P/D로 ESD 했는데 M/D, SM invasion으로 나온 위암. EndoTODAY 이준행

001 | 101 | 201 | 301 | 401 | 501 | 601 | 701 | 801 | 901 | 1000

조직검사는 P/D adenocarcinoma였습니다. ESD를 하시겠습니까? 수술을 권하시겠습니까?

[2014-4-16] 저는 수술을 권했습니다. P/D 형은 보통 수술을 보내고 있습니다. P/D나 signet ring cell carcinoma를 포함한 expanded indication이 그다지 미덥지 않습니다. 적어도 제게는...

1. Location : middle third, center at body and lesser curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 2.7x1.4 cm
6. Depth of invasion : invades submucosa (sm1) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 3.8 cm, distal 11.2 cm
8. Lymph node metastasis : no metastasis in 29 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified

[2026-7-20. update]

2022년 발표되었고 2024년 개정되어 2025년 1월 Journal of Gastric Cancer에 발표된 Korean Gastric Cancer Guideline 2024에서 미분화조직형 위암의 ESD에 대한 추천은 아래와 같습니다. Cautiously consider할 수 있고 근거수준은 낮고 추천강도는 conditional for라는 것입니다. 매우 중요한 내용이므로 가이드라인의 해당 부분 전문을 읽어보실 것을 권합니다. 옮깁니다.

Statement 6: Endoscopic resection could be cautiously considered for poorly differentiated tubular or poorly cohesive (including signet-ring cell) EGCs meeting the following endoscopic findings after sufficient discussion: endoscopically estimated tumor size ≤2 cm, endoscopically mucosal cancer, and no ulcer in the tumor (evidence:low, recommendation: conditional for).

EGCs with poorly differentiated tubular and PCC (including SRCC) are associated with a higher risk of LN metastasis than well and moderately differentiated tubular EGCs, making endoscopic resection very cautious consideration.

In previous Japanese Gastric Cancer Guidelines , a literature review of the literature that endoscopic resection could be considered for poorly differentiated tubular adenocarcinoma or PCC (including SRCC) in cases with histologic confirmation from forceps biopsy specimens, endoscopically estimated tumor size ≤2 cm, endoscopically mucosal cancer, and no ulcer in the tumor. When these criteria were met, the risk of LN metastasis was reported to range from 0% to 2.3%. Under the mentioned endoscopic findings, endoscopic resection could be considered for initial treatment. However, when risk factors for LN metastasis (tumor size >2 cm, submucosal invasion, ulcer in the tumor, and lymphovascular invasion) are revealed in pathologic reports, additional gastrectomy may be necessary.

In this guideline, we reviewed recent literature published since the previous edition. Currently, no prospective RCTs have compared the long-term OS of endoscopic resection with that of gastrectomy with LN dissection, which is the standard treatment for these indications. Retrospective studies have shown no difference in OS between gastrectomy and endoscopic resection, though endoscopic resection had a higher local recurrence rate in terms of recurrence-free survival (RFS), which is consistent with the findings of previous studies. In a prospective, single-arm, phase III observational study in Japan (JCOG1009/1010), the curative resection rate of the endoscopic resection group in undifferentiated EGC was 71% (195/275). Over a median follow-up period of 69.9 months, the 5-year OS rate was 99.3% (95% CI, 97.1% to 99.8%) and 5-year RFS rate was 98.9% (95% CI, 96.5% to 99.6%). In Korea, a study on the Comparison of Endoscopic Resection And Surgery for Early Gastric Cancer with undifferentiated histological type: a multicenter RCT (ERASE-GC trial, NCT04890171), is currently ongoing, and its results should be followed-up.

To date, the standard treatment for these criteria has been gastrectomy with LN dissection. Only retrospective cohort studies support these criteria for endoscopic resection, and the data from prospective trials are still lacking. Additionally, a significant portion of cases estimated to meet these criteria in the pre-endoscopic resection workup are found to be out these criteria upon pathologic examination of endoscopic resection specimens. Therefore, standard surgery (gastrectomy with LN dissection) can also be considered for cases meeting these criteria. It is advisable to choose a treatment method after sufficient discussion with the patient about the possibility of LN metastasis, and complications associated with endoscopic procedure and surgery.

2018년 일본가이드라인에서는 미분화조직형 위암의 ESD는 expanded indication이라고 표현하였습니다. 그런데 2025년 일본가이드라인에서는