12-JKOS (윤진숙-김보람)1410.hwp

Size: px

Start display at page:

Download "12-JKOS (윤진숙-김보람)1410.hwp"

혜옥 견
6 years ago
Views:

1 대한안과학회지 2017 년제 58 권제 12 호 J Korean Ophthalmol Soc 2017;58(12): ISSN (Print) ISSN (Online) Case Report 반복되는인공수정체이탈로발견된안와점막연관림프조직림프종 1 예 A Case of Mucosa-associated Lymphoid Tissue Lymphoma Discovered by Repetitive Intraocular Lens Dislocation 김보람 최성희 서유리 김태임 김응권 윤진숙 Bo-ram Kim, MD, Seonghee Choi, MD, Yuri Seo, MD, Tae-im Kim, MD, PhD, Eung Kweon Kim, MD, PhD, Jin Sook Yoon, MD, PhD 연세대학교의과대학안과학교실시기능연구소 The Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea Purpose: To report a case where bilateral malignant retrobulbar lymphoma was diagnosed after repetitive intraocular lens dislocation to the anterior chamber. Case summary: An 85-year-old male with a history of stroke who had undergone cataract surgery 10 years ago at another hospital presented with repeated intraocular lens (IOL) dislocations of both eyes into the anterior chamber. He had previously undergone IOL scleral fixation once in his left eye and twice in his right eye, but IOL dislocation was still repeatedly occurring. The best-corrected visual acuity was 0.4 in both eyes. Hertel exophthalmetry was 20 mm in his right eye and 18 mm in his left eye. Painless limitation of motion at supraduction was observed in the right eye. Funduscopy showed newly appeared choroidal folding in the right eye, so orbital computed tomography (CT) with contrast was performed. The CT scans showed bilateral homogenously enhancing retrobulbar masses. Biopsy of the masses showed a MALToma. After radiation therapy, the choroidal folds resolved and exophthalmetry improved to 10 mm in both eyes. No additional IOL dislocation occurred. During 2.5 years of follow-up, there was no evidence of recurrence or distant metastasis of the MALToma. Conclusions: Orbital lymphomas can cause lid edema, exophthalmos, strabismus, and diplopia, and can be diagnosed with imaging modalities such as CT. Final diagnosis involves biopsy and radiation therapy or chemotherapy. If IOL dislocation occurs repeatedly, it may result from an increase in retrobulbar pressure, and concurrent choroidal folding using funduscopy is strongly recommended for imaging to check for the presence of retrobulbar masses. J Korean Ophthalmol Soc 2017;58(12): Keywords: Choroidal folds, Dislocation of intraocular lens, Retrobulbar mass, MALToma 점막연관림프조직림프종은 Isaascon 과 Wright 에의해 Received: Revised: Accepted: Address reprint requests to Jin Sook Yoon, MD, PhD Department of Ophthalmology, Severance Hospital, #50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: , Fax: yoonjs@yuhs.ac * Conflicts of Interest: The authors have no conflicts to disclose. 1983년도에처음기술된질환으로질병의진행속도가느리고, 좋은예후를보이며방사선단독치료만으로도효과적으로반응한다. 1-6 B세포표지자 (CD20, CD79a), T세포표지자 (CD3, CD5) 및기타면역조직학적인분석 (CD23, Bcl-2, Cyclin D1 등 ) 은다른비호치킨림프종으로부터안와점막연관림프조직림프종을감별해내는데진단적으로중요한역할을한다. 안와및안구부속기림프종은구후부조직, 눈꺼풀, 외안근, 결막등에발생하며, 염증징후와통증없이 c2017 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1410

- 김보람외 : 구후부종괴로인한인공수정체이탈 - 서서히진행하는경도의안구돌출을특징으로한다. 종양의위치에따라결막충혈, 결막부종, 안구돌출, 종괴의촉진, 눈꺼풀처짐, 복시, 안구운동장애등다양한증상으로나타난다. 일반적으로구후부조직에림프종이발생하는경우, 안구돌출과복시가발생하게된다.

