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[Gastric neuroendocrine neoplasms including carcinoid tumor] - ðû

1. Classification ºÐ·ù

2. Histologic diagnosis and clinical staging

3. Surveillance for small type I gastric neuroendocrine tumor (carcinoid)

4. Korean multicenter study

5. KINGCA 2017 Pathologic findings of gastric NET - Á¶¹Ì¿¬

6. Surgical treatment

7. Endoscopic treatment

8. Á¶Á÷°Ë»ç + ¼ÒÀÛ¼ú·Î Ä¡·áÇÑ À¯¾ÏÁ¾

9. Type III gastric carcinoid

10. Gastric neuroendocrine carcinoma

11. Lanreotide for metastatic neuroendocrine tumor

12. FAQ

13. References


1. Classification

Neuroendocrine neoplasmÀÇ ºÐ·ù´Â ¾à 10³âÀ» ÁÖ±â·Î °è¼Ó ¹Ù²î°í ÀÖ½À´Ï´Ù. 2019³â WHO ºÐ·ù´Â ¾Æ·¡ Ç¥¿Í °°½À´Ï´Ù.

TerminologyDifferentiationGradeMitotic countKi-67 index
NET G1W/DLow<2<2%
NET G2W/DIntermediate2-203-20%
NET G3W/DHigh>20>20%
NEC, small cell type (SCNEC)P/DHigh>20>20%
NEC, large cell type (LCNEC)P/DHigh>20>20%
MiNENW/D or P/DVariableVariableVariable

ÃéÀåÀÇ NET´Â Ki-67ÀÌ 20%¸¦ ÇÑÂü ÃÊ°úÇÒ ¼ö ÀÖ½À´Ï´Ù. ÀÌ ¶§¹®¿¡ 2019³â WHO ºÐ·ù¿¡ NET G3°¡ »õ·Ó°Ô Ãß°¡µÇ¾ú½À´Ï´Ù. 2010³â WHO ºÐ·ù¿¡¼­´Â NET G1, NET G2, NEC¸¸ ÀÖ°í NET G3°¡ ¾ø¾ú½À´Ï´Ù. Unlike G3 NECs, G3 NETs usually have a Ki-67 index below 55% and a prognosis not as poor as G3 NECs (WJGO 2020). Gastric NET Áß¿¡µµ G3°¡ ÀÖ´ÂÁö Àß ¸ð¸£°Ú½À´Ï´Ù. Àú´Â 2023³â ÇöÀç±îÁö Gastric NET G3, Áï well-differentiatedÀ̸鼭 G3ÀÎ °æ¿ì¸¦ ÇÑ ¹øµµ º» ÀûÀÌ ¾ø½À´Ï´Ù.

MiNEN (mixed neuroendocrine-non-neuroendocrine neoplasms)´Â µÎ ¿ä¼Ò°¡ 30%ÀÌ»ó Â÷ÁöÇÒ ¶§ »ç¿ëÇÕ´Ï´Ù. 2000³â WHO ºÐ·ù¿¡¼­´Â mixed exocrine-endocrine carcinoma (MEEC), 2010³â WHO ºÐ·ù¿¡¼­´Â mixed adenoneuroenocrine carcinoma (MANEC)À¸·Î ºÒ¸®´ø °ÍÀÔ´Ï´Ù. À̸§ÀÌ °è¼Ó ¹Ù²î°í ÀÖ½À´Ï´Ù. ÀÌÀ¯´Â ¸ð¸£°Ú½À´Ï´Ù.

NET¿Í NEC´Â ¿©·¯ Ãø¸é¿¡¼­ °ü·ÃÀÌ ¾ø½À´Ï´Ù (unrelated). ¿ÏÀüÈ÷ ´Ù¸¥ Áúº´À¸·Î ÀÌÇØÇÏ´Â °ÍÀÌ ³ªÀ» °ÍÀÔ´Ï´Ù. °ú°Å¿¡´Â well-differentiated NET°¡ metastasis¸¦ º¸À̸é NEC·Î ºÒ·¶Áö¸¸ Áö±ÝÀº poorly-differentiated neoplasm¸¸ NEC·Î ºÎ¸£°í ÀÖ½À´Ï´Ù.

Another characteristic feature of NETs is the expression of somatostatin receptors (in particular, abundant SSTR2), which can be detected by immunohistochemistry or using functional radiographical imaging, such as octreoscan and 68Ga-DOTATOC/DOTATATE/DOTANOC PET-CT.

Type 3 NETÀÇ ³»½Ã°æ Ä¡·á ÈÄ ±¹¼ÒÀç¹ßÀ» DOTATATE PTE-CT·Î È®ÀÎ (À§Áúȯ³»½Ã°æ¾ÆƲ¶ó½º 136ÂÊ)


Gastric neuroendocrine tumor (NET)´Â ¸î °¡Áö ÀÓ»óÀû Ư¡¿¡ µû¶ó ¼¼ Á¾·ù·Î ³ª´©°í ÀÖ½À´Ï´Ù. Neuroendocrine carcinoma (NEC)´Â ¿©±â¿¡ Æ÷ÇÔµÇÁö ¾Ê½À´Ï´Ù. ÀüÇô ´Ù¸¥ Áúº´À¸·Î ÀÌÇØÇÏ´Â °ÍÀÌ ³ªÀ» °Í °°½À´Ï´Ù.

Rindi. Gastroenterology 1993

¹®Á¦´Â type 1ÀÇ Á¤ÀÇÀÔ´Ï´Ù. À¯¸íÇÑ RindiÀÇ 1993³â Gastroenterology ³í¹®¿¡¼­´Â "twenty-eight cases, none metastatic, arose in a background of body-fundus atrophic gastritis and hypergastrinemia"¿Í °°ÀÌ ¾Ö¸ÅÇÏ°Ô ¾º¿© ÀÖ½À´Ï´Ù. Serum gastrinÀÌ ´õ Áß¿äÇÑÁö atrophy°¡ ´õ Áß¿äÇÑÁö ¾ð±ÞµÇ¾î ÀÖÁö ¾Ê½À´Ï´Ù.

Atrophic gastritisµµ ÇöÀúÇÏ°í hypergastrinemia°¡ ÀÖÀ¸¸é 1ÇüÀ¸·Î ºÐ·ùÇÏ´Â °ÍÀº ¹®Á¦°¡ ¾ø½À´Ï´Ù. Atrophic ÇÏÁöµµ ¾Ê°í gastrinµµ Á¤»óÀ̸é 3ÇüÀ¸·Î ºÐ·ùÇÏ´Â °Íµµ ´ë°­ ¹Þ¾ÆµéÀÏ ¼ö ÀÖ½À´Ï´Ù. ±×·±µ¥ atrophic ÇÏÁö¸¸ gastrinÀº Á¤»óÀ̰ųª, atrophicÇÏÁö ¾ÊÀºµ¥ gastrinÀÌ ³ôÀº °æ¿ì´Â ¾Ö¸ÅÇÕ´Ï´Ù.

