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1 Korean Journal of Obstetrics and Gynecology Vol. 53 No. 8 August 2010 개정된부인암 International Federation of Gynecology and Obstetrics (FIGO) 병기결정체계 연세대학교의과대학산부인과학교실 이마리아 김영태 Revised International Federation of Gynecology and Obstetrics (FIGO) staging systems in gynecologic malignancies Maria Lee, M.D., Young Tae Kim, M.D., Ph.D. Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea The International Federation of Gynecology and Obstetrics (FIGO) has reported annually for the development and changes of gynecologic cancer classification and staging since FIGO staging systems in gynecologic malignancies has been reflected on prognostic factors in predicting patients outcomes and organized patients into several groups. The aim of the FIGO staging system is to afford a classification of gynecologic cancer and to share treatment methods with others. The FIGO staging systems have been updated several times every 3 years according to the latest data, which is responsive and adaptive to scientific development including imaging and treatment modalities. In 2008, the FIGO staging system for carcinoma of the cervix, endometrium, vulva, and uterine sarcomas was revised. After applying the revised staging system in clinical setting, it is need to consider and review problems. As a result, we must make up for the weak points in staging systems continuously. Key Words: FIGO, Staging systems, Gynecologic malignancies 부인암의병기 (stage) 는 1958 년처음으로국제산부인과학회 (International Federation of Gynecology and Obstetrics, FIGO) 에서병기와분류 (classification) 에대한규칙을정한이후현재 FIGO 의병기결정체계를채택하여사용하고있다. FIGO 에서는 3년마다부인암의병기결정체계를수정하였고, 1976년에는수년간종양의병기체계확립을위해노력해온미국연합위원회 (The American Joint Committee on Cancer, AJCC) 에서이러한 FIGO 의병기결정체계를채택하게되었다. 또한국제종양연합 (The International Union Against Cancer, UICC) 에서는종 양의병기결정에있어원발종괴의범위 (T), 림프절전이 (N) 및원격전이 (M) 상태를이용한 TNM 체계를사용하여왔는데이두체계는근본적으로같으며상호비교가가능하다. 병기결정은의료기관간환자의비교와예후에따른환자분류에가장큰목적이있다. 부인암병기는진단방법의변화와예후에대한정보제공으로지속적으로변화하였고, 최근 3년간의검토과정을거쳐 2008 년개정된부인암병기결정체계를발표하였다. 자궁경부암 접수일 : 채택일 : 교신저자 : 김영태 ytkchoi@yuhs.ac 전세계적으로자궁경부암은부인암중두번째로흔한암이며, 특히개발도상국에서발생률이높다. 자궁경부암은자궁경질부또는경관내에서유래되는데, 경부는요

2 대한산부회지제 53 권제 8 호, 2010 관전, 후및자궁천골 (uterosacral) 부위를거쳐자궁방결합조직 (parametrium), 하복부 ( 폐쇄, obturator), 외장골 (external iliac), 천골전 (presacral), 총장골 (common iliac) 림프절과같은일차림프절로배액된다. 대동맥주위 (para-aortic) 림프절은이차림프절로간주되며, 전이는자궁경부기질 (cervical stroma), 자궁체부, 질, 그리고자궁방결합조직으로의직접적인침습, 림프절전이, 그리고혈행성파종을통해이루어진다. 원격전이가흔하게이루어지는위치는대동맥및종격동림프절, 폐, 그리고골격계이다. 1. 병기결정원칙자궁경부암의병기결정은 1928 년에처음소개되었고, 1950 년에근대적인병기결정체계가도입되었다. 이후 7차례의수정을거쳐만들어진 1994 년의병기결정방법을최근개정전까지사용하였다 년자궁경부암의병기결정체계개정에있어서주요논쟁점은우선, 임상적병기결정과수술적병기결정에관한것이었다. 수술적병기결정에비해임상적병기결정은정확성이떨어진다. 2 하지만대부분의환자들이개발도상국에서발생하는점을고려하여임상적병기결정방법을지속하기로하였다. 두번째로선암 (adenocarcinoma) 의병기결정에대한것으로편평상피세포암과같은기준을따르기로하였다. 이외에병기 IA1 의임상적의의, 림프혈관침윤과림프절전이상태에관한것이쟁점화되었다 년개정된자궁경부암의병기결정에서변경된 2가지는다음과같다. 0기암은전암병변으로정확한분류기준도없고자궁경부상피내종양 3등급 (cervical intraepithelial neoplasia, CIN 3) 병변과예후를구별하기어려워병기에서삭제되었고, 병기 IIA를종양의장축직경 4 cm 기준으로그이하는 IIA1, 초과는 IIA2 로세분화하였다. 이는기존의연구결과를분석한결과예후인자로중요하다고밝혀졌기때문이다. 3,4 그리고권장사항으로언급된것은다음과같다. (1) 원발종양의크기를영상학적방법으로측정한다. (2) 림프혈관침윤은중요한위험인자이지만그정의가주관적일수있어병기에는포함하지않고가능하면언급하도록한다. (3) 필수검사로시행하였던마취상태에서의내진, 방광경, S결장경검사, 경정맥신우조영술은선택적으로시행가능하다. (4) 자궁경부암치료후완전관해상태로 5년이후에발생한질암은원발성으로간주한다. 1) Clinical-diagnostic staging 자궁경부암의병기는임상적평가에기초한임상적병기체계가우선적으로인정되고있다. 임상적병기는차후에발견되는소견에의해변경되어서는안되며, 병기결정에있어의문이있는경우초기에결정된병기를채택한다. 현재 FIGO 에서제시하는병기결정방법으로질확대경검사및생검, 자궁경부원추절제술, 방광경및직장경검사외에영상진단을시행할수있다. 