1. 서론 상태에서뼈骨의상연을따라 22 G. 或은 23 G. Chiba needle 및 needle bevel 직상부에한개의구멍을뚫어 조직채취량이많도록고안된 22G. Wescott needle 을 限局性 ßr5 病했, 즉 ffr5 맨揚내지 ßr5 結節의該斷에있사용하여,

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1 大韓放射線홈學會誌 Yol. XX, No. 4, 1984 限局性師病變의經皮的吸引生檢 f 끼 ) GitL τ :,- 기 f L / / 서울大學校醫科大學放射線科學敎室任廷基林德朴在亨 서울大學校醫科大學病理學敎室 -Abstract- 威훌융根 %k Percutaneous Needle Aspiration Biopsy of Localized Pulmonary Lesions Chung Kie 1m, M.D., Duk Li m, M.D., Jae Hyung Park, M.D. Department of Radiology, CoIlege of Medicine, Seoul National University Eui Keun Ham, M.D. Department of Pathology, Col/ege of Medicine, Seoul National University Over a period of recent two years, 100 patients who had localized pulmonary lesions and underwent percutaneous needle aspiration and biopsy, were analized. There were 56 malignancies and 44 benign lesions. The diagnostic accuracy of malignancy including specific cell type and benign disease are 89% and 79% respectively. Differentiation of malignancy vs. benignity was possible in 89% of cases obviating unnecessary exploratory thoracotomy for diagnostic purpose. Five cases were misinterpreted and eight cases were non-diagnostic on cytology. Inadequate material was obtained in two casesi one was due to hardness of the mass, which, later, confirmed as chondrosarcoma, and the other was too small (0.8x1.0 cm) to be visible on lateral view. The obtainability of the tissue was 98%. 14 (14%) patients developed pneumothoraxi one of them required treatment and the remainder showed spontaneous resporption. (Transient neglibigle blood tinged sputum was fou nd in 16 (16%) cases.) The method, problems and complications are discussed. Authors recommend the percutaneous needle aspiration and biopsy as the initial procedure in diagnostic work-up of pulmonary coin lesions, especially when they are smaller, more peripheral and metastatic neoplasm is suspected. 이論文은 1984 年 8 月 3 1 日접수하여 1984 年 11 月 22 日에채택되었음

1. 서론 상태에서뼈骨의상연을따라 22 G. 或은 23 G. Chiba needle 및 needle bevel 직상부에한개의구멍을뚫어 조직채취량이많도록고안된 22G. Wescott needle 을 限局性 ßr5 病했, 즉 ffr5 맨揚내지 ßr5 結節의該斷에있사용하여, 수직 로병소를穿刺하였다 {Fig. l).

