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[Á¶±âÀ§¾Ï ³»½Ã°æ ÀýÁ¦ ÈÄ ±¹¼Ò Àç¹ß. Local recurrence after endoscopic resection of EGC] - End of document

1. Á¶±âÀ§¾Ï ³»½Ã°æ ÀýÁ¦ ÈÄ ±¹¼ÒÀç¹ß (±¹¸³¾Ï¼¾ÅÍ, 2012)

2012³â ±¹¸³¾Ï¼¾ÅÍ¿¡¼­´Â Á¶±âÀ§¾Ï ³»½Ã°æÄ¡·á ÈÄ ±¹¼ÒÀç¹ß¿¡ ´ëÇÏ¿© ¹ßÇ¥ÇÏ¿´½À´Ï´Ù (Lee JY. J Gastric Cancer 2012). 2002³âºÎÅÍ 2008³â±îÁö ºñ±³Àû Ãʱ⿡ ½Ã¼úµÈ ȯÀÚ 396¸íÀÇ ¼ºÀûÀ̾ú½À´Ï´Ù. 17¸íÀÌ ±¹¼ÒÀç¹ßÀ» º¸¿´´Âµ¥ EMR 118¿¹ Áß 14¿¹(11.7%), ESD 278¿¹ Áß 3¿¹(1.1%)¿´½À´Ï´Ù.

³»½Ã°æ ½Ã¼ú ÈÄ ÃßÀû°üÂû ¹æ¹ýÀº ¾Æ·¡¿Í °°ÀÌ ±â¼úµÇ¾î ÀÖ¾ú½À´Ï´Ù.

To evaluate local recurrence, two to four biopsy specimens were routinely obtained from the ER ulcer scar during each examination with standard fenestrated open-cup forceps (FB-25K-1; Olympus Co. Ltd) or ellipsoid fenestrated cup forceps with needle (FB-24K-1; Olympus Co. Ltd).

±¹¼ÒÀç¹ß 17¸í Áß 12¸íÀº 4°³¿ù À̳»¿¡ ¹ß°ßµÇ¾ú°í, ³ª¸ÓÁö 5¸íÀº 1³â ÀÌÈÄ¿¡ ¹ß°ßµÇ¾ú½À´Ï´Ù. ´ëºÎºÐÀÇ È¯ÀÚ´Â ´Ü¼ø ±Ë¾ç ¹ÝÈçÀ¸·Î º¸À̰ųª ¹Ì¼¼ÇÑ ¹ßÀû¸¸ ÀÖ¾ú°í Á¶Á÷°Ë»ç·Î ±¹¼ÒÀç¹ßÀÌ Áø´ÜµÇ¾ú½À´Ï´Ù. 2¸íÀº mass·Î ¹ß°ßµÇ¾ú´Âµ¥ ¸ðµÎ incomplete resectionÀ¸·Î ¼ö¼úÀÌ ÇÊ¿äÇߴµ¥ ¼ö¼úÀ» °ÅºÎÇÏ¿© °æ°ú°üÂû ÇÏ´ø Áß ¹ß°ßµÈ ¿¹¿´½À´Ï´Ù.

Àç¹ß À§ÇèÀÎÀÚ ºÐ¼®ÀÔ´Ï´Ù. À§ÇèÀÎÀÚ°¡ Çϳª¶óµµ ÀÖ´Â °æ¿ì 5³â ±¹¼ÒÀç¹ß·üÀÌ 27%ÀÎ ¹Ý¸é, À§ÇèÀÎÀÚ°¡ Çϳªµµ ¾ø´Â °æ¿ì´Â ±¹¼ÒÀç¹ßÀÌ ÀüÇô ¾ø¾ú½À´Ï´Ù.


