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[Á¡¸·ÇÏħÀ±. SM invasion] - ðû


1. Á¡¸·ÇÏÃþÀÇ µÎ²²´Â ¾ó¸¶Àΰ¡?

Á¤»ó ¼ºÀÎÀÇ À§ Á¡¸·ÇÏÃþÀÇ µÎ²²´Â ¾ó¸¶Àϱî¿ä? ¾îµð¿¡µµ Á¤È®È÷ ¾ºÀÎ °÷ÀÌ ¾ø¾î¼­ ´Ã ±Ã±ÝÇߴµ¥ À̹ø ³í¹®¿¡ ¸íÈ®È÷ ³ª¿Í ÀÖ½À´Ï´Ù. Áß¾Ó°ªÀÌ 2.1 mm ¶ó°í ÇÕ´Ï´Ù. Æò±ÕÀº 2.6 mmÀÔ´Ï´Ù.

The mean full thickness of the submucosa (¡¾standard variation) was 2,605 um (¡¾1,760) and the median thickness (range) was 2,100 um (20-13,000).


2. Á¡¸·ÇÏÃþ ħÀ±ÀÇ ±íÀ̸¦ ÃøÁ¤ÇÏ´Â ±âÁØ

Á¡¸·ÇÏÃþ ħÀ±ÀÇ ±íÀ̸¦ ÃøÁ¤ÇÏ´Â ±âÁØÀº ¾îµðÀϱî¿ä? ¾Æ½±°Ôµµ ¾ÆÁ÷±îÁö´Â º´¸®ÇÐÀÚµé »çÀÌ¿¡¼­µµ ÅëÀÏµÈ ±ÔÁ¤ÀÌ ¾ø´Â ¸ð¾çÀÔ´Ï´Ù. ÀÌ ³í¹®ÀÇ discussion¿¡´Â ÀÌ·± ºÎºÐµµ ÀÖ½À´Ï´Ù. "Standardization in measuring submucosal invasion is needed for and objective application of the expanded indication for ESD." µû¶ó¼­ ´Ù¸¥ º´¿ø¿¡¼­ Á¦½ÃÇÑ ±âÁØÀ» ÀÌ¿ëÇÏ¿© ESD ÀûÀÀÁõÀ̳ª ESD ÈÄ ¼ö¼ú ÀûÀÀÁõÀ» Á¤ÇÏ´Â °ÍÀº À§Çèõ¸¸ÇÑ ÀÏÀÔ´Ï´Ù. Àڱ⺴¿ø º´¸®ÇÐÀÚ°¡ ¾î¶² ±âÁØÀ» °¡Áö°í ÀÖ´ÂÁö ¾Ë¾Æ¾ß ÇÕ´Ï´Ù. ¸¸¾à ±âÁØÀÌ µÎ°³¶ó¸é submucosal invasion ±íÀÌ°¡ ±í°Ô ³ª¿À´Â °ÍÀ» ÆÇ´Ü¿¡ ÀÌ¿ëÇÏ´Â ¾ÈÀüÇÒ °Í °°½À´Ï´Ù. Áï ¾î¶»°Ô Àç¸é 400 um, ´Ù¸¥ ¹æ¹ýÀ¸·Î Àç¸é 700 um°¡ ³ª¿À´Â »óȲÀ̶ó¸é 700 um·Î ÆÇ´ÜÇÏ´Â °ÍÀÌÁö¿ä. Áï ¼ö¼úÀ» º¸³»´Â °ÍÀÔ´Ï´Ù. ¾ÆÁ÷ expanded indication¿¡ ´ëÇÑ ¸íÈ®ÇÑ ±Ù°Å°¡ ¾ø´Â »óȲÀ̹ǷΠ¾ÈÀüÇÏ°Ô °¡´Â °ÍÀÌ ÁÁÁö ¾ÊÀ»±î¿ä?

The depth of submucosal invasion was the length (in um) from the lower border of the muscularis mucosae to the point of the deepest tumor penetration. When the continuity of muscularis mucosa was disrupted due to tumor infiltration or ulcer formation, or only a small fragment separately remained in the upper submucosa, the length was measured on the virtual line of the muscularis mucosae, based on the remaining adjacent layer, to the point of the deepest tumor penetration.

¾Æ·¡ ±×¸²À» º¸½Ã¸é submucosal invasion ±íÀ̸¦ ÃøÁ¤ÇÏ´Â °ÍÀÌ ¸¸¸¸ÇÑ ÀÏÀÌ ¾Æ´ÔÀ» ´À³¥ ¼ö ÀÖ½À´Ï´Ù.