Original article¿¡¼­´Â gastrinÀ» Áß¿ä½ÃÇÕ´Ï´Ù. High gastrinÀ̸é 1ÇüÀ¸·Î, normal gastrinÀ̸é 3ÇüÀ¸·Î ºÐ·ùÇÕ´Ï´Ù. ½±°í ¸í·áÇÏ°í °´°üÀûÀ̱⠶§¹®ÀÔ´Ï´Ù. 2018³â »ï¼º¼­¿ïº´¿ø ¹Îº´ÈÆ ±³¼ö´Ô²²¼­ Br J Surg¿¡ º¸°íÇÑ ³í¹® Clinicopathological features and outcome of type 3 gastric neuroendocrine tumours¿¡¼­µµ 3ÇüÀÇ Á¤ÀÇ´Â "biopsy-proven gastric NET and a normal fasting serum gastrin level"À̾ú½À´Ï´Ù. 2016³â ´ëÇÑ»óºÎÀ§Àå°üÇ︮ÄÚ¹ÚÅÍÇÐȸÁö ¹ßÇ¥µÈ ¿ì¸®³ª¶ó ´Ù±â°ü °øµ¿¿¬±¸(Lee HS. KJHUGIR 2016)¿¡¼­ 1ÇüÀÇ ±âÁØÀ» hypergastrinemia·Î »ï¾Ò½À´Ï´Ù ("To classify tumors as type 1 gastric NETs, patients¡¯ plasma gastrin levels were analyzed and other associations, such as Zollinger-Ellison syndrome (ZES) or multiple endocrine neoplasia type 1, were ruled out.")

Br J Surg 2018

Review article¿¡¼­´Â atrophy¸¦ Áß¿ä½ÃÇÕ´Ï´Ù. ȤÀº atrophy¿Í gastrinÀ» µÑ ´Ù ¾ð±ÞÇÏ°í ÀÖ½À´Ï´Ù.

Rindi ºÐ·ù¿¡¼­ atrophic gastritis¸¦ Áß¿ä½ÃÇÏ¿´´ø ¹®Çå

Ä¡·á¹ý °áÁ¤¿¡¼­ hypergastrinemia°¡ Áß¿äÇÑ °Íó·³ µÇ¾î ÀÖÁö¸¸ ÀÚ¼¼È÷ »ìÆ캸¸é ÀúÀÚ°¡ atrophic gastritis¿Í hypergastrinemia¸¦ ¼¯¾î¼­ ±â¼úÇÏ°í ÀÖ´Â ¹®Çå. Áï normal gastrin + atrophic gastritis¿¡ ´ëÇÑ ¼³¸íÀÌ ¾ø´Â ¹®Çå

¹Ú¹«ÀÎ Clinical Endoscopy 2013

ÀÌ·¯ÇÑ ³»¿ëÀ» Á¤¸®ÇÏ¸é ¾Æ·¡ Ç¥¿Í °°½À´Ï´Ù. Original article¿¡¼­´Â gastrinÀÌ Áß¿äÇÏ°í review article¿¡¼­´Â atrophy°¡ Áß¿äÇÕ´Ï´Ù.

AtrophicNon-atrophic
High gastrin1ÇüOriginal article¿¡¼­´Â 1Çü
Review article¿¡¼­´Â 3Çü
Low gastrinOriginal article¿¡¼­´Â 3Çü
Review article¿¡¼­´Â 1Çü
3Çü

ÀÓ»ó ÇöÀå¿¡¼­´Â ¾Ö¸ÅÇÑ °æ¿ì°¡ ¸¹½À´Ï´Ù. Gastrin level°ú atrophy°¡ ÀÏÄ¡ÇÏÁö ¾Ê´Â °æ¿ì°¡ ¸¹±â ¶§¹®ÀÔ´Ï´Ù. AtrophyÀÇ ±âÁصµ ¾Ö¸ÅÇÕ´Ï´Ù. ³»½Ã°æ ¼Ò°ßÀÇ °üÂûÀÚ°£ Â÷À̵µ °ÆÁ¤ÀÌ°í, pepsinogenÀ» °í·ÁÇÒÁö ¸»Áöµµ °í¹ÎÀÔ´Ï´Ù. ±×·¡¼­ case by case·Î Á¢±ÙÇÒ ¼ö ¹Û¿¡ ¾ø½À´Ï´Ù. ¾Æ·¡ Áõ·Ê¸¦ Âü°íÇϽñ⠹ٶø´Ï´Ù.


[Áõ·Ê: Rindi ºÐ·ù°¡ ¾Ö¸ÅÇÑ °æ¿ì - Atrophic gastritis¸¦ Áß¿ä½Ã ÇÒ °ÍÀΰ¡? Gastrin levelÀ» Áß¿ä½Ã ÇÒ °ÍÀΰ¡?]

´ëÀå¾Ï ¼ö¼ú ÈÄ °æ°ú°üÂû ÁßÀÎ ºÐ¿¡¼­ ¿ì¿¬È÷ ¹ß°ßµÈ neuroendocrine tumorÀÔ´Ï´Ù. ¸Å¿ì ÀÛ¾Ò½À´Ï´Ù. Á¶Á÷°Ë»ç´Â WELL DIFFERENTIATED NEUROENDOCRINE TUMOR·Î ³ª¿Ô½À´Ï´Ù. °ú°Å À¯¾ÏÁ¾À¸·Î ºÒ·¶´ø °ÍÀÔ´Ï´Ù. Ç︮ÄÚ¹ÚÅÍ ¾ç¼ºÀ̾ú½À´Ï´Ù. GastrinÀº 31.5·Î Á¤»óÀ̾ú½À´Ï´Ù. ¿©·¯ºÐÀº ¾î¶»°Ô ÇϽðڽÀ´Ï±î?

»óȲÀº ´Ü¼øÇÏÁö ¾Ê½À´Ï´Ù. ¿Ö³ÄÇÏ¸é ³»½Ã°æ »çÁøÀ» º¸¸é ¶Ñ·ÇÇÑ À§Ã༺ È­»ý¼º À§¿°ÀÌ Àֱ⠶§¹®ÀÔ´Ï´Ù (È­»ý¼º À§¿°Àº Á¶Á÷°Ë»ç·Îµµ È®ÀεǾú½À´Ï´Ù). À§Ã༺ À§¿°À» ±âÁØÀ¸·Î Çϸé 1ÇüÀÌ°í gastrin levelÀ» ±âÁØÀ¸·Î Çϸé 3ÇüÀÔ´Ï´Ù. 1ÇüÀº '°æ°ú°üÂû + Ç︮ÄÚ¹ÚÅÍ Á¦±ÕÄ¡·á' Á¤µµ¸é ÃæºÐÇÏ°í 3ÇüÀº ³»½Ã°æ ÀýÁ¦¼úÀÌ ÇÊ¿äÇѵ¥ Rindi ºÐ·ù°¡ ¾Ö¸ÅÇÏ´Ï Ä¡·á¹æħµµ ¾Ö¸ÅÇÕ´Ï´Ù.

ÀÌ·² ¶§¿¡´Â ÃÖ´ëÇÑ º¸¼öÀûÀ¸·Î ¾ÈÀüÇÑ ¹æÇâÀ» ÅÃÇÕ´Ï´Ù. Normal gastrinÀ̶ó´Â °ÍÀ» °í·ÁÇÏ¿© ³»½Ã°æ ÀýÁ¦¼úÀ» ÇÏ¿´½À´Ï´Ù. ´ýÀ¸·Î Ç︮ÄÚ¹ÚÅÍ Á¦±ÕÄ¡·áµµ ÇØ ÁÖ¾ú½À´Ï´Ù. ¹°·Ð °úÀ× Ä¡·áÀÏ ¼öµµ ÀÖ½À´Ï´Ù. ¿©ÇÏÆ° ÃÖ´ëÇÑÀÇ Ä¡·á¸¦ ÇÏ¿´½À´Ï´Ù. °æ°ú°üÂû Çʿ伺µµ Àû¾î¼­ ¸¶À½µµ ÆíÇÕ´Ï´Ù.

