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1 J Korean Surg Soc 2010;79:S26-30 DOI: /jkss Suppl1.S26 증 례 위수술기왕력이없는환자의심낭종성위염에서발생한위암 아주대학교의과대학외과학교실 김준영ㆍ허훈ㆍ조용관ㆍ한상욱 Gastric Cancer Associated with Gastritis Cystica Profunda in Patients without Previous Gastric Surgery June Young Kim, M.D., Hoon Hur, M.D., Yong Kwan Cho, M.D., Sang Uk Han, M.D. Department of Surgery, Ajou University School of Medicine, Suwon, Korea Gastritis cystica profunda (GCP) is an uncommom hyperplastic lesion, which is located within the submucosa. GCP may occur several years after previous gastric surgery. In some reported cases, it was a premalignant condition and may lead to carcinoma of the stomach. We report a case of a 54-year-old man with epigastric pain and dyspepsia. He had undergone peritoneal dialysis for end stage renal disease about 13 years prior. An Upper gastrointestinal endoscopy showed elevated lesion at the gastric antrum, looking like an advanced gastric cancer or gastrointestinal stromal tumor. Endoscopic biopsy results were tubular adenoma with low-grade dysplasia. When followed up 9 months later, the lesion had increased in size and symptoms remained. We therefore performed a subtotal gastrectomy. The final biopsy was adenocarcinoma arising in GCP. (J Korean Surg Soc 2010;79:S26-30) Key Words: Gastric cancer, Gastritis cystica profunda, Peritoneal dialysis 중심단어 : 위암, 심낭종성위염, 복막투석 서론 위암은국내에서발생빈도가가장높은악성종양중의하나다. 국내에서의위내시경검사는비용-효율이높아건강검진에서흔히시행되는검사이며, 위암진단의대부분은위내시경검사에의해이루어진다.(1) 또한위내시경검사중시행되는생검은위암확진을위한가장유용한검사이다. 이러한내시경생검은치료방침에결정적인영향을주지만위암환자의내시경생검진단율은 74 98% 로다양하게보고되고있다. 이렇게내시경생검진단율이차이가나는원인은시술자의숙련부족이나, 채취한검체의개수, 병 변의위치, 그리고병변의조직학적특성에의해생길수있다.(2) Gastritis cystica profunda (GCP) 는조직학적으로낭성샘 (cystic glands) 이점막하에자라는것으로그자체로는악성종양이아니지만장화생과이형성을유발하여위암의중요위험요인으로제시되고있다.(3) 하지만 GCP의진단은명확히알려진방법이없고, 병변의위치가점막하로일반적인내시경적생검으로조직을얻기힘들기때문에 GCP에서자란위암의경우내시경적생검에도진단이안되는경우가있다. 저자들은내시경검사상양성궤양및낮은정도의이형성진단받은환자를수술한결과, GCP에서발생한선암종 1예가있어보고하고자한다. 책임저자 : 한상욱, 경기도수원시영통구원천동산 , 아주대학교의과대학외과학교실 Tel: , Fax: hansu@ajou.ac.kr 접수일 :2010 년 7 월 7 일, 게재승인일 :2010 년 10 월 8 일 S26

June Young Kim, et al:gastric Cancer from Gastritis Cystica Profunda S27 증례 54세남자환자는다낭성신성낭종으로말기신질환을진단받아 13년전부터복막투석을받고있었으며

약 2 3개월동안지속된상복부불편감으로수술 10개월전상부위장관내시경을시행한결과, 위전정부에보르만2형의진행위암의증과장화생, 만성위축성위염소견을보여, 내시경적생검을시행하였으나, 조직검사소견은비정형선종증식을동반한궤양소견만보였다.

이번에는복부 CT 결과를참고하여내시경을통해심부 (strip) 조직검사를시행하여낮은정도의이형성을보이는관상선종 (tubular adenoma with low grade dysplasia) 결과를얻었다.

