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1 대한내분비외과학회지 : 제12권제2호 Vol. 12, No. 2, June 2012 종설 갑상선암에있어서경부림프절절제술의용어및분류에관하여 가천대학교의과대학길병원외과학교실 이영돈 Terminology and Classification System of Lateral Neck Node Dissection in Differentiated Thyroid Carcinoma Young-Don Lee, M.D., Ph.D. The standard radical neck dissection, introduced at the turn of the 20th century, became the uniformly-accepted treatment of cervical metastatic disease through the 1960s. Functional or modified radical neck dissection was developed in the 1950s and 1960s. This procedure became the accepted treatment for suitable tumors by the 1970s. Now, the concept of selective neck dissection, removal of only the node levels likely to be involved with tumor, gained acceptance by the late 1980s as a definitive elective, and eventually, therapeutic neck dissection for suitable cases. In response to the increasing variations of neck dissection procedures, a number of classification systems were proposed and subsequently established. The system of the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery was revised in 2002 and The neck dissections are grouped into four broad categories: radical, modified radical, selective, and extended neck dissection. The Japan Neck Dissection Study Group presented a new system for the classification of neck dissections based on a system of letters and symbols. The system permits a comprehensive and shorthand method of precise designation of neck dissection procedure, but has the disadvantage of departing radically from previously employed systems, by utilizing an entirely new terminology and designation of lymph node groups. In 2011, an international group proposed a classification which conveys precisely the extent of the lymphatic and non-lymphatic structures removed in a neck dissection. So they contended it is logical, simple, and easy to remember, and prevents possible confusion associated with 책임저자 : 이영돈, 인천시남동구구월동 1198 번지 , 가천대학교의과대학길병원외과학교실 Tel: , Fax: peacemk@gilhospital.com 접수일 :2012 년 6 월 16 일, 수정일 :2012 년 6 월 16 일, 게재승인일 :2012 년 6 월 16 일 the ambiguous terminology previously mentioned. And they also maintained it allows the recording of neck dissection procedures that cannot be classified under the existing systems. In 2012, the American Thyroid Association proposed the consensus of lateral neck dissection in DTC. They defined again that a selective neck dissection refers to removal of less than all five nodal levels directed by the patterns of lymphatic drainage from the primary tumor while preserving CN XI, IJV, and SCM. And they also insist that selective neck dissection is the most commonly-used neck dissection in the management of lateral neck metastasis for thyroid cancer, and should be reported with a designation of the side and nodal levels and sublevels dissected (i.e. selective neck dissection of levels IIa, III, IV, and Vb). But most classification systems have some limitations and disadvantages to describe the exact procedures of lymphatic and non-lymphatic structure resection. It is a necessary component of a