그러나영상진단의효용성에대해서는논란이있어 FIGO 에서는병기결정방법에서흉부 X- 선, 경정맥신우조영술 (intravenous pyelograhy, IVP), 바륨관장 (barium enema) 으로제한하였다 (Table 1). Computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) 등과같은복잡한영상진단이나수술적병기결정술은 Table 1. Staging procedures Physical examination * Palpable lymph nodes Examine vagina Bimanual rectovaginal examination (under anesthesia recommended) Radiologic studies * Intravenous pyelogram Barium enema Chest X-ray Skeletal X-ray Procedures * Biopsy Conization Hysteroscopy Colposcopy Endocervical curettage Cystoscopy Proctoscopy Optional studies Computerized axial tomography Lymphangiography Ultrasonography Magnetic resonance imaging Radionucleotide scanning Laparoscopy * Allowed by International Federation of Gynecology and Obstetrics (FIGO). Information that is not allowed by FIGO to change the clinical stage

3 이마리아외 1 인. 개정된부인암 FIGO 병기결정체계 FIGO 에서제시하는병기결정방법에포함되지않았지만, 치료의방침을결정하기위하여선택적으로시행할수있다. 방광경검사, 직장경검사는병기 IB2 또는그이상의병기에서, 그리고방광이나직장쪽으로의침윤암이의심되는경우에시행한다. 이임상적병기를변경하는기초가되어서는안된다. 드물게침윤성자궁경부암이의심되지못한상황에자궁절제술이시행된경우임상적으로병기가결정될수없고치료결과를평가하는데포함될수없으나개별적으로보고되는것이바람직하다. 2) Surgical-evaluative staging 외과적평가는개복술또는복강경술을통한종괴및림프절검사를통해서만가능하다. 전이가의심되는림프절에대한미세침흡입술이치료계획을세우는데도움이될수있다. 경부의원추형생검이나절단은임상적검사로간주되고, 침윤성암이발견될때보고에포함되어야한다. 4) Retreatment staging 재발판정이되었거나의심되는경우원격전이에대한조사를포함하여앞에서언급된여러제반검사를통한완전한평가가이루어져야한다. 특히이전에치료된부위의경화및섬유화가존재할때는생검을통한조직학적확진이바람직하다. 3) Postsurgical treatment-pathologic staging 외과적방법에의해치료된경우제거된조직의병리소견을기초로질병의범위에대해정확히기술할수있으며 TNM 체계가이러한목적에부합한다. 하지만이러한소견 2. 병기분류 1) FIGO 병기체계 자궁경부암은임상적병기결정체계를유지하고있으며 Table 2. The International Federation of Gynecology and Obstetrics (FIGO) clinical staging for uterine cervix (2008) Stage I The carcinoma is strictly confined to the cervix (extension to the corpus would be disregarded) IA Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion 5 mm and largest extension 7 mm IA1 Measured stromal invasion of 3.0 mm in depth and extension of 7.0 mm IA2 Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension of not >7.0 mm IB Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IA * IB1 Clinically visible lesion 4.0 cm in greatest dimension IB2 Clinically visible lesion >4.0 cm in greatest dimension Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina IIA Without parametrial invasion IIA1 Clinically visible lesion 4.0 cm in greatest dimension IIA2 Clinically visible lesion >4 cm in greatest dimension IIB With obvious parametrial invasion Stage III The tumor extends to the pelvic wall and/or involves lower third of the vagina and/or causes hydronephrosis or non-functioning kidney IIIA Tumor involves lower third of the vagina, with no extension to the pelvic wall IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to Stage IV IVA Spread of the growth to adjacent organs IVB Spread to distant organs * All macroscopically visible lesions-even with superficial invasion-are allotted to stage IB carcinomas. Invasion is limited to a measured stromal invasion with a maximal depth of 5.00 mm and a horizontal extension of not >7.00 mm. Depth of invasion should not be >5.00 mm taken from the base of the epithelium of the original tissue-superficial or glandular. The depth of invasion should always be reported in mm, even in those cases with early (minimal) stromal invasion (~1 mm). The involvement of vascular/lymphatic spaces should not change the stage allotment. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. All cases with hydronephrosis or non-functioning kidney are included, unless they are known to be due to another cause