2023³â ¹ßÇ¥µÈ À§¾Ïº´¸® °¡À̵å¶óÀο¡¼­´Â "use the lowest surface of the original, unmodified muscularis mucosase as the reference point"¶ó´Â ¾ð±Þ°ú ÇÔ²² ¾Æ·¡ ±×¸²ÀÌ Á¦½ÃµÇ¾ú½À´Ï´Ù.


3. 500 um¸¦ ±âÁØÀ¸·Î ÇÏ´Â expanded indication¿¡¼­ ¸²ÇÁÀý ÀüÀÌÀÇ ºóµµ´Â?

DiscussionÀº ¾Æ·¡¿Í °°Àº ¹®ÀåÀ¸·Î ½ÃÀÛÇÏ°í ÀÖ½À´Ï´Ù. Áï Gotoda µîÀÇ Ãʱ⠿¬±¸¿Í ´Þ¸® expanded indication¿¡ ÇØ´çÇÏ´Â À§¾Ï¿¡¼­µµ ¸²ÇÁÀý ÀüÀÌ°¡ Á¾Á¾ ¹ß°ßµÈ´Ù´Â °ÍÀÔ´Ï´Ù. À̹ø ¿¬±¸¿¡¼­´Â 3.9%¿´½À´Ï´Ù.

Since Gotoda et al. reported no lymph node metastasis in minute submucosal cancer, a 'depth of submucosal invasion of 500 um' has become a key criterion for the curability of ESD. However, higher incidences of lymph node metastasis were reported in several Korean studies, and the 500 um criterion has been debated. The present study also shows 3.9 % of lymph node metastasis in minute submucosal cancer, and evaluated the validity of the 500 um criterion using ROC curve analysis. As a result, the highest negative predictive value was observed at a cutoff value of 300 um.

µû¶ó¼­ ÀúÀÚµéÀº »õ·Î¿î cutoff¸¦ °ËÅäÇÏ¿´°í 500 um°¡ ¾Æ´Ï¶ó 300 um°¡ ´õ Àû´çÇÏ´Ù°í Á¦¾ÈÇÏ°í ÀÖ½À´Ï´Ù. ¿©ÇÏÆ° expanded indication¿¡ ´ëÇؼ­´Â Á¶½É, Á¶½É, ¶Ç Á¶½É ÇÏ´Â ¼ö ¹Û¿¡ ¾ø´Ù°í »ý°¢ÇÕ´Ï´Ù.


4. 500 um

µü 500um¶ó´Â °á°ú°¡ ³ª¿À¸é ¼ö¼úÀ» ±ÇÇØ¾ß ÇÒÁö ¸»¾Æ¾ß ÇÒÁö °í¹ÎÀÔ´Ï´Ù.

2022 KGCA °¡À̵å¶óÀÎÀº 500 umÀÌÇϱîÁö´Â °æ°ú°üÂûÀÌ °¡´ÉÇÏ´Ù°í ¾º¿©Á® ÀÖ½À´Ï´Ù. 500ÀÌ¸é ¼ö¼úÇÏÁö ¾Ê¾Æµµ ÁÁ´Ù´Â ÀÇ°ßÀ̶ó°í º¸ÀÔ´Ï´Ù.

ȯÀÚ¿¡°Ô ¼³¸íÇϱ⵵ ¾î·Æ½À´Ï´Ù. ¾î¶² ¿¹ÀÔ´Ï´Ù.


[Cases]

[Á¶Á÷°Ë»ç¿¡¼­ Á¡¸·ÇÏħÀ±ÀÌ ³ª¿Â Áõ·Ê, Submucosal invasion in forceps biopsy]

2022-8-3


[À§¾Ï 512]

À§¾Ï ³»½Ã°æ Ä¡·á ÈÄ ÀϺΠȯÀÚ¿¡¼­ expanded criteria¿¡ ÇØ´çÇÏ´Â ¼Ò°ßÀÌ ³ª¿É´Ï´Ù. Å©±â 3cm ÀÌÇÏÀÌ°í minute submucosa invasionÀÌ ÀÖ´Â °æ¿ì´Â expanded criteria¿¡ ¸¸Á·ÇÏ¿© ÃßÀû°üÂûÀ» ±ÇÇÏ´Â °ÍÀ¸·Î µÇ¾î ÀÖ½À´Ï´Ù.

This is a very famous table for expanded indication. Three boxes in group B are expanded indications for ESD. However, the yellow box, group C, is considered to be an expanded indication by some endoscopists. So, there are two different definitions for expanded indications of ESD. Only B versus B and C. We need to be very careful when we read literatures on expanded indications.

There is an important thing that we sometimes forget. Indications are different from criteria. Indication is something that we consider before the treatment. Criteria is something we consider after the treatment. In this regard, selection of patients for ESD can be different from selection of patients for additional surgery after ESD.

