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EndoTODAY ³»½Ã°æ ±³½Ç


[ESD for undifferentiated type EGC] - ðû

2025-8-4. EndoTODAY »ý°¢
ÇϳªÀÇ ±âÁØÀÌ ÀÖ°í ¸ðµÎ ±×¿¡ µû¶ó Áø´ÜÇϰí Ä¡·áÇϸé È¥¼±ÀÌ ÀûÀ» °ÍÀÔ´Ï´Ù. À§¾Ï ³»½Ã°æ Ä¡·á´Â ±¹Á¦±âÁØÀ̶ó°í ºÎ¸£´Â WHO ºÐ·ù¸¦ µû¸£Áö ¾Ê´Â ÀϺ»¿¡¼­ °³¹ßµÇ°í ¹ßÀüµÇ¾ú½À´Ï´Ù. ÀϺ» ÀÇ»çµéÀº ½º½º·Î °³¹ßÇÑ ºÐ·ù¹ý(Nakamura ºÐ·ù)¿¡ µû¶ó, ½º½º·Î °³¹ßÇÑ ÀûÀÀÁõ (Gotoda table)¿¡ ÀÇÇØ ȯÀÚ¸¦ ¼±Á¤Çϰí, ½º½º·Î ¸¸µç ±â±¸(Olympus, Fujifilm ³»½Ã°æ°ú accessory)¸¦ ÀÌ¿ëÇÏ¿©, ½º½º·Î °³¹ßÇÑ ½Ã¼ú(ESD)À» Çϰí, ½º½º·ÎÀÇ °á°ú(JCOG)¿¡ µû¶ó Ãß°¡ Ä¡·á ¿©ºÎ¸¦ °áÁ¤Çϱ⠶§¹®¿¡ ºñ±³Àû ÀϰüµÈ ESD ¼­ºñ½º¸¦ ȯÀÚ¿¡°Ô Á¦°øÇÏ´Â µí ÇÕ´Ï´Ù. ¿ì¸®´Â Nakamura ºÐ·ù°¡ ¾Æ´Ñ WHO ºÐ·ù¿¡ µû¶ó Áø´ÜÇϰí, ÀϺ»¿¡¼­ °³¹ßÇÑ ÀûÀÀÁõÀ» ¾à°£ modifyÇÑ ÀûÀÀÁõÀ» Á¤ºÎ ÀÔ¸À¿¡ µû¶ó ´Ù½Ã modifyÇÑ ±âÁØ¿¡ ÀÇÇØ ȯÀÚ¸¦ ¼±Á¤Çϰí, ÀÏÁ¦ ³»½Ã°æ°ú ÀÏÁ¦ ±â±¸¸¦ ÀÌ¿ëÇÏ¿© ÀÏÁ¦ ½Ã¼ú(ESD)À» Çϰí, ¿ì¸®ÀÇ °á°ú¿Í ÀϺ»ÀÇ °á°ú¸¦ Á¾ÇÕÇÏ¿© Ãß°¡ Ä¡·á¿©ºÎ¸¦ °áÁ¤Çϰí À־ Àϼ± ÇöÀåÀº ¸Å¿ì È¥¶õ½º·´½À´Ï´Ù. °¡Àå È¥¶õÀÌ Å« ºÎºÐÀÌ undifferentiated histology º´¼Ò¿¡ ´ëÇÑ ESDÀÔ´Ï´Ù. °ÆÁ¤½º·¯¿î ºÎºÐÀº Çѵΰ¡Áö°¡ ¾Æ´Õ´Ï´Ù. (1) ÀϺ» ¿¬±¸¿¡ ºñÇÏ¿© ¿ì¸® ¿¬±¸¿¡¼­ Àϰü¼ºÀÖ°Ô ¸²ÇÁÀý ÀüÀ̰¡ ¸¹¾Ò½À´Ï´Ù. (2) ³»½Ã°æ ÀÇ»ç»Ó¸¸ ¾Æ´Ï¶ó º´¸® ÀÇ»çÀÇ interobserver variationÀÌ »ó´çÇÕ´Ï´Ù. (3) ü°èÀûÀÎ longterm ¿¬±¸°¡ ºÎÁ·ÇÕ´Ï´Ù. (4) ±¹¹Î°Ç°­º¸Çè¿¡¼­ ESD ÀûÀÀÁõÀ» ¸Å¿ì Á¼°Ô Á¦½ÃÇϰí ÀÖÀ¸¹Ç·Î undifferentiated histology À§¾Ï¿¡ ´ëÇÑ ESD´Â ¼±º°±Þ¿©ÀÔ´Ï´Ù. Áï ȯÀÚ°¡ µ·À» ´õ ¸¹ÀÌ ³»¾ß ÇÕ´Ï´Ù. ºÒÇÊ¿äÇÏ°Ô È¯ÀÚ¸¦ À¯ÀÎÇÏ¿´´Ù´Â ÀǽÉÀ» ¹Þ±â ½±½À´Ï´Ù. (5) À§¾Ï ESD ÈÄ ¼ö¼úÀÌ ÇÊ¿äÇÏ´Ù°í ³ª¿Â ȯÀÚ Áß ¼ö¼úÀ» ¹ÞÁö ¾Ê´Â ȯÀÚ°¡ Á¦¹ý ¸¹½À´Ï´Ù. (6) Çа迡¼­ ÀǰßÀÌ ÅëÀϵÇÁö ¾Ê¾Ò½À´Ï´Ù. Æø³ÐÀº ÀûÀÀÁõÀ» °¡Áö°í ÀÖ´Â Àü¹®°¡°¡ ÇØ´ç ºÎºÐÀÇ °­ÀǸ¦ ÇÏ´Â °æ¿ì°¡ ¸¹½À´Ï´Ù. Ư¼öÇÑ »óȲÀ» ÀϹÝÀûÀÎ °Íó·³ Æ÷ÀåÇÏ´Â ¿¹µµ ¸¹½À´Ï´Ù. (7) ȯÀÚ¿¡°Ô informed consent¸¦ ¹Þ´Â °úÁ¤ÀÌ ¸Å¿ì Çü½ÄÀûÀÔ´Ï´Ù, µîµî. ÀÌ·± »óȲ¿¡¼­ undifferentiated type histology À§¾Ï¿¡ ´ëÇÑ ³»½Ã°æ Ä¡·á´Â ¾ÆÁ÷µµ ¸Å¿ì Á¶½É½º·´°Ô ÁøÇàµÇ¾î¾ß ÇÑ´Ù°í »ý°¢ÇÕ´Ï´Ù. ¾ÆÁÖ Á¶±ÝÀÌ¶óµµ ¸¶À½¿¡ °É¸®´Â ¿ä¼Ò°¡ ÀÖÀ¸¸é ÇöÀçÀÇ Ç¥ÁØÄ¡·áÀÎ ¼ö¼úÀ» ±ÇÇÏ´Â °ÍÀÌ ¸Â´Ù°í »ý°¢ÇÕ´Ï´Ù.