2 1. 서론 상태에서뼈骨의상연을따라 22 G. 或은 23 G. Chiba needle 및 needle bevel 직상부에한개의구멍을뚫어 조직채취량이많도록고안된 22G. Wescott needle 을 限局性 ßr5 病했, 즉 ffr5 맨揚내지 ßr5 結節의該斷에있사용하여, 수직 로병소를穿刺하였다 {Fig. l). 병소가 어서經皮的뼈吸引生檢의有用性은이미알려져있 ~ Rl 힘部의後뿔에더가까이위치하더라도됩뼈骨 (scap 비 a) 며, 실제閒뼈術을제외하고는가장높은該斷率을보과겹치연뼈뿔前面을택하였다. 병소에檢針이다다르 이고있다. 저자들은최근 2 年간서울大學校病院放연 stylet 을뽑고주사기를연결한후피스톤을장아 射線科에서시행한經皮的뻐吸引生檢 100 예의성적과당겨음압을가하면서짧고세차게몇차례병변을관 입상적의의를보고하는바이다. ll. 대 A c:> 년 10 원부터 1984 년 7 월까지 2 2 개월간시행 한 11 3 예의經皮的뼈吸引生檢종임상적추적이가능 한 100 예를대상으후했 S 며, 이들은대부분陽짧細뼈 檢효나氣管技鏡檢훌등으로該斷이되지않아放射線科로위닥된환자들이다. 환자는 3 명이었다. Ill. 方 대부분은입원환자였고외래 法 통한후檢針과주사기를함께뽑았다. 병소는평균 2 회穿刺하였으며, 睡塊가큰경우는睡塊의변두리에서 조직을채취하여塊死組緣만추출되는것을방지하였다. 조직을얻으연미리준비된슬라이드에쫓妹하여 95 % 알코홀에고정하고또한結核園, 일반細園빛힐園의뚫 妹염색과培養檢흉블의뢰하였으며, 가능하면細脫群集切斷法 Cc 아 I block cxamination) 도시행하였다. 시술 직후에는투시기로氣뼈의여부를관찰하였 S 며, 시술 3 시간후에는반드시單純뼈部題影을하여氣뼈의발 생여부를관찰하였다 3 예의외래환자로시술후 3 시간동안관찰및單 * 뺀며部廣影에서이상소견이없음 을確認하고귀가시켰다. 병소의위치에따라띠없位 (supine), 或은趙位 (p rone) 로환자의자세를취한후 $ 벅 f 투시기 Cbiplane f1uoros. N. 결과 cope) 로병소의위치를確認하고, 표적부를소독하며, 性別분포는남자가 76 명, 여자가 2 4 명으로남자가 2 % Procaine 으로局所麻解後가능한한호흡정지 3 배가량많았고, 연령군은 20 代에서 70 代까지이며 % A -=: -' τ 二二二二二二二二二二 -8 Fig. l. A.B. Fine needle is introduced to the mass at left upper lobe through anterior chest wall

代가제일많았다. 병변의크기는장경과단경의평균치로 2 αn 이하가 27 예였 며, 제일작았던것은 0.8cm 였고, 큰것은 20 cm 이넘는것도있었다. K훨塊의평균크기는 3.4 cm 이었고睡塊의크기와經皮的뼈吸引生檢의진단율과는유의한상관관계는없었다. 睡塊의위치는뼈中心部기. 6 예였고나머지는師邊 Y감部였다.

3 代가제일많았다. 병변의크기는장경과단경의평균치로 2 αn 이하가 27 예였 며, 제일작았던것은 0.8cm 였고, 큰것은 20 cm 이넘는것도있었다. K훨塊의평균크기는 3.4 cm 이었고睡塊의크기와經皮的뼈吸引生檢의진단율과는유의한상관관계는없었다. 睡塊의위치는뼈中心部기. 6 예였고나머지는師邊 Y감部였다. 經皮的뼈吸引生檢術을도엽한후, 첫 1 2 개월간 結核이 24 예로良性훌愚중제일많았고 C Fig. 6), 그외에아스페르길루스肉穿睡이 4 예 C Fig. 7), 크럽토코쿠스肉穿睡이 1 예, 題錫이 3 예, 睡題細뼈나結核園이보이지않아진단이不可能했던예가 8 예, 적절한 조직채취를못했던것이 2 예있었다 CTable I ). Table I. Result of needle aspiration biopsy 은 41 예플시행했으며, 이중 37 예에서는우선적으로氣管技鏡檢훌를했으냐모두진단을옷했던예들이고, 후반 10 7~ 월간은 72 예를시행했 며이중 37 예에서氣管技鏡檢흉를하여 51 예에서진단을내릴수있었다. 細 6힘病理檢홀의결과는惡性睡揚이 55 예였으며이중扁平上皮細뼈 } 훨 C squamous cell ca. ) 이 24 예로제일많았고 CFig.2) 臨찮 Cadeno ca.) 이 15 예였으며 CFig.3), 大型未分化細뼈癡 Cundifferentiated ca. large cell type) 이 7 예, 小型細뼈홉 Csmall cel l ca.) 이 5 예 CFig.4) 未分化및非小型細 R빙 } 폼 Cpoor ly di fferentiated ca. non - small cell type) 이 3 예, 惡性睡癡 S로만보고된것이 1 예있었다. 良性睡場으로는過誤睡 Chamartoma) 이 3 예있었 A며 αig. 5) 이중 1 예는手術을하여확진되었고 2 예는 1 년이상추적하였으나그크기의변화나증세가없었다. Cytologic diagnosis of aspirates Squamous cell ca. Adeno ca. Small cell ca. Large cell ca. undifferentiated Probable non-small cell ca. poorly differen tiated Malignancy of undetermined type Tuberculosis Aspergilloma Hamartoma Cryptococcosis Abscess Negative* Inadequate specimen No. 껴4 / 1i,3 q) 7 3 μl * No tumor cell, no A.F.B., necrotic tissue only Fig.2. Lobulated mass is noted at right lower lobe without boliterating right cardiac border Right para-tracheal node enalargement is also noted. Percutaneous needle aspiration biopsy was performed and diagnosed as squamous cell carcinoma. Fig. 3. Chest P.A shows round mass with fuzzy border at right upper lobe, medial portion. The mass was punctured and diagnosed as adenocar. cinoma