Fig. 1. Endoscopic and abdominal CT finding.

base. (B) 4 months before surgery, endoscopic view of 4 cm and 3 cm fungating masses are noted.

2 June Young Kim, et al:gastric Cancer from Gastritis Cystica Profunda S27 증례 54세남자환자는다낭성신성낭종으로말기신질환을진단받아 13년전부터복막투석을받고있었으며 6년전한차례복막투석관련한복막염으로도관을교체한과거력외에수술력은없으며, 17년전고혈압을진단받아투약중이다. 약 2 3개월동안지속된상복부불편감으로수술 10개월전상부위장관내시경을시행한결과, 위전정부에보르만2형의진행위암의증과장화생, 만성위축성위염소견을보여, 내시경적생검을시행하였으나, 조직검사소견은비정형선종증식을동반한궤양소견만보였다. 그후본원 소화기내과에서위궤양치료를지속하였으나상복부불편감은사라지지않아, 이후로도몇차례내시경과생검을시행하였지만장화생외에특이소견없었다. 다른원인을감별하기위해수술 3개월전복부 CT를시행한결과, 위전정부에악성병변이의심되어내시경을다시시행하였다. 이번에는복부 CT 결과를참고하여내시경을통해심부 (strip) 조직검사를시행하여낮은정도의이형성을보이는관상선종 (tubular adenoma with low grade dysplasia) 결과를얻었다. 일반적인경우수술의적응증이되지는않지만병변의크기가 5.2 cm로크고과거내시경소견과비교하여점차커지는양상보여수술적절제를결정하였다 (Fig. 1). 복강경을통해수술을시행하였고, 위전정부대만부위에 cm의덩어리가있었으며장막침범은없었다. Fig. 1. Endoscopic and abdominal CT finding. (A) 10 months before surgery, endoscopic view of 4 cm sized ulcerofungating mass-like lesion is noted on the low body with irregular base. (B) 4 months before surgery, endoscopic view of 4 cm and 3 cm fungating masses are noted. (C) 1 month before surgery, endoscopic view of fungating mass lesion with hyperemic mucosa and partial ulcerative change. (D) 1 month before surgery endoscopic ultrasonography shows that a cm sized well-marginated mixed echoic hard mass lesion arose from 3rd layer. (E) 3 months before surgery, abdominal CT shows gastric wall thickening at gastric antrum (white arrow).

S28 J Korean Surg Soc. Vol. 79, Suppl. 1 Fig. 2. Pathologic finding.

(B) Gross cut section: Yellowish white solid and fibrotic tumor involves the muscle layer and suspicious subserosal layer.

(D) Well differentiated tubular adenocarcinoma (black arrowhead) with lymphocyte infiltration (white arrowhead) is shown (H&E stain, 100).

수술후시행한조직검사는 Lauren 분류상장형의고분화형관상선암종이었으며이는 GCP에서자란것이었다. 암은고유근층에만국한되어점막혹은점막하조직의침범은없었고, 장막또는장막하조직의침범도없었다 (Fig. 2).