³»½Ã°æ ÀýÁ¦¼úÀ» ½±°í ¾ÈÀüÇÏ°Ô ÇÒ ¼ö ÀÖ´Â »óȲÀ̶ó¸é ±×³É º¹ÀâÇÏ°Ô »ý°¢ÇÏÁö ¾Ê°í ÀýÁ¦¼úÀ» ÇÏ¸é µÇ°Ú½À´Ï´Ù (½ÇÁ¦ ÀÌ È¯ÀÚ´Â 10¿©ºÐ °É·È½À´Ï´Ù). ³»½Ã°æ ÀýÁ¦¼úÀÌ ¸Å¿ì ±î´Ù·Î¿î ºÎÀ§¶ó¸é¡¦ ±×¶§´Â ÀÌ·± Àú·± °í¹ÎÀÌ ÇÊ¿äÇÕ´Ï´Ù. ºñ·Ï gastrin ¼öÄ¡´Â Á¤»óÀÌÁö¸¸ ÇöÀúÇÑ atrophic gastritis¸¦ °í·ÁÇÏ¿© Ç︮ÄÚ¹ÚÅÍ Á¦±ÕÄ¡·á¸¸ ÇÏ°í °æ°ú°üÂûÀ» ÇÒ ¼öµµ ÀÖÁö ¾Ê³ª »ý°¢µË´Ï´Ù.


ºÐ·ù»óÀÇ ¸ðÈ£ÇÑ Á¡À» °í·ÁÇÏ¿© Àú´Â ¾Æ·¡¿Í °°Àº ¹æ¹ýÀ¸·Î Ä¡·á¿øÄ¢À» Á¤ÇÏ°í ÀÖ½À´Ï´Ù. GastrinÀ» Áß½ÃÇÏµÇ Å©±â°¡ ÀÛÀ¸¸é 1Çü°ú ºñ½ÁÇÑ ¹æ¹ýÀ¸·Î Á¢±ÙÇÏ´Â ¹æ½ÄÀÔ´Ï´Ù. ¿©ÀüÈ÷ ¸ðÈ£ÇÑ Á¡ÀÌ ÀûÁö ¾ÊÁö¸¸...


2. Histologic diagnosis and clinical staging - G2¸¦ Áß½ÉÀ¸·Î

[TNM classification for gastrid well-differentiated NETs (G1 and G2)

T1: tumor invades mucosa or submucosa and 1cm or less in greatest dimension (Å©±â°¡ Æ÷ÇԵȴٴ Á¡ÀÌ Æ¯Â¡ÀÔ´Ï´Ù.)

T2: Tumor invades muscularis propria or is more than 1 cm in greatest dimension

T3: Tumor invades subserosa

T4: TUmor perforates visceral peritoneum (serosa) or invades other organs or adjacent structures


Granular cell tumor °°´Ù´Â Á¶Á÷°Ë»ç °á°ú·Î ÀÇ·ÚµÈ ºÐÀ¸·Î ESD¸¦ ½ÃÇàÇÏ¿´½À´Ï´Ù.

ESD: Well differentiated neuroendocrine tumor (G2)
1. Name of Procedure: ESD
2. Site of Tumor: Stomach (anterior wall of mid body)
3. Diagnosis: Neuroendocrine tumor
4. WHO classification(2010): Well-differentiated Neuroendocrine tumor (G2)
5. Multiplicity: Single
6. Size: 1.0x0.8x0.3 cm
7. Extent: Mucosa and submucosa
8. Grading: Mitotic Count(/10HPF): 2-20, Ki-67 labeling index: 4%
9. Immunohistochemical Stains: 1) Synaptophysin : Positive, 2) Chromogranin A: Positive
10. Lymphovascular invasion: Not identified
11. Perineural invasion: Not identified
12. Lymph node metastasis: not evaluated
13. Resection Margins: Negative

À§ ½Å°æ³»ºÐºñÁ¾¾çÀº ¹«Ã´ È¥µ¿½º·¯¿î Áúº´ÀÔ´Ï´Ù. ¿ì¼± À̸§ºÎÅÍ Çò°¥¸³´Ï´Ù. Neuroendocrine tumor¿Í carcinoidÀÇ °æ°è°¡ ºÒ¸íÈ®Çϱ⠶§¹®ÀÔ´Ï´Ù. Ä¡·á ¿øÄ¢µµ staging¿¡ µû¶ó °áÁ¤µÇÁö ¾Ê°í type°ú gradingÀÌ Áß¿äÇÏ°í stagingÀÌ º¸Á¶ÀûÀÎ ¿ªÇÒÀ» Çϱ⠶§¹®¿¡ grey zoneÀÌ ¸¹½À´Ï´Ù. ±×¸®°í ¹®Çå¿¡¼­ Á¦½ÃµÈ ¹æ¹ý´ë·Î ÀÓ»ó¿¡¼­ Àû¿ëµÇ°í ÀÖ´Â °Íµµ ¾Æ´Õ´Ï´Ù. ¾ÏÀÎÁö ¾Æ´ÑÁö ¸íÈ®ÇÏÁö ¾Ê±â ¶§¹®¿¡ coding¿¡¼­µµ ³í¶õÀÌ ¸¹½À´Ï´Ù.

°í½Å´ëÇб³º´¿ø ¹Ú¹«ÀÎ ±³¼ö´ÔÀÇ Endoscopic treatment for early foregut neuroendocrine tumors¿¡¼­ Àß Á¤¸®µÈ table µÎ°³¸¦ ¾Æ·¡¿¡ ¿Å±é´Ï´Ù.

Àú´Â À§ ½Å°æ³»ºÐºñÁ¾¾çÀ» ÀÏÁ¾ÀÇ spectrumÀ¸·Î »ý°¢ÇÏ°í ÀÖ½À´Ï´Ù. °¡Àå ÁÁÀº Á¾·ù´Â (1) Rindi type 1, (2) T1N0M0, (3) 1cm ÀÌÇÏ, (4) º´¸®ÇÐÀû grade 1Àε¥ °æ°ú°üÂûÀ» ¼±ÅÃÇÒ ¼ö ÀÖ½À´Ï´Ù. °¡Àå ³ª»Û ÇüÅ´ neuroendocrine carcinomaÀÔ´Ï´Ù. ¹®Á¦´Â ±× Áß°£µµ ¸¹°í ¾Ö¸ÅÇÑ °æ¿ìµµ ÀûÁö ¾Ê´Ù´Â °ÍÀÔ´Ï´Ù. ƯÈ÷ '°æ°ú°üÂû - ³»½Ã°æ ÀýÁ¦¼ú - ¼ö¼ú'À̶ó´Â ¼¼ Ä¡·á¹ýÀÇ °æ°è¿¡ ÇØ´çÇϴ ȯÀڵ鿡°Ô ¾î¶°ÇÑ Ä¡·á¸¦ ±ÇÇÏ´Â °ÍÀÌ ÁÁÀ»Áö ´Ã °í¹ÎÇÏ°í ÀÖ½À´Ï´Ù. ¿¹¸¦ µé¾î fundusÀÇ ÀÛÀº º´¼Ò¿¡ ´ëÇÑ Á¶Á÷°Ë»ç¿¡¼­ º´¸®ÇÐÀû grade 2·Î ³ª¿Â °æ¿ì ¾Õ table¿¡ µû¸£¸é surgery¸¦ ±ÇÇØ¾ß ÇÕ´Ï´Ù. ±×·±µ¥ grade 2·Î ³ª¿Â ±Ù°Å°¡ mitotic index 2/10 HPFs (±âÁØ: 2-20) Ki-67 labeling index 3-4% (±âÁØ 3-20%)·Î ±âÁØÀÇ ÇÏÇѼ±À» »ì¦ ³ÑÀº °ÍÀÌ ÀüºÎ¶ó¸é ¾î¶»°Ô ÇØ¾ß ÁÁÀ»±î¿ä?

¿øÄ¢À» µû¸£´Â ¼ö ¹Û¿¡ ¾øÀ» °Í °°½À´Ï´Ù. ¾Ö¸ÅÇÑ °æ¿ìÀÇ ¿øÄ¢Àº ´Ã ÀÌ·¯ÇÕ´Ï´Ù. ÃÖ´ëÇÑ ÀÚ¼¼È÷ ¼³¸íÇÏ°í ȯÀÚÀÇ ¼±ÅÃÀ» Á¸ÁßÇÑ´Ù.


