·¿½Äµµ°¡ ÀÖÀ¸¸é ¹Ù·¿½Äµµ¾ÏÀ̶ó°í Áø´ÜÇÒ ¼ö ÀÖ½À´Ï´Ù. ´ëºÎºÐ µÑÀÌ µ¿½Ã¿¡ Áø´ÜµË´Ï´Ù. ÇϺνĵµ ¼±¾ÏÀÌ ¸Å¿ì Å©¸é ¿ø·¡ ¹Ù·¿½Äµµ¿´´ø ºÎºÐÀÌ ¾ø¾îÁ®¼­ ¹Ù·¿½Äµµ¾ÏÀÌ ÀǽɵÇÁö¸¸ ³»½Ã°æÀûÀ¸·Î ȤÀº º´¸®ÇÐÀûÀ¸·Î ¹Ù·¿½Äµµ¼±¾ÏÀ̶ó°í È®½ÇÈ÷ ºÎ¸£Áö ¸øÇÏ°Ô µÇ´Â °æ¿ìµµ ¸¹½À´Ï´Ù. µû¶ó¼­ Á¤È®È÷ ¹Ù·¿½Äµµ¾ÏÀ̶ó°í ºÎ¸¦ ¼ö ÀÖ´Â °ÍÀº ºñ±³Àû early stageÀÇ ÇϺνĵµ¼±¾ÏÀÔ´Ï´Ù.

»ï¼º¼­¿ïº´¿ø ¹Ù·¿½Äµµ¼±¾Ï

¹Ù·¿½Äµµ°¡ ¹Ù·¿½Äµµ¾ÏÀÇ Àü±¸º´º¯À̱â´Â ÇÕ´Ï´Ù. ±×·¯³ª ¹Ù·¿½Äµµ·Î ÃßÀû°üÂûÇÏ´ø ȯÀÚ¿¡¼­ ³ªÁß¿¡ ¹Ù·¿½Äµµ¾ÏÀÌ ¹ß°ßµÇ´Â ¿¹´Â ¸Å¿ì µå¹´´Ï´Ù. Àú´Â ±×·± °æ¿ì¸¦ ÇÑ ¹øµµ º» ÀûÀÌ ¾ø½À´Ï´Ù. 2017³â IDEN¿¡¼­ ¾Æ»êº´¿ø ±èµµÈÆ ±³¼ö´Ô²²¼­ ¹Ù·¿½Äµµ °æ°ú°üÂû Áß ¹ß°ßµÈ ¹Ù·¿½Äµµ¾ÏÀÇ ³»½Ã°æ Ä¡·á Áõ·Ê¸¦ ¹ßÇ¥ÇϽŠ°ÍÀ» º» ÀûÀº ÀÖ½À´Ï´Ù.

2017³â IDEN

¹Ù·¿½Äµµ¼±¾ÏÀÌ Àß ¹ß»ýÇÏ´Â ¹æÇâÀÌ ÀÖ½À´Ï´Ù. 2-4½Ã ¹æÇâÀÔ´Ï´Ù. ÀÌÀ¯´Â ¸ð¸£°Ú½À´Ï´Ù.

ÀÚ·á Á¦°ø: À̼±¿µ ±³¼ö´Ô


2. Endoscopic treatment of early stage Barrett's adenocarcinoma

Tongue-like projectionÀ» º¸ÀÌ´Â short segment Barrett esophagus·Î ÃßÁ¤ÇÏ°í Á¶Á÷°Ë»ç¸¦ ÇÏ¿´´Âµ¥ ÀÇ¿ÜÀÇ °á°ú(adenoma with HGD, suspicious carcinomatous transformation)°¡ ³ª¿Í ÀÇ·ÚµÈ ºÐÀÔ´Ï´Ù.

ESD°¡ ½ÃÇàµÇ¾ú°í ´ÙÇེ·´°Ô º´¸®ÇÐÀû complete resection °á°ú¿´½À´Ï´Ù.


