The Korean Journal of Pathology 2005; 39: 위암병리보고서기재사항표준화 김우호 박철근 김영배 김윤화김호근 배한익 송규상 장희경장희진 채양석 대한병리학회소화기병리학연구회 A Standardized Pathology Report

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1 The Korean Journal of Pathology 2005; 39: 위암병리보고서기재사항표준화 김우호 박철근 김영배 김윤화김호근 배한익 송규상 장희경장희진 채양석 대한병리학회소화기병리학연구회 A Standardized Pathology Report for Gastric Cancer Woo Ho Kim, Cheol Keun Park, Young Bae Kim, Youn Wha Kim, Ho Guen Kim, Han Ik Bae, Kyu Sang Song, Hee Kyung Chang, Hee Jin Chang and Yang Seok Chae The Gastrointestinal Pathology Study Group of the Korean Society of Pathologists 접수 : 2004년 12월 21일게재승인 : 2005년 1월 25일 책임저자 : 박철근우 서울시강남구일원동 50 성균관대학교의과대학삼성서울병원병리과전화 : Fax: ckpark@smc.samsung.co.kr Background and Methods : The Gastrointestinal Pathology Study Group of the Korean Society of Pathologists developed a standardized pathology reporting format for gastric cancer in collaboration with the Korean Gastric Cancer Association. Results : The diagnostic parameters are divided into two part: the standard part and the optional part. The standard part contains most of the items listed in the Japanese classification, the TNM classification by UICC, the WHO classification, and the Korean Gastric Cancer Association classification. Therefore, the standard part is adequate for routine surgical pathology service. We included detailed descriptions on each item. Conclusions : The authors anticipate that this standardization can improve the diagnostic accuracy and decrease the discrepancies that occur in the pathologic diagnosis of gastric cancer. Furthermore, the standard format can encourage large scale multi-institutional collaborative studies. Key Words : Stomach neoplasm; Pathology report; Surgical pathology; Neoplasm staging; Histologic type 위암은우리나라에서가장많이발생하는암으로, 1 가장수술이많이이루어지는암인동시에병리과에서검사하는절제암중에서가장흔한암이다. 그럼에도이제까지우리나라에서는위암병리보고서를작성하는기준을표준화하려는시도가없었다. 따라서위암병리검사보고서는병원에따라또는병리의사에따라기록하는항목의편차가컸을뿐아니라, 병리학적진단에대한기준도일관성이없었다. 미국외과학회 (American College of Surgeons Commissions on Cancer) 에서는 2004년 1월부터인증받은병원의병리의사에게병리보고서에각각의검체에대해과학적으로검증되거나통상적으로사용하는모든정보를기록할것 을요구하였다. 2 그러나현실적으로전체장기에대해기록해야할모든정보의범위를병리의사가빠짐없이파악하기는어려우므로보고서의표준화작업이가속화되었고, 이를위해서는체크리스트형태의보고서가가장적합하다고알려져있다. 3 미국에서는병리학회 (College of American Pathologist, CAP) 와병리과장협회 (Association of Directors of Anatomic and Surgical Pathology, ADASP) 에서각종암에대한보고서를작성할때참고할표준안을발표하였다. CAP 안은좀더광범위한반면, 4 ADASP 안은검증된내용인필수적인부분과, 아직 검증되지않은내용인선택적인사항으로나누어져있다. 5 그러나위암은미국에서는극히드문반면에, 우리나라에서는가장흔한암이기때문에미국의표준안을우리나라에서그대로사용하기에는부적절하다. 대한외과학회에서는국내의위암증례를분석할수있는바탕을마련하기위해서 1992년도에 위암규약집 을작성하였고, 많은외과의사들이이방법에따라위암증례를정리해왔다. 또한대한위암학회에서는 2002년 1월에이를보완하여 위암기재사항을위한설명서 라는소책자를제작하여배포하였다. 6 그러나이에대한병리의사의호응이저조하여우리나라전체에서사용하는표준화단계에는이르지못하였다. 대한병리학회소화기병리학연구회에서는대한위암학회와함께위암병리보고서를표준화하는작업을하기로하였다. 2004년 8 월부터 10월까지두번의소화기병리학연구회산하의위장관상피성종양소위원회모임및두번의연구회전체의논의를거쳐, 본 위암병리보고서기재사항 을완성하였다. 이를위해먼저현재국내대형병원에서사용하는보고서양식을참고하였으며, 미국병리학회의권장사항, 미국병리과장협회의체크리스트, 일본의 扱い規, 7 UICC 분류법 ( 제6 판 ), WHO 분류 (2000) 8 등을참고하였다. 또한보건복지부에서시행하는한국중앙암등 106