4 대한산부회지제 53 권제 8 호, 년개정된 FIGO 병기체계는다음과같다 (Table 2). 2) 병기결정시유의사항이형세포가상피의전층에침습되어있으나간질로의침윤증거가없는경우 0기로분류하였으나새로운병기결정에서는제외되었다. 병기 IA1 과 IA2 의진단은제거된조직의현미경적검사에기초되어야하며전병소가포함되는원추형생검이바람직하다. 침윤의깊이는 5 mm 이상이되어서는안되고너비는 7 mm를초과해서는안된다. 정맥또는림프절침윤은병기에영향을미치지는않으나치료결정에영향을미칠수있기때문에기록되어야한다. 보다큰병소는병기 IB로결정되어야하고대개자궁체부로확장되면임상적으로측정하는것이불가능하기때문에체부로의확장은무시되어야한다. 짧고경화되어있으나결절이없는자궁방조직에의해골반벽에고정된경우는 IIB로병기를결정한다. 임상적검진시부드럽고경화된자궁방조직이진정한암성인지단지염증성인지결정하는것은불가능하므로, 자궁방조직이결절성이거나종괴자체가골반벽으로확장되어있다면병기 III로결정되어야 한다. 암에의한요관협착의결과로생긴수신증이나비기능성신장을보이는경우는비록다른소견은 I 또는 II 를시사할지라도 III로병기가결정된다. 수포성부종 (bullous edema) 의존재시 IV로병기를결정해서는안되며방광벽으로의융기 (ridges) 및구 (furrow) 는촉진시 ( 예를들면방광경시질또는직장을통한검진시 ) 고정되어있으면방광점막침윤으로해석되어야한다. 방광세포세척검사시악성세포를발견할경우추가검사및방광벽조직검사가필요하다. 3) 조직병리자궁경부에서종괴의일차성장을보이는경우자궁경부암으로분류되어야한다. 모든조직학적유형이포함되어야하고 (Table 3) 하나의분화도체계 (grading system) 가권장되지만병기를수정하는기초가되지는않는다 (Table 4). 외과적치료가일차적으로시행될때, 조직학적소견을토대로앞에서기술된조직학적병기결정및외과적평가의병기결정이가능하다. Table 3. Modified World Health Organization (WHO) histological classification of malignant tumors of the uterine cervix by the Gynecological Pathology Study Group of the Korean Society of Pathologists A. Epithelial tumors ㆍOther epithelial tumors ㆍSquamous tumors Adenosquamous carcinoma Squamous cell carcinoma Glassy cell carcinoma variant Keratinizing Adenoid cystic carcinoma Nonkeratinizing Adenoid basal carcinoma Basaloid Neuroendocrine tumors Verrucous Undifferentiated carcinoma Warty B. Mesenchyal tumors Papillary ㆍLeiomyosarcoma Lymphoepithelioma-like ㆍStromal sarcoma Squamotransitional ㆍSarcoma botryoides Microinvasive squamous cell carcinoma ㆍOthers Cervical intraepithelial neoplasia (CIN) 3/ Squamous cell carcinoma in situ C. Mixed epithelial and mesenchymal tumors ㆍGlandular tumors ㆍCarcinosarcoma (malignant müllerian mixed tumor, Adenocarcinoma MMMT) Mucinous adenocarcinoma ㆍAdenosarcoma (Endocervical, intestinal, signet ring cell, minima deviation, villoglandular) D. Melanocytic tumors Endometrioid Clear cell adenocarcinoma E. Miscellaneous tumors Serous adenocarcinoma Mesonephric adenocarcinoma F. Lymphoid and hematopoietic tumors Early invasive adenocarcinoma Adenocarcinoma in situ G. Secondary tumors

5 이마리아외 1 인. 개정된부인암 FIGO 병기결정체계 자궁내막암 자궁체부는경관내구위에위치한자궁의상부 2/3 로서, 양측난관이상부외측모서리에연결되어있고난관자궁개구부를연결하는선위의근육조직부분은자궁저 (fundus) 로불린다. 주요림프절은자궁-난소 ( 골반-누두, infundibulo-pelvic), 자궁방조직, 천골전림프절로서하복부, 외장골, 총장골, 천골전및대동맥주위림프절로배액된다. 가장흔한전이부위는질과폐이다. 1. 병기결정원칙자궁내막암의병기결정은 1971 년발표된임상적병기결정이유지되다가, 1988 년개정되면서수술적병기결정이채택되었다. 그이후 20년간의수술결과와예후에대한많은자료가축적되었고, 이를바탕으로 FIGO 의연례보고서 23권에 42,000명을대상으로한첫자궁내막암의수술적병기결정결과가발표되었다. 이후의 26권까지의자료가분석되어이에따라병기가수정되었다. 5,6 FIGO 의 Table 4. Histopathologic grade of malignant tumors of the uterine cervix G1 Well differentiated G2 Moderately differentiated G3 Poorly differentiated G4 Undifferentiated 연례보고서자료를분석한결과림프절전이가없는경우, 병기 IA G1, IB G1, IA G2, IB G2의 5년생존율이각각 93.4%, 91.6%, 91.3%, 91.4% 로큰차이가없었다. 따라서 IA G123, IB G123, IC G123 의 9개로세분되던 I기는자궁근층 1/2 이상과이하의침범을기준으로 IA G123, IB G123 의 6개로바뀌었다. 병기 IIA로구별되던자궁경관분비샘의침윤 (endocervical glandular involvement) 은병기 I로, 병기 II는자궁경관의실질조직을침윤한경우만으로제한하였다. 병기 III은부대동맥림프절침윤이있는경우에골반림프절침윤만있는경우보다예후가좋지않아, 골반림프절만침윤한 IIIC1과부대동맥림프절의침윤이있는 IIIC2로따로분류하였다. 마지막으로복강세척세포검사결과가병기에영향을주지는않지만, 병기 III의경우에그결과를첨부하도록하였다. 2. 병기분류 1) FIGO 병기체계자궁내막암은외과적병기결정체계를유지하고있으며 2008 년개정된병기체계는다음과같다 (Table 5). 