2. Endoscopic prediction of recurrence after margin-negative endoscopic resection (¼­¿ï¾Æ»êº´¿ø, 2016)

¼­¿ï¾Æ»êº´¿ø Ãֱ⵷ ±³¼ö´Ô ÆÀ¿¡¼­ À§¾Ï ³»½Ã°æÄ¡·á ÈÄ ±¹¼ÒÀç¹ßÀ» ºÐ¼®ÇÏ¿´½À´Ï´Ù (Na HK. JGH 2016) . 1995³âºÎÅÍ 2011³â±îÁö 3,347¿¹ÀÇ Á¶±âÀ§¾Ï ³»½Ã°æÄ¡·á Áß 3,027¿¹(90.7%)°¡ margin-negative EGC¿´½À´Ï´Ù. 22¿¹ÀÇ ±¹¼ÒÀç¹ß°ú 4¹è¼öÀÇ controlÀ» ºñ±³ÇÏ¿´½À´Ï´Ù. Differentiated type EGCÀÇ en-block margin negative resection scar°¡ hyperemic change ¾øÀÌ flat Çϸé Á¶Á÷°Ë»ç¸¦ ÇÒ ÇÊ¿ä°¡ ¾ø´Ù°í °á·ÐÁþ°í ÀÖ½À´Ï´Ù.


4. ±¹¼ÒÀç¹ßÀ» ¹ß°ßÇϱâ À§ÇÑ Àü·« (2015³â 12¿ù 24ÀÏ ÀáÁ¤¾È)

1) Á¶±âÀ§¾Ï EMR/ESD: 5³â±îÁö ÃßÀû ³»½Ã°æ¸¶´Ù scar¿¡¼­ Á¶Á÷°Ë»ç (2Á¡) → 5³â ÈĺÎÅÍ´Â Àç¹ß ÀÇ½É ¼Ò°ßÀÌ ÀÖÀ» ¶§¸¸ Á¶Á÷°Ë»ç (´Ü, Á¶±âÀ§¾Ï EMR/ESD ÈÄ Ã¹ ÃßÀû ³»½Ã°æ¿¡¼­´Â H. pylori Á¶Á÷°Ë»çµµ ÇÔ²² ½ÃÇàÇÑ´Ù.)

2) ¼±Á¾ EMR/ESD: 1³â±îÁö ÃßÀû ³»½Ã°æ¸¶´Ù scar¿¡¼­ Á¶Á÷°Ë»ç (2Á¡) → 1³â ÈĺÎÅÍ´Â Àç¹ß ÀÇ½É ¼Ò°ßÀÌ ÀÖÀ» ¶§¸¸ Á¶Á÷°Ë»ç

Âü°í. 'EMR/ESD ÈÄ Ã¹ ÃßÀû ³»½Ã°æ¿¡¼­´Â scar¿¡¼­ Á¶Á÷°Ë»ç¸¦ ÇÏÁö ¸»ÀÚ'´Â °ú°ÅÀÇ °áÁ¤Àº Ãë¼ÒÇÕ´Ï´Ù. ù ÃßÀû°Ë»ç¿¡¼­µµ scar Á¶Á÷°Ë»ç¸¦ ÇØ Áֽñ⠹ٶø´Ï´Ù. ¾à°£ ÆíÇÏÀÚ°í Á¤ÇÑ °áÁ¤Àε¥ ±¦ÇÑ È¥µ¿¸¸ ÀÖ´Ù°í ÆǴܵDZ⠶§¹®ÀÔ´Ï´Ù. ¾ÆÁ÷ Á» ´õ °æÇè°ú ÀÚ·á ÃàÀûÀÌ ÇÊ¿äÇÏ´Ù°í »ý°¢µÇ¹Ç·Î ´çºÐ°£ ±¹¸³¾Ï¼¾ÅÍ ¹× ¼­¿ï¾Æ»êº´¿ø¿¡¼­ Á¦¾ÈÇÑ °Íº¸´Ù Á¶±Ý tightÇÏ°Ô °Ë»çÇÏ´Â Àü·«À» À¯ÁöÇսôÙ.


[Cases]

À§°¢ºÎ Á¶±âÀ§¾Ï ESD ÈÄ local recurrence·Î ÀÇ·ÚµÈ ºÐÀÔ´Ï´Ù. ³»½Ã°æ °Ë»ç¿¡¼­ scar Á¡¸· ÁÖº¯ÀÌ ÆòźÇÏÁö ¾Ê¾Æ ¿©·¯ °÷ Á¶Á÷°Ë»ç¸¦ Çߴµ¥ ¸ðµÎ ¾ÏÀÌ ³ª¿Í ESD¸¦ ½ÃµµÇÏÁö ¾Ê°í ¼ö¼úÀ» ÇÏ¿´½À´Ï´Ù.
Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : middle third, Center at antrum, angle and lesser curvature
2. Gross type : EGC type IIb
3. Histologic type : tubular adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 2.7x2.3 cm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal 3.3 cm, distal 3.4 cm
8. Lymph node metastasis : no metastasis in 17 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 7th edition: pT1a N0