new systemic classification and nomenclature system for neck dissection, not only because the method of describing operative procedures must be unified to allow comparisons of therapeutic methods, but also because of the need to customize therapies individually. A new neck dissection classification system in thyroid cancer has to overcome all these limitations and will facilitate communication around the world with reliable reporting and comparison of outcomes among different surgeons and institutions. (Korean J Endocrine Surg 2012;12:79-86) Key Words: Thyroid cancer, Terminology of neck dissection, Classification of neck dissection 중심단어 : 갑상선암, 경부림프절절제술의용어, 경부림프절절제술의분류 Department of Thyroid and Endocrine Surgery, Gachon University Gil Medical Center, Incheon, Korea 서 경부림프절절제술이처음소개된이래여러술기가발 전하면할수록오히려용어상에혼란과불명확성이갈수록증대되어의사간, 기관간에또한국제적으로통용되는통일된용어와분류의필요성이대두되고있는실정이다. 이 론 79

2 80 대한내분비외과학회지 : 제 12 권제 2 호 2012 에경부림프절절제술의분류와용어가어떻게발전해왔으며각나라에서또는국제적으로이들의통일을위해서어떠한노력을기울이고있는지알아보고, 우리나라에서도특히갑상선암의경우, 경부림프절절제술의분류와용어의통일을어떤방향으로해야하는지에대해단초를제공하고자한다. 경부림프절절제술의발전사 1) 근치 (radical) 경부림프절절제술시대외과의들은 19세기이래두경부암의경부림프절전이를치료하기위해예방적혹은치료적으로경부림프절절제술을시행해왔다. 외과적경부림프절절제술은 1800년대말 Kocher, Billroth, von Langenbeck와 von Volkmann 등에의해처음시도되었다.(1) 1888년 Jawdynski는종양에침범된경동맥을포함한동측의모든림프조직들을광범위하게제거하는수술을성공적으로시행하였다. 1905년과 1906년에 Crile (2,3) 은경부의모든심부림프조직을 근치적으로덩어리째절제 하는술기를보고하였는데, 근치경부절제술 이라불리어졌다. 20세기초반에여러외과의들에의해산발적으로사용되고개선되었으나, 보편적으로수용되고사용된것은, 1951년에 Martin 등 (4) 이논문을발표하고난후부터이다. Crile의수술술기와거의유사한 Martin의수술은그후근치경부림프절절제술의표준이되었으며, 오랫동안두경부암의림프절전이를치료하는유일한표준술식으로여겨졌다. 이수술은오직경동맥, 설하신경, 혀신경, 미주신경과가로막신경만을보존하고하악골로부터쇄골까지, 넓은목근과척추앞근막사이의모든림프조직과비-림프조직을제거하는술기이다. 2) 기능적 (functional)/ 변형 (modified) 근치경부림프절절제술시대아르헨티나의 Suárez (5) 는 1952년부터자신이시행하였던변형근치경부림프절절제술즉흉쇄유돌근, 견갑설골근 (omohyoid muscle), 턱밑샘, 내경정맥과가능하면척수부신경을보전하는수술의결과를 1963년에발표하였다 년대 M.D. Anderson 병원의 Jesse 등 (6) 도원발병소의위치에따라서전이의위험이가장큰림프절군만선택적으로제거하는수술을시도하였다. 이경부림프절절제술도변형경부림프절절제술이라명명되었으며, 이는척수부신경, 흉쇄유돌근, 견갑설골근, 내경정맥과총안면정맥을보전하면서목의모든건막사이의림프조직들을제거하는술기로서점차미국에서보편적으로사용되게되었다. 이술기는 Suárez의기능적경부림프절절제술과동일한것으로서, 미국의외과의들은근치적수술이아닌모든경부림프절절제술을변형적경부림프절절제술이라부르게되었다. 3) 선택 (selective) 경부림프절절제술시대 Shah (7) 는 Memorial Sloan-Kettering Cancer Center에서시행한 1,100예가넘는두경부점막암의수술표본을종합적으로연구한후, 이들의림프절전이양상을 1990년에발표하였다. 이연구에서원발병소에따른특이적림프절전이양상, 즉원발병소와관련된림프절군들중일관성있게처음전이되는림프절군을확인하였다. 이런통찰이두경부점막의편평세포암환자에게서, 임상적으로는전이를보이지는않지만미세전이여부를알아내어, 정확한병기를결정하기위한선택경부림프절절제술을시행하게한시초가되었으며, 결국경부림프절절제에있어광범위절제와선택적절제를분류하게된시발점이되었다. 경부림프절절제술의용어들여러경부림프절절제술이문헌에보고되면서, 다양하고혼란스럽기까지한용어들이대두되었다. 이런용어들은절제범위에따라또한절제의의도와목적에따라서이름이붙여졌다. 즉제 I림프구역부터 V구역까지의림프절들을모두절제하는술기를보더라도수많은용어들이사용되고있다. 열거하면근치, 변형근치, 변형근치 I III형, 변형광범위 (modified comprehensive) I III형, 확대근치 (extended radical), 근치일괄 (radical en bloc), 확대근치일괄 (extended radical en bloc), 인습적근치 (conventional radical), 고전적근치 (classical radical), 보존적 (conservative), 완전기능적 (complete functional), 신경보전적근치 (nerve-sparing radical), 신경 / 근육보전적근치, 신경 / 근육 / 정맥보전적근치, 전 (total) 경부림프절절제술등이다. 다섯림프절구역전체절제보다제한된수술술기에대해서도많은용어들이범람하고있다. 이들은선택적 (selective), 확대선택적 (extended selective), 과도선택적 (superselective), 상부견갑설골 (supraomohyoid), 확장상부견갑설골 (extended supraomohyoid), 상부설골 (suprahyoid), 경정맥림프절, 측경부, 전방 (anterior), 후-측방, 전-측방, 상-측방, 하-측방, 국소적 (regional), 작은 (minor), 제한적 (limited) 경부절제술등매우많은용어들이사용되고있다. 그러나 기능적 이거나 보존적, 또는 제한적 경부림프절절제술등의용어는부정확하고막연한용어이므로원칙적으로사용되어서는안되는용어들이다. 이러하듯여러술기의변형들이점차증가할수록, 용어의불일치와부정확성이점점커져, 결국용어의통일성이필요하게되었다. 이런취지로몇몇분류체계가최근등장하게되었다. 최근의분류체계들거의모든경부림프절절제술의분류체계는 1930년대뉴