Adenocarcinoma, well differentiated, arising from Barrett esophagus with high grade dysplasia ;
1. Location : gastroesophageal junction
2. Size of carcinoma : (1) longest diameter,9 mm (2) vertical diameter, 6 mm
3. Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
4. Resection margin : free from carcinoma(N), safety margin : distal 16 mm, proximal 3 mm, anterior 6 mm, posterior 14 mm
5. Lymphatic invasion : not identified(N)
6. Venous invasion : not identified(N)
7. Perineural invasion : not identified(N)


°ËÁø ³»½Ã°æ¿¡¼­ sentinel polyp ÀǽÉÀ¸·Î Á¶Á÷°Ë»ç¸¦ ÇÏ¿´´Âµ¥ atypical gland·Î ³ª¿Í ÃßÀû°Ë»ç¸¦ ÅëÇÏ¿© adenocarcinoma·Î Áø´ÜµÇ¾ú½À´Ï´Ù. Barrett adenocarcinoma·Î ÆǴܵǾî ESD¸¦ ½ÃÇàÇÏ¿´½À´Ï´Ù.


Esophagus, #1x1 : GE junction, biopsy(ESD) :
Early gastric carcinoma arising from Barrett's esophagus
1. Location : GE junction
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, 9 mm (2) vertical diameter, 4.5 mm
6. Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 8 mm, proximal 9 mm, anterior 12 mm, posterior 14 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

¾Æ¹«¸® sentinel polyp °°¾Æµµ óÀ½ ¹ß°ßµÇ¾ú°Å³ª °ú°Å¿Í ¸ð¾çÀÌ ´Ù¸£´Ù¸é Á¶Á÷°Ë»ç¸¦ ÇØ¾ß ÇÕ´Ï´Ù.


3. EG junction cancer Áß ¹Ù·¿ ½Äµµ¾Ï

EG junction¿¡ Å« ¼±¾ÏÀÌ ¹ß°ßµÇ¸é À§¾ÏÀÎÁö ½Äµµ¾ÏÀÎÁö ±¸ºÐÇϱ⠾î·Á¿ï ¼ö ÀÖ½À´Ï´Ù. Á¾¾çÀÇ Áß¾ÓÀÌ ¾îµð¿¡ À§Ä¡Çϴ°¡¿¡ µû¶ó ´ë°­ÀÇ groupingÀ» ÇÏÁö¸¸ ÀÌ ¶ÇÇÑ ¸íÈ®ÇÑ °ÍÀº ¾Æ´Õ´Ï´Ù.

º´¼ÒÀÇ Áß¾ÓÀÌ ½ÄµµÀÌ°í ±× ÁÖº¯¿¡ ¹Ù·¿½Äµµ°¡ ¶Ñ·ÇÇÏ¸é ¹Ù·¿½Äµµ¾ÏÀ¸·Î Áø´ÜÇÕ´Ï´Ù. ¾ÏÀÌ ÀÛÀ¸¸é ÀÌ¿Í °°Àº °³³äÀ» Àû¿ëÇÒ ¼ö ÀÖ½À´Ï´Ù (±×·¯´Ï±î Áö±Ý±îÁö ±¹³»¿¡¼­ Áø´ÜµÈ ¹Ù·¿½Äµµ¾ÏÀº ´ëºÎºÐ Á¶±â½Äµµ¾ÏÀ̾ú½À´Ï´Ù). ¾ÏÀÌ Ä¿Áö¸é º´¼Ò Áß¾ÓÀÌ ¾îµðÀÎÁö ¾Ë±â ¾î·Æ°í, ÁÖº¯¿¡ ¹Ù·¿½Äµµ°¡ ÀÖ´ÂÁö º¸ÀÌÁö ¾ÊÀ» ¼ö ÀÖ½À´Ï´Ù.