[ȯÀÚ ¼³¸í¹® - Small and Grade 2 (G2)]

ÀÛÀº À§½Å°æ³»ºÐºñÁ¾¾ç¿¡ ´ëÇÑ ³»½Ã°æÀýÁ¦¸¦ ÇÏ¿´´Âµ¥ º´¸®ÇÐÀûÀ¸·Î grade 2(G2)°¡ ³ª¿Â »óȲÀÔ´Ï´Ù. ÀÏ´Ü ¾Ï ÄÚµå·Î º¯°æÇÏ°Ú½À´Ï´Ù.

Àü¹®°¡ÀÇ ±Û¿¡¼­ °¡Á®¿Â Table¿¡ µû¸£¸é ¼ö¼úÀ» ±ÇÇØ¾ß ¸¶¶¥ÇÕ´Ï´Ù. ¿Ö³ÄÇÏ¸é ½Å°æ³»ºÐºñÁ¾¾çÀº Àç¹ßÀ§ÇèÀÎÀÚ (G2´Â À¯¸íÇÑ Àç¹ß À§ÇèÀÎÀÚÀÔ´Ï´Ù)°¡ ÀÖÀ¸¸é ¸ðµç °æ¿ì ¼ö¼úÀ» Çϵµ·Ï µÇ¾î Àֱ⠶§¹®ÀÔ´Ï´Ù. ±×·±µ¥ ÀÛÀº G2¶ó¸é À§ÇèÀÎÀÚ Áß¿¡´Â ¾àÇÑ Æí¿¡ ¼ÓÇÕ´Ï´Ù. ÀÌ Á¤µµ±îÁö ²À ¼ö¼úÀ» ±ÇÇØ¾ß ÇÏ´ÂÁö Àǻ縶´Ù ÀÇ°ßÀÌ ´Ù¾çÇÒ ¼ö ÀÖ½À´Ï´Ù.

¼ö¼úÀ» ÇÏ°Ô µÇ¸é Àç¹ß·üÀ» ¾à°£ ÁÙÀÏ ¼ö ÀÖÀ» °ÍÀÔ´Ï´Ù. ±×·¯³ª ¼ö¼úÀº ¼ö¼úÀÔ´Ï´Ù. À§¸¦ ÀüºÎ (ȤÀº ÃÖ¼ÒÇÑ 2/3) À߶ó¾ß ÇÏ°í ÁÖº¯ ¸²ÇÁÀý±îÁö ¹Ú¸®Çϱ⠶§¹®¿¡ ¼ö¼ú¿¡ µû¸¥ ÇÕº´Áõ°ú ¼ö¼ú ÈÄ »îÀÇ Áú ÀúÇϸ¦ ÇÔ²² °í·ÁÇØ¾ß ÇÕ´Ï´Ù. Àü½Å¸¶ÃëÀÇ À§Çèµµ ¹«½ÃÇÒ ¼ö ¾ø½À´Ï´Ù.

Á¦ÀÏ Å« ¹®Á¦´Â µ¥ÀÌŸ°¡ ¾ø´Ù´Â °ÍÀÔ´Ï´Ù. ¾çÂÊ ±Ø´ÜÀº ¸¹½À´Ï´Ù. ¸Å¿ì ÀÛ°í G1ÀÎ °æ¿ì³ª ¸Å¿ì Ä¿¼­ Ʋ¸²¾øÀÌ ¾ÏÀÎ °æ¿ì´Â Á¾Á¾ ¸¸³¯ ¼ö ÀÖ½À´Ï´Ù. ±×·±µ¥ ÀÛÀº Á¾¾çÀÎ G2´Â ¹«Ã´ µå¹® »óȲÀÔ´Ï´Ù. ¸î ³â¿¡ ÇÑ ¸í ºÉ±î ¸»±î ÇÕ´Ï´Ù. Çö´ë ÀÇÇÐÀº ±Ù°Å Áß½ÉÀ¸·Î ÀÌ·ç¾îÁý´Ï´Ù. ±×·±µ¥ ÀÚ·á°¡ ¾øÀ¸´Ï Á¤È®ÇÑ ÆÇ´Ü ±Ù°Å°¡ ¾ø´Â »óȲÀÎ ¼ÀÀÔ´Ï´Ù. ÀÌ·¯ÇÑ °æ¿ì ÀÇ»çµéÀº Àü¹®°¡ ÀÇ°ßÀ» µû¸£´Â °æ¿ì°¡ ¸¹½À´Ï´Ù. ¾Õ¼­ ¼³¸íµå¸° tableÀÔ´Ï´Ù. ¼ö¼úÀ» ±ÇÇÏ´Â °ÍÀÌ Ç¥ÁØÀÔ´Ï´Ù. ¼ö¼ú ÀÌ¿ÜÀÇ ¼±ÅÃÀ» ÇÏ¿´À» ¶§ ¾î¶² °á°ú°¡ ¿¹»óµÇ´ÂÁö¸¦ ¾Ë ¼ö ¾ø½À´Ï´Ù. ÀÇ»çÀÇ °¨À¸·Î´Â ¾È Çصµ µÉ °Í °°Àºµ¥... Ç¥ÁØ ÁöħÀº ¼ö¼úÀÌ´Ï... ÀÌ·¯Áöµµ ¸øÇÏ°í Àú·¯Áöµµ ¸øÇÏ´Â »óȲ, Àǻ縶´Ù ÃßõÀÌ ´Ù¸¥ »óȲÀÏ ¼ö ¹Û¿¡ ¾ø½À´Ï´Ù.

Àǻ縶´Ù ÃßõÀÌ ´Ù¸¥ ¼ö ¹Û¿¡ ¾ø´Â »óȲÀÔ´Ï´Ù. ±×·¡¼­ ÀúÈñ´Â ÃÖ´ëÇÑ ÀÚ¼¼È÷ ¼³¸íÇÏ°í ȯÀÚÀÇ ¼±ÅÃÀ» Á¸ÁßÇÏ°í ÀÖ½À´Ï´Ù.

ÀÏ´Ü 1ÁÖÀÏ ÈÄ ¿Ü·¡¸¦ Àâ¾Æ³õ°Ú½À´Ï´Ù. °¡Á·°£ Àß »óÀÇÇϽðí ÃÖÁ¾ °á·ÐÀ» °¡Áö°í 1ÁÖÀÏ ÈÄ ¿Ü·¡¸¦ ¹æ¹®ÇÏ¿© Áֽñ⠹ٶø´Ï´Ù.

Çö½ÇÀûÀ¸·Î ÀÛÀº NETÀÌ°í ºñ·Ï Á¡¸·ÇÏħÀ±ÀÌ ÀÖ´õ¶óµµ º´¸®ÇÐÀû ¿ÏÀüÀýÁ¦°¡ µÈ °æ¿ì G2¿¡¼­ ¼ö¼úÀ» ¼±ÅÃÇϴ ȯÀÚ´Â ¸¹Áö ¾Ê½À´Ï´Ù.


[ÇÑ º´¸®ÇÐÀÚÀÇ ½Å¼±ÇÑ ÁÖÀå] Neuroendocrine hyperplasia, neuroendocrine dysplasia, carcinoidÀÇ ±¸ºÐÀÌ ±×´ÙÁö Áß¿äÇÏÁö ¾Ê´Ù´Â °ÍÀÔ´Ï´Ù. ÀÚ°¡¸é¿ª¼º À§¿° autoimmune gastritis ȯÀÚ¿¡¼­ type 1, hypergastrinemia¸¦ µ¿¹ÝÇÑ NET¿¡ ´ëÇÑ À̾߱⠰°½À´Ï´Ù. Helicobacter-associated¿¡¼­´Â ¾î¶»°Ô ÇÏ´Â °ÍÀÌ ÁÁÀ»Áö °í¹ÎÀÔ´Ï´Ù.