3 이영돈 : 갑상선암에있어서경부림프절절제술의용어및분류에관하여 81 욕의 Memorial병원에서개발된전통적인림프절군분류에기초하고있다.(8) 1987년 Suen과 Goepfert (9) 는처음으로모든사람들이인정할수있는경부림프절절제술분류체계를제시하였다. 세가지분류로나누었는데, (1) 표준적근치절제술, (2) 광범위변형근치 (comprehensive modified radical) 절제술, (3) 선택절제술등으로서, 선택경부림프절절제는원발병소로부터예상되는림프전이경로중, 전이위험 성이큰한개이상의림프절군만절제하는것을의미하였다. 2년후 Medina (10) 는이분류를보다더세분하였다. Medina는근치경부림프절절제술을 A형과 B형으로나누어, 모든림프절군 (I V) 을절제하면 A형, II V 림프절군을절제하면 B군이라하였다. 또한변형근치수술은보전된비-림프절조직에따라 I, II, III형으로나누었는데, I형은척수부신경을보전하였을때, II형은척수부신경과흉쇄유돌 Terminology Table 1. Currently employed definitions of neck dissections (by AHNS and AAO-HNS) Definition Radical Removal of lymph node levels I V, SCM*, SAN, and IJV. Modified Removal of lymph node levels I V (as in radical neck dissection), but preservation of at least one of the non-lymphatic structures (SCM, SAN, and IJV). Each non-lymphatic structure that is removed should be named. Selective Preservation of one or more lymph node levels relative to a radical neck dissection. Extended Removal of an additional lymph node level or group or a non-lymphatic structure relative to a radical neck dissection (muscle, blood vessel, nerve). An example of other lymph node groups can be-superior mediastinal, parapharyngeal, retropharyngeal, peri-parotid, postauricular, suboccipital, or buccinator. An example of other non-lymphatic structure can be external carotid artery, hypoglossal or vagus nerves. *SCM = sternocleidomastoid muscle; SAN = spinal accessory nerve; IJV = internal jugular vein. Table 2. Lymph node groups found within the 6 levels and the 6 sublevels Lymph node group Submental (Ia) Submandibular (Ib) Upper jugular (IIa &IIb) Mid jugular (III) Lower jugular (IV) Posterior triangle (Va & Vb) Description Lymph nodes within the triangular boundary of the anterior belly of the digastric muscles and the hyoid bone. Lymph nodes within the boundaries of the anterior belly of the digastric muscle, the stylohyoid muscle, and the body of the mandible. It includes the preglandular and the postglandular nodes and the prevascular and postvascular nodes. The submandibular gland is included in the specimen when the lymph nodes within the triangle are removed. Lymph nodes located around the upper third of the IJV and adjacent SAN extending from the level of the skull base (above) to the level of the inferior border of the hyoid bone (below). The anterior (medial) boundary is the stylohyoid muscle (the radiologic correlate is the vertical plane defined by the posterior surface of the submandibular gland) and the posterior (lateral) boundary is the posterior border of the SCM. Sublevel IIa nodes are located anterior (medial) to the vertical plane defined by the SAN. Sublevel IIb nodes are located posterior (lateral) to the vertical plane defined by the SAN. Lymph nodes located around the middle third