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EndoTODAY 내시경 교실

[Ulcer or ulceration in ESD] -

1. 2023년 병리 가이드라인에 언급된 ulcer관련 내용

Ulceration is defined as a full-thickness disruption of muscularis mucosae, both active and scarring, and determined by histological findings, not endoscopic findings. The presence or absence of an ulcer is an important criterion for judging whether an endoscopic resection is curative in mucosal cancer, so it must be described in the pathology report for mucosal cancer. Because ulcers are included in the indications for an endoscopic resection, the presence of ulcers is determined by endoscopic findings. Ultimately, however, it must be confirmed by pathological examination findings of the resected specimen. Endoscopic diagnosis is difficult in the absence of a mucosal break, and ulcer-negative endoscopy findings with ulcer-positive pathology findings were reported in 4.6%?5.5% of cases.

Another problem that occurs in practice is a lack of clarity in the criteria for differentiating original small ulcers from biopsy-induced changes after endoscopic biopsy in a case that did not originally have ulcers. Due to the low accuracy of ulcer determination in endoscopic findings, a finding of no ulcer during endoscopy cannot guarantee a biopsy-induced change. Diagnostic criteria for this have been suggested by Shimoda et al., and the Japanese gastric cancer treatment guidelines describe this as follows: “A biopsy-derived scar is usually observed histologically as fibrosis restricted to small areas just beneath the muscularis mucosae. If it cannot be discriminated from the ulcer scar, it should be classified as UL1.” According to JCOG1009/1010, a clinical study on undifferentiated-type EGC: “UL was judged as present if the muscularis propria was completely disrupted and if fibrosis in the submucosal layer was observed to be wider than the range of disrupted muscularis propria.”. In our study group, ulcer size was measured in the ongoing GIPSG study on the criteria for curative resection, and the possibility of offering differentiation criteria for this problem was investigated. We found that the risk of lymph node metastasis with an ulcer of 4 mm or less was the same as in cases with no ulcer. Using that criterion, very small ulcers can be excluded from the risk factors for lymph node metastasis, which removes the need to differentiate them from biopsy-induced changes. The grading of ulcer size is reflected as a conditional element. The method for measuring the size of an ulcer is similar to that used to measure the submucosal invasion width. If an ulcer (full-thickness disruption of the muscularis mucosae) is observed on only one section, write the actual size measured on the slide. If it is observed across two or more slices, write the larger of the following two values: (1) the actual size measured on the slide with the largest disruption size or (2) the number of slices spanned by the disruption×2 mm (thickness of slice). The ulcer size is measured only within the tumor. If the ulcer spans the tumor and surrounding mucosa, measure the ulcer size only within the tumor area.


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