EG junction adenocarcinomaÀε¥ óÀ½ºÎÅÍ ±¤¹üÀ§ÇÑ hepatic metastasis°¡ ÀÖ¾ú½À´Ï´Ù. ÀÏ´Ü À§¾Ï¿¡ ÁØÇÏ¿© Ç×¾ÏÄ¡·á°¡ ½ÃÀ۵Ǿú½À´Ï´Ù. ¸î °³¿ù ÈÄ ÃßÀû³»½Ã°æ¿¡¼­ ¾ÏÀÌ ÇöÀúÈ÷ ÀÛ¾ÆÁö¸é¼­ º´¼Ò Áß¾ÓÀÌ ½Äµµ¿´´Ù´Â Á¡, ÁÖº¯¿¡ ¹Ù·¿ ½Äµµ°¡ ³Ð°Ô ºÐÆ÷ÇÏ°í ÀÖ´Ù´Â Á¡ÀÌ È®ÀεǾú½À´Ï´Ù. ±×·¯´Ï±î ÀÌ È¯Àڴ óÀ½ºÎÅÍ ¹Ù·¿½Äµµ¾ÏÀ̾ú´ø °ÍÀÔ´Ï´Ù.

(2015)

ù »çÁøÀ» ´Ù½Ã º¸´Ï Å« Á¾¾ç ¿·¿¡ ¹Ù·¿À¸·Î ÀǽɵǴ º¯È­°¡ °üÂûµË´Ï´Ù. ´äÀ» ¾Ë°í º¸¸é ½±½À´Ï´Ù.

EG junction cancer¸¦ ¹ß°ßÇÏ¿´À» ¶§¿¡´Â º´¼ÒÀÇ Áß¾ÓÀÌ ¾îµðÀÎÁö, ÁÖº¯¿¡ ¹Ù·¿ ½Äµµ´Â ¾ø´ÂÁö Àß »ìÆ캸¾Æ¾ß ÇÒ °Í °°½À´Ï´Ù.


4. ½Äµµ¾Ï°ú À§¾ÏÀÇ ¸²ÇÁÀý ¸í¸í¹ý (¼­¾ç½Ä°ú ÀϺ»½Ä)

Barrett adenocarcinoma³ª cardia cancerÀÇ ¼ö¼ú¿¡ ´ëÇÏ¿© ÈäºÎ¿Ü°ú³ª ÀϹݿܰú ÀÇ»ç¿Í ´ëÈ­ÇÒ ¶§ ¸²ÇÁÀý ¹Ú¸® ¹üÀ§¸¦ ³íÇϱâ´Â ½±Áö ¾Ê½À´Ï´Ù. ƯÈ÷ ÈäºÎ¿Ü°ú¿¡¼­ »ç¿ëÇÏ´Â ¿ë¾î¿Í ÀϹݿܰú¿¡¼­ »ç¿ëÇÏ´Â ¿ë¾î°¡ ´Ù¸£±â ¶§¹®ÀÔ´Ï´Ù. ÈäºÎ¿Ü°ú¿¡¼­´Â ¹Ì±¹½Ä ¼ýÀÚ¸¦ »ç¿ëÇÏ°í ÀϹݿܰú¿¡¼­´Â ÀϺ»½Ä ¼ýÀÚ¸¦ »ç¿ëÇϱ⠶§¹®ÀÔ´Ï´Ù. ¿¹¸¦ µé¾î lower paratracheal nodes´Â ¹Ì±¹½ÄÀ¸·Î´Â 8L¹ø, ÀϺ»½ÄÀ¸·Î´Â 110¹øÀÔ´Ï´Ù.