3. Surveillance for small type I gastric neuroendocrine tumor (carcinoid)

¿ì¸®³ª¶ó ¿µ¹® ³»½Ã°æÇÐȸÁöÀÎ Clinical Endoscopy¿¡¼­´Â 2013³â IDENÀ» Á¤¸®ÇÑ Special Issue¸¦ ³Â½À´Ï´Ù. Àú´Â °í½Å´ëÇб³º´¿ø ¹Ú¹«ÀÎ ±³¼ö´ÔÀÇ Endoscopic treatment for early foregut neuroendocrine tumorsÀ» Èï¹Ì·Ó°Ô Àоú½À´Ï´Ù. ¿©·¯ºÐ¿¡°Ô ¼Ò°³ÇÏ°í ½ÍÀº ³»¿ëÀº 1 cm ÀÌÇÏÀÇ type I NE tumor´Â Ä¡·á¸¦ ÇÏÁö ¾Ê´Â´Ù(surveillance only !)´Â °ÍÀÔ´Ï´Ù. Ç¥¸¦ º¸½Ã¸é surveillance¸¦ ÇÏ°Ô µÇ¾î ÀÖ½À´Ï´Ù (»¡°£ º°Ç¥). Type IÀº atrophic gastritis (+) and/or hypergastrinemiaÀÎ ÇüÅÂÀÔ´Ï´Ù.

Serum markerÀÇ ¿ªÇÒÀº ¾ÆÁ÷ ºÒ¸íÈ®ÇÕ´Ï´Ù. ¸î¸î ¿¬±¸´Â ÀÖÁö¸¸, Åë»óÀÇ ÀÓ»ó protocol¿¡´Â µé¾î°¡ ÀÖÁö ¾Ê½À´Ï´Ù. ¹Ú¹«ÀÎ ±³¼ö´Ô Á¾¼³ÀÇ ÇØ´ç ³»¿ëÀÔ´Ï´Ù.

¾à°£ ¿À·¡µÈ ÀÚ·áÀÌÁö¸¸ Consensus statemenet on behalf of the European Neuroendocrine Tumore Society (ENETS) ¿¡¼­µµ ºñ½ÁÇÑ ³»¿ëÀÌ ÀÖ½À´Ï´Ù. 1 cm ÀÌÇÏÀÇ type I NE tumor´Â Ä¡·á¸¦ ÇÏÁö ¾Ê´Â´Ù(surveillance only !)´Â ¹Ù·Î ±× ³»¿ëÀÔ´Ï´Ù.

¾Æ·¡ ¿¹µéÀº ¸ðµÎ °æ°ú°üÂûÀÌ °¡´ÉÇÏ´Ù°í »ý°¢ÇÕ´Ï´Ù.


[More cases with observation]

Á¦ ¿Ü·¡¿¡´Â ¼ö¼úÀû ȤÀº ³»½Ã°æÀû Ä¡·á¸¦ ÇÏÁö ¾Ê°í °æ°ú °üÂû ÁßÀÎ type I gastric carcinoid´Â 6-7¸í Á¤µµ °è½Ê´Ï´Ù. (2015³â 8¿ù ÇöÀç)


1994³âºÎÅÍ °æ°ú°üÂûÁßÀÎ multiple gastric carcinoids (gastrin = 386). óÀ½ total gastrectomy¸¦ ±ÇÀ¯¹Þ°í ¿À¼ÌÀ¸³ª 10³â ÀÌ»ó ¾Æ¹« ¹®Á¦°¡ ¾øÀ½.


2¹ø° ȯÀÚ. Gastrin 119


3¹ø° ȯÀÚ. Gastrin 140


4¹ø° ȯÀÚ. Gastrin 404


5¹ø° ȯÀÚ. Gastrin 395


6¹ø° ȯÀÚ. Gastrin 530. ¿Ü±¹ÀÎ


7¹ø° ȯÀÚ. Gastrin 410


4. Korean multicenter study

2016³â ´ëÇÑ»óºÎÀ§Àå°üÇ︮ÄÚ¹ÚÅÍÇÐȸÁö¿¡ Á¦1Çü À§À¯¾ÏÁ¾ Ä¡·á¼ºÀû¿¡ ´ëÇÑ ´Ù±â°ü °øµ¿¿¬±¸°¡ ¹ßÇ¥µÇ¾ú½À´Ï´Ù (Lee HS. KJHUGIR 2016).

À§ ½Å°æ³»ºÐºñÁ¾¾ç 223¿¹ Áß 104¿¹(46.6%)°¡ Á¦1ÇüÀ̾úÀ¸¸ç, 94¿¹ÀÇ ÃßÀû°üÂû °á°ú°¡ ºÐ¼®µÇ¾ú½À´Ï´Ù.67¿¹´Â ³»½Ã°æÄ¡·á, 27¿¹´Â °æ°ú°üÂûµÇ¾ú½À´Ï´Ù. ³»½Ã°æÄ¡·á±ºÀÇ 14¿¹(20.9%)´Â ±¹¼ÒÀç¹ßÇÏ¿© ³»½Ã°æ Ä¡·á°¡ Ãß°¡µÇ¾ú°í, °æ°ú°üÂû±ºÀÇ 8¿¹(29.6%)´Â Á¾¾çÀÌ Ä¿Á®¼­ ³»½Ã°æÄ¡·á°¡ ÇÊ¿äÇß½À´Ï´Ù. ¸ðµç ȯÀÚ¿¡¼­ ¿ø°Ý ÀüÀÌ´Â ¾ø¾ú½À´Ï´Ù.


5. [2017-3-25. KINGCA] Pathologic findings of gastric NET - Á¶¹Ì¿¬

Atrophic gastritis¿¡ ÀÇÇÑ ECL cell hyperplasia°¡ dysplasia·Î µÇ±â À§Çؼ­´Â ¸î °¡Áö Ãß°¡ÀûÀÎ º¯È­°¡ ÇÊ¿äÇÕ´Ï´Ù.

Atrophic gastritis¿¡ ÀÛÀº neuroendocrine noduleÀ» ¸¸µé¾úÀ» ¶§¿¡´Â ±× Å©±â¿¡ µû¶ó hyperplasia¿Í dysplasia·Î Á¤ÀÇÇÕ´Ï´Ù.

Poorly-differentiated NEC¿Í NET G3´Â ºñ½ÁÇØ º¸ÀÏ ¼ö ÀÖ½À´Ï´Ù.

Differentiation (well differentiated vs. poorly differentiated)°ú grading (G1, G2, G3)Àº ¾î¶² °ü°è°¡ ÀÖÀ»±î¿ä?

Ki-67°ú mitosis´Â ¾î¶² »ó°ü°ü°è°¡ ÀÖÀ»±î¿ä? µÑ ´Ù Áß¿äÇÏ´Ù´Â °ÍÀÌ ÀϹÝÀûÀÌÁö¸¸, Ki-67 labeling index °Ë»ç¹ý ÀÚü¿¡ »ó´çÇÑ limitationÀÌ ÀÖ½À´Ï´Ù. ÃÖ±Ù¿¡´Â digital image analyzerÀÇ µµ¿òÀ» ¹ÞÀ¸¸é °Ë»çÀÇ ¼ºÀûÀ» Çâ»ó½Ãų ¼ö ÀÖ´Ù°í ÇÕ´Ï´Ù. NET¿¡¼­´Â mitosis ÃøÁ¤ÀÌ ¸Å¿ì ¾î·Æ½À´Ï´Ù. ¾ÆÁÖ ÂªÀº ½Ã°£¿¡ cell cycle¿¡¼­ escape¸¦ ÇÒ ¼ö ÀÖÀ¸¹Ç·Î NET¿¡¼­´Â Ki-67ÀÌ Áß¿äÇÕ´Ï´Ù. ¹Ý¸é GIST¿¡¼­´Â mitosis°¡ Áß¿äÇÏ°í Ki-67Àº routineÇÏ°Ô ÃøÁ¤ÇÏÁö´Â ¾Ê°í ÀÖ½À´Ï´Ù.