2010³â ½Ã¼úÇÑ 60´ë ¿©¼ºÀÔ´Ï´Ù. Pyloric ring¿¡ °ÉÃÄÀÖ¾ú½À´Ï´Ù. Resection marginÀ» ÃæºÐÈ÷ È®º¸ÇÒ ¼ö ¾ø¾ú½À´Ï´Ù. ¾Æ½±°Ô ½ÊÀÌÁöÀå ÂÊÀ¸·Î Àç¹ßÇÏ¿© ¼ö¼úÀ» ½ÃÇàÇÏ¿´½À´Ï´Ù. ³¯¹®¿¡ °ÉÄ£ À§¾ÏÀ» °¡Áø ȯÀÚ¿¡°Ô´Â ´ÙÀ½°ú °°ÀÌ ¼³¸íÇÏ°í ÀÖ½À´Ï´Ù.
Àç¹ß·üÀ» ³·°Ô À¯ÁöÇϱâ À§ÇÏ¿© º´¼ÒÀÇ 4 ¹æÇâ¿¡ ¾î´À Á¤µµÀÇ ¿©ºÐÀ» µÎ°í ÀýÁ¦ÇÏ°í ÀÖ½À´Ï´Ù. ±×·±µ¥ º´¼ÒÀÇ À§Ä¡°¡ À½½ÄÀÌ ³ª°¡¹®, Áï À§¿Í ½ÊÀÌÁöÀåÀÇ Á¢ÇÕºÎÀÎ ³¯¹®¿¡ ±ÙÁ¢ÇÑ °æÇÑ´Â ÇѵΠ¹æÇâÀÇ ¿©ºÐÀº È®º¸ÇÒ ¼ö ¾ø½À´Ï´Ù. ¿©ºÐÀÌ ºÎÁ·ÇÏ´Ù°í ¸ðµÎ Àç¹ßÇÏ´Â °ÍÀº ¾Æ´Ï¸ç ¹«Á¶°Ç ¼ö¼úÇÏ´Â °Íµµ ¾Æ´Õ´Ï´Ù. ´Ù¸¸ Àç¹ß·üÀÌ º¸ÅëÀÇ °æ¿ìº¸´Ù ¾à°£ ´õ ³ô´Ù°í »ý°¢ÇÏ½Ã¸é ¹«³­ÇÕ´Ï´Ù. Åë»óÀÇ Àç¹ß·üÀº 5% Á¤µµ·Î º¸°í Àִµ¥, À̺¸´Ù ¾à 2¹è °¡·® À§ÇèÇÏ´Ù°í ÃßÁ¤ÇÏ°í ÀÖ½À´Ï´Ù. ³¯¹®Àº Á¼Àº °ø°£ÀÔ´Ï´Ù. ¿©ºÐÀ» È®º¸ÇÑ »óÅ¿¡¼­ ³»½Ã°æÁ¡¸·ÇÏÀýÁ¦¼ú(ESD)°¡ °ï¶õÇÏ¸é ³»½Ã°æÁ¡¸·ÀýÁ¦¼ú(EMR)À̶ó´Â Á¶±Ý ´Ù¸¥ ¹æ¹ýÀ¸·Î ºÐÇÒÀýÁ¦¸¦ Çϱ⵵ ÇÕ´Ï´Ù. ³¯¹® ±Ùó¿¡¼­ ½Ã¼úÇÏ¸é ±× ºÎºÐÀÌ ´Ù¼Ò Á¼¾ÆÁö°Ô µË´Ï´Ù. °£È¤ À½½Ä¹°ÀÌ Åë°úÇÏÁö ¸øÇÒ Á¤µµÀÇ ÇùÂøÀÌ ¹ß»ýÇÒ ¼ö ÀÖ½À´Ï´Ù. ³»½Ã°æ È®Àå¼ú ȤÀº ¼ö¼ú·Î Ä¡·áÇÏ°í ÀÖ½À´Ï´Ù."