2) 병기결정시유의사항 1 조직분화도분류내막암은다음과같은선암의분화도에따라분류되어 Table 5. The International Federation of Gynecology and Obstetrics (FIGO) staging for endometrial cancer (2008) Stage I * Tumor confined to the corpus uteri IA * No or less than half myometrial invasion IB * Invasion equal to or more than half of the myometrium Stage II * Tumor invades cervical stroma, but does not extend beyond the uterus Stage III * Local and/or regional spread of the tumor IIIA * Tumor invades the serosa of the corpus uteri and/or adnexae IIIB * Vaginal and/or parametrial involvement IIIC * Metastases to pelvic and/or para-aortic lymph nodes IIIC1 * Positive pelvic nodes IIIC2 * Positive para-aortic lymph nodes with or without positive pelvic lymph nodes Stage IV * Tumor invades bladder and/or bowel mucosa, and/or distant metastases IVA * Tumor invasion of bladder and/or bowel mucosa IVB * Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes * Either G1, G2, or G3. Endocervical glandular involvement only should be considered as Stage I and no longer as Stage II. Positive cytology has to be reported separately without changing the stage

6 대한산부회지제 53 권제 8 호, 2010 야한다 (Table 6). 2 조직분화도결정시주의사항핵의이형성 (nuclear atypia) 이심하여구조적분화도 (architectural grade) 결정이어려울경우 grade 1 또는 2로종괴의분화도를한단계씩올린다. 장액성및투명세포선암의경우핵분화도 (nuclear grade) 를우선적으로고려하고편평세포분화를갖는선암의경우에는선성분 (glandular component) 의핵분화도에따라분화도를결정한다. 3 병기결정에관련된규칙자궁내막암은외과적병기결정을따르기때문에병기 I, II의분류를위한 fractional dilatation and curettage (D&C) 와같이임상적병기결정체계를위해이전에사용된술기는더이상반드시요구되지는않는다. 최근에는자궁내막샘플링방법도 D&C 와비교했을때그정확도에차이가없다고보고되고있다. 초음파검사는자궁내막암을찾아내는데매우민감도가높은검사방법이며비침습적이라는장점때문에자궁내막암진단을위한보조적수단으로흔하게사용된다. 초음파검사이외에도임상적으로자궁내막암이강하게의심될경우에는필요에따라 CT, MRI, PET 등의검사를시행할수있다. 방사선치료가주된치료로시행될자궁내막암환자의경우 1971 년 FIGO 에서채택된임상적병기가적용될수있으나, 이경우그러한병기결정체계를명시해야한다. 자궁체부암의모든조직학적유형은다음과같다 (Table 7). 자궁육종 자궁육종 (Uterine sarcomas) 은부인암중에서는드문질환으로, 자궁체부암의 2~5% 를차지한다. 자궁육종은 Table 6. Histopathologic grade of endometrial carcinoma G1 5% nonsquamous or nonmorular solid growth pattern G2 6~50% nonsquamous or nonmorular solid growth pattern G3 >50% of a nonsquamous or nonmorular solid growth pattern 자궁평활근육종 (leiomyosarcoma, LMS), 자궁내막기질육종 (endometrial stromal sarcoma, ESS), 암육종 (carcinosarcoma), 선육종 (adenosarcoma) 등을포함하며자궁경부보다체부에서많이발생하고대부분은근육에서발생한다. 임상증상이나병력에서자궁육종의가능성이있는환자에서는전혈검사, 일반화학검사, 흉부 X-선검사, 심전도검사, 요검사를포함한기본검사를실시하고조직학적확진을위해자궁내막조직검사또는자궁경관확대소파술을시행한다. 영상진단 ( 초음파, CT, MRI, PET) 은기본적인검사에는포함되지않으나필요에따라시행하여수술전진단과병기설정에도움을얻을수있다. 모든자궁육종의병기결정은 1988 년 FIGO 에서제정한자궁내막암의병기결정체계를이용해왔다. 자궁육종의빈도가낮아상대적으로독립된병기결정을위한노력이적었고기존의병기체계는자궁육종의생존율을잘반영하지못하는한계가있었다 년개정에서는지금까지밝혀진자궁육종에대한정보와특성을반영하여별도의병기체계를발표하였다. 7,8 자궁육종중자궁평활근육종, 자궁내막기질육종, 선육종의세가지조직학적아형에따른새로운병기체계 (Table 8) 를만들었고, 암육종은개정 Table 7. Modified World Health Organization (WHO) histological classification of malignant tumors of the uterine corpus by the Gynecological Pathology Study Group of the Korean Society of Pathologists A. Epithelial tumors C. Mixed epithelial and ㆍEndometrial carcinoma mesenchymal tumors Endometrioid ㆍCarcinosarcoma adenocarcinoma (malignant müllerian mixed Mucinous tumor, MMMT) adenocarcinoma ㆍAdenosarcoma Serous adenocarcinoma Clear cell adenocarcinoma Squamous cell carcinoma Small cell carcinoma Undifferentiated carcinoma Others B. Mesenchymal tumors ㆍEndometrial stromal tumors Endometrial stromal sarcoma, low grade Undifferentiated endometrial sarcoma ㆍSmooth muslcle tumors Leiomyosarcoma Smooth muscle tumors of uncertain malignant potential Miscellaneous mesenchymal tumors

7 이마리아외 1 인. 개정된부인암 FIGO 병기결정체계 Table 8. The International Federation of Gynecology and Obstetrics (FIGO) staging for leiomyosarcomas and Endometrial stromal sarcomas (ESS) and Adenosarcomas * Leiomyosarcomas Stage I IA IB Stage II IIA IIB Stage III IIIA IIIB IIIC Stage IV Tumor limited to uterus Less than 5 cm Greater than or equal to 5 cm Tumor extends to the pelvis Adnexal involvement Tumor extends to extrauterine pelvic tissue Tumor invades abdominal tissues (not just protruding into the abdomen) One site More than one site Metastasis to pelvic and/or para-aortic lymph nodes Tumor invades bladder and/or rectum and/or distant metastasis Tumor invades bladder and/or rectum Distant metastasis IVA IVB Endometrial stromal sarcomas (ESS) and adenosarcomas * Stage I IA IB IC Stage II IIA IIB Stage III IIIA IIIB IIIC Stage IV Tumor limited to uterus Tumor limited to endometrium/endocervix (without myometrial invasion) Tumor invades up to less than half of myometrium Tumor invades to more than one half of myometrium Tumor extends to the pelvis Adnexal involvement Tumor extends to extrauterine pelvic tissue Tumor invades abdominal tissues (not just protruding into the abdomen) One site More than one site Metastasis to pelvic and/or para-aortic lymph nodes Tumor invades bladder and/or rectum and/or distant or metastasis Tumor invades bladder and/or rectum Distant metastasis IVA IVB * Simultaneous tumors of the uterine corpus and ovary/pelvis in association with ovarian/pelvic endometriosis should be classified as independent primary tumors. 된자궁내막암의병기체계를사용하기로하였다. 자궁내막기질육종과선육종은동일한병기체계를사용하기로하였다. 난소암 부인암중난소암은다른암종에비해특이증상이없어 조기진단이어렵고, 발견당시병기가진행된경우가많아이로인한사망률이높은것이특징이다. 난소는복막주름에의해광인대에, 골반누두인대에의해골반외벽에연결되어있는조직으로, 다양한병리조직학적유형의악성종양이발생하여치료방침도이의분류에따라결정된다. 림프절배액은자궁- 난소및원인대줄기와외장골부속경로를통해외장골, 총장골, 하복부, 외천골, 대동맥주위및드물게는서혜부림프절과같은국소림프절로이루어진다. 망을포함한복막, 골반및복부장이주된전이부위이다. 횡격막침범및간전이가흔하며폐및늑막침범도종종발견된다. 1. 병기결정원칙난소암은외과적병기결정체계를따른다. 종괴절제술이전의수술적소견이병기를결정하며, 이는임상적또는방사선적뿐아니라조직병리학적평가에의해수정될수있다. 개복술을통한자궁절제술및난소종괴의절제가병기결정의기초가되며. 대망 (omentum), 장간막, 간, 횡격막, 골반및대동맥주위림프절과같은모든의심되는부위의조직생검을요한다. 수술후최종조직학적소견 ( 가능하면세포검사결과와함께 ) 이병기결정시고려되어야한다. 만약난소암이진단되면흉부방사선검사를포함한임상적검사가시행된다. 전산화단층촬영술및자기공명영상술이최초병기결정및종양의추적관찰에도움이될수있다. 수술후병리조직학적으로난소암진단이이루어진후전원되는경우가있는데, 이들중일부는이미종양감축술 (cytoreductive surgery) 과포괄적병기설정술 (comprehensive surgical staging) 이시행된경우도있다. 그러나불완전한수술또는불충분한병기설정술후에전원되는경우, 진단검사는전술한바와같은절차를시행한다. 또한모든환자에서기존병리조직의재검토가추천된다. 1) Clinical-diagnostic staging 다른부위에사용되는임상적검사가이용될수있으나, 진단은대부분개복술을필요로한다. 난소암이진단되면흉부및복부방사선검사, 간검사, 피검사와같은임상적검사가시행된다

8 대한산부회지제 53 권제 8 호, ) Surgical-evaluative staging 개복술을통한침윤이의심되는모든부위의조직검사가기초가된다. 조직학적및세포검사자료가요구되며, 종종수술후병기와일치한다. 3) Postsurgical treatment-pathologic staging 개복술을통한자궁절제술및난소종양절제를포함하며, 망, 장간막, 간, 횡격막, 골반및대동맥주위림프절과같은모든의심되는부위의조직생검이요구된다. 늑막삼출 (pleural effusion) 은세포검사로입증되어야한다. 4) Retreatment staging 조기재발을발견하는데있어골반및복부검사의제한성때문에이차추시개복술및복강경술이시행될수있으며혈중 CA-125 의측정은난소암재발을진단하는데매우유용하다. 다른선택검사로는초음파검사와전산화단층촬영검사등이있다. 모든재발이의심되는부위는조직검사를통한확진을필요로한다. 2. 병기분류병기결정은주로외과적조사시발견되는소견에기초한다. 임상적검사와영상적진단방법들은적절하게시행되어야하며이러한소견들이최종병기에영향을미칠수있다. 삼출액의존재시세포검사결과가고려되듯이조직검사결과가병기결정시고려된다. 골반외에의심되는부위의생검을시행하는것이바람직하다. 1) FIGO 병기체계최근개정된난소암의 FIGO 병기체계는다음과같다 (Table 9). 2) 조직병리 AJCC 에따라난소종양의조직학적유형은 1973 년 9차 World Health Organization (WHO) publication에제시된것과같이나뉘어지고모든상피세포성종양은단순화형인장액성 (serous), 점액성 (mucinous), 자궁내막양 (endometrioid), 투명세포 (clear cell; mesonephroid), 미분화형 (undifferentiated) 및미분류형 (unclassified) Table 9. The International Federation of Gynecology and Obstetrics (FIGO) staging for ovarian cancer (2008) Stage I IA IB IC Stage II IIA IIB IIC Stage III IIIA IIIB IIIC Stage IV Growth limited to the ovaries Growth limited to one ovary; no ascites present containing malignant cells. No tumor on the external surfaces; capsules intact Growth limited to both ovaries; no ascites present containing malignant cells; no tumor on the external surfaces; capsules intact Tumor stage IA or IB but with tumor on the surface of one or both ovaries; or with capsule ruptured; or with ascites present containing malignant cells or with positive peritoneal washings Growth involving one or both ovaries with pelvic extension Extension and/or metastases to the uterus and/or tubes