2 위암병리보고서기재사항표준화 107 록사업에필요한정보가빠지지않도록유념하였다. 1 우리나라에위암환자가많음에도좋은임상결과가발표되지않는것은애석한일이다. 특히수많은위암환자들이 adjuvant chemotherapy 를받고있으나, 어떤약제가효과가있는지알아보기위해국내자료를참조하는일도어려운실정이다. 또한최근에는빠른결과를얻기위해임상시험을여러병원이협력하여많은환자에대해수행하는것이보편적이다. 위암병리보고서의표준화는여러병원이함께임상시험에참가하더라도동일한환자군을정확히선택하는데큰도움이될것으로기대한다. 본소위원회를시작할때는간단한보고서를선호하는병리의사와자세한보고서를선호하는병리의사사이에매우큰의견차이가있었다. 그러나일부항목을선택기재사항으로분류함으로써의견차이를좁힐수있었다. 각병원에서는특성에맞추어선택기재사항이외의항목을얼마든지추가할수있으므로선택기재사항이큰의미가없다고볼수도있으나, 사용하는단어나진단기준을일원화하는데는도움이된다는의견이많았다. 예를들면 lymphatic invasion을판정할때, 표준기재사항에서는 not identified, present 로분류하지만, 선택기재사항에서는 not identified, minimal, moderate, marked 로분류하고있다. 그러나이를 not identified, minimal, severe 의 3단계로판정하는것은바람직하지않다고의견을모았다. 선택기재사항은이러한기준을정하는데도움이될것으로생각하였다. 위암의조직학적분류방법에는크게일본의분류법과 WHO 분류법이있으며, 둘사이에큰차이는없다. 그러나위암은조직학적형태가다양해서, 조직학적으로대표성있는유형을고르는기준역시다르다. WHO 분류에서는가장넓은범위를차지하는유형에대표성을부여하고, 일본의분류법은분화가나쁜유형에대표성을부여한다. 또미국병리과장협회에서는, 선구조를만드는면적이 95% 를초과하면고분화형, 50-95% 면중분화형, 5-49% 면저분화형, 5% 미만이면미분화형으로규정하였다. 이번표준안에서는 WHO의분류를사용하기로하였으나, 어떠한분류를사용하더라도관찰자개인또는관찰자사이의변이를피하기힘든어려움이있다. 병리보고서는국제적인비교가필요한경우가많으므로영어로기록하도록하였다. 기재사항을표준화하면서약자는극히제한적으로사용하였고, 새로운약자를만들어내지않았다. 예를들면 sm1은 invades up to 1/3 of submucosa 라고기재하며, Borrmann 5형은 unclassifiable로기재하였다. 이는각항목의판정기준이나분류법이바뀌더라도추후에추적할수있도록하기위함이다. 본기재사항을각병원에서어떻게사용할지는각병원의특성에맞추어결정할일이지만, 판독용양식을작성해놓고해당항목에동그라미또는숫자나글씨를적은후에별도로입력하는방법이바람직하기때문에이런용도로사용할수있는판독용양식을본논문에첨부하였다. 본논문에기록된사항은대한병리학회소화기병리학연구회의홈페이지에서얻을수있으며, 판독용양식파일을다운받아사용할수있다. 절제위의표준기재사항 결과및고찰 Specimen type total gastrectomy distal subtotal gastrectomy proximal gastrectomy wedge resection endoscopic mucosal resection other 해설 : 본기재사항은수술로절제한위암뿐아니라내시경절제표본에서도동일하게적용할수있도록하였다. Main diagnosis Early gastric carcinoma Advanced gastric carcinoma ( Multiple gastric carcinomas) 해설 : 종양이두개이상있는경우에는 multiple gastric carcinomas로표시하고, 가장깊은종양부터각각의종양에대해 모든항목을적되, lymph node metastasis, associated findings, separate lesions은가장깊은종양에만적는다. ( 조기위암과진행위암을기재하는것은중요한의미가있는것은아니지만, 대부분의병원에서사용하고있으므로편의상이를주진단명으로기록하기로하였다.) Location involvement [ ] esophagus [ ] upper third [ ] middle third [ ] lower third [ ] duodenum center cardia fundus body antrum pylorus / lesser curvature greater curvature anterior wall posterior wall circle 해설 : Involvement에는침범한부위를세군데까지적되가장많이침범한순서대로기록한다. 예 ) location: middle third and upper third Center에는병변의중심부를각각한군데씩기록한다. 예 ) antrum, lesser curvature ( 위의위치를지정하는방법을두고매우많은토의를했다. 중앙암등록통계에서사용하는국제질병분류 (ICD-O) 분류법에서는위암이처음발생한부위를기준으로 cardia, fundus, body, antrum, pylorus, lesser curvature, greater curvature, overlapping lesion, NOS 으로나누고있다. 9 미국의 CAP 방법은위를 11개구역으로나누고침범한구역을모두표시한다고되어있으나, 너무복잡해서현실성이없다. 일본의분류법및대한위암학회의표준안은 upper third, middle third, lower third 로나누고있다 (Fig. 1). 이분류법은종양의위치에따라원격전이에

