연하곤란

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1 부울경소화기내시경지회 Intramucosal gastric cancer: The rate of lymph node metastasis in signet ring cell carcinoma was as low as that in welldifferentiated adenocarcinoma 인제대부산백병원 소화기내과 지삼룡

2 Signet ring cell cancer (SRC) % of all gastric cancers frequent in the young and in females scirrhous and infiltrative However, less lymph node metastasis and better survival rates were reported in early gastric SRC than adenocarcinoma

3 Japanese Classification of Gastric Carcinoma Papillary adenocarcinoma (pap) Tubular adenocarcinoma Well-differentiated type (tub 1) Moderately differentiated type (tub 2) Poorly differentiated adenocarcinoma Solid type (por 1) Non-solid type (por 2) Signet-ring cell carcinoma (sig) Mucinous adenocarcinoma (muc) - 2nd English Edition - Differentiated Cancer Undifferentiated Cancer "por" and "sig" can be regarded as the undifferentiated or diffuse type. Japanese Gastric Cancer Association. Gastric Cancer 1998; 1:10.

4 Indication for ER in EGC Well or moderately differentiated ADC or papillary carcinoma Cancer confined to mucosa or IMC IIa less than 20 mm Cancer confined to mucosa or IMC IIb or IIc less than 10 mm Without evidence of venous or lymphatic involvement

5 LN Metastasis in Intramucosal Cancer All intramucosal cancers By tumor size and histological type Gotoda T, et al. Gastric Cancer 2000;3:219.

6 LN Metastasis in Intramucosal Cancer By tumor size and histological type All intramucosal cancers without ulcer findings Gotoda T, et al. Gastric Cancer 2000;3:219.

7 Indication for ER in EGC Well or moderately differentiated ADC or papillary carcinoma Cancer confined to mucosa or IMC IIa less than 20 mm Cancer confined to mucosa or IMC IIb or IIc less than 10 mm Without evidence of venous or lymphatic involvement Regardless of tumor size without ulcer finding (expanded criteria) 30 mm in size with ulcer finding (expanded criteria) Minute submucosal cancer (sm1) 30 mm or less in size (expanded criteria)

8 Gotoda T, et al. Gastric Cancer 2009;12:148.

9 Criteria Incidence 95% CI Intramucosal cancer 0/ % differentiated adenocarcinoma, no lymphatic-vascular invasion, irrespective of ulcer findings, tumor less than 3cm in size Intramucosal cancer 0/ % differentiated adenocarcinoma, no lymphatic-vascular invasion, without ulcer findings, irrespective of tumor size Undifferentiated intramucosal cancer 0/ % no lymphatic-vascular invasion, without ulcer findings, tumor less than 2cm in size Minute submucosal penetration (SM1) 0/ % differentiated adenocarcinoma, no lymphatic-vascular invasion, tumor less than 3cm in size Gotoda T, et al. Gastric Cancer 2000;3:219.

10 SRC vs. UDC 1520 patients with EGC, gastrectomy from September 1994 to December 2001 Retrospectively 879 : differentiated 641 : undifferentiated 5 : mucinous 388 : SRC Ha TK, et al. Ann Surg Oncol 2008;15:508.

11 SRC vs. UDC Risk factors for LNM in EGC by univariate analysis Ha TK, et al. Ann Surg Oncol 2008;15:508.

12 SRC vs. UDC SRC < 2cm Confined to M 일때 LN meta : (-) Ha TK, et al. Ann Surg Oncol 2008;15:508.

13 EGC with SRC, LN Meta 215 patients with EGC with SRC radical gastrectomy with LN dissection January 1999 to December 2007 Retrospectively analyzed. LN + : 7.9 % Kim SW, et al. Eur J Gastroenterol Hepatol 2009;21:1132.

14 EGC with SRC, LN Meta Tumor size < 25 mm Even infiltrate the sm 2 Kim SW, et al. Eur J Gastroenterol Hepatol 2009;21:1132.

15 sm 1a 300 µm sm 1b > 300 µm 500 µm

16 이준행선생님이보내준사진

17

18 Optimal Submucosal Invasion of Early Gastric Cancer for Endoscopic Resection BACKGROUND: A small differentiated gastric cancer with minute submucosal invasion after endoscopic resection is regarded as the curative resection criterion of an expanded indication. However, recent studies have shown a high incidence of lymph node metastasis in those meeting the expanded criteria. The aim of this study was to evaluate the validity of the 500 μm criterion and to determine an optimal cutoff value for the expanded indication. 1,322 patients who underwent curative resection for submucosal gastric cancer Choi IJ Ann Surg Oncol 2015 Jan 21. [Epub ahead of print]

19 RESULTS: The mean full thickness of the submucosa was 2,605 ± 1,760 μm, and the incidence of lymph node metastasis in 103 tumors meeting the expanded indication was 3.9 % (4/103). In the ROC analysis, the area under the curve was (95 % confidence interval ; p = 0.017), and the highest negative predictive value of 98 % was observed when the cutoff value was 300 μm. CONCLUSIONS: This study suggests that a range reduction in the depth of submucosal invasion is required to obtain a high negative predictive value. Further large-scale studies are required to validate the optimal cutoff value proposed in this study. Choi IJ Ann Surg Oncol 2015 Jan 21. [Epub ahead of print]

20 EGC among patients who had undergone a curative gastrectomy with lymph node dissection at Busan Paik Hospital January 2003 to September 2011, retrospectively. We evaluated and compared the clinicopathologic characteristics of endoscopic and surgical features in early gastric SRC and adenocarcinomas in accordance with histologic differentiation. Lee SH, Jee SR, Eur J Gastroenterol Hepatol. 2015;27:170.

21 Total : SRC, 582 adenoca. (214 well-diff, 270 mod-diff, 98 poorlydiff) 615 patients : RSG, 81 : RTG Lee SH, Jee SR, Eur J Gastroenterol Hepatol. 2015;27:170.

22 Clinical and pathological features X Lee SH, Jee SR, Eur J Gastroenterol Hepatol. 2015;27:170.

23 Lee SH, Jee SR, Eur J Gastroenterol Hepatol. 2015;27:170. Univariate analysis of risk factors of LNM

24 Lee SH, Jee SR, Eur J Gastroenterol Hepatol. 2015;27:170. Multivariate analysis of risk factors of LNM

25 Lee SH, Jee SR, Eur J Gastroenterol Hepatol. 2015;27:170. X Subgroup analysis of IM SRC vs. adenoca. without LVI n=386

26 Lee SH, Jee SR, Eur J Gastroenterol Hepatol. 2015;27:170. X Subgroup analysis of IM gastric ca. <20 mm without LVI

27 early gastric SRC was more frequently observed in younger women. The rate of LNM and submucosal invasion in early SRC was as low as those in early well-differentiated adenocarcinoma. Therefore, early gastric SRC is considered a favorable prognostic group. Our study shows that early gastric SRC is a more suitable candidate for ER than moderately and poorly differentiated EGC. There was no evidence of LNM if gastric SRC was limited to mucosa less than 20mm without LVI. Under these conditions, we recommend modifying the extended criteria of ER for EGC, in that indication for ER in early gastric SRC can be equated with that in early well-differentiated adenocarcinoma.

28 Early SRC Gotoda T, et al. Gastric Cancer 2009;12:148.

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