À§Ä¡¼­¾ç½ÄÀϺ»½Ä
Lower paratracheal nodes8L110
Diaphragmatic nodes15111
Paracardial nodes161 (éÓ) ¶Ç´Â 2 (ñ§)


1) AJCC 7ÆÇ¿¡ µû¸¥ ¸²ÇÁÀý ¸í¸í¹ý

1L = left supraclavicular, 1R = right supraclavicular, 2L = left upper paratracheal, 2R = right upper paratracheal, 4L = left lower paratracheal, 4R = right lower paratracheal, 5 = aortopulmonary, 6 = anterior mediastinal, 7 = subcarinal, 8L = lower paraesophageal, 8M = middle paraesophageal, 9 = pulmonary ligament, 10L = left tracheobronchial, 10R = right tracheobronchial, 15 = diaphragmatic, 16 = paracardial, 17 = left gastric, 18 = common hepatic, 19 = splenic, 20 = celiac. The posterior mediastinal lymph node (3P) is not shown.


2) ÀϺ» ½ÄµµÁúȯÇÐȸ ¸²ÇÁÀý ¸í¸í¹ý (Esophagus 2004;1:61-88)


3) ÀϺ» À§¾ÏÇÐȸ ¸²ÇÁÀý ¸í¸í¹ý

17 = lymph nodes on the anterior surface of the pancreatic head, 18 = lymph nodes along the inferior margin of the pancreas, 19 = lnfradiaphragmatic lymph nodes, 20 = lymph nodes in the esophagus hiatus of the diaphragm, 110 = lower throacic paraesophageal nodes, 111 = supradiaphragmatic lymph nodes, 112 = posterior mediastinal nodes


[FAQ]

[2016-11-10. 2016³â 11¿ù 3ÀÏ ¸ñ¿ä³»½Ã°æÁý´ãȸ Áõ·Ê¿¡ ´ëÇÑ ¾Öµ¶ÀÚ (±¹¸³¾Ï¼¾ÅÍ Á¶¼öÁ¤) ÆíÁö]

¿À´Ã º¸³»ÁֽŠÁõ·Ê Áß cardia ESD case´Â Ȥ½Ã GE junctional early cancer°¡ ¾Æ´ÑÁö ÇÕ´Ï´Ù. Ȥ½Ã Barrett's esophagus-associated cancerÀÏ ¼öµµ ÀÖÀ» °Í °°½À´Ï´Ù. ÀÌ case¿¡¼­´Â »ó°ü¾øÁö¸¸ ±»ÀÌ cardia cancer¿Í ±¸ºÐÇÏ´Â ÀÌÀ¯´Â sm cancer¿¡¼­ LNM risk°¡ ¾ÆÁ÷ Á¤¸³µÇÁö ¾Ê¾Ò±â ¶§¹®ÀÔ´Ï´Ù. ¾ó¸¶Àü ESDÈÄ Á¤¸®ÇÑ ÆÄÀÏÀÌ ÀÖ¾î º¸³»µå¸³´Ï´Ù.

Esophagogastric junctional cancer, type 0-IIa
Adenocarcinoma, tubular, well differentiated (intestinal)
Size of tumor: 1.6x1.2x0.06cm
Depth of invasion: sm1 (0.02cm) (pT1b)
LM(-) / DM(-) / LVI(-)
EG junctional adenocarcinoma developed from the Barrett¡¯s esophagus

* Âü°í: Fotis D. United European Gastroenterol J 2015 PDF

[2016-11-13. ÀÌÁØÇà ´äº¯]

ÁÁÀº Áõ·ÊÀÔ´Ï´Ù. ESD ½Ã¼úÀÌ Àß µÇ¾ú´ø °Í °°½À´Ï´Ù. ¾Ë·ÁÁֽŠ¹®Çå(Fotis D. United European Gastroenterol J 2015 PDF)µµ Àß º¸¾Ò½À´Ï´Ù.