FiS- 4. n 씌 r: Left hilum is enlarged with adjacent lobulated mass. This was diagnosed as small cell carcinoma by percutaneous needle aspiration biopsy.

4 FiS- 4. n 씌 r: Left hilum is enlarged with adjacent lobulated mass. This was diagnosed as small cell carcinoma by percutaneous needle aspiration biopsy. 手術을하여該斷이바뀐예가 5 예였는데 2 예의 大型未分化細泡훨이각각臨癡및轉移 f 生精上皮睡 ÚTIetastatic seminoma) _ 으로판명되었고, 未分化및非小型細뼈행 2 예는각각過誤睡및 ~ 모! 치穿睡 tlî C IymriJomatoid granulomatosis) 으로꽉진되었 며, 平上皮細뼈 I 예는眼찮으흐판명되었다. 조직채취는 하였무나細뼈病理檢흉上확살한談斷을할수없었던 예가있었는데이들은轉移性扁 2JS 上皮細脫提扁 1 예, 아 Table 1I. 13 cases of mismatched histology or negative resu1ts. Cytologic Dx. No. Final Dx.. Undifferentiated ca. 2 1: adeno ca. large cell' 1: metastatic. Poor1y differen tiated ca. 2 1: hamartoma. Squamous cell ca.. Negative* 1: lymphomatoid granulomatosis 1: adeno ca. 8 1: metastatic squamous cell ca. e 냉mιx 찌*No tumor cel1, no A.F.B., necrotic tissue only li li - J 째빼뼈e κ m 비m $ 않m Fig.5. Chest P-A taken for routine physic외 exammation shows well circumscribed round mass with mott1ed calcifications at right mid-lung field. Chondrocyte and cartilage were demonstrated on the aspirated materia1 and diagnosed as chondromatous hamartoma. So, no operation was performed on this patient. 스페르길루스肉穿睡 1 예, 類肉睡 Csarcoidosis) 1 예그 리고 5 예의結核 o 로확진되었다 CTable 표 ) 細뼈病理上談斷을할수없을정도로조직채취가부적당했던 것이 2 예였는데, 1 예는睡塊의섬한石짜質침착으로 檢針이통과를못한예였고, 手術하여軟骨肉睡 CChondrosarcoma) 으로확진 되었고 CFig.8) 다은 1 예는 직경이 O. 8cmX 1. 0cm 의결절로서투시기에서보이 지 않을정도로작았는데, 추적검사상결정의크기의 변화가없어結核性結節로생각되는예이다 CTable ßD 따라서經皮的師吸引生檢으로病變조직의채취율은 98 % 이며惡性핏愚을惡性훌愚으로의진단율은 95 %, 細뼈型까지고려한확진율은 79 % 이고, 전체적으로惡性과良性흉愚의감별율은 89 % 에이른다 CTable 1V). Table III. Two cases of inadequate material No. Mass character Final Dx. 1 Densely calcified mass at left anterior chest wal x 1.0 cm sized nodule at right upper lung and invisible on lateral vjew Chondrosarcoma Tuberculous granuloma