3 108 김우호 박철근 김영배외 7 인 해당하는림프절이달라지는 topographic N stage를판정하는데기준이된다. 그러나절제위에서는남아있는위의크기를알수없으므로, 병리의사혼자서판정하기는쉽지않다. 이 3등분법은외과의사에게는매우쉽고편한방법이지만, 이분류결과를외과의사에게전적으로의존할수는없다고결론지었다. 왜냐하면, 외과의사의기록이부정확한경우가있으며, 특히조기위암, 다발성위암과같이육안으로병변의범위를정확히파악하기어려운상황에서는현미경판독에의하지않고는위치를판정할수없기때문이다. 이러한이유로표준기재사항에는세가지항목을기록하기로함으로써종양의위치를표시하는일이조금번거로워졌다.) Gross type EGC-I EGC-IIa EGC-IIb EGC-IIc EGC-III combination of above Borrmann 1 Borrmann 2 Borrmann 3 Borrmann 4 unclassifiable carcinoma로분류한다. Others에는 carcinoid, adenocarcinoid, parietal cell carcinoma, choriocarcinoma, endodermal sinus tumor, embryonal carcinoma, Paneth cell rich-adenocarcinoma 등이포함된다. Malignant lymphoma, stromal tumor 등은포함하지않는다. Histologic type by Lauren classification intestinal diffuse mixed indeterminate 해설 : Intestinal type은주로장상피를닮은선구조로구성된종양이다. Diffuse type은종양세포가작고둥글며, 내강을형성하는선구조가거의없는종양이다. Mixed type은 intestinal type과 diffuse type이각각 50% 씩보이는경우다. Indeterminate type은분화가나빠서어느쪽으로도분류하기곤란한경우다. Adenocarcinoma (signet-ring cell carcinoma 포함 ) 만분류한다. 해설 : 조기위암은일본의분류법을따르며, 진행위암은 Borrmann의분류법을따른다. 식도 * Unclassifiable 은일본의분류법에따르면 Borrmann 5 형에해 당한다. 상부 Histologic type papillary adenocarcinoma tubular adenocarcinoma, well differentiated tubular adenocarcinoma, moderately differentiated tubular adenocarcinoma, poorly differentiated mucinous adenocarcinoma signet-ring cell carcinoma adenosquamous carcinoma squamous cell carcinoma small cell carcinoma hepatoid adenocarcinoma undifferentiated carcinoma other 십이지장 식도 * 하부 중부 * 해설 : WHO의분류법 (2000) 을따른다. 선암종에서두가지이상의분화도가섞여나올때는간질을제외한암세포의면적이가장많은유형으로분류한다. 원주세포로구성된뚜렷한선구조는 well differentiated로분류하고, 입방형세포로구성된작은선구조는 moderately differentiated로분류한다 (Fig. 2). 분화가나쁜관상선암종에서내강을형성하는선구조는 moderately differentiated로, 내강을형성하지않을때는 poorly differentiated로분류한다. 선구조나편평상피분화가없는경우에는 undifferentiated 위 소만 전벽 후벽 대만 Fig. 1. Schematic view of tumor location. Stomach is longitudinally divided into three equal parts, and cross-sectionally divided into four parts.