of the IJV extending from the inferior border of the hyoid bone (above) to the inferior border of the cricoid cartilage (below). The anterior (medial) boundary is the lateral border of the sternohyoid muscle, and the posterior (lateral) boundary is the posterior border of the SCM. Lymph nodes located around the lower third of the IJV extending from the inferior border of the cricoid cartilage (above) to the clavicle below. The anterior (medial) boundary is the lateral border of the sternohyoid muscle and the posterior (lateral) boundary is the posterior border of the SCM. This group is composed predominantly of the lymph nodes located along the lower half of the SAN and the transverse cervical artery. The supraclavicular nodes are also included in posterior triangle group. The superior boundary is the apex formed by convergence of the SCM and trapezius muscles, the inferior boundary is the clavicle, the anterior (medial) boundary is the posterior border of the SCM, and the posterior (lateral) boundary is the anterior border of the trapezius muscle. Sublevel Va is separated from sublevel Vb by a horizontal plane marking the inferior border of the anterior cricoid arch. Thus, sublevel Va includes the spinal accessory nodes, whereas sublevel Vb includes the nodes following the transverse cervical vessels and the supraclavicular nodes with the exception of the Virchow node, which is located in level IV.

82 대한내분비외과학회지 : 제 12 권제 2 호 2012 근을보전할때, III형은척수부신경과흉쇄유돌근및내경정맥을보전할때라정의하였다. Spiro 등 (11) 은 AHNS와 AAO-HNS의초기분류에서미해결된문제점을보완하는제안을하였는데, 절제된림프절군의수에따라분류하자는것이었다.

4 82 대한내분비외과학회지 : 제 12 권제 2 호 2012 근을보전할때, III형은척수부신경과흉쇄유돌근및내경정맥을보전할때라정의하였다. Spiro 등 (11) 은 AHNS와 AAO-HNS의초기분류에서미해결된문제점을보완하는제안을하였는데, 절제된림프절군의수에따라분류하자는것이었다. 즉 4 5개의림프절군절제이면 근치, 3개의림프절군절제는 선택적, 2개이하면 제한적 경부림프절절제술이라고명명하였고, 또한 근치절제술 을절제된조직과남긴조직에따라더세분하여 인습적, 변형적, 확대 혹은 변형및확대 등으로구분하였다. 최근가장많이사용하는분류체계는 1991년 (12) 에 AHNS (American Head and Neck Society) 와 AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) 에의해처음발표된것으로서 2002년 (13) 에개정된것이다. 2008년 (14) AHNS의경부림프절절제위원회는개정된분류체계안을발표하였는데, 이개정안은경부림프절절제술의명확한분류및선택절제술용어에대해확실한정의를포함하였다 (Table 1). 또한이개정안은 AJCC (American Joint Committee on Cancer) 병기분류체계를적용하였고, 외과의와영상의학전문의들과암전문의들과함께다학제적협력을통해마련되었다. 이분류체계는간단명료하여쉽게이해될수있는것으로서, 림프절군을 7개로나누었으며, 임상적으로그리고영상의학적으로명확하게림프절군간을 구획짓는해부학적구조물에대해명시하고있다 (Table 2, 3, Fig. 1). Fig. 1. Nodal levels with corresponding anatomic landmarks.(14) Table 3. Anatomical structures defining the boundaries of the neck levels and sublevels Boundary Lymph node group Superior Inferior Anterior (medial) Posterior (lateral) IA Symphysis of mandible Body of hyoid Anterior belly of contralateral digastric muscle IB Body of mandible Posterior belly of muscle Anterior belly of digastric muscle IIA Skull base Stylohyoid muscle by the inferior body of the hyoid bone IIB Skull base Vertical plane defined by the inferior body of by the SAN the hyoid bone III IV VA VB by inferior body of hyoid by the inferior border of the cricoid cartilage Apex of the convergence of the SCM and trapezius muscles by the lower border of the cricoid cartilage by the