ÀúÈñ º´¿ø ÀÌÇõ ±³¼ö´Ô²²¼­ ½Ã¼úÇÑ ¾Æ·¡ Áõ·Ê°¡ ´Ü¼øÇÑ cardia cancer°¡ ¾Æ´Ï¶ó Barrett's adenocarcinomaÀÏ ¼ö ÀÖ´Ù´Â ¼±»ý´ÔÀÇ ÀÇ°ß¿¡ µû¶ó ÃßÈÄ ´Ù½Ã Çѹø À̹ø Áõ·ÊÀÇ º´¸® ½½¶óÀ̵带 °ËÅäÇØ º¸°Ú½À´Ï´Ù. ÀÏ´Ü ³»½Ã°æ ¼Ò°ß¿¡¼­´Â ¶Ñ·ÇÈ÷ ÁÖº¯ Á¡¸·¿¡¼­ Barrett esophagus´Â ¾ø¾î º¸¿´½À´Ï´Ù. º´¸®¿¡¼­ ¾ÏÀÇ ÇÏ´Ü¿¡ esophageal gland ¼Ò°ßÀÌ º¸Àδٸé Barrett's adenocarcinoma·Î º¯°æÇÒ ¼ö´Â ÀÖ°ÚÁö¸¸...

2016³â 11¿ù 3ÀÏ ¸ñ¿ä³»½Ã°æÁý´ãȸ 2¹ø° Áõ·Ê

EMR/ESD specimenÀÇ depth of invasionÀÇ ±¸ºÐÀº ½±Áö ¾Ê½À´Ï´Ù. ¹Ù·¿ ½Äµµ¾ÏÀ» ºÐ¼®ÇÑ ¾Ë·ÁÁֽŠ¹®Çå(Fotis D. United European Gastroenterol J 2015 PDF)¿¡¼­´Â pragmatic classfication°ú Paris classification(Gastrointest Endosc 2003)À» ºñ±³ÇÏ°í ÀÖ¾ú½À´Ï´Ù. ¹®Çå¿¡¼­ ¸»ÇÏ´Â pragmatic classificationÀº ¼ö¼ú·Î ÀýÁ¦ÇÑ Ç¥º»¿¡¼­ SM layer¸¦ 3µîºÐÇÏ¿© ¸Ç À§ 1/3À» SM1À¸·Î Á¤ÇÏ´Â ¹æ½ÄÀ̾ú°í, Paris classificationÀº 500um±îÁö¸¦ SM1À¸·Î Á¤ÇÏ´Â ¹æ½ÄÀÔ´Ï´Ù. Pragmatic classification¿¡ µû¸¥ ¸²ÇÁÀý ÀüÀÌ´Â SM1¿¡¼­ 29%(2/7), SM2¿¡¼­ 71%(5/7), SM3¿¡¼­ 38%(6/16)¿´½À´Ï´Ù. ±×·¯³ª ÀúÀÚµéÀº SM1¿¡¼­ ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ¾ú´ø 2 Áõ·Ê(¾Æ·¡ ±×¸² 3¹ø, 24¹ø Áõ·Ê)´Â °¢°¢ 690 um, 700 umÀÇ SM invasionÀÌ ÀÖ¾úÀ¸¹Ç·Î ¸ðµÎ Paris classification¿¡ µû¶ó SM2/3ÀÌ°í, Paris classification¿¡¼­ SM1À̾ú´ø 5 Áõ·Ê´Â ¸ðµÎ ¸²ÇÁÀý ÀüÀÌ°¡ ¾ø¾úÀ¸¹Ç·Î EMR/ESD ÈÄ °æ°ú°üÂûÀ» ÇÒ ¼ö ÀÖ´Ù´Â ÁÖÀåÀ̾ú½À´Ï´Ù.

Paris classification¿¡¼­´Â ½Äµµ EMR/ESD specimen¿¡¼­ squamous cell carcinomaÀÇ °æ¿ì 200 um±îÁö, Barrett's adenocarcinomaÀÇ °æ¿ì 500 um±îÁö SM1À¸·Î °£ÁÖÇÏÀÚ°í µÇ¾î ÀÖ½À´Ï´Ù. ÀϺ»¿¡¼­´Â Barrett's adenocarcinoma´Â À§¾Ï°ú ºñ½ÁÇÏ°Ô °£ÁֵǹǷΠÀ§¾Ï°ú ¸¶Âù°¡Áö°í 500 um°¡ Àû¿ëµÈ °ÍÀÌÁö¸¸, »ç½Ç ±Ù°Å´Â ºÎÁ·ÇÕ´Ï´Ù.