뇌경색과거력이있었으며, 10년전타병원에서양안백내장수술받았고, 1년 5개월동안인공수정체이탈로좌안 1차례, 우안 2차례인공수정체공막고정술을시행받았다. 이후좌안망막분지정맥폐쇄로인한황반부종으로좌안테논낭하스테로이드주사술을 2차례시행받았으며, 초진당시황반부종은안정화된상태로교정시력우안 0.4, 좌안 0.

2 - 김보람외 : 구후부종괴로인한인공수정체이탈 - 서서히진행하는경도의안구돌출을특징으로한다. 종양의위치에따라결막충혈, 결막부종, 안구돌출, 종괴의촉진, 눈꺼풀처짐, 복시, 안구운동장애등다양한증상으로나타난다. 일반적으로구후부조직에림프종이발생하는경우, 안구돌출과복시가발생하게된다. 저자들은양안인공수정체이탈이반복적으로일어나는환자에서안저소견상맥락막주름소견이보여시행한안와전산화단층촬영상양안의구후부종괴를확인하였다. 이를통해악성림프종을의심하여시행한구후부종괴생검결과점막연관림프조직림프종으로나타난증례를경험하여이를국내최초로보고하고자한다. 증례보고 85 세남자환자가 1 년 5 개월동안발생한반복되는양안 인공수정체이탈을주소로내원하였다. 뇌경색과거력이있었으며, 10년전타병원에서양안백내장수술받았고, 1년 5개월동안인공수정체이탈로좌안 1차례, 우안 2차례인공수정체공막고정술을시행받았다. 이후좌안망막분지정맥폐쇄로인한황반부종으로좌안테논낭하스테로이드주사술을 2차례시행받았으며, 초진당시황반부종은안정화된상태로교정시력우안 0.4, 좌안 0.4 소견을보였고, 우안안압 27 mmhg, 좌안안압 12 mmhg였다. Hertel 안구돌출계측치상우안 20 mm, 좌안 18 mm로우안 2 mm 안구돌출이있었으며특히우안의전방향에서안구운동장애가관찰되었고, 전방향복시를호소하였다 (Fig. 1). 또한안저검사상이전에보이지않던우안맥락막주름소견을보여 (Fig. 2A) 이에안와전산화단층촬영을시행하였으며양측에균일하게조영증강되는구후부종괴가관찰되었다 (Fig. 3A). 이에우안내측눈구석을통하여절개하여종양 Figure 1. The picture shows the ocular movement of the patient. Limitations of motion in the right eye at all gazes are noted. Also, the patient experienced diplopia at all gaze. A B Figure 2. The patient's fundus photographs. (A) Choroidal folds shown on fundus photograph. (B) After radiation therapy, the choroidal folding resolved and the fundus had a normal appearance. 1411