inferior border of the cricoid cartilage Clavicle by the lower border of the cricoid cartilage Clavicle Lateral border of the sternohyoid muscle Lateral border of the sternohyoid muscle Posterior border of the SCM or sensory branches of cervical plexus Posterior border of the SCM or sensory branches of cervical plexus Anterior belly of ipsilateral digastric muscle Stylohyoid muscle Vertical plane defined by the SAN Lateral border of the SCM Lateral border of the SCM or sensory branches of cervical plexus Lateral border of the SCM or sensory branches of cervical plexus Anterior border of the trapezius muscle Anterior border of the trapezius muscle

5 이영돈 : 갑상선암에있어서경부림프절절제술의용어및분류에관하여 83 일본의경부림프절절제술연구그룹의분류 (15) 일본의경부림프절절제술연구그룹 (Japan Neck Dissection Study Group, JNDSG) 의주목적은림프절과비-림프절조직의절제범위, 여러절제술의적응증과수술후기능을평가하는방법등을연구하여, 다양한비-근치경부림프절절제술의표기를표준화하는것이었다. Japan Society of Clinical Oncology가발표한림프절구역의분류에기초하여, 경부림프절을세개의기본구역으로나누었고, 각각의기본구역을여러부 (sub) 구역으로나누었다. 기본구역은알파벳대문자로표기하며, 숫자는세부기본구역을표시하는데사용하였다. S 는턱끝밑과하악림프절, J 는내경정맥림프절, P 는뒤목삼각림프절 (Table 4, Fig. 2) 을나타내며, 두 Table 4. Terminology and symbols of neck lymph nodes Cervical lymph node group JNDSG symbols AAO-HNS symbols Submental and Submandibular lymph S I node groups Submental group S1 IA Submandibular group S2 IB Jugular lymph node groups J II IV Upper jugular group J1 IIA and IIB Middle jugular group J2 III Lower jugular group J3 IV Posterior triangle lymph node groups P V Spinal accessory group P1 VA Supraclavicular group P2 VB Fig. 2. Neck regions and sub-regions as divided by the Japan Neck Dissection Study Group (JNDSG). 개의영어소문자는다른림프절군과비-림프절조직을나타낸다 (Table 5, 6). JNDSG는경부림프절절제를크게두군으로나누는것을제안하였는데, 절제범위에따라전절제 (total neck dissection, TND) 와선택절제 (SND) 로나누었다.(15) 전절제는세기본구역즉 S1을제외한 S, J와 P 구역을모두절제하는것이 Table 5. JNDSG - abbreviations for resected lymph nodes not included in the three basic neck regions Table 6. JNDSG - abbreviations for resected non-lymphatic neck structures Structure Sternocleidomastoid muscle Internal jugular vein Spinal accessory nerve Vagus nerve Sympathic nerve Carotid artery Deep cervical muscles Proposed by JNDSG Lymph node group Paratracheal lymph nodes Retropharyngeal lymph nodes Parotid gland lymph nodes Superficial cervical lymph nodes Superior mediastinal lymph nodes Abbreviation Abbreviation M V N vn sn ca dm Pt Rp Pg Sc Sm Table 7. Comparisons of Japanese and American terminology for different types of neck dissection Type of neck dissection in accordance with AAO-HNS classification ND (SJP/VNM) Radical neck dissection ND (SJP/VM) MRND with preservation of SAN* ND (SJP/V) MRND with preservation of SAN and SCM ND (SJP/M) MRND with preservation of SAN and IJV ND (SJP) MRND with preservation of SAN, IJV and SCM ND (J) or ND (J1 3) SND (II IV) ND (SJ1 2) SND (I III) ND (J, pt) SND (II IV, VI) ND (pt, sm) SND (VI, VII) ND (JP, pt) SND (II VI) ND (JP, rp/vnm, vn) SND (II V with retropharyngeal node dissection, with resection of IJV, SAN, SCM & vagal nerve) *SAN = spinal accessory nerve; SCM = sternocleidomastoid muscle; IJV = internal jugular vein; SND = selective neck dissection.