3 S28 J Korean Surg Soc. Vol. 79, Suppl. 1 Fig. 2. Pathologic finding. (A) Gross finding: The mucosal surface of the whole body shows a dome-shaped elevated lesion, measuring cm. (B) Gross cut section: Yellowish white solid and fibrotic tumor involves the muscle layer and suspicious subserosal layer. (C) Gastritis cystica profunda (white arrow) and gastric carcinoma arises in gastritis cystica profunda (H&E stain, 25). (D) Well differentiated tubular adenocarcinoma (black arrowhead) with lymphocyte infiltration (white arrowhead) is shown (H&E stain, 100). 위영역림프절비대나원격전이소견은보이지않았고, 복막투석으로인한약간의복수가관찰되었으며, 유착등수술에영향을줄특별한문제는없었다. 하지만복강경소견상암을배제할수없어, 원위부위절제술및 D1+α 림프절절제술후 Billroth I 위십이지장문합을시행하였다. 수술후시행한조직검사는 Lauren 분류상장형의고분화형관상선암종이었으며이는 GCP에서자란것이었다. 암은고유근층에만국한되어점막혹은점막하조직의침범은없었고, 장막또는장막하조직의침범도없었다 (Fig. 2). 환자는채취된 38개의영역림프절에서모두음성소견을보였으며, 림프관이나, 혈관, 신경의침범은없었다. 병기는 T2N0M0로 Stage IB에해당하며, 수술후 11일째별다른합병증없이퇴원하였다. 환자는 13년째복막투석중인분으로, 수술후에도복막 투석을원하였기때문에수술전후에만혈액투석으로전환하였다가, 수술후 31일째복막투석을다시시작하였으며, 이후별다른문제없이복막투석을시행하고있다. 고찰 Gastritis cystica polyposa는수술이나궤양등손상에의하여부분적이며만성적인허혈과염증방응으로인해낭성샘 (cystic glands) 조직이점막하조직에자라는것으로고유한위분비샘이위축되고장화생및이형성을유발하는것으로알려져있다. Gastritis cystica polyposa는위벽이두껍고, 여러개의낭종이발견되며, 점막이과다증식되며, 낭성샘이점막근육층이나점막하층및고유근층까지파급되는모습이관찰되며, GCP는낭성샘조직이점막하층에국

