간암의조직검사 : 언제, 어떻게? 계명대학교의과대학내과학교실 정우진

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1 간암의조직검사 : 언제, 어떻게? 계명대학교의과대학내과학교실 정우진

2 간생검한다 vs 안한다? M/81 Alcoholic LC, albumin 4.0, bil 0.6, Cr 1.06, glucose 141, afp 2.2, CA CT: R/O HCC in S8, R/O CC M/69 HBV(-), HCV(-), social alcoholics albumin 4.4, bil 0.75, Cr 0.67, glucose 86, CA CT: R/O CC in S2-4, MRI: R/O CC, R/O Parasite abscess Bx: Cholangiocarcinoma, poorly differentiated VS Bx: Hepatocellular carcinoma, well differentiated

3 간생검이란? 간생검 : 간의해부병리학적진단을위하여간조직을소량채취하는것.

4 1 st Liver Biopsy 간생검 : 1 st liver aspirate was performed by Paul Ehrlich at 1883 : 1 st percutaneous liver biopsy was reported in the 1920s : 1 st transjugular approach was pioneered by Charles dotter at 1964

5 증례 1 M/73, Known alcoholic LC, 10년전 choledochal cyst로수술, albumin 2.8, bil 1.86, Cr 0.88, PT INR 1.3, glucose 81, afp 1.8, CA 영상판독 : CT - R/O Cholangiocarcinoma with lymph node metastases Liver cirrhosis with splenomegaly. MRI - R/O Cholangiocarcinoma with lymph node metastases Liver cirrhosis with splenomegaly. 조직검사결과 : consistent with inflammatory pseudotumor.

6 증례 2 M/51, 16년 8월 Ampulla of Vater ca, Sigmoid colon ca. 진단 -> PPPD, EMR치료 albumin 4.2, bil 0.5, Cr 0.69, glucose 112, CEA Colonoscopy: two 5mm sized colon polyps. 영상판독 : 17년 2월 - No local recurrence, Two mildly enlarged mesenteric LNs 17년 5월 - A hepatic metastasis in S6, Slight growing and increased number of mildly enlarged mesenteric LNs. 조직검사결과 : metastatic adenocarcinoma, poorly differentiated

7 증례 3 M/73, known CHF, Af. 3 년전개인의원에서다수의대장용종제거, 최근들어서의체중감소가있어검사시행. HBV(-), HCV(-) albumin 3.6, bil 0.94, Cr 0.98, glucose 118, CEA Colonoscopy: 2 small colon polyps(tubular adenoma with LGD) 영상판독 : Multiple hypovascular lobulating masses in liver both lobes. A spiculated mass in pelvic cavity (21mm) -- Primary-unknown metastases is suggested. Liver cirrhosis, Parapelvic cysts, left 조직검사결과 : adenocarcinoma, poorly differentiated

8 증례 4 M/63, Ex-alcoholics, 3개월전부터의 back pain. HBV(-), HCV(-) albumin 4.0, bil 0.66, Cr 1.03, glucose 190, afp 2.2, CEA 0.96, PSA 2.54, CA 영상판독 : Multiple hypovascular lobulating masses in liver both lobes. Colonoscopy: normal 조직검사결과 : malignant lymphoma, B-cell phenotype

9 증례 5 F/57, Known CHB, 감기, 몸살로검사로우연히발견 albumin 4.4, bil 0.83, Cr 0.63, glucose 91, afp 1.3, HBV DNA(-). 영상판독 : CT: 1. Liver cirrhosis. R/O CLD, 2. HCC in S4. MRI: CLD, HCC in liver S4(19 mm in size) 분엽절제술후조직검사결과 : cholangiocarcinoma, moderately differentiated.

10 국내간암의초치료방법 한국인간질환백서대한간학회 2013

11 간암에서간생검 : 언제했는가? 간세포암 간종괴 생검 (+) 간세포암 담도암 생검 (-) 전이성암 호산구성 육아종 간세포암환자에서간생검비율 <KMUDH 2017> : 3% 진단명 비율 전이성암 48% 간암 15% 담도암 15% 염증 15% 호산구성육아종 5% 괴사 5%

12 간암의조직검사 : 언제?