.""IF"" A B Cl C2 Fig.6. A. Well circuscribed increased density of nodular shadow is noted at right upper lobe with some emphysematous Langhan s giant cell were aspirated. B. Round mass shadow is noted at left upper and pleural invasion is suggested on tomography Fibrostreaky density is also noted at right upper lober.

5 .""IF"" A B Cl C2 Fig.6. A. Well circuscribed increased density of nodular shadow is noted at right upper lobe with some emphysematous Langhan s giant cell were aspirated. B. Round mass shadow is noted at left upper and pleural invasion is suggested on tomography Fibrostreaky density is also noted at right upper lober. Percutaneous needle aspiration biopsy showed many A.F.B. instead of malignant cell. Cl,2. Hemorrhagic fluid was aspirated from this loculated effusion at right major fissure containing many A.F.B. and histiocyte. Tissue 0 btainability Benignity vs. malignancy Table IV. Diagnostic accuracy 98% 89% Pneumothorax Table V. CompJications (n=100). malignancy as malignancy 95 %. Spontaneous resorption 13. type specific accuracy of malignancy 89%. Requiring treatment. type specific accuracy of benign disease ; 79%. Minimal hemoptysis

시술로인한合佛효으후는 1 4 예의氣關이발생했는데 CFig.9), 1 3 예에서는자연소실됐으며, 1 예에서는氣뼈및臨뼈 C empyema) 이생겨뼈管 CChest - tube) 으로치료하였다. 그외에시술후가래에피가묻어나오거나, 穿刺부위의가벼운통증등이있었무냐일시적인것이어서우시할정도의것이었다 CTable V). v. 고찰 Fig. 7.

6 시술로인한合佛효으후는 1 4 예의氣關이발생했는데 CFig.9), 1 3 예에서는자연소실됐으며, 1 예에서는氣뼈및臨뼈 C empyema) 이생겨뼈管 CChest - tube) 으로치료하였다. 그외에시술후가래에피가묻어나오거나, 穿刺부위의가벼운통증등이있었무냐일시적인것이어서우시할정도의것이었다 CTable V). v. 고찰 Fig. 7. Numerous hyphae with branching pattern was aspirated from left upper lobe mass and diagno. sed as aspergilloma. This was confirmed by surgery. 經皮的 nrlí 吸引生檢은 년영국의 Holder 등에의 해처음기술된이래 2> 새로운檢針의개발과 2,, 7) 透視機 해상력의말전으로현재는뼈睡塊의 該斷에있 어서보편화된요긴한檢훌가되고있다. 섬세한針을 사용한經皮的細吸引生檢法은뼈睡塊에관한한기존 의氣管技짧生檢法, 氣管技브러쉬生檢法, 經氣管技生檢法및切斷針 Ccuttir몽 needle ) 을사용한師生檢法보다 그확진율이높으며, 안전하고쉽게반복시행할수있다 는장점이있다 1 J 5 ) 실제로시울에 要하는시간은 10 分정도로서, 환자나시술자에게부담이적은검사임 을알수있다. 經皮的師吸引生檢의일반적인적응증 으로는소위 말하는銷殘型病變 Ccoin Iesion) 이라하 겠으며 1,5) 轉移性뼈癡인경우 (Fig.l0 ), 細뼈型을알 아등? 斷기간을단축시킬수있겠다. 氣管技內病變이나無氣 ßr!i, 或은홉潤性뼈횟愚인경우는圖塊의위치가확 Fig. 8. Densely calcified mass is noted at anterior mediastinum. Percutaneous needle aspiration was tried only to fail due to hardness of the mass. This was confirmed as chondrosarcoma on surgery Fig. 9. Right upper lobe nodule was aspirated and diagnosed as Tbc granuloma. Chest P-A taken 3 hours after aspiration shows pneumothorax. This was resorbed spontaneously without treatment.