4 June Young Kim, et al:gastric Cancer from Gastritis Cystica Profunda S29 한된경우를말한다.(4,5) 이러한상황이일어날수있는가장흔한경우는위아전절제술후위공장문합부위에서발생하는것이며, 위내시경적용종절제술이나점막절제술후에도일어날수있다. 이외에도위축성위염, 그리고만성적인위궤양, 담즙의위역류에서도발생할수있다.(5) Franzin 등 (3) 이 20명의 GCP 환자들을추적관찰한결과 GCP가장화생과이형성을보이고있어, 암이전상태일가능성을제시하였고, 여러논문에서 GCP에서발생한위암을보고하였다.(5-8) 그럼에도위암과 GCP의연관성은명확하지않다. GCP가생기는원인으로추측되는위수술과거력, 위궤양, 담즙역류, 만성위축성위염등이모두그자체로위암의위험인자로밝혀진것들이기때문이다. 또한 GCP에서위암이발생한경우그병기를설정함에있어기존의병기설정을적용하기에는다소무리가있음에도불구하고특별히제시된병기결정방법이없어기존의위암병기를그대로따르고있으며, 그예후또한보고된바가없다. 그러므로 GCP 자체만으로수술적치료를제시하기에는증거가더필요하지만, 위암발생가능성이있고대량출혈의가능성 (9) 도있음으로면밀한추적관찰이필요하다. GCP의진단은 CT나내시경으로이루어지게되는데특징적으로다발성의밖으로자라는양상의위종양양상을보여, 위암이나위장기질종양으로오인되기도한다. 이러한경우내시경초음파가도움이되기도하지만정확한진단방법은확립되어있지않다.(5) 본증례의경우내시경소견에서위암또는위장기질종양을의심하였고, 내시경적초음파를시행하였음에도 GCP를의심하지못하였다. 또한의심부위에대한두차례의조직검사와 CT 시행후이를근거로한심부조직검사에도불구하고, 위암세포는발견되지못하였다. 이는병변의깊이가일반적인조직검사로는조직을얻어내기가어렵기때문인것으로생각된다. 즉, 위내시경을통한종양의조직검사결과가양성질환으로판명되었다할지라도 CT나내시경초음파검사를통해병변의깊이와범위를확인하고이러한결과를종합하여신중한진단을하여야할것으로생각된다. 본증례에서환자의복부불편감이지속되었고, 점차커지는양상을보였으며, 내시경초음파결과고유근층의병변으로내시경적절제술이아닌수술적치료를결정하였고, 또한수술시행중위암이강력히의심되어영역림프절절제술 (D1+α) 이추가적으로시행되었다. 영역림프절절제술이 D1+α로제한적으로시행된이유는, 말기신병증인환자의일반적인상태에대한고려와, 수술중림프절비대 등의소견이없었기때문이다. 본증례환자의경우말기신질환으로복막투석을시행하고있던환자였다. 또한복막투석으로인한복막염을앓았던과거력이있어, 복강내장유착이의심되었으나, 실제수술중장유착이확인되지않았다. 위절제수술후복막투석의경우는 Shimizu 등 (10) 에의해보고된바가있으나, 복막투석과위암수술후복강내전이와의상관성등에대한보고는현재밝혀진바가없다. 따라서복막투석액을통한세포진검사등지속적인경과관찰이필요하다. GCP는드문질환이다. 따라서내시경적진단과정에서 GCP에대한고려가없으면간과되기쉬운질환이며, 조직학적특징상암전단계일가능성이높다. 하지만 GCP가진단되었다하더라도이에대한치료방침은세워져있지않다. 만약 GCP가진단되었을경우위내시경적심부조직검사를통해암세포의존재여부를알아봐야하며, 조직학적인진단이없다하더라도, 모양과크기의변화를지속적으로관찰하여수술적절제도고려해봐야한다. 또한더많은증례에대한예후관찰을통해적절한치료방침을세우는것이남아있는과제이다. REFERENCES 1) Choi KS, Kwak MS, Lee HY, Jun JK, Hahm MI, Park EC. Screening for gastric cancer in Korea: population-based preferences for endoscopy versus upper gastrointestinal series. Cancer Epidemiol Biomarkers Prev 2009;18: ) Ahn JH, Kim SY, Kim JN, Park SM, Kim DI, Jung SW, et al. Diagnostic yield of gastroscopic biopsy in advanced gastric cancer. Korean J Helicobacter Up Gastrointest Res 2009;9: ) Franzin G, Musola R, Zamboni G, Manfrini C. Gastritis cystica polyposa: a possible precancerous lesion. Tumori 1985;71: ) Littler ER, Gleibermann E. Gastritis cystica polyposa (Gastric mucosal prolapse at gastroenterostomy site, with cystic and infiltrative epithelial hyperplasia). Cancer 1972;29: ) Park CH, Park JM, Jung CK, Kim DB, Kang SH, Lee SW, et al. Early gastric cancer associated with gastritis cystica polyposa in the unoperated stomach treated by endoscopic submucosal dissection. Gastrointest Endosc 2009;69:e ) Moon SY, Kim KO, Park SH, Yoo KS, Park CH, Kim JH, et al. Gastritis cystica profunda accompanied by multiple early gastric cancers. Korean J Gastroenterol 2010;55: ) Ochiai M, Matsubara T, Zhi LZ, Funabiki T, Sakurai Y, Hasegawa S, et al. Gastritis cystica polyposa associated with a gastric stump carcinoma, with special reference to cell ki-

5 S30 J Korean Surg Soc. Vol. 79, Suppl. 1 netics and p53 gene aberrations. Gastric Cancer 2000;3: ) Tsuji T, Iwahashi M, Nakamori M, Ueda K, Ishida K, Naka T, et al. Multiple early gastric cancer with gastritis cystica profunda showing various histological types. Hepatogastroenterology 2008;55: ) Itte V, Mallick IH, Moore PJ. Massive gastrointestinal haemorrhage due to gastritis cystica profunda. Cases J 2008;1:85. 10) Shimizu H, Ishibashi Y, Kumagai T, Kawarazaki H, Kawarazaki W, Kaname S, et al. Successful reinstitution of peritoneal dialysis after gastric resection: a case report. Perit Dial Int 2006; 26:

내시경 conference

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