위암병리보고서기재사항표준화 109 Tumor size cm 해설 : 종양의크기는가장긴축의길이와이에수직인길이의곱으로표시하며, 종양의깊이는가장두꺼운곳에서현미경으로측정한다.

1/3 of submucosa (sm1) (pt1b) invades up to 2/3 of submucosa (sm2) (pt1b) invades greater than 2/3 of submucosa (sm3) (pt1b)

일본의분류에서는 carcinoma in situ (CIS) 를인정하지않는다. 궤양에의해근육층이소실된부위에종양이있으면 subserosa 침범으로판정한다.

암세포가 mesothelial cell과붙어있거나, 복강으로노출되어있는경우는 pt3로분류한다 (Fig. 4). 암세포가 pancreas capsule을관통하면 pt4로분류한다.

[EMR only] carcinoma in situ (ptis) invades lamina propria of mucosa (pt1a) invades muscularis mucosa (pt1a) invades submucosa

Submucosal invasion이있는경우에는점막하층내에침윤된깊이를소수점두자리까지적는다. A B C D Fig. 3. Involvement of proper muscle layer.

(Inlet) High magnification of tumor cells. Fig. 2.

4 위암병리보고서기재사항표준화 109 Tumor size cm 해설 : 종양의크기는가장긴축의길이와이에수직인길이의곱으로표시하며, 종양의깊이는가장두꺼운곳에서현미경으로측정한다. Depth of invasion carcinoma in situ (ptis) invades lamina propria of mucosa (pt1a) invades muscularis mucosa (pt1a) invades up to 1/3 of submucosa (sm1) (pt1b) invades up to 2/3 of submucosa (sm2) (pt1b) invades greater than 2/3 of submucosa (sm3) (pt1b) invades proper muscle (pt2a) invades subserosa (pt2b) penetrates serosa (pt3) directly invades adjacent structure (pt4) 해설 : 일본의분류에서는 carcinoma in situ (CIS) 를인정하지않는다. 궤양에의해근육층이소실된부위에종양이있으면 subserosa 침범으로판정한다. 근육층을직접침범하지않았더라도점막하층-근육층의경계 에해당하는가상의선아래로침윤하면근육층침범으로판정한다 (Fig. 3). Omentum 내의침윤은 pt2b로분류한다. 암세포가 mesothelial cell과붙어있거나, 복강으로노출되어있는경우는 pt3로분류한다 (Fig. 4). 암세포가 pancreas capsule을관통하면 pt4로분류한다. Duodenum, esophagus는 adjacent structure가아니다. Adjacent structure 침범시에는침범장기를기록한다. [EMR only] carcinoma in situ (ptis) invades lamina propria of mucosa (pt1a) invades muscularis mucosa (pt1a) invades submucosa (pt1b) depth of submucosal invasion: cm 해설 : EMR검체는핀을박아고정판에고정한후, 폭 0.2 cm 의연속평행절편을만든다. Submucosal invasion이있는경우에는점막하층내에침윤된깊이를소수점두자리까지적는다. A B C D Fig. 3. Involvement of proper muscle layer. The cancer cells do not invade smooth muscle, but invlove the imaginary line between submucosa and proper muscle layer. (Inlet) High magnification of tumor cells. Fig. 2. The histologic features of (A) well differentiated tubular, (B) moderately differentiated tubular, (C) poorly differentiated tubular adenocarcinoma, and (D) signet-ring cell carcinoma. Fig. 4. When the tumor cells (arrow) touched the mesothelial cells (left) or exposed to the serosal surface (right), the tumor is classified as T3. Fig. 5. The tumor cells present in subserosal layer as an endolymphatic emboli. In this case, depth of invasion is as follow: invades into proper muscle layer (invades subserosa by lymphatic emboli).