¹Îº´ÈÆ, °­±âÁÖ ¼±»ý´Ô µî°ú ÇÔ²² "Endoscopic Resection for Undifferentiated Early Gastric Cancer: Focusing on Histologic Discrepancies Between Forceps Biopsy-Based and Endoscopic Resection Specimen-Based Diagnosis"¶ó´Â ±ä Á¦¸ñÀ» °¡Áø ³í¹®À» ³Â½À´Ï´Ù.

ÀÏÀü¿¡ undifferentiated ¶ó´Â ¿ë¾î°¡ ¹®Á¦°¡ ÀÖ´Ù°í ³íÀÇÇÑ ¹Ù ÀÖÀ¸³ª ÀúÈñµµ ¾²Áö ¾ÊÀ» ¼ö ¾ø¾ú½À´Ï´Ù. ´õ °£·«ÇÑ ´ë¾ÈÀ» ãÀ» ¼ö ¾ø¾ú±â ¶§¹®ÀÔ´Ï´Ù. "Undifferentiated type histology"°¡ °¡Àå ÀûÀýÇÏÁö ¾ÊÀ»±î »ý°¢Çغ¸±âµµ ÇßÁö¸¸ ÆíÀÇ»ó °ü·Ê¸¦ µû¸¥ °ÍÀÌÁö¿ä. ¿©ÇÏÆ° ´õ ÁÁÀº terminology¸¦ °í¹ÎÇØ º¸°Ú½À´Ï´Ù.