7 설치않아적절한대상이되지않으며, 저자들의경우발한바있어 CFig.ll), 이런경우에는시솔을피하는에도감염에의한홈潤性師훌愚에서園채취를위하여것이좋으리라생각된다. 그외에유아나뼈氣睡 Cemph. 經皮的뼈吸引生檢을실시했었으나該斷을못했던경 ysema) 이섬한환자, 매우작은轉移結節이뼈에퍼져우가 3 예있었으며이中 1 예에서는뼈의찢효性病있는경우, 出血性碩向이심한환자는부적당한대상뚫를助願으후파급시키는결과를招來하여 8 郞힘을유이되나可能한合佛효과吸引生檢에의한該斷의必要性을比較하여후자의비중이클경우시술의대상이됨은물론이다. 진단율은 % 3 ) 에서 86.4 % 5 ) 까지보고자마다다양하며 Lanφnan 6) 이나 Walls 등 )0 ) 은뼈睡塊의진단에있어서氣管技鏡檢훌, 氣管技브리쉬生檢등보다는經皮的뼈吸引生檢의우월성을주장하고있다. 특히病變이작을수록, 邊땀部에있을수록, Pancoast t뻐α 냐轉移性뼈 } 끊등외경우에는經皮的 ffrli 吸引生檢이우선적 인진단법이된다 7.9, 10> 시슐에의한合혐훈으로는氣뼈이제일흔한것으로, 보고자마다 20 % 내외를보고하고있고, 이증치료를要하는경우는 10 % 미만이라했 며 1쩔血은약 8% 정도를보고하고있다 3, 5, 11 ) 저자들의경우 年 10 月처음經皮的뼈吸引生 Fig. 10. Multiple variable sized mass are noted at both upper lobes in alleged laryngeal cancer patient. Lung aspiration material showed squamous cell carcinoma suggesting lung metastasis of laryngeal cancer. 檢術을도입한이래최근까지施術횟수가증가하는추세에있a며, 초기의 41 예에서는무조건氣管技鏡檢훌흘우선적 즈로시행했 나 ) ) 후반기에서는환자를선별하여氣管校鏡檢효를시행하는추세로바뀌고있으며, A B Fig. 11. A. Superior mediastinum is widened and triangular shaped pneumonic infiltration is noted at right mid.lung field. Percutaneous needle aspiration biopsy was tried for the organism of right lung infiltration. B. Lots of pleural effusion developed at right side after lung aspiration. Chest tube was inserted and pus was drained