5 110 김우호 박철근 김영배외 7 인 [lymphatic or vascular invasion] ( 예 ) invades proper muscle (pt2a), (invades subserosa by lymphatic invasion) 해설 : Lymphatic or vascular space 내에국한된암세포는침윤깊이에해당하지않으며, 별도로괄호안에기록한다 (Fig. 5). ( 이부분은소위원회에서가장논란이된부분중하나다. UICC 에서는 liver, kidney 이외의모든종양에이러한원칙을적용하는반면, 일본의규약집에서는 lymphatic or venous invasion도침윤깊이에포함시키고있다. 우리는 UICC의기준을적용하기로하였으나, 추후이러한증례를추적한결과에따라재분류해야할것이라고생각한다.) [after treatment] ( 예 ) invades proper muscle after treatment (ypt2a) 해설 : 치료후의침윤깊이는 ypt로기록한다. ( 치료전의침윤깊이를알수있다면기록하면되겠지만, 치료전의상태를정확히평가할수없기때문에치료후침윤깊이를표시한다. 이경우에치료하지않은증례와구별하기위해서별도의표시를한다.) [recurrent cancer] ( 예 ) invades subserosa, recurred cancer (rpt2b) 해설 : 재발암의침윤깊이는 rpt로기록한다. Resection margin involved by carcinoma free from carcinoma safety margin, proximal cm distal cm 해설 : Involved by carcinoma인경우에는 safety margin을 0 cm으로적는다. [EMR only] involved by carcinoma free from carcinoma safety margin, proximal cm distal cm anterior cm posterior cm deep cm (sm invasion only) 해설 : 방향이표시되어있지않은경우에는가장가까운 lateral margin과 deep margin만기록한다. 절제연이 involved by adenoma인경우에는 free from carcinoma로표시하고, pre-existing adenoma 항목에서절제연침범을기록한다. Regional lymph node metastasis no metastasis in all regional lymph nodes metastasis to out of regional lymph nodes pn pn0: no metastasis pn1: metastasis in 1-6 LN pn2: metastasis in 7-15 LN pn3: metastasis in more than 15 LN 해설 : Isolated tumor cells는전이숫자에포함하지않는다. ( 전이된종양의크기가 0.2 mm 이하면 isolated tumor cells로, mm면 micrometastasis로정의하고있다. 그러나크기가 0.2 mm 이하더라도헤마톡실린에오신염색으로발견되는림프절전이의대부분은 malignant activity (gland formation, stromal reaction, proliferation) 가동반되어있으므로 micrometastasis로분류하는것이옳다. 면역염색으로발견되는 isolated tumor cells 의대부분은헤마톡실린에오신염색에서는암세포인지아닌지전혀알수없다.) [Lymph node groups] ( 예 ) LN#4,3/5; LN#5,0/4; 해설 : 별도로표시되어접수된림프절의결과는별도로기록한다. Lymphatic invasion not identified present Venous invasion not identified present 해설 : 작은 vessel 침범은 lymphatic invasion으로, 근육층이있는큰 vessel 침범은 venous invasion으로간주한다. ( 헤마톡실린에오신염색으로 lymphatic vessel과 blood vessel을구별할수없는경우가흔하다. 그러므로크기및근육층유무를기준으로감별한다.) Perineural invasion not identified present 해설 : Intraneural invasion은별도로구별하지않고 perineural invasion에함께기록한다. Pre-existing adenoma (describe when present) histology, grade size and involvement of resection margin 해설 : Carcinoma in adenoma에해당하는경우에만기록하며, 암종과분리된선종은 separate lesion에기록한다. 위선종은 WHO의종양분류에따르면 intraepithelial neoplasia-adenoma다. 일본에서는융기형, 평탄형, 함몰형을모두선종이라한다. 서양에서는경계가분명한융기형을선종이라하고나머지모두를 epithelial dysplasia라고한다. Histology는 tubular, tubulovillous, villous로나눈다. Grade는 low grade dysplasia와 high grade dysplasia로나누며, 핵의길이가세포길이의 1/2 이하인경우 low grade dysplasia로분류하고, 인접한세개이상의선구조가 high grade dysplasia ( 핵의길이가세포길이의 1/2 이상 ) 의소견을보일경우 high grade dysplasia로분류한다. 예 ) Pre-existing adenoma: Tubular adenoma with high grade dysplasia ( cm, involvement of proximal resection margin)