Extension to the other pelvic tissues Tumor stage IIA or IIB but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites present containg malignant cells or with positive peritoneal washings Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastases equal to stage III; tumor limited to the true pelvis but with histologically proven malignant extension to the small bowel or omentum Tumor grossly limited to the true pelvis with negatives nodes but with histologically confirmed microscopic seeding of the abdominal peritoneal surfaces Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes negative Abdominal implants>2 cm in diameter and/or positive retroperitoneal or inguinal nodes Growth involving one or both ovaries with distant metastases. If pleural effusion is present, there must be positive cytology to allot a case to stage IV. Parenchymal liver metastasis equals stage IV 으로분류된다 (Table 10). 난소가일차근원지가아니라부수적으로침범된것처럼보이는복강내암종은복막암종으로분류되어야한다. 3) 조직분화도난소암의조직분화도는중요한예후인자로 1, 2, 3세

9 이마리아외 1 인. 개정된부인암 FIGO 병기결정체계 Table 10. Modified World Health Organization (WHO) classification for ovarian cancer by the Gynecological Pathology Study Group of the Korean Society of Pathologists A. Surface epithelial tumors ㆍ Serous tumors Malignant Borderline ㆍ Mucinous tumor Malignant Borderline ㆍ Endometrioid tumors Malignant Adenocarcinoma, NOS Malignant mullerian mixed tumor (carcinosarcoma) Adenosarcoma Endometrioid stromal sarcoma Borderline ㆍ Clear cell tumors Malignant Borderline ㆍ Transitional cell tumors Malignant Transitional cell carcinoma (non-brenner type) Malignant Brenner tumor Borderline ㆍ Squamous cell carcinoma ㆍ Mixed epithelial tumors ㆍ Undifferentiated and unclassified carcinoma B. Sex cord-stromal tumors ㆍ Granulosa-stromal tumors Granulosa cell tumor Adult Juvenile ㆍ Sertoli-stromal tumors Sertoli-Leydig cell tumor ㆍ Sex-cord-stromal tumor of mixed or unclassified cell types ㆍ Steroid cell tumors C. Germ cell tumors ㆍ Primitive germ cell tumors Dysgerminoma Yolk sac tumor Embryonal carcinoma Polyembryoma Choriocarcinoma Mixed germ cell tumor ㆍ Teratoma Immature teratoma Mature teratoma with maglignant component D. Germ cell sex-cord-stromal tumors ㆍ Gonadoblastoma E. Miscellaneous tumors F. Lymphoid and hematopoietic tumors G. Secondary tumors 등급으로분류하였다 (Table 11). 난관암난소암과같이개복술을통한자궁절제술및난관종괴의절제가병기결정의기초가되며, 모든의심되는부위 ( 망, 장간막, 간, 횡격막, 골반및대동맥주위림프절 ) 의조직생검이요구된다. 수술후최종조직학적소견이병기에고려되어야한다. 난관암의병기는외과적병기결정체계를따르며난소암의병기결정체계와동일하다. 난관암이진단되면흉부방사선검사를포함한임상적검사를시행하며전산화단층촬영술이최초병기결정과종양의추적관찰에도움이될수있다. 질암종괴의일차성장부위가질에존재할때질암으로분류되어야하며생식기또는생식기외의부위로부터질로의 Table 11. Histopathologic grade of ovarian cancer Well differentiated Moderately differentiated Poorly differentiated or undifferentiated 이차성장을보이는종양은배제되어야한다. 자궁경부의병변이질로의확장을보이고경관외구에달하는것은자궁경부암으로분류되어야한다. 요도에국한된성장을보이는종양은요도암으로분류된다. 병기결정의원칙은자궁경부암의경우와유사하다. 질암은대개상부 2/3 에위치하는골반림프절및하부 1/3 에있는서혜부림프절을통해배액된다. 1. 병기분류 1) FIGO 병기체계질암은임상적병기체계를유지하고있으며 FIGO 병기체계는다음과같다 (Table 12)

10 대한산부회지제 53 권제 8 호, 2010 Table 12. The International Federation of Gynecology and Obstetrics (FIGO) staging for vaginal cancer Stage I The carcinoma is limited to the vaginal wall Stage II The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall Stage III The carcinoma has extended to the pelvic wall Stage IV The carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum; bullous edema as such does not permit a case to be allotted to stage IV IVA The growth spreads to adjacent organs and/or direct extension beyond the true pelvis IVB The growth spreads to distant organs 외음부암 종괴의일차성장부위가외음부에있을때외음부암으로분류하며, 생식기또는생식기외의부위로부터외음부로의이차성장을보이는종양은배제되어야한다. 악성흑색종은따로보고되어야하고질로의확장을보이는외음부암은외음부암으로간주되어야한다. 대퇴부및서혜부림프절이국소전이부위이며, 외, 내총장골림프절과같은골반림프절의침윤은원격전이로간주된다. 1. 병기분류 외음부암의병기는 TNM 체계에기초하여 1969 년 FIGO 에서임상적병기결정체계가채택되었으나, 임상적으로촉지되지않는림프절에미세전이가있을수있고촉지되는림프절도염증에의해커져있을수있기때문에 1988 년에외과적병기결정체계를도입하였다. 이후 1994 년에재편되어현재까지이르다가각병기간의생존율차이를반영하지못한다는문제점이지적되어 2008 년외음부암의병기결정체계가개정되었다 (Table 13). 9 기존의병기 I, II은생존율에차이가없어통합되었고 IA, IB로재분류되었다. 10 병기 I, II에서암세포침윤이없는림프절의크기는예후와상관이없으며침윤된림프절의모양과양상이예후와관련이있다는연구들이보고되어이를반영한것이다. 기존의 III기는다양한상태의환자를포함하여생존율의차이가컸다. 9 따라서침윤된림프절의개수와형태에따라병기를세분화하였다. 크기가 5 mm 이상인림프절이 1개이거나이보다작지만 2개인경 Table 13. The International Federation of Gynecology and Obstetrics (FIGO) staging for vulva cancer (2008) Stage I IA IB Stage II Stage III IIIA IIIB IIIC Stage IV IVA IVB Tumor confined to the vulva Lesions 2 cm in size, confined to the vulva or perineum and with stromal invasion 1.0 mm *, no nodal metastasis Lesions >2 cm in size or with stromal invasion >1.0 mm *, confined to the vulva or perineum, with negative nodes Tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with negative nodes Tumor of any size with or without extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes (i) With 1 lymph node metastasis ( 5 mm), or (ii) 1~2 lymph node metastasis(es) (<5 mm) (i) With 2 or more lymph node metastases ( 5 mm), or (ii) 3 or more lymph node metastases (<5 mm) With positive nodes with extracapsular spread Tumor invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures Tumor invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone, or (ii) fixed or ulcerated inguino-femoral lymph nodes Any distant metastasis including pelvic lymph nodes * The depth of invasion is defined as the measurement of the tumor from the epithelialstromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. 우는 IIIA, 5 mm 이상인림프절이 2개이상이거나, 크기가더작지만 3개이상인경우는 IIIB, 림프절의침윤이피막을벗어나있을경우 IIIC 로분류하였다. 또한림프절침윤의양측성이예후와관련이없다는결과가반영되어 IV기에서림프절전이의양측성이삭제되었고림프절이고정되어있거나궤양이있는경우는 IVA 로분류하였다. 6,11 1) FIGO 병기체계외과적병기체계를도입하고있는외음부암의병기체계는 2008 년개정되었다 (Table 13)

11 이마리아외 1 인. 개정된부인암 FIGO 병기결정체계 2. 병기결정원칙 외음부에발생한악성흑색종은병변의크기가대개더작고예후가직경보다는침윤깊이와관련이있기때문에 FIGO 병기체계를적용할수없다. Clark 등의병기체계는피부형태가다르기때문에외음부병변에는잘적용되지않는다. Chung 등은 level I, V에대한 Clark 의정의는유지하고밀리미터를측정하여 level II, III, IV를결정하는변형된체계를제안하였다. Breslow 는흑색종의가장두꺼운부분을정상상피표면에서부터가장깊이침윤된부분까지측정하여병기를분류하였다 (Table 14). 임신성융모성종양 임신성융모성종양의병기는 1962 년에융모성종양의전이부위에기초를둔해부학적병기결정체계가최초로고안되었지만 1983 년에이르러서야 FIGO 에의해채택되었다 년 FIGO 는해부학적병기결정체계에비수술적 - 병리적인예후인자를추가하였다. 임신성융모성종양은대부분높은치료율을보이기때문에병기결정의궁극적인목적은관해를이루기위해덜침습적인항암치료방법에반응하는환자와보다침습적인항암치료방법에반응하는환자를구분하는것이다. 병기결정은병력, 임상적검진, 적절한실험실및방사선검사에기초해야한다. 혈중 β -hcg 값이임상적질병을정확히반영하기때문에조직학적확진이치료에도움이될수는있으나반드시진단에요구되지는않는다. 1. 병기분류 현재임신성융모성종양의병기분류는해부학적병기 Table 14. Microstaging of vulvar melanoma Clark et al. Chung et al. Breslow I Intraepithelial Intraepithelial <0.76 mm II Into papillary 1 mm from 0.76~1.50 mm dermis glandular layer III Filling dermal 1.1~2 mm from 1.51~2.25 mm papillae glandular layer IV Into reticular dermis >2 mm from glandular layer 2.26~3.0 mm V Into subcutaneous fat Into subcutaneous >3 mm fat 와예후점수제분류를혼합하여만든것이다. 병기 I은종양이자궁체부에국한되어있는경우, 병기 II는질또는골반전이를동반하는경우, 병기 III은자궁, 질또는골반침범과관계없이폐전이가있는경우, 병기 IV는뇌, 간, 신장, 또는소화기계침범이있는진행된경우로항암제에반응성이떨어지고대부분선행임신이포상기태가아닌경우가많고조직학적으로융모상피암이다. 1) FIGO 병기체계임신성융모성병기체계는임상적병기결정체계를유지하고있으며다음과같다 (Table 15). 2. 예후점수제 병기결정체계와더불어약제에대한저항성을예측하고적합한항암제선택으로치료결과를높이기위해예후인자를고려한예후점수제가도입되었다. Bagshawe 에의해최초로고안되어 1982 년 WHO에의해채택되었다. FIGO 는 2000년에기존의 WHO 분류체계에사용된위험인자중 ABO group 을제외하고간전이에대한위험도를 2점에서 4점으로상향조정한예후점수제를도입하였다 (Table 16). 12 결과해석시 6점이하를저위험군, 7점이상을고위험군으로이분화하여이전과차이를두었다. 결론 부인암영역에있어서자궁체부암, 난소암, 난관암및외음부암에는외과적병기결정이, 자궁경부암, 질암및임신성융모성종양에서는임상적병기결정이이용되고있다. 부인암환자의치료성적과예후에관한자료들의축적으로 2008 년부인암의병기결정체계가개정되었고이는 Table 15. The International Federation of Gynecology and Obstetrics (FIGO) staging for gestational trophoblastic neoplasia Stage I Disease confined to the uterus Stage II Disease outside of uterus but is limited to the genital structures (adnexa, vagina, and broad ligament) Stage III Disease extends to the lungs with or without known genital tract involvement Stage IV All other metastatic sites