13 간생검의적응증 Liver biopsy indication 1. Make or confirm the diagnosis 2. Assess the severity of liver damage 3. Assess the prognosis of a given case 4. Monitor the response to the treatment

14 Korean guideline 간세포암종진료가이드라인대한간암학회 - 국립암센터

15 Hepatology 2011;53: AASLD guideline 2011

16 AASLD guideline Biopsy may be required in selected cases, but its routine use is not suggested. Biopsy has the potential to establish a timely diagnosis in cases in which a diagnosis is required to affect therapeutic decision making; however, biopsy has a risk of bleeding, tumor seeding, and the possibility that a negative biopsy is due to the failure to obtain tissue representative of the nodule rather than a truly benign nodule. 2. Stringent imaging criteria with high specificity for 10 mm HCC have been developed by the American College of Radiology through its Liver Imaging Reporting and Data System (LIRADS), the OPTN, and previous AASLD guidelines, and include arterial phase hyper-enhancement in combination with washout appearance and/or capsule appearance. Lesions that do not meet these guidelines or are smaller than 1cm are considered indeterminate. Hepatology 2018;67(1):

17 EASL guideline 2012 J Hepatol 2012;56:

18 Hepatol Int 2017;11: APASL guideline 2017

19 간생검의금기증 Absolute contraindications 1. Uncooperative patients 2. History of unexplained bleeding 3. Tendency to bleed 4. Prothrombin time 3~5sec more than control 5. Platelet count <50,000/mm3 6. Prolonged bleeding time (>10min) 7. Suspected hemangioma of other vascular tumor 8. Inability to identify an appropriate site for biopsy by USG or CT 9. Suspected echinococcal cysts in the liver

20 간암의조직검사 : 어떻게?

21 간생검경로 1. Percutaneous 2. Transjugular 3. Laparoscopic 1. Percutaneous - transthoracic 2. Guided or not - blind procedure - Image guided USG, CT, MRI 1. Done in coagulation disorders or ascites 2. Performed in a vascular catheterization laboratory with videofluoroscopy and profer cardiac monitoring 1. Transvenous liver biopsy is not available 2. In patients who have a combination of focal liver lesion and coagulopathy

22 B형간염바이러스생검용바늘 : 관리대책작동방식문제점 1. Broadly classified into Suction needle - Menghini, - Klatskin Cutting needle - Vim-Silverman, - Tru-cut (commonly used) 2. Spring-loaded cutting needles that have a triggering mechanism

23 간암환자에서의기억할 B형간염바이러스간생검의방법 : 초음파관리대책유도하

24 간암환자에서의기억할 A형간염바이러스간생검의방법관리대책 : CT 유도하

25 간암의조직검사 : 부작용

26 간생검의부작용 Liver biopsy complication 1. Pain (~84%) : pleuritic, peritoneal, diaphragmatic 2. Hemorrhage : intraperitoneal (0.03~0.7%), hemobilia (0.06~0.2%) intrahepatic and/or subcapsular (0.59~23%) 3. Bile peritonitis (0.03~0.22%) 4. Bacteremia 5. Sepsis or abscess formation 6. Pneumothorax and/or pleural effusion 7. Hemothorax 8. Arteriovenous fistula 9. Subcutaneous emphysema 10. Biopsy of other organs 11. Death (usually related with hemorrhage, less than or equal to 1/10,000, 9/10,000 after transvenous biopsy, greater after biopsy of malignant lesion than diffuse lesion)

27 결론 간질환의진단을위한혈액학적방법과영상학적방법의발달로인하여 생검을통한조직학적진단의필요성이많이감소하고있긴하지만, 간생검은아직도주요한진단의수단임에는분명하다. 향후의료의방향이개인별정밀의료로진행하는현시점에서는조직학적 진단및유전학적진단의필요성이점점대두될가능성이많아보인다.

28 경청해주셔서대단히감사합니다.