This is an algorithm from a Japanese literature. ESD candidates are selected by the absolute indications. Expanded indications are not considered for ESD in this flowchart. After ESD and histological assessment, you can see the concept of expanded criteria. When the lesion is slightly over the standard guideline criteria, you can choose close follow-up rather than additional surgery. So this group of patients was originally considered as an absolute indication, but after ESD they were changed into expanded criteria. So, indication and criteria is different in terms of the timing. Indication is before ESD, criteria is after ESD. We should not confuse them. But until now, the two terminologies are used interchangeably. I don¡¯t like it.

Àú´Â 2-3cm »çÀÌ´Â ¾à°£ Á¶½É½º·´°Ô Á¢±ÙÇÏ°í ÀÖ½À´Ï´Ù. ÃÖ´ëÇÑ ÀÚ¼¼È÷ ¼³¸íÇÏ°í ȯÀÚÀÇ ÆÇ´ÜÀ» Á¸ÁßÇÑ´Ù´Â ÀÔÀåÀ» °¡Áö°í ÀÖ½À´Ï´Ù. Áõ·ÊÀÔ´Ï´Ù.


Stomach ESD
Early gastric carcinoma
1. Location : angle, lesser curvature
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, 22 mm (2) vertical diameter, 19 mm
6. Depth of invasion : invades submucosa, (depth of sm invasion : 100 §­) (pT1b)
7. Resection margin : free from carcinoma(N), safety margin : distal 7 mm, proximal 5 mm, anterior 4 mm, posterior 10 mm, deep 200 §­ (sm only)
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

Àú´Â ȯÀÚ¿¡°Ô ¾Æ·¡¿Í °°ÀÌ ¼³¸íÀ» ÇÏ¿´½À´Ï´Ù.

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1ÁÖÀÏ ÈÄ °æ°ú°üÂûÀ» °áÁ¤ÇϽøé Àΰø ±Ë¾çÀº ´Ù ¾Æ¹°¾ú´ÂÁö, ÀÜ·ùº´¼Ò´Â ¾ø´ÂÁö È®ÀÎÇϱâ À§ÇÏ¿© 2-3°³¿ù ÈÄ ³»½Ã°æ °Ë»ç¸¦ ÇÏ°í ÀÖ½À´Ï´Ù. Åð¿ø½Ã ÀÌ¹Ì ¿¹¾àµÇ¾î ÀÖÀ» °ÍÀÔ´Ï´Ù. ÀÌÈÄ´Â 3³â µ¿¾ÈÀº 6°³¿ù °£°ÝÀ¸·Î, ±× ÀÌÈÄ´Â °Ë»ç °£°ÝÀ» Á¶±Ý ´Ã¸®°í ÀÖ½À´Ï´Ù. °¡±ÞÀûÀ̸é 1³â Á¤µµ´Â º» º´¿ø¿¡¼­ °Ë»ç¹ÞÀ¸½Ã±â ¹Ù¶ø´Ï´Ù. ±× ÀÌÈÄ´Â ¿øÇÏ½Ã¸é °¡±î¿î ÀÇ·á±â°üÀ¸·Î µÇÀÇ·Ú ¼Ò°ß¼­¸¦ ÀÛ¼ºÇÏ¿© ¿Å°Üµå¸®°í ÀÖ½À´Ï´Ù. ½Ì°Ì°Ô µå½Ã°í ±ÕÇüµÇ°í °Ç°­ÇÑ ½Ä»ýÈ°À» ±ÇÇÕ´Ï´Ù. ¼ú°ú ´ã¹è´Â ÁÁÁö ¾Ê½À´Ï´Ù.

º¸Åë 2´Þ Á¤µµ ¾àÀÌ ÇÊ¿äÇѵ¥ ³²Àº ¾àÀº ÃæºÐÇϽʴϱî?

°èȹ: 1ÁÖÀÏ ÈÄ ¿Ü·¡


°í·É ȯÀÚ¿¡¼­´Â Àý´ëÀûÀÀÁõÀ» ¾à°£ ÃÊ°úÇÑ °æ¿ì ³»½Ã°æ ÀýÁ¦¼úÀ» ½ÃµµÇϱ⵵ ÇÕ´Ï´Ù. ±×·±µ¥ ÃÖÁ¾ º´¸®°ú ¾Æ·¡°ú °°ÀÌ ³ª¿À¸é ¼ö¼úÀ» ±ÇÇÏÁö ¾ÊÀ» ¼ö ¾ø½À´Ï´Ù.

°³¾÷°¡ÀÇ Ã¹ ³»½Ã°æ

¿ÜºÎ ½½¶óÀ̵å ÀçÆǵ¶: M/D adenocarcinoma


[References]

1) Á¡¸·ÇÏħÀ±. Submucosal invasion

2) Undifferentiated¿¡ ´ëÇÏ¿©

3) Expanded indication/criteria



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