6 84 대한내분비외과학회지 : 제 12 권제 2 호 2012 고, 선택절제는적어도한개이상의세부구역절제를포함하는경우라정의하였다. 여러유형의절제술에대한예는 Table 7에기술되어있다. 그러나미국과유럽의대부분의외과의들은이친숙하지않은분류체계를사용하지않고있는실정이다. 경부림프절절제술의합리적인분류에대한국제적그룹의제안 (16) 경부림프절절제술의용어와분류에있어혼란과중복성과오해를피하고자유럽의의사들이주축이된국제적연구그룹이 2011년다음과같은경부림프절절제술의분류체계를제안하였다. 1. ND 을경부림프절절제술을표기할때처음에기술한다. 좌측은 L, 우측은 R 로표시하며 ND 의앞에표기한다. 양측인경우에는좌, 우측을따로기술하여야한다. 2. 두번째기술해야할것은절제된림프절군으로서, 로마숫자인 I VII로오름차순으로기술한다. 부림프절군이있는 I, II, V 군은, 전체절제 (A와 B 모두 ) 를하는경우가아니면 A 혹은 B를첨가하여기술한다. 3. 세번째로기술해야할것은절제된비-림프절조직들로서각각범용의두문자어 ( 심볼 ) 로표기한다 (Table 8). 이분류체계는기존의불명확하고혼돈을주는용어와달리논리적이고, 간단하며, 기억하기쉽고, 그리고구체적으로절제된림프절군과비-림프절조직을기술할수있는장점이있다. 가장중요한장점은기존의용어체계로는기술할수없었던여러형태의변형된경부림프절절제술을표기할수있다는것이다. 경부림프절절제술의용어에관한 ATA 의합의문 (17) ATA 합의문에서는 2008년 AHNS(14) 가제안한경부림프절군의해부학적및영상의학적분류를그대로따랐으며, 경부림프절절제술의분류도 AHNS 것과동일하여, 변형근치경부림프절절제술이란 I V 림프절군을모두절제하면서비-림프절조직인척수부신경이나내경정맥, 혹은흉쇄유돌근중하나이상을보전하였을때로정의하였으며, 선택경부림프절절제술이란척수부신경과내경정맥및흉쇄유돌근을보전하면서, 5개 (I V) 미만의림프절군, 즉원발병소에연관된림프절군만을절제하였을때라고정의하였다. ATA의갑상선암의권고안 (27a and 28) 에따르면,(18) 경부림프절절제술은치료적목적으로만시행되어야한다고기술하고있다. 갑상선암에서예방적경부림프절절제술은생존율을증가시키지않기때문에,(19) 치료적절제술이어야하며, 중앙경부와마찬가지로 Berry picking 은안되고, 치료적절제술은바로선택절제술이어야한다고주장하고있다. 즉분화된갑상선암의경부림프절전이에대한경부림프절절제술은 IIa, III, IV와 Vb에국한된선택적수술이어야한다고권고하고있다. 갑상선암의 I 구역으로의전이는매우드물기때문에, I 구역의절제는통상적으로할필요가없으며,(20) 또한 IIb 구역인척수부신경의위쪽도전이가의심되거나, IIa 구역에전이가확인된경우가아니면 IIb 구역은통상적으로절제할필요가없으며, Va 구역역시수술전초음파검사에서전이가의심되지않으면통상적으로절제할필요가없다고주장하고있다. ATA 합의문에서는결론적으로선택절제술이야말로갑상선암에대한가장적절한경부림프절절제술이며, 기술할때좌, 우어느쪽인지와절제된림프절군과부림프절군을반드시표기 ( 예, 선택경부림프절절제술 : IIa, III, IV와 Vb) 하여야 Table 8. Comparison of the new proposed terminology with the current widely used American terminology for different types of neck dissections Proposed nomenclature ND (I V, SCM, IJV, CN XI) ND (I V, SCM, IJV, CN XI, and CN XII) ND (I V, SCM, IJV) ND (II IV) ND (II IV, VI) ND (II IV, SCM) ND (I III) ND (I III, SCM, IJV, CN XI) ND (II, III) ND (IIA, III) ND (VI) ND (VI, VII) Nomenclature recommended by AAO-HNS/AHNS Radical neck dissection Extended neck dissection with removal of the hypoglossal nerve MRND with preservation of SAN Selective neck dissection (II IV) Selective neck dissection (II IV, VI) NA Selective neck dissection (I III) NA Selective neck dissection (II, III) Selective neck dissection (IIA, III) Selective neck dissection (VI) Selective neck dissection (VI, VII)

