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[Papillary adenocarcinoma]

1. Introduction

Papillary adenocarcinoma´Â fibrovascular core¸¦ Áß½ÉÀ¸·Î ¾ÏÀÌ Áõ½ÄÇÏ´Â °ÍÀ» Ư¡À¸·Î ÇÕ´Ï´Ù. Papillary adenocarcinoma¸¦ ESD ÀûÀÀÁõ¿¡ Æ÷ÇÔ½ÃųÁö ¿©ºÎ´Â ³í¶õÀÌ ¸¹Àºµ¥ »ï¼º¼­¿ïº´¿ø¿¡¼­´Â ±àÁ¤ÀûÀÎ °á°ú¸¦ ¹ßÇ¥ÇÑ ¹Ù ÀÖ½À´Ï´Ù (Kim TS. Gastric Cancer 2019).


2. Papillary adenocarcinoma´Â °£È¤ SMT-like cancerÀÇ ¸ð½ÀÀ» °¡Áú ¼ö ÀÖ½À´Ï´Ù.

EndoTODAY À§¾Ï 021

³»½Ã°æÀ» Çϸ鼭 ¸¸³ª´Â ¿©·¯ ¹®Á¦ Áß decision makingÀÌ ¾î·Á¿î °Í ÁßÀÇ Çϳª°¡ SMTÀÔ´Ï´Ù. Á¶Á÷°Ë»ç·Î °á·ÐÀ» ¾òÀ» ¼ö ¾ø´Â °æ¿ì°¡ ´ëºÎºÐÀÔ´Ï´Ù. EUS, CT µîÀ» ½ÃÇàÇÒ ¼ö ÀÖÁö¸¸ °áÁ¤ÀûÀÎ µµ¿òÀ» ÁÖ´Â °æ¿ì´Â ¸¹Áö ¾Ê½À´Ï´Ù. Àú´Â Á¦°¡ ÇÏ´Â EUS¸¦ ±×´ÙÁö ½Å·ÚÇÏÁö ¾Ê±â ¶§¹®¿¡ (¿ö³« ¸¹ÀÌ Æ²·Á¿Ô½À´Ï´Ù) CT¸¦ ÁÁ¾ÆÇÕ´Ï´Ù. ±×·¯³ª ´Ã ´À³¢´Â °ÍÀº "¿ª½Ã ³»½Ã°æ À°¾È¼Ò°ßÀÌ °¡Àå Áß¿äÇÏ´Ù"´Â Á¡ÀÔ´Ï´Ù. Á¶Á÷°Ë»ç, EUS, CT¿¡¼­ ¾î¶°ÇÑ °á°ú°¡ ³ª¿À´õ¶óµµ À°¾È¼Ò°ß¿¡¼­ ¾ÏÀÌ ÀÇ½ÉµÇ¸é ¾Ï¿¡ ÁØÇÑ Ä¡·á¸¦ ÇØ¾ß ÇÕ´Ï´Ù. °£È¤ SMT-like cancer¶ó´Â °ÍÀÌ Àֱ⠶§¹®ÀÔ´Ï´Ù. ÀÌ È¯ÀÚ¿¡¼­´Â ³»½Ã°æÁ¶Á÷°Ë»ç°¡ µÎ¹ø ½ÃÇàµÇ¾ú´Âµ¥ ÇѹøÀº ¾ÏÀÌ ³ª¿ÀÁö ¾Ê¾Ò°í ÇѹøÀº ¾ÏÀ¸·Î È®ÀεǾú½À´Ï´Ù. ¼ö¼úÀ» ½ÃÇàÇÏ¿´À¸¸ç "Advanced gastric carcinoma, Borrmann type: unclassifiable, papillary adenocarcinoma (M/D), 4x1.8 cm, extension to proper muscle, no metastasis in 50 regional lymph nodes"¿´½À´Ï´Ù.

SMT¿¡ ´ëÇÑ Æò°¡, ƯÈ÷ SMT-like cancer¸¦ °ñ¶ó³»´Â °ÍÀº Ç×»ó ¾î·Æ½À´Ï´Ù. ÀÌ·± ȯÀÚµéÀ» Àß Áø´ÜÇÏ°í ÀûÀýÈ÷ Ä¡·áÇϱâ À§ÇÏ¿© ¿ì¸®°¡ ¸ÅÀÏ ³»½Ã°æ Áø´Ü¼úÀ» °¥°í ´Û´Â °Í ¾Æ´Ï°Ú½À´Ï±î?


[SMT-like cancer µ¿¿µ»ó °­ÀÇ]

2020-8-17. EoA


[More cases]

À§ ȯÀÚÀÇ ¼ö¼ú ÈÄ º´¸®»çÁø. Papillary adenocarcinoma (depth of invasion: SM2)
ESD ½Ã¼úÀ» ÇÏ¿´°í pylorus circumferenceÀÇ Àý¹Ý Á¤µµ°¡ ÀýÁ¦µÇ¾ú±â ¶§¹®¿¡ ÇùÂøÀ» ¹æÁöÇϱâ À§ÇÏ¿© oral steroid¸¦ 4ÁÖ »ç¿ëÇÏ¿´½À´Ï´Ù (Âü°í: EndoTODAY ESD ÈÄ ÇùÂø ¿¹¹æ °æ±¸ steroid 4ÁÖ ÄÚ½º).
Stomach, endoscopic submucosal dissection:
Early gastric carcinoma
1. Location : pylorus
2. Gross type : EGC type IIc
3. Histologic type : papillary adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 6 mm (2) vertical diameter, 6 mm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 2 mm, proximal 6 mm, anterior 4 mm, posterior 8 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: absent

EndoTODAY À§¾Ï 363
Stomach, endoscopic submucosal dissection:
Early gastric carcinoma
1. Location : antrum, lesser curvature
2. Gross type : EGC type IIa
3. Histologic type : papillary adenocarcinoma, moderately differentiated >> papillary adenocarcinoma, poorly differentiated (about 20%)
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 34mm (2) vertical diameter, 22mm
6. Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 4 mm, proximal 10 mm, anterior 6 mm, posterior 10 mm
8. Lymphatic invasion : present (++)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: present
ESD °á°ú ÀÇ°Å ¼ö¼úÀ» Ãß°¡ÇÏ¿´½À´Ï´Ù.

EndoTODAY À§¾Ï 244
ESD for Early gastric carcinoma
1. Location : lower body, greater curvature
2. Gross type : EGC type IIa
3. Histologic type : papillary adenocarcinoma, moderately differentiated > papillary adenocarcinoma, poorly differentiated (about 20%)
4. Histologic type by Lauren : intestinal
5. Size : 1.0x0.9 cm
6. Depth of invasion : invades submucosa, (depth of sm invasion : 1000 §­) (pT1b)
7. Resection margin: involved deep margin by carcinoma
8. Lymphatic invasion : present
9. Venous invasion : not identified
10. Perineural invasion : not identified
11. Microscopic ulcer : absent
12. Histologic heterogeneity: present
ESD ÈÄ ¼ö¼úÀ» ÇÏ¿´½À´Ï´Ù. No residual tumor·Î ³ª¿Ô½À´Ï´Ù.

EndoTODAY À§¾Ï 345
Stomach, subtotal gastrectomy:
. Early gastric carcinoma
1. Location : lower third, Center at angle and lesser curvature
2. Gross type : EGC type IIa+IIc
3. Histologic type : papillary adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 5.7x3.2 cm
6. Depth of invasion : invades submucosa (sm3) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 2.6 cm, distal 3.5 cm
8. Lymph node metastasis : no metastasis in 51 regional lymph nodes (pN0)
9. Lymphatic invasion : present
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. Associated findings : ulceration
13. Peritoneal cytology : negative
14. AJCC stage by 7th edition: pT1b N0