3 - 대한안과학회지 2017 년제 58 권제 12 호 - A B Figure 3. The patient's computed tomography (CT) images. (A) The axial and coronal views of the CT show approximately 3.6 cm sized homogeneously enhancing mass in the right interconal space encasing the optic nerve. Another 2.5 cm sized enhancing mass is shown in the left extraconal space with superior rectus muscle involvement. It suggests orbital lymphoma, bilateral. (B) The axial and coronal views of the CT 6 months after radiation therapy. The picture shows decreased mass size of the right orbital mass and no residual mass in the left orbit. 의조직학적생검술을시행하였으며, 조직면역화학염색상 CD20(+), CD3(-), Cyclin D1(-) 소견을보이며작은림프구모양세포의증식이관찰되어점막연관림프조직림프절외변연부세포림프종으로진단되었다 (Fig. 4). 이에따라약 1 달의기간에걸쳐안와에외부방사선치료를진행하였고, 우안은 20회에걸쳐총 3,600 cgy, 좌안은 17회에걸쳐총 3,060 cgy를조사하였다. 방사선치료 6개월후시행한안저검사상정상소견을보였다 (Fig. 2B). 또한전산화단층촬영상우안의구후부종괴의크기가감소한것을관찰할수있었으며, 좌안에남아있는종괴는관찰할수없었다 (Fig. 3B). 방사선치료후 1년 6개월뒤교정시력양안모두 0.5 소견을보였으며, 안구돌출계검사에서양안 10 mm로뚜렷이안구돌출증상은호전되었고, 추가적인인공수정체이탈은발생하지않았다. 또한방사선치료와관련한기타전신적인합병증은없었으며, 점막연관림프조직림프종의재발및전이소견은관찰되지않았다. 하지만방사선치료후약 2년 6개월이지나교정시력우안 0.5, 좌안 0.05 소견을보여시행한빛간섭단층촬영상좌안황반부종재발소견을보여안내스테로이드주사술후외래경과관찰중이다. 고찰 안와및안구부속기림프종은매우드문질환으로안와종양의약 10% 정도를차지한다. 7 이중가장흔하게발생하는것은비호지킨림프종의한종류인 B 세포형태의점막연관림프조직림프종 (Mucosa-associated lymphoid tissue lymphoma, MALToma) 이다. 8,9 MALT 림프종은흔히위점막에발생하는것으로알려져있으나, 피부, 침샘, 폐등점막이있는장소라면어디에서도발생할수있다. 안와부속기에발생하는 MALT 림프종은결막, 눈꺼풀, 안와등에서나타날수있으며전신으로의전이가드물고진행속도가느려대부분국소적인방사선치료만으로완치가가능하다. 최근들어면역조직학적인분석의발전과더불어안와및안구부속기림프종의발생빈도또한증가하고있다. 형태학적인분석, 면역학적인분석, 유전학적인분석등을통해림프종을감별할수있는데, 특히면역조직학적인분석은림프종의진단에있어중요하게여겨진다. 점막연관림프조직림프종의경우 B 세포표지자인 CD19, CD20, CD22 등의양성소견, T 세포표지자인 CD5, CD10, CD23 등의음성소견을보인다. 또한서던블롯분석과표준중합효소연쇄반응 (polymerase chain reaction) 을기반으로하여기존에감별진단하던방식과더불어추가적으로 im- 1412

4 - 김보람외 : 구후부종괴로인한인공수정체이탈 - A B C D Figure 4. Immunohistopathological characteristics of the mass. It is consistent with extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). (A) Tumor cells are negative for CD3 ( 200), (B) positive for CD20 antigen ( 200) and (C) negative for Cyclin D1 ( 200). (D) Small lymphoid cell proliferation was easy to be observed (Hematoxylin and eosin stain, 200). munoglobulin heavy chain (IgH) 유전자의중합효소연쇄반응을통한분자생물학적인분석을통해증식성결절 (lymphoid hyperplasia) 과더정확히감별진단을할수있게되었다 본증례에서는 B 세포표지자인 CD20 양성이고, T 세포표지자인 CD3 음성으로 B 세포기원의림프종임을알수있었으며, 또한 Cyclin D1 음성으로외투세포림프종과감별을할수있었다. 병리학적으로는점막연관림프조직림프종에합당한소견을보였다. 인공수정체이탈은백내장수술합병증중의하나로약 % 에서발생한다. 인공수정체이탈의선행요인에대해서는그동안여러연구들에서다루어져왔다. 수정체낭내이탈의경우거짓비늘증후군, 포도막염, 외상, 유리체절제술후상태, 긴장축등이원인으로알려져있고, 점진적인섬모체소대의약화로인해발생하기때문에진행이느리다. 한편, 수정체낭외이탈의경우인공수정체이차삽입술, 백내장수술시발생한후낭파열, 성숙백내장, neodymium-doped yttrium aluminium garnet; Nd:Y 3Al 5O 12 (Nd:YAG) 후낭절개술, 유리체절제술후상태등이원인으로알려져있고발생시기는다양하다. 13,14 이에본증례에서인공수정체이탈의원인은종괴에의해구후부압력이높아지면서안압이상승되고, 그에따른섬모체소대의약화에기인한인공수정체의불안정성이원인으로생각된다. 안와방사선치료이후뚜렷한구후부종괴크기가줄어들고안압이안정화되었으며, 이후로인공수정체이탈은더이상발생하지않았다. 현재까지국내에구후부의악성림프종으로인한인공수정체이탈에대해보고된바는없다. 또한, 맥락막주름의경우다양한질환과연관되어나타날수있는소견으로구조적으로맥락막내층, 브루크막, 망막색소상피층과감각신경망막까지구불거리는형상으로나타나게된다. 15 다양한원인이이를유발할수있는것으로알려져있는데, 갑상선안병증 16, 후부공막염 17,18, 종양 19,20, 저안압증 21, 공막돌륭술 22, 연령관련황반변성 15,18 등이그원 1413