7 이영돈 : 갑상선암에있어서경부림프절절제술의용어및분류에관하여 85 한다고권고하고있다. 고찰처음근치적수술로부터시작된경부림프절절제술은비 -림프절조직을보전하는보다보수적인수술들, 즉기능적인손실과변형을최소화하는변형근치적수술들로점차발전해왔다. 두경부암에서는국소제어에효과적인외부방사선치료등의도입으로, 변형근치적수술들도기능적손실의정도와범위를보다더최소화할수있는선택적절제술로발전했다. 선택경부림프절절제술의대두는여러원발병소로부터림프절전이양상을예측할수있게됨으로가능하게되었다. 선택적림프절절제술의타당성은림프절전이양상에대해정확한해설이가능할때만정당화될수있는데, 즉보전된림프절군으로의잠재적전이위험이아주낮을때만정당화될수있는것이다. 앞에서도언급하였듯이갑상선암의 I 구역으로의전이는아주드물고,(20) Va로의전이도아주드문것으로알려져있다. Roh 등과 (21) Farrag 등 (22) 도 V 구역으로의림프절전이는어느정도있지만, 그중 Va로의전이는한예도없었다고보고하였다. 여러문헌이나, 저자의경험으로보아도갑상선암의경부림프절절제술은선택적절제술이타당한것같다. 그간국내에서는 II V 림프절절제를변형근치적절제술이라고표기하여왔으나, 우리나라에서도용어와분류체계의변경이필요한시점이된것같다. 즉우리의실정에맞는분류체계와용어의제정이필요한것으로생각된다. 경부림프절절제술에대한서술의일관성은그동안문헌에보고된술기들의성적을비교하는데꼭필수적인요건이기때문이다. 유럽의의사들이중심이되어 2011년발표한국제적그룹의제안 (16) 이간단하고, 쉽고, 무엇보다도여러변형들 ( 예를들면내경정맥을 II V 구역과같이절제한경우등 ) 을잘표기할수있을것이라생각되지만, 모든경부림프절절제술을 ND 라표기하고부수적으로절제된림프절군과비-림프절조직을괄호안에넣게되어, AHNS의경부림프절절제술의분류체계와는다른모습을보여자칫오해를불러일으킬수있을것같다. ATA consensus는갑상선암의경부림프절절제시, 선택경부림프절절제술 (IIa, III, IV, Vb) 등으로기술하는것을권장하지만, 비-림프절조직을절제하는경우에대한언급이없어, 이것역시완전하지않으며이또한의사들간에표기방법의차이를불러일으킬소지가있을수있다. 일본 (JNDSG) 의분류체계는복잡하고, 특히경정맥림프절군의분류번호가기존의분류번호와달라, 어렵고, 오해를일으킬수있어아마도국제적으로통용되기는어려울것같다. 결 보다더쉽고, 명확하고, 국제적으로통용될수있는경부림프절절제술의새로운용어와분류체계가그어느때보다더필요한시기인것같다. 갑상선암의경부전이의치료성적의비교를위해서, 또한향후환자각개인에게적합한치료, 즉적절한절제범위의결정을위해서도새로운분류체계는꼭필요하다. 우리나라에서도새로운경부림프절절제술의용어와분류체계가필요한시점이며, 이것은기존것들의한계를극복할수있어야하며, 각외과의들간에, 기관간에, 나아가서국제적으로소통과비교가가능한분류체계가되어야할것이다. 론 REFERENCES 1) Ferlito A, Johnson JT, Rinaldo A, Pratt LW, Fagan JJ, Weir N, et al. European surgeons were the first to perform neck dissection. Laryngoscope 2007;117: ) Crile GW. On the surgical treatment of cancer of the head and neck. With a summary of one hundred and twenty-one operations performed upon one hundred and five patients. Trans South Surg Gynecol Assoc 1905;18: ) Crile G. Excision of cancer of the head and neck. With special reference to the plan of dissection based on one hundred and thirty-two operations. JAMA 1906;47: )Martin HE, Del Valle B, Ehrlich H, Cahan WG. Neck dissection. Cancer 1951;4: ) Suárez O. El problema de las metastasis linfaticas y alejadas del cancer de laringe e hipofaringe. Rev Otorrinolaringol 1963;23: ) Jesse RH, Ballantyne AJ, Larson D. Radical or modified neck dissection: a therapeutic dilemma. Am J Surg 1978;136: ) Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg 1990;160: ) Patel KN, Shah JP. Neck dissection: past, present, future. Surg Oncol Clin N Am. 2005;14: ) Suen JY, Goepfert H. Standardization of neck dissection nomenclature. Head Neck Surg 1987;10: ) Medina JE. A rational classification of neck dissections. Otolaryngol Head Neck Surg 1989;100: ) Spiro RH, Strong EW, Shah JP. Classification of neck dissection: variations on a new theme. Am J Surg 1994;168: ) Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW. Standardizing neck dissection terminology. Official report of the Academy's Committee for Head and Neck Surgery and Oncology. Arch Otolaryngol Head Neck Surg 1991;117:601-5.

8 86 대한내분비외과학회지 : 제 12 권제 2 호 ) Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha A, et al. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. Arch Otolaryngol Head Neck Surg 2002;128: ) Robbins KT, Shaha AR, Medina JE, Califano JA, Wolf GT, Ferlito A, et al; Committee for Neck Dissection Classification, American Head and Neck Society. Consensus statement on the classification and terminology of neck dissection. Arch Otolaryngol Head Neck Surg 2008;134: ) Hasegawa Y, Saikawa M, Hayasaki K, Sugasawa M, Kishimoto S, Nakashima T, et al. A new classification and nomenclature system for neck dissections: a proposal by the Japan Neck Dissection Study Group (JNDSG). Jpn J Head Neck Cancer 2005;31: ) Ferlito A, Robbins KT, Shah JP, Medina JE, Silver CE, Al-Tamimi S, et al. Proposal for a rational classification of neck dissections. Head Neck 2011;33: ) Stack BC Jr, Ferris RL, Goldenberg D, Haymart M, Shaha A, Sheth S, et al; American Thyroid Association Surgical Affairs Committee. American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer. Thyroid 2012;22: ) Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19: ) Moreno MA, Agarwal G, de Luna R, Siegel ER, Sherman SI, Edeiken-Monroe BS, et al. Preoperative lateral neck ultrasonography as a long-term outcome predictor in papillary thyroid cancer. Arch Otolaryngol Head Neck Surg 2011;137: ) Wu G, Fraser S, Pai SI, Farrag TY, Ladenson PW, Tufano RP. Determining the extent of lateral neck dissection necessary to establish regional disease control and avoid reoperation after previous total thyroidectomy and radioactive iodine for papillary thyroid cancer. Head Neck [Epub ahead of print] 21) Roh JL, Kim JM, Park CI. Lateral cervical lymph node metastases from papillary thyroid carcinoma: pattern of nodal metastases and optimal strategy for neck dissection. Ann Surg Oncol 2008;15: ) Farrag T, Lin F, Brownlee N, Kim M, Sheth S, Tufano RP. Is routine dissection of level II-B and V-A necessary in patients with papillary thyroid cancer undergoing lateral neck dissection for FNA-confirmed metastases in other levels. World J Surg 2009;33:

KISEP Head and Neck Korean J Otolaryngol 2001;44:190-5 두경부암종에서병리학적으로확인한 Level IIb 림프절전이 - 예비결과 - 고윤우 1 김동영 2 최재진 1 김인섭 1 김상엽 1 최은창 1 Pathologically Pr

KISEP Head and Neck Korean J Otolaryngol 2001;44:190-5 두경부암종에서병리학적으로확인한 Level IIb 림프절전이 - 예비결과 - 고윤우 1 김동영 2 최재진 1 김인섭 1 김상엽 1 최은창 1 Pathologically Proven Level IIb Lymph Node Metastasis in Head and Neck