EndoTODAY À§¾Ï 122
Advanced gastric carcinoma
1. Location : lower third, center at antrum and lesser curvature
2. Gross type : Borrmann type 3
3. Histologic type : papillary adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 4.3x3.2 cm
6. Depth of invasion : extension to proper muscle (pT2a)
7. Resection margin: free from carcinoma, safety margin: proximal, 7.5 cm; distal, 1.8 cm
8. Lymph node metastasis: metastasis to one out of 63 regional lymph nodes (pN1)
9. Lymphatic invasion : present
10.Venous invasion : present (intramural)
11.Perineural invasion : not identified
Note: This carcinoma can be classified as SM3-massive by Japanese classification.
ÀÌ»óÇÑ note°¡ ºÙ¾îÀÖÁö¿ä? Á¶±âÀ§¾Ï°ú ÁøÇ༺À§¾ÏÀÇ ±¸ºÐ¿¡µµ ±¹°¡°£ Â÷ÀÌ°¡ ÀÖ½À´Ï´Ù. ÀÌ Áõ·Ê°¡ ÀüÇüÀûÀÎ ¿¹ÀÔ´Ï´Ù. 2021³â 6¿ù 4ÀÏ º´¸®°ú ¾È¼ö¹Î ¼±»ý´ÔÀ» ¸ð½Ã°í Á¦2ȸ ³»½Ã°æ º´¸® ¼¼¹Ì³ª¸¦ ÁøÇàÇϸ鼭 SM3 massive¿¡ ´ëÇÏ¿© ³íÀÇÇÏ¿´½À´Ï´Ù.

EndoTODAY À§¾Ï 397
Stomach, subtotal gastrectomy:
Early gastric carcinoma
1. Location : lower third, Center at antrum and greater curvature
2. Gross type : EGC type IIa
3. Histologic type : papillary adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 2.7x1.8 cm
6. Depth of invasion : invades mucosa (muscularis mucosae) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal 8 cm, distal 4.5 cm
8. Lymph node metastasis : no metastasis in 34 regional lymph nodes (pN0)
9. Lymphatic invasion : present
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 7th edition: T1a N0
À¶±âÇü Á¶±âÀ§¾ÏÀ̳ª Å©±â±âÁØÀ» ÃÊ°úÇÑ °ÍÀ¸·Î ÆÇ´ÜÇÏ¿© ¼ö¼úÀ» ±ÇÇÏ¿´½À´Ï´Ù. Expanded indication Áß ±Ë¾çÀÌ ¾ø´Â Á¡¸·¾ÏÀº Å©±â±âÁØ°ú ¹«°üÇÏ´ÙÁö¸¸ ±×·¡µµ ´Ã °ÆÁ¤ÇÏ°í ÀÖ½À´Ï´Ù. ¸¸¾à ESD¸¦ Çß´õ¶óµµ lymphatic positive·Î ³ª¿Ô±â ¶§¹®¿¡ additional surgery¸¦ ±ÇÇßÀ» °ÍÀÔ´Ï´Ù. ±×·±µ¥ ¸¸¾à ÀÌ È¯ÀÚ°¡ ESD¸¦ ¹Þ¾Ò°í ¼ö¼úÀ» °ÅºÎÇÏ¿´´Ù¸é ¾î¶»°Ô µÇ¾úÀ»±î¿ä? Á¶±âÀ§¾Ï ³»½Ã°æÄ¡·áÀÇ ÀûÀÀÁõ ¼±Á¤°ú Ä¡·á ÈÄ additional surgery ±ÇÀ¯ °úÁ¤¿¡´Â ¾ÆÁ÷±îÁö ÁÖ°üÀû ¿ä¼Ò°¡ ¸¹´Ù°í »ý°¢µË´Ï´Ù.

EndoTODAY À§¾Ï 395
Stomach, endoscopic submucosal dissection:
Early gastric carcinoma
1. Location : antrum, lesser curvature
2. Gross type : EGC type IIa
3. Histologic type : tubular adenocarcinoma, moderately differentiated >> papillary adenocarcinoma, moderately differentiated (about 35%)
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 32mm (2) vertical diameter, 15mm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin : free from carcinoma(N) safety margin : distal 6 mm, proximal 10 mm, anterior 12 mm, posterior 14 mm
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Hstologic heterogeneity: absent
13. Associated findings: gastritis cystica profunda
ÀÌó·³ ¼¯¿© ÀÖ´Â °æ¿ìµµ ÀÖ½À´Ï´Ù.



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