6 위암병리보고서기재사항표준화 111 Associated findings Ulceration Perforation Mesenteric seeding (M1) Metastasis in other sites (M1) specify 해설 : 병변이있을때는기록하고, 없을때는기록하지않는다. Separate lesions Peptic ulcer Adenoma GIST Polyp specify 해설 : 병변이있을때는기록하고, 없을때는기록하지않는다. 절제위의선택기재사항 해설 : 선택기재사항은병원의특성에따라필요한항목을선택하여사용할수있다. Lymphatic invasion mural or extramural intratumoral or peritumoral minimal or moderate or marked Venous invasion mural or extramural intratumoral or peritumoral minimal or moderate or marked Perineural invasion perineural or intraneural or both mural or extramural intratumoral or peritumoral minimal or moderate or marked Tumor border by Ming s classification expanding infiltrative Stromal reaction absent desmoplasia lymphocytes ( absent, mild, moderate, severe) eosinophils neutrophils granulomatous Therapeutic efficacy grade 해설 : Adjuvant chemotherapy 또는 radiation therapy 에의 한치료효과를조직학적으로판정하는데사용하며, 아직국제적 으로공인된기준이없으므로일본의규약집을따르기로한다. (Viable cells include cells having eosinophilic cytoplasm with vacuolation and swollen nuclei.) Grade는다음과같이분류한다. grade 0: no effect grade 1: viable cells account for 1/3 or more grade 1a: viable cells 2/3 or more grade 1b: viable cells 1/3-2/3 grade 2: viable cells account for less than 1/3 grade 3: no viable cells evident Mucin phenotype gastric type intestinal type mixed unclassified 해설 : Gastric type 은 muc5ac (gastric foveolar) 와 muc6 (pyloric gland), 그리고 intestinal type 은 muc2 (goblet cell) 와 CD10 (brush border) 의염색결과에따라분류한다 Gastric type과 intestinal type은한가지만 10% 이상이면해당형, 두가지가 10% 이상이면 mixed, 두가지가 10% 미만이면 unclassified로판정한다. Isolated tumor cells and micrometastasis ( 예 ) Regional lymph node metastasis: Metastasis to 2 out of 20 lymph nodes, including 1 micrometastasis (pn1) Isolated tumor cells in 5 lymph nodes ( 예 ) Regional lymph node metastasis: No metastasis in all (20) lymph nodes Isolated tumor cells in 2 lymph nodes (pn0[i+]) 해설 : 0.2 mm 이하의전이에서 malignant activity가없을때 (no gland formation, no stromal reaction, no proliferation, usually in venous or in lymphatic) isolated tumor cell로판정하고, 전이숫자에포함하지않지만, 별도로기록한다 mm 크기거나그보다작더라도 malignant activity가있으면 micrometastasis로판정하고, 전이숫자에포함하며, 별도로기록한다. Subclassification of GE junction cancer type I (adenocarcinoma of distal esophagus) : epicenter of the tumor is between 1 cm and 5 cm above the GE junction type II (true cardia cancer of the stomach) epicenter of the tumor is located within 1 cm oral and 2 cm aboral of the GE junction type III (subcardia cancer of the stomach) epicenter of the tumor is located between 2 cm and 5 cm aboral of the GE junction 해설 : Type I 은식도암으로분류한다. Chronic gastritis Graded variables H. pylori density polymorphonuclear neutrophilic activity chronic inflammation glandular atrophy intestinal metaplasia Non-graded variables erosion lymphoid follicle foveolar hyperplasia pseudopyloric metaplasia pancreatic metaplasia endocrine cell hyperplasia