5 - 대한안과학회지 2017 년제 58 권제 12 호 - 인이될수있다. 이전연구들에서구후부종괴로인해맥락막주름이발생한증례가발표된바있다. 19 저자들은본증례에서반복되는인공수정체이탈, 상승된안압, 전방향의안구운동장애및복시, 그리고안저검사상확인된맥락막주름을통해구후부종괴를의심할수있었고, 안와전산화단층촬영을통해이를확인하였다. 이어안와절개술을통한조직학적검사를통해점막연관림프조직림프종으로최종진단을하였고방사선치료를받은후재발소견을보이지않았다. 반복되는인공수정체이탈과맥락막주름에동반되는구후부종괴는매우드문형태로아직국내에는보고된예가없기에저자들은이를보고하는바이다. 앞으로, 반복되는인공수정체이탈및맥락막주름이안저검사상에서나타날경우감별진단에드물지만구후부종괴의가능성을고려해야하며, 전산화단층촬영상조영증강되는구후부종괴가발견될경우, 특히양안에서발생하였을때는안와악성종양의심하에조직학적생검을통해정확한진단그리고치료가이루어져야한다. REFERENCES 1) Suh CO, Shim SJ, Lee SW, et al. Orbital marginal zone B-cell lymphoma of MALT: radiotherapy results and clinical behavior. Int J Radiat Oncol Biol Phys 2006;65: ) Lee JL, Kim MK, Lee KH, et al. Extranodal marginal zone B-cell lymphomas of mucosa-associated lymphoid tissue-type of the orbit and ocular adnexa. Ann Hematol 2005;84: ) Uno T, Isobe K, Shikama N, et al. Radiotherapy for extranodal, marginal zone, B-cell lymphoma of mucosa-associated lymphoid tissue originating in the ocular adnexa: a multiinstitutional, retrospective review of 50 patients. Cancer 2003;98: ) Le QT, Eulau SM, George TI, et al. Primary radiotherapy for localized orbital MALT lymphoma. Int J Radiat Oncol Biol Phys 2002;52: ) Ejima Y, Sasaki R, Okamoto Y, et al. Ocular adnexal mucosa-associated lymphoid tissue lymphoma treated with radiotherapy. Radiother Oncol 2006;78:6-9. 6) Tsang RW, Gospodarowicz MK, Pintilie M, et al. Localized mucosa-associated lymphoid tissue lymphoma treated with radiation therapy has excellent clinical outcome. J Clin Oncol 2003;21: ) Shields JA, Bakewell B, Augsburger JJ, Flanagan JC. Classification and incidence of space-occupying lesions of the orbit. A survey of 645 biopsies. Arch Ophthalmol 1984;102: ) Carbone PP, Kaplan HS, Musshoff K, et al. Report of the Committee on Hodgkin's Disease Staging Classification. Cancer Res 1971;31: ) Liesegang TJ. Ocular adnexal lymphoproliferative lesions. Mayo Clin Proc 1993;68: ) Coupland SE, Krause L, Delecluse HJ, et al. Lymphoproliferative lesions of the ocular adnexa. Analysis of 112 cases. Ophthalmology 1998;105: ) Hardman-Lea S, Kerr-Muir M, Wotherspoon AC, et al. Mucosalassociated lymphoid tissue lymphoma of the conjunctiva. Arch Ophthalmol 1994;112: ) Strauss EC, Warren JF, Margolis TP, Holsclaw DS. Diagnosis of conjunctival B-cell lymphoma by polymerase chain reaction heteroduplex analysis. Am J Ophthalmol 2003;136: ) Hayashi K, Hirata A, Hayashi H. Possible predisposing factors for in-the-bag and out-of-the-bag intraocular lens dislocation and outcomes of intraocular lens exchange surgery. Ophthalmology 2007;114: ) Kristianslund O, Råen M, Østern AE, Drolsum L. Late in-the-bag intraocular lens dislocation: a randomized clinical trial comparing lens repositioning and lens exchange. Ophthalmology 2017;124: ) Gass JD. Radial chorioretinal folds. A sign of choroidal neovascularization. Arch Ophthalmol 1981;99: ) Kowal L, Georgievski Z. Choroidal folds in Graves' ophthalmopathy. Aust N Z J Ophthalmol 1994;22: ) Singh G, Guthoff R, Foster CS. Observations on long-term follow-up of posterior scleritis. Am J Ophthalmol 1986;101: ) Haruyama M, Yuzawa M, Kawamura A, et al. Indocyanine green angiographic findings of chorioretinal folds. Jpn J Ophthalmol 2001; 45: ) Hedges TR Jr, Leopold IH. Parallel retinal folds; their significance in orbital space-taking lesions. Arch Ophthalmol 1959;62: ) Khairallah M, Ladjimi A, Messaoud R, et al. Sectorial choroidal ischemia associated with ipsilateral lacrimal gland tumor. Am J Ophthalmol 1997;124: ) Fannin LA, Schiffman JC, Budenz DL. Risk factors for hypotony maculopathy. Ophthalmology 2003;110: ) Friberg TR. The etiology of choroidal folds. A biomechanical explanation. Graefes Arch Clin Exp Ophthalmol 1989;227:

6 - 김보람외 : 구후부종괴로인한인공수정체이탈 - = 국문초록 = 반복되는인공수정체이탈로발견된안와점막연관림프조직림프종 1 예 목적 : 백내장수술후반복되는양안의인공수정체전방이탈이발생한환자에서양안안와구후부의일차성악성림프종이발견된 1 예를보고하고자한다. 증례요약 : 85 세남자환자가반복적인인공수정체전방이탈을주소로내원하였다. 뇌경색과거력이있으며, 10 년전타병원에서백내장수술후인공수정체이탈로내원하였고, 좌안 1 차례, 우안 2 차례인공수정체공막고정술을시행받았다. 최대교정시력은우안 0.4, 좌안 0.4 였고, 양안의안구돌출수치는 Hertel 계측치상우안 20 mm, 좌안 18 mm 였으며, 통증없이특히우안전방향의안구운동장애가뚜렷하였다. 안저검사상이전에보이지않던맥락막주름소견이우안에관찰되어시행한안와전산화단층촬영에서양측에균일하게조영증강되는구후부종괴가관찰되었다. 조직검사를통해점막연관림프조직림프종이진단되었으며방사선치료를진행하였다. 이후맥락막주름이호전되었으며, 안구돌출수치양안 10 mm 소견및추가적인인공수정체이탈은발생하지않았다. 또한 2 년 6 개월의경과관찰중점막연관림프조직림프종의재발이나전신전이소견은없었다. 결론 : 안와림프종은안검부종, 안구돌출, 사시, 복시등을유발하며, 영상검사상안와의종괴소견을보인다. 조직검사를통해진단하며, 방사선치료또는항암치료를하게된다. 인공수정체이탈이반복될경우후방부압력의상승이원인이될수있으며, 특히맥락막주름이발견될경우, 구후부종괴에의해안구가직접적으로눌리며발생할수있기때문에적절한영상검사가필요하다. 따라서원인을알수없는인공수정체이탈이반복될때에는안와종괴로인한후방의높은압력이드문원인이될수있으므로안저검사및안와에대한영상학적검사를통해감별진단을해야한다. < 대한안과학회지 2017;58(12): > 1415

( )Jkstro011.hwp

( )Jkstro011.hwp 비인강암의방사선치료결과및생존율에관한예후인자분석 2005 2 1 2005 3 28. :, Tel: 053)250-7665, Fax: 053)250-7984 E-mail: jhkim@dsmc.or.kr 정영연외 2 인 : 비인강암의예후인자분석 정영연외 2 인 : 비인강암의예후인자분석 Carcinoma of the nasopharynx treated by radiotherapy