8 經皮的 nrü f!& 引生檢에의한 % 뼈病理的장斷을팍진의수단으로상는인식의변화가두드머지게나타나고있다. 지자들의경우외i!!l 현者에대한施術은 3 예 C 3 % ) 로서, 49.4 % 가外來, 월者었던 Lalli 5, 등의경우와큰차이릎보였는데, 이는앞으로經皮的 Hrlí I 及引生檢의談斷的가치및안전성에대한임상의사들의인식의폭이넓어질수록외래환자의비율이높아지리 라보며, 또는엽원하더라도그기간을단축시키는결 과가되어비용 - 효과 Ccost - effectiveness) 변에서도 바람직한진료가되리라믿는다., VI. 결 저자들은 年 1 0 月부터, 1984 年 7 月까지 22 개 월간서울大學校病院 응t~ 예放져t 綠科에서 施行한 11 3 예 의經皮的 8 市吸引生檢中 임상적 S로추적이가능한 1 00 예플대상으로하여放射綠學的, 病理學的 및 임상 적결과를분석하여다음과같은결론을얻었다. 1. 經皮的 Hrlí 吸引生檢에의한양斷은惡샘 :OC휠 55 예, 良 { 生 흉愚 35 여 i, 5? 斷이 불확실했던것이 8 예, 그려고조직채취가불충분했던것이 2 예있었다. 2. 수울을시행하여 細뼈型, 或은 談斷이 비뀐것 이 5 예였고, 塊死組織만추출됐던것이 8 예, 조직이 추출되지 않았던것이 2 예있었다. 3. 經皮的師吸引生檢의組熾및 組織 /IX; 分채취율은 98 % 이며惡性과良 { 生族愚의감별율은 89 %, 惡性 f쫓 愚의등? 斷率은 95 % 였고, 細뼈型까지고러한惡性훗 4뿔 과良性훌愚 의등짧新率은각각 89 % 및 79 % 였다. 4 시솔로 인한合하효으로는 14 예의氣뼈아있었 으며 l 중 1 3 예는자연소실되었고, 1 예는뼈管 S로 치료하였다. 5. 시술의횟수는초만기의月 zp: 均 3. 4 회에서후반 기에는 7.2 배로 2 배 이상의증가가있었 며뽑者를 선별하여氣管技鏡檢흉를시행하는추세로바뀌었다. 진단율도 초기 41 예의 83 % 에서후반기에는 90 % 로 向上되었고, 經皮的 Hr5 吸引生檢을확진의수단으로삼 는인식의변화가있었다. 따라서저자플은 M에 睡塊가있는愚者에서 우선적 으로 간편하고안전한經皮的 뻐 吸引生檢을실시하 여 진단기간의단축과높은진단율을기대하는바적 극권장하는바이다. REFERENCES 1. 박재형, 엮 덕, 임정기 : 局所的뼈찢愚의經皮的師生檢, 대한방사선의학회지제 20 권 45-50, 1984 론 2. Zornoza J. 5now J, J r., Lukem an J M Aspiration biopsy of discrete pulmonary lesions using a new thin needle. Radiology 723: , Westcott J L Direct percutaneous needle aspiration of localized pulmonary lesions; Results in 422 patients. Radiology 737:35, House A J5, Thomso n KR Evaluation of a new transthoracic needle for biopsy of benign and malignant lung lesions. AJ R 729: α Lalli AF, McCormack Lj, Zelch M et al : Aspiration biopsies of chest lesions. Radiology 127:35-4'0, Landman 5, Burgenera FA, Lim G Comparison of bronchial brushing and percutaneous needle aspiration biopsy in the diagnosis of malignant lung lesions. Radiology 175: , J ereb M The usefulness of needle biopsy in chest lesions of different sizes and locations. Radiology 734: , Fennessy J J, Fry WA, Manalo-Estrella P : Th e bornchial brushing technique for obtaining cytologic specimens from peripheral lung lesions. Acta Cytol 74:25-3α inner WN Thornbury J R, Naylor B : Pulmonary needle aspirations biopsy in the diagnosis of pancoast tumors, Radiology 777 : , Wall s W J, Thornbury J R, Nay lor B Pulmonary needle aspirations biopsy in the diagnosis of pancoast tumors, Radiology 777 :99-102, Heimlich J H Valve drainage of pleural cavity. Dis Chest 53: , argent EN, Turner AF Emergency treatment of pneumotheroax. A simple catheter technique for use in the radiology department. Am J Roentgenol 709: , argent EN, Turner AF, Gordouson J : Percutaneous pulmonary needle biopsy. Report of 350 patients Am J Roentgenol 722: , Li ndstrom RR, Collins JD, Byfield JE Obtaining viable tumor ce//s through percutaneous pulmonary needle biopsy. Radiology 94: , Björn Nordenstrõm New instruments fo r biopsy. Radiology 777:474-47ε Herm an PG, Hesse l 5J The diagnostic accuracy and complication of closed lung biopsies. Radiology 725: 77-74,

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김범수 Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma Purpose: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis