위암내시경진단 (2019) - 융기형위암을중심으로 성균관대학교의과대학내과이준행

Transcription

1 위암내시경진단 (2019) - 융기형위암을중심으로 성균관대학교의과대학내과이준행

2 위암내시경진단 (2019) 위암검진에대한짧지않은 comment 융기형암은융기되어있는가? 함몰형암은함몰되어있는가? Semi-pedunculated polyp Sentinel polyp or EGJ cancer? IIa + IIc

3 위암검진에대한짧지않은 comment 성균관대학교의과대학내과이준행

4 M/I ratio was 0.31 in Korea - Mortality/incidence ratio per 100, Male per 100, Female Incidence Mortality Incidence Mortality Age standardization was based on the Segi s world standard population

5 Estimated gastric cancer incidence and mortality in 2012 (Top 20 countries) Korea and Mongolia is number one and two in the incidence of gastric cancer. The survival rate is highest in Korea followed by Japan. It is probably due to early detection by screening program and high surgical and endoscopic techniques.

6 Brief history of Korean Caner Screening Program Year 1996 First term of 10-Year Plan of Cancer Control was launched The National Cancer Screening Program launched for stomach, breast, cervical cancer free of charge. Target population was Medical Aids (lowest 10% income group) Liver cancer screening program added 2004 Colon cancer screening program added 2005 Target population expanded to the lower 50% of National Health Insurance beneficiaries (Free of charge) 2006 Screening for upper 50% income group (20% self payment) 2010 Self payment of upper 50% income group lowered to 10%

7 Payment by the population: 0-10% 100% Income level NHI Cancer Screening - 10% charge 50% 10% Medical Aid National Cancer Screening - Free of charge

8 Cancer screening program (2018) Stomach Liver Colorectal Breast Cervix (accessed: )

9 Two types of cancer screening Organized screening National program (public) Most budget comes from national or public fund Standard Opportunistic screening Personal program (private) Payment by individuals Expansive

10 0.25% (65/25,526) Kim. APT 2008;27:

11 EGC undetected on previous EGD No reference

12 AGC undetected on previous EGD Sung. Korean J Gastroenterol 2011;57:

13 [ 질문 ] 진단은? 1) 비후성위염, 2) 림프종, 3) 보만 4 형진행성위암

14 한학회에서 voting 을해보았습니다. 1) 비후성위염 (17), 2) 림프종 (6), 3) 보만 4 형진행성위암 (11) 위대장내시경학회

15 답. 보만 4 형진행성위암 (M/49, 2015) - 문제보다 1 년후사진입니다. 수술을하였고 peritoneal seeding 이있었습니다.

16 1 년전 문제로드렸던사진입니다.

17 2 년전

18 1 년전에진단할수있었을까? 1 년전

19 주름은두꺼워지고골짜기는얕아진다

20 Shoulder by shoulder

21 정상과비정상의경계

22 Antral type

23 잔위보만 4 형진행성위암 Remnant stomach s/p STG due to AGC (5 years ago) Colon involvement

24 하복부통증. 산부인과에서 hemorrhagic cyst rupture 의심 (2014)

25 True Helicobacter (-) cancer is rare. - Rapid urease tests, serology examinations, and histological evaluations gastric cancer Current HP infection (1378, 75.2%) Past HP infection (412, 22.5%) HP-negative Gastric cancer (43, 2.3%) Kwak. J Gastroenterol Hepatol 2014

26 A very famous lie. Is it white?

27 Screening is not a prevention. Screening is just early detection and prevention of gastric cancer-related death. In order to prevent gastric cancer, H. pylori eradication may be the best option.

28 AGC Borrmann type IV EGC Other AGCs

29 융기형암은융기되어있는가? 함몰형암은함몰되어있는가? 성균관대학교의과대학내과이준행

30 상부소화관내시경소견의판독및감별진단. 박인서옮김

31 빠른내시경보다바른내시경을 그런데, 시간이부족합니다.

32 DEX / BOXIM

33 잘못된그림

34 AGC, B-II NO YES

35 Ulcerative mass 말이되는가? 된다.

36 Paris classification for EGC Type 0 Polypoid Non-polypoid elevated flat depressed excavated 0-I (Ip, Is) 0-IIa 0-IIb 0-IIc 0-III

37 EGC I 과 EGC IIa 의경계 2.5mm 는비현실적 The cut-off limit is 2.5 mm in the columnar epithelium and 1.2 mm in the stratified epithelium of the esophagus. Endoscopy 2005;37:

38 첫사진 ( 조직검사전 ) 을살펴봅시다.

39 EGC IIa, W/D, 18mm, LP

40 EGC I, W/D, 36mm, LP

41 잔위암. 내시경 : 융기형, 병리 : 함몰형 - 내시경소견 : Shallow elevated mucosal lesion with central depression and mucosal friability - 수술병리 : EGC IIc, SRC. 1.1cm. Subserosal (pt3)

42 1 년전

43 금년과작년의비교

44 Semi-pedunculated polyp 성균관대학교의과대학내과이준행

45 [ 질문 ] 전정부용종입니다. 진단은? 1) 과형성용종 2) 위저선용종 3) Inflammatory fibrinoid polyp 4) Adenoma 5) EGC

46 한학회에서 voting 을해보았습니다. 1) 과형성용종 (16) 2) 위저선용종 (3) 3) Inflammatory fibrinoid polyp (9) 4) Adenoma (17) 5) EGC (4) 위대장내시경학회

47 조직검사없이용종절제술을하면

48 용종절제술최종병리결과 EGC type I Well differentiated tubular adenocarcinoma Resection margin Proximal: negative for malignancy Distal: presence of malignancy Lateral: negative for malignancy Base: presence for malignancy

49 추적내시경조직검사암 (+)

50 과형성용종을의심했는데조직검사에서암으로나왔습니다.

51 조기위암에적합한내시경치료가가능

52 Hyperplastic polyp 추적중선종 6 년전 4 년전 2 년전최근

53 Sentinel polyp or EGJ cancer? 성균관대학교의과대학내과이준행

54 Is it a sentinel polyp or cancer? (1/4)

55 Is it a sentinel polyp or cancer? (2/4)

56

57 Early gastric carcinoma 1. Location : upper third, center at cardia (Siewert II) 2. Gross type : EGC type IIc 3. Histologic type : tubular adenocarcinoma (P/D) 4. Histologic type by Lauren : mixed 5. Size : 2.2x1.5 cm 6. Depth of invasion : invades submucosa (sm3) (pt1b) 7. Resection margin: free from carcinoma. safety margin: proximal 2.3 cm, distal 16 cm 8. Lymph node metastasis : no metastasis in Lymphatic invasion : present 10. Venous invasion : not identified 11. Perineural invasion : not identified

58 EMR specimen 에서 AGC 가나온경우

59 IIa + IIc 성균관대학교의과대학내과이준행

60 상부소화관내시경소견의판독및감별진단. 박인서옮김

61 Choi. Gastrointest Endosc 2011

62 EGC IIa + IIc - ESD: W/D, 10mm, LP. L/V (-/-)

63 Would you ESD? - M/69. W/D adenocarcinoma

64 ESD was done.

65 Early gastric carcinoma 1. Location : low body, greater curvature 2. Gross type : EGC type IIc+IIa 3. Histologic type : tubular adenocarcinoma, moderately differentiated 4. Histologic type by Lauren : intestinal 5. Size of carcinoma : (1) longest diameter, 14 mm (2) vertical diameter, 9 mm 6. Depth of invasion : invades submucosa, (depth of sm invasion : 2000 μm ) (pt1b) 7. Resection margin : involved deep margin by carcinoma, free other resection margins from carcinoma(n) safety margin : distal 12 mm, proximal 15 mm, anterior 14 mm, posterior 18 mm 8. Lymphatic invasion : present (+++) 9. Venous invasion : not identified(n) 10. Perineural invasion : not identified(n) 11. Microscopic ulcer : absent 12. Histologic heterogeneity: absent

66

67 EGC - 외부슬라이드재판독 : M/D (WHYX lesion) - ESD: SRC >> M/D, 26mm, SM 700um, L/V (-/-)

68 IIa+IIc 는나쁘다. M/D. SM 1,100 um

69 Bx: W/D. Would you ESD? (F/40) - Total gastrectomy: W/D, 2x1.3cm, SM3, LN (-)

70 Diagnostic ESD 후수술 (M/75) - 외과에서는내과로, 내과에서는다시외과로보내서헷갈려서왔습니다. - MM. 16mm, SM 2000um. 수술 : no residual tumor

71 Random cases 성균관대학교의과대학내과이준행

72 2 년전내시경을했는데 - proper muscle cancer, LN (-)

73 Adenocarcinoma (P/D), SS, 0/46

74 출혈환자에서도위전체를잘관찰합시다. - Paraesophageal hernia with bleeding

75 Paraesophageal hernia with bleeding - 5 개월후추적내시경에서위암발견되어이차의견위하여방문 - 원병원에서수술받기로함 5 개월전사진

76 Extranodal NK/T cell lymphoma

77 F14. SMT gastroblastoma

78 Gastroblastoma (see note); size: 2.6x2.2 cm negative resection margins Note: All but one reported gastroblastoma showed favorable prognosis (low malignant potential). CD 10, (CALLA, common acute lymphocytic leukemia antigen, surface glycoprotein) : Positive in tumor cells. EMA (epithelial membrane antigen = MUC1): Positive in tumor cells. Vimentin (intermediate filament protein that is expressed in mesenchymal cell): Focal positive in tumor cells. C-KIT (CD 117) : Negative in tumor cells. CD 56 (neural cell adhesion molecule, NK cell): Positive in tumor cells. Ki-67 : Positive in about 2% of tumor cells. Synaptophysin : Negative in tumor cells. Chromogranin : Negative in tumor cells

79 F14. SMT gastroblastoma Gastroblastoma is a rare gastric biphasic tumor with both epithelial and mesenchymal components. PMID:

80 개인병원초음파에서 SMT 발견 수술하였고 GIST 로나옴

81 [ 법원 ] 문서제출명령

82 위암내시경진단 (2019) 위암검진은충분하지않습니다. Helicobacter 제균치료를추가합시다. 매우전형적인과형성용종아니면조직검사를하고절제술을합시다. 보초용종과접합부암의구분은어렵습니다. IIa + IIc는특히조심합시다.