G3 NENs¿¡´Â NET G3 (¼¼Æ÷Çü: well differentiated) ¿Í NEC (¼¼Æ÷Çü: poorly differentiated)°¡ ÀÖ½À´Ï´Ù.

G3 NENs¿¡´Â ¼ÓÇÏ´Â NET G3¿Í NEC´Â ¿¹ÈÄ°¡ ´Ù¸£´Ù´Â ¸Å¿ì Áß¿äÇÑ ¿¬±¸ÀÔ´Ï´Ù.

2010³â¿¡´Â G3¸¦ carcinoma·Î ºÐ·ùÇÏ¿´½À´Ï´Ù. ±×·±µ¥ well-differentiated NET Áß grade 3ÀÎ °æ¿ì´Â poorly differentiated¿Í È®¿¬È÷ ´Ù¸£´Ù´Â °ÍÀÌ ¾Ë·ÁÁ³½À´Ï´Ù (ƯÈ÷ ÃéÀå¿¡¼­). µû¶ó¼­ 2017³â¿¡´Â well differentiated G3¸¦ NEC·Î ºÎ¸£Áö ¾Ê°í NET G3·Î ºÎ¸£µµ·Ï ÇÏ°í ÀÖ½À´Ï´Ù.


6. ¼ö¼úÀû Ä¡·á

ù ¿ÜºÎ ³»½Ã°æ

Á¶Á÷°Ë»ç. NET

ÀÇ·Ú ÈÄ Àç°Ë

±âÀúÁúȯÀÌ ÀÖ´ÂÁö Ç÷¾×°Ë»ç·Î È®ÀÎÇØ º¸¾Ò½À´Ï´Ù.

¼ö¼úÀº wedge resectionÀ» ÇÏ¿´°í ´ÙÇེ·´°Ô G1À¸·Î ³ª¿Ô½À´Ï´Ù.


7. ³»½Ã°æÄ¡·á


Stomach, endoscopic submucosal dissection:
Well-differentiated neuroendocrine tumor (G1)
1. Name of Procedure: ESD
2. Site of Tumor: Stomach (low body, greater curvature)
3. Diagnosis: Neuroendocrine tumor
4. WHO classification(2010): Neuroendocrine tumor(G1)
5. Multiplicity: Single
6. Size: 0.4x0.4 cm
7. Extent: Mucosa and submucosa
8. Grading: Mitotic Count: 1/5 HPFs
   Ki-67 labeling index: 2 %
9. Immunohistochemical Stains:
   1) Synaptophysin : Positive
   2) Chromogranin A: Positive
10. Lymphovascular invasion: Not identified
11. Perineural invasion: Not identified
12. Lymph node metastasis: not evaluated
13. Resection Margins: Negative


8. Á¶Á÷°Ë»ç + ¼ÒÀÛ¼ú·Î Ä¡·áÇÑ À¯¾ÏÁ¾

Á¶Á÷°Ë»ç·Î Á¦¹ý Á¶Á÷À» Á¦°ÅÇÒ ¼ö ÀÖ½À´Ï´Ù. ¼ÒÀÛ¼ú·Î »ó´çÈ÷ ±í°Ô Å¿ö ¾ø¾Ù ¼ö ÀÖ½À´Ï´Ù. ÀýÁ¦¼úÀ» ÇÏ·Á°í µé¾î°¬´Âµ¥ ¸·»ó À¯¾ÏÁ¾ÀÌ ³Ê¹« À۾Ƽ­ Á¶Á÷°Ë»ç·Î Á¦°ÅÇÏ¿´°í (ÀÌ ¶ÇÇÑ À¯¾ÏÁ¾À¸·Î ³ª¿ÔÀ½), ¿¬ÀÌ¾î ¼ÒÀÛ¼úÀ» ÇÏ¿´½À´Ï´Ù. ¸î ³â µÚ¿¡ º¸¾Ò´õ´Ï ±ú²ýÇÑ ¹ÝÈ縸 ³²¾ÆÀÖ¾ú½À´Ï´Ù.


9. Type III gastric carcinoid

Á¦3Çü À¯¾ÏÁ¾Àº ¼ö¼úÀÌ Ç¥ÁØ Ä¡·áÀÔ´Ï´Ù.

60¼¼ ¿©¼º (2020). Gastrin 63.6 pg/ml

NET G1, 1.0cm, mucosa and submucosa, Ki 67 1%, mitotic count 1/10 HPF

Synaptophysin

Gastrin = 34.6 ng/ml·Î ¼ö¼ú ÀÇ·ÚÇÔ
1. Name of Procedure: wedge resection
2. Site of Tumor: Stomach (high body and anterior wall)
3. Diagnosis: Neuroendocrine tumor, G2
4. WHO classification(2010): Neuroendocrine tumor(G2)
5. Multiplicity: Single
6. Size: 1.2x1.1 cm
7. Extent: Submucosa
8. Grading: Mitotic Count: 2-20 (2/10 HPF), Ki-67 labeling index: G2 3-20%
9. Immunohistochemical Stains: Synaptophysin : Positive, Chromogranin A: Positive, weak
10. Lymphovascular invasion: Not identified
11. Perineural invasion: Not identified
12. Resection Margins: Negative (Safety margin : 0.5 cm)
13. CEA: Negative
14. D2-40: Revealed no endolymphatic emboli

ÃÖ±Ù¿¡´Â ¹«Áõ»ó ¼ºÀο¡¼­ ¹ß°ßµÇ´Â ÀÛÀº Á¦3Çü ½Å°æ³»ºÐºñÁ¾¾çÀ» ³»½Ã°æÀ¸·Î Ä¡·áÇÏ·Á´Â ½Ãµµ°¡ ÀÖ½À´Ï´Ù (Min BH. Br J Surg 2018). ±×·¯³ª ³»½Ã°æ Ä¡·áÀÇ ÀûÀÀÁõ ¼±Åÿ¡ »ó´çÈ÷ ÁÖÀÇÇØ¾ß ÇÕ´Ï´Ù.

50´ë ¿©¼º. Gastrin 23.5, ¼ö¼ú ±ÇÀ¯ÇÏ¿´À¸³ª ³»½Ã°æÄ¡·á ¿øÇÏ¿© ESD. 5³â ÈÄ perigastric node metastasis·Î ´Ù½Ã ¼ö¼ú ±ÇÀ¯
Stomach, high body, posterior, endoscopic submucosal dissection:
WELL DIFFERENTIATED ENDOCRINE TUMOR (CARCINOID TUMOR):
1) size: 1.6x1.5 cm
2) confined to mucosa/submucosa
3) lymphovascular invasion: not identified
4) mitosis: 0/10 HPFs
5) negative resection margins
Chromogranin : Strong positive
Synaptophysin: Positive
Ki-67 : Positive in less than 1% of tumor cells