12 대한산부회지제 53 권제 8 호, 2010 Table 16. The International Federation of Gynecology and Obstetrics (FIGO) 2000 classification for gestational trophoblastic neoplasia Scores Age < Antecedent pregnancy Mole Abortion Term - Interval months from index pregnancy <4 4 to <7 7 to <13 13 Pretreatment serum hcg (IU/mL) < to < to < Largest tumor size (including uterus) <3 cm 3 to <5 cm 5 cm - Site of metastases Lung Spleen, Kidney Gastro-intestinal Liver, Brain Number of metastases - 1 to 4 5 to 8 >8 Previous failed chemotherapy - - Single drug Two or more drug 암환자의치료계획수립및예후의예측그리고암연구의기초적인자료를제공해줄것으로기대된다. 이전병기결 정체계와의비교분석과앞으로보다객관적이며효율적인체계의확립을위해지속적인검토보완이필요하다. 1. Pecorelli S, Zigliani L, Odicino F. Revised FIGO staging for carcinoma of the cervix. Int J Gynaecol Obstet 2009; 105: Hricak H, Gatsonis C, Coakley FV, Snyder B, Reinhold C, Schwartz LH, et al. Early invasive cervical cancer: CT and MR imaging in preoperative evaluation ACRIN/GOG comparative study of diagnostic performance and interobserver variability. Radiology 2007; 245: Hong JH, Tsai CS, Lai CH, Chang TC, Wang CC, Chou HH, et al. Risk stratification of patients with advanced squamous cell carcinoma of cervix treated by radiotherapy alone. Int J Radiat Oncol Biol Phys 2005; 63: Horn LC, Fischer U, Raptis G, Bilek K, Hentschel B. Tumor size is of prognostic value in surgically treated FIGO stage II cervical cancer. Gynecol Oncol 2007; 107: 참고문헌 5. Creasman W. Revised FIGO staging for carcinoma of the endometrium. Int J Gynaecol Obstet 2009; 105: Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet 2009; 105: Prat J. FIGO staging for uterine sarcomas. Int J Gynaecol Obstet 2009; 104: Horn LC, Schmidt D, Fathke C, Ulrich U. New FIGO staging for uterine sarcomas. Pathologe 2009; 30: Homesley HD, Bundy BN, Sedlis A, Yordan E, Berek JS, Jahshan A, et al. Assessment of current International Federation of Gynecology and Obstetrics staging of vulvar carcinoma relative to prognostic factors for survival (a Gynecologic Oncology Group study). Am J Obstet Gynecol 1991; 164: ; discussion Tantipalakorn C, Robertson G, Marsden DE, Gebski V, Hacker NF. Outcome and patterns of recurrence for International Federation of Gynecology and Obstetrics (FIGO) stages I and II squamous cell vulvar cancer. Obstet Gynecol 2009; 113: Fons G, Hyde SE, Buist MR, Schilthuis MS, Grant P, Burger MP, et al. Prognostic value of bilateral positive nodes in squamous cell cancer of the vulva. Int J Gynecol Cancer 2009; 19: Kohorn EI. The new FIGO 2000 staging and risk factor scoring system for gestational trophoblastic disease: description and critical assessment. Int J Gynecol Cancer 2001; 11: = 국문초록 = 1958년이래로국제산부인과학회 (International Federation of Gynecology and Obstetrics, FIGO) 는부인암에대한분류와병기에대한변화, 발전에대해해마다보고하고있다. FIGO 의병기결정체계는환자의예후를예측하는인자를반영해서환자를분류하는체계이다. 이러한병기결정체계의목적은부인암환자의분류를제공하여여러기관들이치료방법을공유하는데있다. FIGO 의병기결정체계는가장최근의자료를통해매 3년마다수정을계속해오고있으며, 영상과치료방법을포함한과학적발전에의해지속적인개정이이루어지고있다. 2008년자궁경부암, 자궁내막암, 외음부암및자궁육종에대한 FIGO 병기결정체계가발표되었다. 임상에이를적용하여기존의병기결정체계와의비교를통한문제점을보완하고재수정하는지속적인노력이필요하다. 중심단어 : 국제산부인과학회, 병기결정체계, 부인암