°æ°è°¡ ºÒºÐ¸íÇÑ À§¾Ï¿¡ ´ëÇÑ ESD ÈÄ lateral margin ¾ç¼ºÀ¸·Î ablation Ä¡·á¸¦ Ãß°¡ÇÏ¿´À¸³ª 1³â ¹Ý ÈÄ local recurrence


Stomach, ESD:
Early gastric carcinoma
1. Location : angle, lesser curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 40 mm (2) vertical diameter, 25 mm
6. Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 2 mm, proximal 1 mm, anterior 4 mm, posterior 6 mm, deep 1000 §­
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
Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : lower third, Center at antrum and lesser curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size : 1.9x1 cm
6. Depth of invasion : invades mucosa (muscularis mucosae) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal 4 cm, distal 6.3 cm
8. Lymph node metastasis : no metastasis in 34 regional lymph nodes (pN0), (0/34: "1", 0/2; "3", 0/10; "4", 0/5; "4sb", 0/2; "5", 0/4; "6", 0/0; "7", 0/5; "8a", 0/3; "9", 0/1; "11p", 0/2; "12a", 0/0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 7th edition: pT1a N0

4³â Àü ESD¸¦ ¹Þ°í °æ°ú°üÂû Áß ³»½Ã°æ À°¾È¼Ò°ß¿¡¼­ scarÀÇ ¹ßÀûÀÌ º¸¿© Á¶Á÷°Ë»ç¸¦ ÇÏ°í local recurrenc·Î ÀÇ·ÚµÈ ºÐÀÔ´Ï´Ù. ȯÀÚ¿Í Àß »óÀÇÇÏ¿© ESD¸¦ ÇÏ¿´°í 13mm lamina propria ¾ÏÀ¸·Î ³ª¿Ô½À´Ï´Ù. ESD ÈÄ local recur·Î ÀÇ·ÚµÇ¸é ´Ã °í¹ÎÀÔ´Ï´Ù. ¾Æ¹«·¡µµ ù ¼Ò°ßÀ» Á¤È®È÷ ¾Ë±â ¾î·Æ±â ¶§¹®ÀÔ´Ï´Ù. AvailableÇÑ Á¤º¸¸¦ Àß È°¿ëÇÏ°í ȯÀÚ¿Í ¿À·¡ »óÀÇÇÏ´Â ¼ö ¹Û¿¡ ¾øÀ» °Í °°½À´Ï´Ù.


[À§¾Ï 805]

ESD for EGC was recommened by a surgeon. The margin of the lesion was not discrete, but the forceps biopsy showed "tubular adenocarcinoma, moderately differentiated (WHYX lesion)". ESD was done.


ESD: Early gastric carcinoma
1. Location : antrum, greater curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, moderately differentiated > poorly differentiated (30 %)
4. Histologic type by Lauren : mixed
5. Size of carcinoma : (1) longest diameter, 38 mm (2) vertical diameter, 30 mm
6. Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
7. Resection margin : free from carcinoma(N) but very close to proximal margin, safety margin : distal 4 mm, proximal less than 1 mm, anterior 2 mm, posterior 18 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: present

The ESD pathology showed multiple risk factors of recurrence (size larger than 3 cm, mixed type histology with 30% of poorly differentiated component, negative resectiona margin but very close). I explained to the patient that there is no definite reason for surgey right now but the chance of recurrence is higher than usual, so careful follow-up is recommended.

Six years after the ESD, local recurrence was found. I recommended surgery.


Stomach, radical subtotal gastrectomy: Early gastric carcinoma
1. Location : middle third, Center at angle and greater curvature
2. Gross type : EGC type IIb
3. Histologic type : tubular adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 1.5x0.6 cm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal 5.0 cm, distal 3.7 cm
8. Lymph node metastasis : no metastasis in 41 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 8th edition: pT1a N0

Careful follow-up is a very important part of endoscopic treatment of early gastric cancer.


2021-8-22. ³»½Ã°æÇÐȸ ¼¼¹Ì³ª¿¡¼­ ¿¬¼¼´ë À±¿µÈÆ ±³¼ö´Ô²²¼­ ¸ÚÁø µ¿¿µ»ó °­ÀǸ¦ Çϼ̽À´Ï´Ù.


[References]

1) Local recurrence associated with an adjacent neoplastic precursor lesion. Kikuchi S. Acta Med Okayama. 2016

Dysplasia-like atypia



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