7 112 김우호 박철근 김영배외 7 인 해설 : 분류는 Sydney classification에준한다. Graded variables는 negative, mild, moderate, marked로나눈다. Non-graded variables는관찰되는경우에만기록한다. 내시경생검의표준기재사항 Location cardia fundus body antrum/ lesser curvature greater curvature anterior wall posterior wall Specimen type endoscopic biopsy Histologic type papillary adenocarcinoma tubular adenocarcinoma, well differentiated tubular adenocarcinoma, moderately differentiated tubular adenocarcinoma, poorly differentiated mucinous adenocarcinoma signet-ring cell carcinoma adenosquamous carcinoma squamous cell carcinoma small cell carcinoma hepatoid adenocarcinoma undifferentiated carcinoma other 위암판독용양식 Stomach, (subtotal, total, proximal) gastrectomy, (endoscopic mucosal resection):. (Multiple, Early, Advanced) gastric carcinoma 1. Location : [ ] esophagus, [ ] upper third, [ ] middle third, [ ] lower third, [ ] duodenum Center at (cardia, fundus, body, antrum) (lesser curvature, greater curvature, anterior wall, posterior wall, circle) 2. Gross type : EGC type (I, IIa, IIb, IIc, III, ), Borrmann type (1, 2, 3, 4, unclassifiable) 3. Histologic type : papillary adenocarcinoma, tubular adenocarcinoma, (well, moderately, poorly) differentiated, mucinous adenocarcinoma, signet-ring cell carcinoma, small cell carcinoma, undifferentiated carcinoma, other 4. Histologic type by Lauren : (intestinal, diffuse, mixed, indeterminate) 5. Size : cm 6. Depth of invasion : carcinoma in situ (ptis), invades mucosa (lamina propria, muscularis mucosa) (pt1a), invades submucosa (sm1, sm2, sm3, sm) (pt1b), [depth of sm invasion : cm] invades proper muscle (pt2a), invades subserosa (pt2b), penetrates serosa (pt3), directly invades adjacent structure (pt4) 7. Resection margin: (involved by carcinoma, free from carcinoma) safety margin: distal cm, proximal cm [anterior cm, posterior cm, deep cm (sm only)] 8. Lymph node metastasis : no metastasis in regional lymph nodes (pn0) metastasis to out of regional lymph nodes (pn_) (lesser curvature /, greater curvature /, LN /, ) 9. Lymphatic invasion : (not identified, present) 10. Venous invasion : (not identified, present) 11. Perineural invasion : (not identified, present) 12. Pre-existing adenoma : histology, grade, size, resection margin 13. Associated findings : (ulceration, perforation, mesenteric seeding, metastasis) 14. Separate lesions : (peptic ulcer, adenoma, GIST, polyp, etc.) ( 이탤릭체는 EMR 검체에서만사용하는항목임.) 위암병리보고서작성예 Stomach, subtotal gastrectomy:. Advanced gastric carcinoma 1. Location : lower third and middle third, Center at antrum and lesser curvature 2. Gross type : Borrmann type 2 3. Histologic type : tubular adenocarcinoma, moderately differentiated 4. Histologic type by Lauren : intestinal 5. Size : cm 6. Depth of invasion : invades proper muscle (pt2a) 7. Resection margin : free from carcinoma safety margins: distal 1.5 cm, proximal 6.6 cm 8. Lymph node metastasis : no metastasis in 39 regional lymph nodes (pn0) (lesser curvature 0/10, greater curvature 0/10, LN3 0/2, LN4 0/14, LN 0/3) 9. Lymphatic invasion : present 10. Venous invasion : not identified 11. Perineural invasion : not identified 12. Pre-existing adenoma : tubular adenoma with high grade dysplasia ( cm, resection margin : free from adenoma) Stomach, endoscopic mucosal resection:. Early gastric carcinoma 1. Location : antrum, lesser curvature 2. Gross type : EGC type IIb+IIc 3. Histologic type : tubular adenocarcinoma, moderately differentiated 4. Histologic type by Lauren : intestinal 5. Size : cm 6. Depth of invasion : invades submucosa (depth of sm invasion : 0.03 cm) (pt1b) 7. Resection margin : free from carcinoma safety margin: distal 1.0 cm, proximal 0.6 cm, anterior 0.4 cm, posterior 0.7 cm, deep 0.05 cm 8. Lymphatic invasion : present 9. Venous invasion : not identified 10. Perineural invasion : not identified Stomach, antrum, lesser curvature, endoscopic biopsy:. Tubular adenocarcinoma, moderately differentiated 참고문헌 1. Ministry of Health and Welfare, Republic of Korea. Korea Central Cancer Registry Annual Report of the Korea Central Cancer

8 위암병리보고서기재사항표준화 113 Registry Connolly JL, Fletcher CD. What is needed to satisfy the American College of Surgeons Commission on Cancer (COC) requirements for the pathologic reporting of cancer specimens? Hum Pathol 2003; 34: Kempson RL. The time is now. Checklists for surgical pathology reports. Arch Pathol Lab Med 1992; 116: Campton CC. College of American Pathologists. Reporting on cancer specimen: Case summaries and background documentation. Northfield, IL, USA: ( 5. Association of Directors of Anatomic and Surgical Pathology. Recommendations for the reporting of major tumor types. Gastric carcinoma. Ver 1-1, ( 6. The Korean gastric cancer association. Korean classification of gastric cancer. 1st ed. Seoul: Medlang, Japanese Research Society for Gastric Cancer. Japanese Classificaiton of Gastric Carcinoma. 2nd ed. Tokyo: Kanehara Co, Hamilton SR, Aaltonen LA. WHO Classification of Tumours. Pathology and Genetics. Tumours of the Digestive System. Lyon: IARC- Press, Frita A, Percy C, Jack A, et al. WHO International Classification of Diseases for Oncology (ICD-O). 3rd ed. Genova: 2000.

조기 위암 집담회 부산대학교 병원 CASE

조기 위암 집담회 부산대학교 병원 CASE 부산대학교병원 CASE PRESENTATION 전임의이현정 2013.10.02 CASE PRESENTATION F/79 C.C) Epigastric soreness P.I) 2011년 4월외부병원시행한 EGD 상병변보여본원의뢰됨 P.Hx) HT / DM / Hepa / Tbc - / - / - / - S.Hx) smoking (-), alcohol (-) F.Hx)