위 ESD 후내시경소견 성균관대학교의과대학내과이준행

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1 위 ESD 후내시경소견 성균관대학교의과대학내과이준행

2 문제의식 위궤양, 조기위암, 진행위암의내시경소견은배운다. 위암수술후소견은가끔배운다. 위암내시경시술후소견은배운적이없다. 관찰과조직검사에대한가이드라인이없다.

3 ESD 후정상내시경소견 성균관대학교의과대학내과이준행

4 처음의뢰되었을때의사진

5 ESD M/D, 18mm, LP, RM (-), L/V (-)

6 추적내시경소견 2 달후 6 달후 3 년후

7 ESD (x2) for EGCs 두달후관찰 2 달후

8 8 주후인공궤양이덜아물기도합니다. - M/74, DM, angina, H/O CVA - M/D, 12mm, MM, 8 주후

9 Converging fold 를만들기도함

10 2017 묘한모양의 scar 도있습니다.

11 ESD 후융기형반흔 11 년간관찰

12 다양한융기형반흔 (15%) 대한위암학회지 2001;1:55-59

13 ESD scar 의모양은계속변해갑니다. ESD: W/D, 24mm, LP, RM (-), L/V (-/-)

14 Stricture after a very large ESD - 14 x 10 cm resection for 7 x 6 cm EGC 6 weeks after ESD for EGC

15 세번 ESD 후상당히좁아졌으나증상은없음 첫번째 ESD: 9 년전 두번째 ESD: 3 년전 세번째 ESD: 2 달전

16 협착예방을위한경구 steroid 치료 8 주코스 ESD 2일째 Pd 투약시작 1주 : 매일 30mg (5mg 6알 ) 2주 : 매일 30mg (5mg 6알 ) 3주 : 매일 25mg (5mg 5알 ) 4주 : 매일 25mg (5mg 5알 ) 5주 : 매일 20mg (5mg 4알 ) 4 주코스 ESD 2일째 Pd 투약시작 1주 : 매일 30mg (5mg 6알 ) 2주 : 매일 20mg (5mg 4알 ) 3주 : 매일 10mg (5mg 2알 ) 4주 : 매일 5mg (5mg 1알 ) 5주 : 중단 6주 : 매일 15mg (5mg 3알 ) 7주 : 매일 10mg (5mg 2알 ) 8주 : 매일 5mg (5mg 1알 ) 9주 : 중단

17 ESD 후병소가커서 steroid 를 PPI 와함께사용함 8 weeks later 6 months later

18 SMC policy EGD after ESD - 조기위암 / 위선종내시경치료후추적검사 조기위암 EMR/ESD: 5 년까지추적내시경마다 scar 에서 조직검사 (1-2 점 ) 5 년후부터는재발의심소견이있 을때만조직검사 ( 단, 조기위암 EMR/ESD 후첫추적내 시경에서는 H. pylori 조직검사도함께시행한다.) 선종 EMR/ESD: 1 년까지추적내시경마다 scar 에서조직 검사 (1-2 점 ) 1 년후부터는재발의심소견이있을때 만조직검사 선종 APC: 재발의심소견이있을때만조직검사

19 1.2cm, M/D, LP 암. 7 년후. 조직검사?

20 Local recurrence 성균관대학교의과대학내과이준행

21 위각 ESD 후재발로의뢰되었으나 수술할수밖에없음 조직검사에서모두암으로나옴

22 Stomach, subtotal gastrectomy: Early gastric carcinoma 1. Location : middle third, Center at antrum, angle and lesser curvature 2. Gross type : EGC type IIb 3. Histologic type : tubular adenocarcinoma, moderately differentiated 4. Histologic type by Lauren : intestinal 5. Size : 2.7x2.3 cm 6. Depth of invasion : invades mucosa (lamina propria) (pt1a) 7. Resection margin: free from carcinoma, safety margin: proximal 3.3 cm, distal 3.4 cm 8. Lymph node metastasis : no metastasis in 17 regional lymph nodes (pn0) (0/17 : "3", 0/2; "4", 0/2; "5", 0/0; "6", 0/5; "7", 0/1; "9", 0/2; "8a", 0/0; "11p", 0/2; "12a", 0/2; "4sb", 0/1; "1", 0/0) 9. Lymphatic invasion : not identified 10. Venous invasion : not identified 11. Perineural invasion : not identified 12. AJCC stage by 7th edition: pt1a N0

23 2006 국소재발 - M/D, 3.2x2.5 cm - Depth of invasion: pt1a - RM (-) - safety margin: 0.1, 0.2, 0.9, and 2cm Subtotal gastrectomy: M/D, 0.8x0.4cm, pt1a, RM (-), LN (-)

24 Initial biopsy: M/D ESD: P/D, 14mm, LP, RM (-) >= 10 mm Biopsy: M/D Subtotal gastrectomy: W/, 0.7cm, lamina propria

25 EMR-C at a low-volume center (2010) 국소재발로의뢰되어재검하여또다른암발견 수술 사망

26 ESD 후첫내시경에서암 (locally residual cancer) ESD for EGC - Gross type : EGC type IIb - Tubular adenocarcinoma, moderately differentiated - Size of carcinoma: 48 x 28mm - Depth of invasion : mucosa (lamina propria) - Resection margin : free from carcinoma(n) - safety margin : D 3 mm, P 1.5 mm, A 10 mm, P 4 mm - L/V/N (-) Ablation 후수년간재발 (-)

27 경계가불분명한위암 ESD 후 lateral margin 양성으로 ablation 치료를했으나국소재발 수술하여 1.5 cm residual 확인 경계가불분명한위암 ESD 소작술국소재발 W/D adenocarcinoma, 1.5 cm, lamina propria, LN (-)

28 Local recurrence ESD - tumor 와 scar 를포함하여 en bloc resection 하였음 ESD for adenoma with HGD Review: EGC in MM EGC at 6 month

29 Stomach, LC of mid antrum, endoscopic submucosal dissection: Status post endoscopic submucosal dissection (O ) Early gastric carcinoma 1. Location : antrum, lesser curvature 2. Gross type : EGC type IIa+IIc 3. Histologic type : tubular adenocarcinoma, well differentiated (foveolar type) 4. Histologic type by Lauren : intestinal 5. Size of carcinoma : (1) longest diameter, 26 mm (2) vertical diameter, 23 mm 6. Depth of invasion : invades mucosa (muscularis mucosa) (pt1a) 7. Resection margin : free from carcinoma(n), safety margin : distal 8 mm, proximal 8 mm, anterior 14 mm, posterior 12 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

30 ESD 후국소재발 (1 년반 ) Local recurrence 1. Location : body, lesser curvature 2. Gross type : EGC type IIa+IIc 3. Histologic type : tubular adenocarcinoma, moderately differentiated >> tubular adenocarcinoma, poorly differentiated (about 10%) 4. Histologic type by Lauren : intestinal 5. Size of carcinoma : (1) longest diameter, 38 mm (2) vertical diameter, 24 mm 6. Depth of invasion : invades submucosa, (depth of sm invasion : 250 μm ) (pt1b) 7. Resection margin : free from carcinoma(n): safety margin : distal 5 mm, proximal 2 mm, anterior 14 mm, posterior 4 mm, deep 150 μm 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: present Stomach, subtotal gastrectomy: Early gastric carcinoma - Histologic type : tubular adenocarcinoma, moderately differentiated - Size : 2.8x2.4 cm - Depth of invasion : invades mucosa (muscularis mucosae) (pt1a) - Lymph node metastasis : no metastasis in 33 regional lymph nodes (pn0) - LVN (-)

31 ESD 후국소재발 (1 년반 ) 환자의과거사진은어떠하였을까? Local recurrence Stomach, subtotal gastrectomy: Early gastric carcinoma - Histologic type : tubular adenocarcinoma, moderately differentiated - Size : 2.8x2.4 cm - Depth of invasion : invades mucosa (muscularis mucosae) (pt1a) - Lymph node metastasis : no metastasis in 33 regional lymph nodes (pn0) - LVN (-) 2M 12M 6M 18M

32 ESD 후수술거부 ( 증례 1)

33

34

35 ESD 후수술거부 28 개월후재발

36 28 months after EMR

37 재발 6 개월전

38 ESD 후수술거부증례 (2) 1. Location : antrum, anterior wall 2. Gross type : EGC type IIc 3. Histologic type : tubular adenocarcinoma, M/D >> papillary adenocarcinoma, M/D (about 20%) > tubular adenocarcinoma, P/D (about 10%) 4. Histologic type by Lauren : intestinal 5. Size : 2.8x1.8 cm 6. Depth of invasion : invades submucosa, (depth of sm invasion: 1500 μm ) (pt1b) 7. Resection margin: free from carcinoma 8. Lymphatic invasion : present 9. Venous invasion : present 10. Perineural invasion : not identified 11. Microscopic ulcer : absent 12. Histologic heterogeneity: present

39 ESD 후수술거부 38 개월후재발 Advanced gastric carcinoma Histologic type : tubular adenoca (M/D) Size : 2.8x2.4 cm Penetrates subserosal connective tissue Lymph node metastasis : positive (1/34) Lymphatic invasion : present Venous invasion : not identified Perineural invasion : not identified Recurrent mass at 38 months Peritoneal cytology : negative

40 Limited role of follow-up EGD ESD 7 months 13 months 20 months 26 months 38 months

41 어떤경우에 local recur 를의심? Unclear tumor border before ESD Not sufficient resection margin Larger tumor SM invasion Mixed histology / undifferentiated type Delayed healing Asymmetry, focal hyperemia, SMT-like buldging

42 Other site recurrences - synchronous / metachronous 성균관대학교의과대학내과이준행

43 EMR/ESD data analysis at SMC Endoscopic resection Differentiated Undiffererentiated Curative resection Poorly differentiated Noncurative resection Signet ring cell carcinoma

44 Study population EGCs treated by ESD at Samsung Medical Center 1,838 patients with 1,889 differentiated-type EGCs November 2003 May 2011 Censoring date: May 2014 Differentiated-type EGC Well or moderately differentiated or papillary EGC According to the quantitatively predominant histologic type Differentiated-type EGC > 50% Min BH (SMC). Endoscopy 2015

45 Immediate outcome measures - 1,838 cases with 1,889 EGCs treated by ESD - Patients enrollment: November May 2011 En bloc resection rate: 96.9% R0 resection rate: 94.0% En bloc and R0 resection rate: 92.2% Curative resection: 81.5% (1,539 EGCs in 1,497 patients / 1,838 EGCs in 1,889 patients) Bleeding: 4.1%, perforation: 3.2% Min BH (SMC). Endoscopy 2015

46 1,838 patients with 1,889 differentiated-type EGCs 1151 patients with 1171 EGCs-absolute - Single lesion: Two lesions: patients with 331 EGCs-expanded - Single lesion: 325 -Two lesions: 3 18 patients with 37 EGCs including both EGC-absolute and EGC-expanded - Two lesions: 17 -Three lesions: patients with at least one lesion treated with non-curative resection - Single lesion: Two lesions: 7 - Three lesions: 1 - Op: 1 - Residual lesion: 2 - Synchronous lesion: 9 - Follow up < 1 year: Op: 21 - Residual lesion: 0 - Synchronous lesion: 4 - Follow up < 1 year: 44 - Op: 0 - Residual lesion: 0 - Synchronous lesion: 0 - Follow up < 1 year: 3 *1032 patients with 1049 EGCs-absolute *259 patients with 261 EGCs-expanded *15 patients with 31 EGCs including both EGC-absolute and EGC-expanded 1 LR - EGC: 1 38 MR - EGC: 36 - pt2 AGC: 2 1 EGR 0 LR 8 MR - EGC: 7 - pt2 AGC: 1 1 EGR 0 LR 1 MR - EGC: 1 0 EGR Op: 1 Op: 16 ER: 22 Op: 1 Op: 3 ER: 5 Palliative Op: 1 ER: 1 * A total of 1,306 patients with 1,341 EGCs were included in the outcome analysis.

47 Metachronous recurrence (n=47, 3.6%) - Among 1,306 curative ESDs from December 2003 to May 2011 EGC: 44 cases - ESD alone: 28 - Surgery +/- ESD: 16 AGC: 3 cases - pt2, LN (-): 1 - pt2, LN (+): 2 Min BH (SMC). Endoscopy 2015

48 Min BH (SMC). Endoscopy 2015

49 전정부위암 2 개 ESD

50 전정부위암 2 개 ESD 3 년후 fundus cancer 발견 - Histologic type : TA M/D with focal P/D - Size : 2.7x2.0 cm - Proper muscle invasion (pt2) - LN (-) 11 months ago

51 Second gastric cancer 10 months after ESD ESD First follow up Second follow up

52 ESD for EGC

53 Stomach, ESD. Early gastric carcinoma 1. Location : proximal antrum, anterior wall 2. Gross type : EGC type IIa 3. Histologic type : tubular adenocarcinoma, moderately differentiated 4. Histologic type by Lauren : intestinal 5. Size of carcinoma : (1) longest diameter, 28 mm (2) vertical diameter, 16 mm 6. Depth of invasion : invades mucosa (muscularis mucosa) (pt1a) 7. Resection margin : free from carcinoma(n). safety margin : distal 9 mm, proximal 8 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. Histologic heterogeneity: absent

54 ER for EGC EGC detected during surveillance in patient with UIP (M/73) EMR (submucosal dissection method using IT knife) W/D, 16mm, MM

55 Fold effect - 첫추적검사에서인근부위에서두번째암발견

56 처음사진을다시열어보겠습니다. Fold effect 를알수있겠습니까? Initial endoscopy before ER

57 첫추적검사에서두번째암발견 M/D, 6mm, MM

58 위선종 EMR 1 년후위암발견

59 ESD using needle knife (2009) ESD: Early gastric carcinoma : - Histologic type : tubular adenocarcinoma, well differentiated - Size : 1x0.6x0.1 cm - Depth of invasion : invades mucosa (lamina propria) (pt1a) - Resection margin: free from carcinoma, safety margin: distal 0.8 cm, proximal 1 cm, anterior 1.2 cm, posterior 1.2 cm - Lymphatic invasion : not identified - Venous invasion : not identified

60 이소성위암을모두 ESD 할수있지않다. - Biopsy: P/D adenocarcinoma

61 집으로가져가는메세지 Field cancerization. 위암혹은위선종환자에서다른부위의병소는언제나발생할수있습니다. ESD 후 local recurrence에유의합시다. 특히고위험환자에서. ESD 후첫추적검사에서는인근부위위암에유의합시다. Fold effect. 식도와십이지장도주의합시다.

62 SMC policy EGD after ESD - 조기위암 / 위선종내시경치료후추적검사 조기위암 EMR/ESD: 5 년까지추적내시경마다 scar 에서 조직검사 (1-2 점 ) 5 년후부터는재발의심소견이있 을때만조직검사 ( 단, 조기위암 EMR/ESD 후첫추적내 시경에서는 H. pylori 조직검사도함께시행한다.) 선종 EMR/ESD: 1 년까지추적내시경마다 scar 에서조직 검사 (1-2 점 ) 1 년후부터는재발의심소견이있을때 만조직검사 선종 APC: 재발의심소견이있을때만조직검사