Serum gastrin 41.9
Stomach, laparoscopic wedge resection: Well differentiated neuroendocrine tumor (CARCINOID) (G1)
1. Name of Procedure: laparoscopic wedge resection
2. Site of Tumor: Stomach (high body, greater curvature)
3. Diagnosis: Neuroendocrine tumor
4. WHO classification(2010): Well-differentiated Neuroendocrine tumor (G1)
5. Multiplicity: Single
6. Size: 1.7x1.5 cm
7. Extent: Mucosa and submucosa
8. Grading: Mitotic Count(/10HPF): 0-1, Ki-67 labeling index: G1: <3%
9. Immunohistochemical Stains:
1) Synaptophysin : Positive
2) Chromogranin A: Positive
10. Lymphovascular invasion: Not identified
11. Perineural invasion: Not identified
12. Lymph node metastasis: not evaluated
13. Resection Margins: Negative, Safety margin : 1.5 cm

50´ë ³²¼ºÀÔ´Ï´Ù. ESD ÈÄ lymphatic invasion ¼Ò°ßÀÌ ÀÖ¾î G2¿´Áö¸¸ ¼ö¼úÀ» ±ÇÇß½À´Ï´Ù. ´ÙÇེ·´°Ô residual tumor´Â ¾ø¾ú½À´Ï´Ù. ¸²ÇÁÀý ÀüÀ̵µ ¾ø¾ú½À´Ï´Ù.
Stomach, endoscopic submucosal dissection:
Well-differentiated neuroendocrine tumor (G2)
1. Name of Procedure: ESD
2. Site of Tumor: Stomach (mid body, anterior wall-lesser curvature)
3. Diagnosis: Neuroendocrine tumor
4. WHO classification(2010): Neuroendocrine tumor(G2)
5. Multiplicity: Single
6. Size: 9x8 mm
7. Extent: Mucosa and submucosa
8. Grading: Mitotic Count: 0-1/10HPF, Ki-67 labeling index: G2: about up to 3%
9. Lymphovascular invasion: Present
10. Perineural invasion: Not identified
11. Resection Margins: Negative, Safety margin: distal, 5 mm; proximal, 9 mm; anterior, 12 mm; posterior, 14 mm; deep, less than 100 §­

À§½Å°æ³»ºÐºñÁ¾¾çÀÇ ½ºÆåÆ®·³Àº ¸Å¿ì ´Ù¾çÇÕ´Ï´Ù. Hypergastrinemia¸¦ µ¿¹ÝÇÑ ÀÛÀº type IÀº °æ°ú°üÂû¸¸ ÇÕ´Ï´Ù. ±×·¯³ª metastasis¸¦ º¸ÀÌ´Â ½ÉÇÑ °æ¿ìµµ ÀÖ½À´Ï´Ù. ±× °æ°è´Â »ó´çÈ÷ ¾Ö¸ÅÇÕ´Ï´Ù.

Á¶Á÷°Ë»ç¿¡¼­ neuroendocrine carcinoma°¡ ³ª¿Í ÀǷڵǾú½À´Ï´Ù. Serum gastrinÀº 65.8 pg/ml·Î Á¤»óÀ̾ú½À´Ï´Ù. ³»½Ã°æ Àç°ËÀ» ÇÏ¿´´Âµ¥ ³î¶ø°Ôµµ "tumor emboli of neuroendocrine tumor"¶ó°í ³ª¿Ô½À´Ï´Ù. ¼ö¼úÀ» ½ÃÇàÇÏ¿´°í ¶Ç ´Ù½Ã ³î¶ø°Ôµµ ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ¾ú½À´Ï´Ù. TumorÀÇ grade´Â G2¿´½À´Ï´Ù.


Well-differentiated neuroendocrine carcinoma (G2)
1. Name of Procedure: Subtotal gastrectomy
2. Site of Tumor: Stomach (body)
3. Diagnosis: Neuroendocrine tumor
4. WHO classification(2010): Neuroendocrine tumor (G2)
5. Multiplicity: Single
6. Size: 1.4x1.0 cm
7. Extent: Mucosa and submucosa
8. Graging: Mitotic count: 2-20/10 HPF, Ki-67 labeling index: G2 3-20%
9. Immunohistochemical Stains:
- Synaptophysin: Positive
- Chromogranin A: Positive
10. Lymphovascular invasion: Present
11. Perineural invasion: Not identified
12. Lymph node metastasis : metastasis to 1 out of 44 regional lymph nodes (pN1) (perinodal extension: absent) (1/44: LN3,5, 1/13; LN4,6, 0/9; "1", 0/0; "4sb", 0/1; "5", 0/1; "6", 0/5; "8a", 0/2; "7", 0/4; "9", 0/3; "11p", 0/4; "12a", 0/2)
13. Resection Margins: Negative, Safety margin : 1.5 cm(proximal), 14.5 cm(distal)

Subtotal gastrectomy with D2 lymph node dissectionÀ» ÇÏÁö ¾Ê¾ÒÀ¸¸é ¾î¶°ÇÑ °á°ú°¡ ³ª¿ÔÀ»±î »ý°¢ÇØ º¸¾Ò½À´Ï´Ù. »ç½Ç hypergastrinemia¸¦ µ¿¹ÝÇÑ ÀÛÀº G1 NET´Â ³»½Ã°æ Ä¡·á³ª ¼ö¼úÀ» ÇÏ´õ¶óµµ wedge resectionÀ» ÇÏ°í ¸¶´Â °æ¿ì°¡ ¸¹±â ¶§¹®ÀÔ´Ï´Ù.

¿äÄÁµ¥ G2´Â ¸Å¿ì ÁÖÀÇÇØ¾ß ÇÕ´Ï´Ù. Serum gastrinÀÌ Á¤»óÀÏ ¶§¿¡´Â ´õ¿í ±×·¸½À´Ï´Ù. ¹®Á¦´Â forcep biopsy¿¡¼­ grade¸¦ ³ª´©±â ¾î·Á¿î °æ¿ì°¡ ¸¹´Ù´Â Á¡Àä...... °í¹ÎÀº °è¼ÓµÇ´Âµ¥ ´äÀº ¾ø°í...... ÀáÀÌ ¿ÀÁú ¾Ê½À´Ï´Ù. ȯÀÚ °ÆÁ¤¿¡.


10. Gastric neuroendocrine carcinoma

Regular endoscopic followup was done after endoscopic resection of early gastric cancer arising from adenoma. He suddenly developed upper abdominal discomfort. Endoscopy showed a large ulcerative lesion in the antrum, and the pathology was neuroendocrine carcinoma. There were multiple metastases in the liver. Previous endoscopic images (8 months ago) were reviewed, but there was no evidence of gastric cancer recurrence or neuroendocrine neoplasms. Only subtle erosions were suspicious. (À§¾Ï 663)
NEUROENDOCRINE CARCINOMA, POORLY DIFFERENTIATED (grade 3)
. Mitosis: 12 / 10 HPF
. Synaptophysin: Positive in some tumor cells
. Chromogranin: Negative
. CD56: Diffuse strong positive
. Ki-67: Positive in about 30% of tumor cells


Poorly-differentiated neuroendocrine carcinoma (G3)
1. Name of Procedure: Organ resection+Node dissection (specify: subtotal gastrectomy)
2. Site of Tumor: Stomach (Antrum and pylorus)
3. Diagnosis: Neuroendocrine carcinoma
4. WHO classification(2010): Neuroendocrine carcinoma
5. Multiplicity: Single
6. Size: 2.5x1.8 cm
7. Extent: Mucosa and submucosa (pT1b)
8. Grading: Mitotic Count: >20/10HPF, Ki-67 labeling index: G3>20%
9. Immunohistochemical Stains: 1. Synaptophysin : Positive 2. Chromogranin A: Positive OPTIONAL : CD56 (+)
10. Lymphovascular invasion: Present (intra- and extramural)
11. Perineural invasion: Present
12. Lymph node metastasis: metastasis to 6 out of 71 regional lymph nodes (pN2) (perinodal extension: absent) (6/71: "1", 0/9; "3", 4/19; "4", 1/3; "4sb", 0/5; "5", 0/0; "6", 0/5; "7", 0/6; "8a", 1/3; "9", 0/8; "11p", 0/9; "12a", 0/3; "11d", 0/1)
13. Resection Margins: Negative Safety margin : proximal, 4 cm; distal, 2.8 cm
14. AJCC stage by 7th edition: pT1b N2