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ÀúÈñ º´¿ø¿¡¼­´Â poorly differentiated adenocarcinoma³ª signet ring cell carcinoma¿¡ ´ëÇÑ ESD¸¦ ÀÚÁÖ ½ÃÇàÇÏÁö´Â ¾Ê°í ÀÖ½À´Ï´Ù. ¾Æ·¡ Ç¥¿Í °°ÀÌ ½Ã¼ú Àü¿¡ differentiated type histology¿´°Å³ª ¾Ö¸ÅÇϳª °æ¿ì¿´´ø °ÍÀÌ ½Ã¼ú ÈÄ undifferentiated typeÀ¸·Î ³ª¿Â °ÍÀÌ ´ëºÎºÐÀÔ´Ï´Ù. Áï ESDÇÒ È¯ÀÚ¸¦ ¼±ÅÃÇÒ ¶§¿¡´Â º¸¼öÀûÀÎ conventional indication (= ½ÉÆò¿ø ÀûÀÀÁõ)À» ÀÌ¿ëÇϰí ESD ÈÄ º´¸®°á°ú´Â expanded criteria¸¦ Àû¿ëÇϰí ÀÖÀ» »ÓÀÔ´Ï´Ù. µû¶ó¼­ ÃÖÁ¾ º´¸®°á°ú undifferentiated Çü(poorly differentiated¿Í signet ring cell carcinoma)ÀΠȯÀÚÀÇ ´ëºÎºÐ(84.7%, 50/59)Àº ½Ã¼ú Àü¿¡´Â undifferentiated°¡ ¾Æ´Ï¾ú½À´Ï´Ù. ÀÌ ºñÀ²Àº º´¿ø¿¡ µû¶ó Å©°Ô Â÷À̰¡ ³³´Ï´Ù. P/D³ª SRC À§¾ÏÀ̶ó°í ÇÏ´õ¶óµµ Å©±â°¡ ÀÛÀ¸¸é ESD¸¦ Àû±ØÀûÀ¸·Î ½ÃÇàÇÏ´Â º´¿ø¿¡¼­´Â ÀÌ ºñÀ²ÀÌ ³ôÀ» °ÍÀ̱⠶§¹®ÀÔ´Ï´Ù.


½Ã¼ú Àü Á¶Á÷°Ë»ç¿¡¼­ M/D¿´À¸³ª, ESD ÈÄ ÃÖÁ¾ º´¸®°á°ú¿¡¼­ P/D·Î ³ª¿Ô´ø ¿¹


½Ã¼ú Àü Á¶Á÷°Ë»ç¿¡¼­ atypicalÀ̾úÀ¸³ª, ESD ÈÄ ÃÖÁ¾ º´¸®°á°ú¿¡¼­ SRC·Î ³ª¿Í ÀǷڵǾú´ø ¿¹


Undifferentiated typeÀ¸·Î °á·Ð³­ 59¿¹´Â differentiated type º¸´Ù Å©°í, lymphovascular invasionÀÌ ¸¹°í, complete resection rate°¡ ³·¾Ò½À´Ï´Ù. ±×·¯³ª P/D¿Í SRC°£¿¡´Â ÀǹÌÀÖ´Â Â÷À̰¡ ¾ø¾ú½À´Ï´Ù. P/D´Â Á¶±Ý ±íÀº °æÇâÀÌ, SRC´Â size discrepancy°¡ Å©°í lateral margin involvement°£ ÈçÇÑ °æÇâÀÌ ÀÖ¾ú½À´Ï´Ù.


Endolymphatic tumor emboli (signet ring cell carcinoma with minute submucosal invasion)


Ä¡·á ÈÄ °æ°ú´Â ¾çÈ£ÇÏ¿´½À´Ï´Ù.


ESD ÈÄ undifferentiated·Î ¹Ù²î´Â °æ¿ì´Â ¿¹»óÇÑ ¹Ù¿Í °°ÀÌ º´¼ÒÀÇ Å©±â°¡ Å©°í À§Ã¼ºÎ¿¡ ÈçÇÏ¿´½À´Ï´Ù.


[References]

1) Undifferentiated¶ó´Â ¿ë¾î¿¡ ´ëÇÏ¿©

2) È®´ëÀûÀÀÁõ¿¡ undifferentited-typeÀÌ Æ÷ÇԵǴ°¡?

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