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[Gastric cancer 481]

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[2017-2-24. 애독자 질문]

보내주신 아래 위암(EndoTODAY 위암 457)은 최종결과가 EGC type I 으로 나왔는데 size가 커서 AGC Borrmann type I과 많이 헷갈렸습니다.

Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : lower third, Center at antrum and lesser curvature
2. Gross type : EGC type I
3. Histologic type : tubular adenocarcinoma, moderately differentiated (80%) with mucinous carcinoma component (20%)
4. Histologic type by Lauren : mixed
5. Size : 6.3x4.2cm
6. Depth of invasion : invades submucosa (sm3) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 8.5 cm, distal 1.7 cm
8. Lymph node metastasis : no metastasis in 41 regional lymph nodes (pN0)
9. Lymphatic invasion : present
10. Venous invasion : not identified
11. Perineural invasion : not identified

이 둘을 쉽게 구별할 수 있는 감별 포인트가 있으면 가르쳐주시면 감사하겠습니다.

[2017-5-4. 이준행 답변]

답변이 늦어졌습니다. 죄송합니다.

일전 가톨릭의대 김태호 선생님의 내시경학회 교육자료에서는 아래와 같은 언급이 있습니다.

Borrmann type I 형의 진행성위암과 EGCa I 형의 조기위암을 내시경 소견만으로 명확히 감별할 수는 없으나, 둔덕이나 bridging fold 와 같이 주변 점막의 변화, 겸자로 압박했을 때 밀리지 않는 소견은 점막하층 이상의 침윤이 있음을 시사하는 소견이다.

보만 1형 진행성위암이 커지면서 중앙에 함몰부가 발생하여 보만 2형이 되는 경우도 있을 것입니다. 경우에 따라서는 내시경의사는 보만 1형으로, 병리의사는 보만 2형으로 서로 다르게 분류하기도 합니다.

아래 사진을 보면 아시겠지만.... 엄밀한 의미의 보만 1형 진행성 위암은 흔하지 않습니다. 내시경에서 보만 1형 진행성 위암으로 추정하였어도 막상 SM cancer로 나오는 경우도 적지 않았습니다. 그러면... '환자에게는 다행스러운 일이군' 정도 생각하고 넘어갈 수 밖에 없을 것 같습니다. 요컨데 누구나 틀릴 수 밖에 없을 것 같으니 너무 신경쓰지 않으셔도 좋을 것 같습니다.

내시경의사는 보만 1형으로, 병리의사는 보만 2형으로 서로 다르게 분류한 경우. Signet ring cell carcinoma with mucin production, intestinal type, 6x6cm, serosa exposure, LN 22/27

내시경의사와 병리의사가 모두 보만 1형으로 분류한 경우
Stomach, total gastrectomy:
Advanced gastric carcinoma
1. Location : upper third, center at fundus and posterior wall
2. Gross type : Borrmann type 1
3. Histologic type : tubular adenocarcinoma, poorly differentiated
4. Histologic type by Lauren : mixed
5. Size : 3.3x2.4x0.8 cm
6. Depth of invasion : extension to proper muscle (pT2a)
7. Resection margin: free from carcinoma, safety margin: distal 17 cm, proximal 1.7 cm
8. Lymph node metastasis : metastasis to 1 out of 47 regional lymph nodes (pN1)
9. Lymphatic invasion : present
10. Venous invasion : not identified
11. Perineural invasion : not identified

오래 전 대장암 수술을 받으셨다는 환자의 위암입니다.
Advanced gastric carcinoma
1. Location : upper third, Center at body and greater curvature
2. Gross type : Borrmann type I
3. Histologic type: tubular adenocarcinoma, poorly(poorly cohesive) differentiated
4. Histologic type by Lauren : mixed
5. Size : 4.8x1.5 cm
6. Depth of invasion : invades proper muscle (pT2)
7. Resection margin: free from carcinoma, safety margin: proximal 6.8 cm, distal 5.8 cm
8. Lymph node metastasis : metastasis to 3 out of 64 regional lymph nodes (pN2)
9. Lymphatic invasion : present
10. Venous invasion : present(intramural)
11. Perineural invasion : not identified
12. AJCC stage by 7th edition: T2 N2

의외로 조기위암, 그것도 점막암으로 나옴
Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : middle third, center at body and lesser curvature
2. Gross type : EGC type I
3. Histologic type : tubular adenocarcinoma, well differentiated, arising in tubular adenoma with high grade dysplasia
4. Histologic type by Lauren : intestinal
5. Size : 4.8x2.3 cm
6. Depth of invasion : extension to mucosa (lamina propria) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal, 3.1 cm; distal, 5.7 cm
8. Lymph node metastasis : no metastasis in 64 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10.Venous invasion : not identified
11.Perineural invasion : not identified

AGC로 생각했는데 deep SM cancer로 나옴
Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : lower third, Center at antrum and lesser curvature
2. Gross type : EGC type I
3. Histologic type : gastric carcinoma with lymphoid stroma (medullary carcinoma)
4. Histologic type by Lauren : intestinal
5. Size : 3x2.3 cm
6. Depth of invasion : invades submucosa (sm3) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 17 cm, distal 4.5 cm
8. Lymph node metastasis : no metastasis in 41 regional lymph nodes (pN0)
9. Lymphatic invasion : present
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. Peritoneal cytology : negative
13. AJCC stage by 7th edition: T1b N0

AGC로 생각했는데 deep SM cancer로 나옴
Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : lower third, Center at antrum and lesser curvature
2. Gross type : EGC type I
3. Histologic type : papillary adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 6.5x5 cm
6. Depth of invasion : invades submucosa (sm3) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 3.5 cm, distal 3.2 cm
8. Lymph node metastasis : metastasis to one out of 38 regional lymph nodes (pN1), (perinodal extension: absent) (1/38: "1", 0/0; "3", 0/10; "4", 0/7; "4sb", 0/0; "5", 1/2; "6", 0/6; "7", 0/4; "8a", 0/4; "9", 0/1; "11p", 0/3; "12a", 0/1)
9. Lymphatic invasion : present
10. Venous invasion : present(intramural)
11. Perineural invasion : not identified
12. Peritoneal cytology : negative
13. AJCC stage by 7th edition: T1b N1

AGC로 생각했는데 deep SM cancer로 나옴
Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : lower third, Center at antrum and posterior wall
2. Gross type : EGC type I
3. Histologic type : papillary adenocarcinoma, well differentiated(20%) + tubular adenocarcinoma, moderately differentiated(80%)
4. Histologic type by Lauren : intestinal
5. Size : 3.7x3.1 cm
6. Depth of invasion : invades submucosa (sm3) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 2 cm, distal 6.1 cm
8. Lymph node metastasis : no metastasis in 28 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. Separate lesions : hyperplastic polyp on prepyloric antrum
13. AJCC stage by 7th edition: pT1b N0

Stomach, subtotal gastrectomy:
Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : [1] lower third, [2] middle third, Center at proximal antrum and greater curvature
2. Gross type : EGC type I
3. Histologic type : tubular adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 3.8x2.3 cm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal 6.9 cm, distal 6.5 cm
8. Lymph node metastasis : no metastasis in 77 regional lymph nodes (pN0), (0/77: "1", 0/4; "3", 0/14; "5", 0/12; "4sb", 0/0; "5", 0/11; "6", 0/1; "8a", 0/12; "7", 0/9; "9", 0/4; "11p", 0/6; "12a", 0/4)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. Separate lesions : gastritis cystica profunda

* 참고: EndoTODAY 심달도 depth of invasion

© 일원내시경교실 바른내시경연구소 이준행. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.