Squamous cell carcinoma¿¡¼­´Â 200 um

Barrett's adenocarcinoma¿¡¼­´Â 500 um

Barrett's adenocarcinoma´Â °³³ä»ó 'Barrett's esophagus¿¡¼­ ½ÃÀÛÇÑ ½Äµµ¼±¾Ï'À̶ó°í Á¤ÀÇÇÒ ¼ö ÀÖÁö¸¸, ½ÇÁ¦·Î ¾î¶² Áõ·Ê°¡ Barretts' adenocarcinomaÀÎÁö cardia cancerÀÎÁö ±¸ºÐÇÏ´Â °ÍÀº ½±Áö ¾Ê½À´Ï´Ù. º´¸®ÇÐÀûÀ¸·Îµµ ¸Å¿ì º¹ÀâÇÕ´Ï´Ù (Takubo K. Dig Endosc 2014). ÀϺ»¿¡¼­ Barrett's adenocarcinoma¶ó°í ºÎ¸£´Â Áõ·ÊÀÇ ´ëºÎºÐÀº ¼­¾çÀÎÀÇ ´«À̳ª ¿ì¸®ÀÇ ´«À¸·Î º¼ ¶§¿¡´Â cardia cancerÀÔ´Ï´Ù. ÀϺ»ÀÎÀÌ Barrett's adenocarcinoma¶ó°í ¹ßÇ¥ÇÏ´Â °ÍÀ» º¸°í ¼­¾ç »ç¶÷µéÀº °í°³¸¦ °¼¿ì¶×Çϸ鼭 Áú¹®ÇÏ´Â °æ¿ì°¡ ¸¹½À´Ï´Ù. ±×°ÍÀº Barrett's adenocarcinoma°¡ ¾Æ´Ï¶ó°í Çϸ鼭...

2009³â »ï¼º¼­¿ïº´¿ø¿¡¼­ °æÇèÇÏ¿´´ø Barrett's adenocaricnoma¿¡ ´ëÇÑ ÂªÀº º¸°í¸¦ ³½ ÀûÀÌ ÀÖ½À´Ï´Ù (±è»óÁß. ´ëÇѼÒÈ­±â³»½Ã°æÇÐȸÁö 2009).

±× ÀÌÈķεµ ¸î Áõ·Ê¸¦ °æÇèÇÏ¿´Áö¸¸, ¾ÆÁ÷±îÁö Á¦ ½º½º·Î ¶Ñ·ÇÇÏ°Ô °³³ä Á¤¸®°¡ µÇ¾î ÀÖÁö ¾ÊÀº »óÅÂÀÌ°í, ÀϺ»°úÀÇ °ßÇØÂ÷¸¦ ¼³¸íÇÒ ³í¸®¸¦ ¼¼¿ìÁö ¸øÇÏ¿© EndoTODAY¿¡¼­µµ ÀÚ¼¼È÷ ´Ù·é ÀûÀÌ ¾ø½À´Ï´Ù. Á¶¸¸°£ Çѹø Á¤¸®Çغ¸°Ú½À´Ï´Ù. ÁÁÀº ÀÇ°ß °¨»çÇÕ´Ï´Ù.


[2021-10-30. ÀÌÁØÇà »ý°¢]

2021³â 10¿ù 30ÀÏ Ç︮ÄÚ¹ÚÅÍ ½ÉÆ÷Áö¾ö¿¡¼­ ¹ßÇ¥µÈ ½½¶óÀ̵åÀÔ´Ï´Ù. ³Ê¹« °úÇÑ °Í ¾Æ´Ñ°¡ »ý°¢µÇ´Âµ¥¿ä....


[References]

1) EndoTODAY ¹Ù·¿½Äµµ



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