Stomach, subtotal gastrectomy:
Poorly-differentiated neuroendocrine carcinoma (G3)
1. Name of Procedure: Organ resection
2. Site of Tumor: Stomach (Antrum)
3. Diagnosis: Neuroendocrine carcinoma (G3)
4. WHO classification(2010): Poorly differentiated neuroendocrine carcinoma, large cell type
5. Multiplicity: Single
6. Size: 6x6 cm
7. Extent: Serosa
8. Grading: Mitotic Count(/10HPF): >20 (about 60/10 HPF)
9. Immunohistochemical Stains: Synaptophysin : Positive, Chromogranin A: Negative, CD56 (+)
10. Lymphovascular invasion: present
11. Perineural invasion: present
12. Lymph node metastasis: [Number of positive nodes/Total number of nodes(7/32)]
13. Resection Margins: Negative
14. Other Pathologic Components: Presence of tumor necrosis (60 %)

melena·Î ³»¿øÇÏ¿© ¼ö¼úÀ» ÀÇ·ÚÇÏ¿´½À´Ï´Ù.
1. WHO classification(2010): Neuroendocrine carcinoma (G3)
2. Size: 7.5x4.5x4 cm
3. Grading: Mitotic Count: >20/10HPF, Ki-67 labeling index: G3>20%
4. Immunohistochemical Stains: Synaptophysin : Positive; Chromogranin A: Positive; CD56 (-)
5. Lymphovascular invasion: Present
6. Perineural invasion: Not identified
7. Resection margins: Negative
8. Other pathologic components: presence of tumor necrosis (20 %)

À§¾Ï 698
Subtotal gastrectomy: Neuroendocrine carcinoma (G3)
1. Name of Procedure: Radical subtotal gastrectomy
2. Site of Tumor: Stomach (distal antrum and posterior wall)
3. Diagnosis: Neuroendocrine tumor
4. WHO classification(2010): Poorly differentiated Neuroendocrine carcinoma (G3)
5. Multiplicity: Single
6. Size: 1.9x0.5 cm
7. Extent: Mucosa and submucosa
8. Grading: Mitotic Count(/10HPF): >20, Ki-67 labeling index: G3>20%
9. Immunohistochemical Stains: Synaptophysin : Positive
10. Lymphovascular invasion: Not identified
11. Perineural invasion: Not identified
12. Lymph node metastasis: 0/20: "3", 0/7; "4", 0/4; "5", 0/0; "6", 0/3; "7", 0/0; "9", 0/0; "8a", 0/5; "11p", 0/1; "12a", 0/1; "4sb", 0/0; "1", 0/6)
13. Resection Margins: Negative: Safety margin : 2 cm
14. AJCC stage by 8th edition: pT1 N0

MUO·Î ³»¿øÇϽŠºÐÀ¸·Î ÀüÁ¤ºÎ º´¼Ò À§³»½Ã°æ Á¶Á÷°Ë»ç¿Í transabdominal biopsy ¸ðµÎ neuroendocrine carcinoma·Î È®ÀεǾúÀ½ (2018)


11. Lanreotide for metastatic neuroendocrine tumor


[FAQ]

[2016-9-6. ¾Öµ¶ÀÚ Áú¹®]

¸ÅÀÏ ±³¼ö´ÔÀÇ °¡¸£Ä§ Àß ¹Þ°í ÀÖ½À´Ï´Ù. Ç×»ó °¨»çµå¸³´Ï´Ù.

Áø·á Áß ±Ã±ÝÇÑ °ÍÀÌ ÀÖ¾î Áú¹®µå¸³´Ï´Ù. °£ÇæÀûÀÎ ¼Ó¾²¸² ȯÀÚ·Î ³»½Ã°æ»ó 5mm Á¤µµÀÇ gastric neuroendocrine tumor ·Î È®ÀÎµÇ¾î °æ°ú°üÂûÇÏ·Á°í ÇÏ¿´À¸³ª Áõ»óÀÌ ½ÉÇØ EMR ½ÃÇàÇÏ¿´½À´Ï´Ù. Resection margin negative ·Î È®ÀÎµÇ¾î °æ°ú°üÂû Áß °£ÇæÀûÀÎ ¼Ó¾²¸²ÀÖ°í ³»½Ã°æ»ó ÀÌ»ó ¼Ò°ß º¸ÀÌÁö ¾ÊÀ¸³ª gastrin levelÀÌ 1000À¸·Î ¸Å¿ì ³ô°Ô È®ÀεǾú´Âµ¥, ´Ù¸¥ ºÎÀ§¿¡ ´ëÇÑ evaluationÀ» ½ÃÇàÇؾߵÉÁö PPI ¾²¸é¼­ °æ°ú °üÂûÇؾߵÉÁö ±³¼ö´ÔÀÇ °í°ßºÎŹµå¸³´Ï´Ù.

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°æ°ú°üÂûÀ» °í·ÁÇÏ¿´´Ù´Â Á¡À¸·Î º¸¾Æ À¯¾ÏÁ¾¿¡ ´ëÇÑ EMR ÀüºÎÅÍ gastrinÀÌ ³ô¾ÒÀ» °Í °°±º¿ä. À¯¾ÏÁ¾ Ä¡·á Àü CT µîÀ» ÇϼÌÀ» °ÍÀ̱¸¿ä.

CT¿¡¼­ ÃéÀåÀ̳ª ½ÊÀÌÁöÀå¿¡ Á¾¾çÀÌ ¾ø°í (= gastrinoma°¡ ¾Æ´Ï°í), gastrinÄ¡°¡ ³ôÀ¸¸é¼­ À§À¯¾ÏÁ¾ÀÌ ÀÖ´Â °æ¿ì´Â Á¦1Çü À¯¾ÏÁ¾À̱⠶§¹®¿¡ Å©±â°¡ ÀÛÀ¸¸é °æ°ú°üÂûÀ» ÇÒ ¼ö ÀÖ½À´Ï´Ù. Áõ»óÀÌ À־ Ä¡·áÇϼ̴ٰí ÇϼÌÁö¸¸ »ç½Ç ÀÛÀº Á¦1Çü À¯¾ÏÁ¾°ú Áõ»óÀº ¾Æ¹« °ü°è°¡ ¾ø½À´Ï´Ù.

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[References]

1) The pathologic classification of neuroendocrine tumors (PDF) Nature Guidelines (2010)

2) Carcinoid tumor (PDF) ´ëÇÑ Helicobacter ¹× »óºÎÀ§Àå°ü ¿¬±¸ÇÐȸ Ãá°è½ÉÆ÷Áö¾ö (ÀÌÁØÇà. 2009)

3) EndoTODAY Gastric carcinoid À§À¯¾ÏÁ¾

4) EndoTODAY Duodenal carcinoid ½ÊÀÌÁöÀå À¯¾ÏÁ¾

5) EndoTODAY Colorectal neuroendocrine tumor °áÀåÁ÷Àå ½Å°æ³»ºÐºñÁ¾¾ç. Á÷Àå À¯¾ÏÁ¾.

6) EndoTODAY Case: rectal carcinoid with metastasis Á÷Àå À¯¾ÏÁ¾ ¸²ÇÁÀý ÀüÀÌ Áõ·Ê

7) ÀÚ°¡¸é¿ª¼º ¸¸¼º À§Ã༺ À§¿°°ú ¿¬°üÇÏ¿© ¹ß»ýÇÑ À§ ½Å°æ³»ºÐºñÁ¾¾ç Neuroendocrine tumoe associated with autoimmune gastritis

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