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1 대한소화기내시경학회지 2008;37: 장결핵에동반된대장암 1 예 경희대학교의과대학내과학교실, * 외과학교실 차재명ㆍ이정일ㆍ최재원ㆍ주광로ㆍ정성원ㆍ신현필ㆍ허우영ㆍ이석환 * A Case of Colon Cancer Coexisting with Colonic Tuberculosis Jae Myung Cha, M.D., Joung Il Lee, M.D., Jae Won Choe, M.D., Kwang Ro Joo, M.D., Sung Won Jung, M.D., Hyun Phil Shin, M.D., Woo Young Hew, M.D. and Suk-Hwan Lee, M.D.* Departments of Internal Medicine and *Surgery, Kyunghee University College of Medicine, Seoul, Korea 만성염증성장질환은대장암을유발할수있는전암성병변으로잘알려져있다. 하지만, 장결핵은대장암과동반된일부증례들이보고되었음에도불구하고그인과관계가뚜렷하지않다. 장결핵과대장암이동시에발생한경우병리조직학적으로오진을할수있고, 영상의학적으로장결핵에의한림프절종대를대장암의림프절전이로오인할수있기때문에수술전정확한병기판정이어려울수있어서주의가요구된다. 저자들은복통으로내원한 43 세여자의상행결장에대장암과장결핵이중복된 1 예를경험하여이를보고하며, 문헌고찰을통하여국내외에서보고된유사한증례들의임상적인특징에대해분석하였다. 색인단어 : 대장암, 장결핵 서 론 증 례 궤양성대장염이나크론병과같은만성염증성장질환은대장암을유발할수있는전암성병변으로산발적대장암발생과연관이있다고알려져있다. 1,2 장결핵도대장에발생하는염증성장질환으로대장암과동시에발견된증례들이드물게보고된바있지만, 3-8 장결핵은치료가능한감염성질환이기때문에이환기간이짧아다른염증성장질환에비해대장암과의인과관계가불분명하다. 저자들은복통으로내원하여시행한대장내시경검사에서대장암과장결핵이동반된 1예를경험하여이를보고하며, 문헌고찰을통하여국내에서보고된유사한증례들의임상적인특징에대해분석하였다. 접수 :2008 년 7 월 4 일, 승인 :2008 년 9 월 16 일연락처 : 차재명, 경희대학교동서신의학병원내과 ( ) 서울시강동구상일동 149 전화 : , 팩스 : 이메일 : dramc@hanmail.net 평소건강하던 45세여자가 15일전부터우하복부통증이발생하여개인의원에서치료하였으나증상이호전되지않아전원되었다. 가족력과폐결핵을포함한과거력에서특이사항은없었다. 내원당시활력징후는혈압 120/80 mmhg, 호흡 20회 / 분, 맥박 54회 / 분, 체온 36.3 o C 로안정적이었다. 복부진찰에서장음이감소되어있었지만복부압통이나반발통은없었으며, 그외신체검사에서다른이상소견은관찰되지않았다. 말초혈액검사는백혈구 9,000/mm 3, 혈색소 12.7 g/dl, 혈소판 274,000/mm 3 였으며, 혈청생화학검사는정상이었다. 종양표지자검사는각각 CEA 12.1 ng/ml ( 정상범위 : 0 5 ng/ml) 와 CA IU/mL ( 정상범위 : 0 27 IU/ ml) 로상승되어있었다. 단순흉부및복부촬영에서특이소견은없었다. 대장내시경검사에서근위부상행결장의궤양성종괴가관찰되었으며, 협착으로인해내시경이통과하지않아종괴의근위부는관찰할수없었다 (Fig. 1A). 장관협 369

370 대한소화기내시경학회지 2008;37:369-373 착의원위부상행결장에서는점막위축및반흔과함께다발성의불규칙한궤양과윤상궤양이관찰되었다 (Fig. 1B).

복부및골반전산화단층촬영에서약 8 cm 길이의상행결장장관벽의이상비후소견이관찰되었고 (Fig.

하지만, 이어서시행한양전자방출단층촬영에서는간동맥및장간막림프절전이나복막전이는관찰되지않았으며, 간전이만확인할수있었다 (Fig. 3).

(A) The lumen of ascending colon is partially obstructed by a mass of which the mucosa is

(B) There are multiple irregular-shaped ulcers with dirty exudates. Figure 2.

(A) Coronal image demonstrates long segment annular wall thickening (arrowheads) with diffuse

2 370 대한소화기내시경학회지 2008;37: 착의원위부상행결장에서는점막위축및반흔과함께다발성의불규칙한궤양과윤상궤양이관찰되었다 (Fig. 1B). 내시경병리조직검사에서궤양성종괴는선암으로확인되었고, 다발성궤양에서는만성염증을동반한육아종이관찰되어장결핵을의심할수있었다. 복부및골반전산화단층촬영에서약 8 cm 길이의상행결장장관벽의이상비후소견이관찰되었고 (Fig. 2A), 간의후 상엽과꼬리엽에각각 15 mm와 12 mm 크기의암전이가의심되었으며 (Fig. 2B), 국소림프절전이, 간동맥및장간막림프절전이, 복막전이가의심되었다. 하지만, 이어서시행한양전자방출단층촬영에서는간동맥및장간막림프절전이나복막전이는관찰되지않았으며, 간전이만확인할수있었다 (Fig. 3). 대장암과장결핵이동반되어있었기때문에대장암의정확한병기를판정하 Figure 1. Colonoscopic findings. (A) The lumen of ascending colon is partially obstructed by a mass of which the mucosa is congested and bled easily by endoscopic touch. (B) There are multiple irregular-shaped ulcers with dirty exudates. Figure 2. Abdominopelvic CT findings. (A) Coronal image demonstrates long segment annular wall thickening (arrowheads) with diffuse enhancement in ascending colon. (B) A mass-like lesion with low attenuation is noted at posterosuperior segment (arrow) of the liver. Figure 3. Positron emission tomography findings. (A) It reveals hypermetabolic lesion in the ascending colon (maxsuv 3.5). (B) Another hypermetabolic lesion in the posterosuperior segment of the liver (maxsuv 4.0).

차재명외 : 장결핵에동반된대장암 1 예 371 기가어려웠고, 지속적인복통을호소하고있었기때문에수술을하기로결정하였다. 수술소견에서는간, 복막, 장간막, 난소에미만성암파종을동반한복수와직장선반이관찰되었으며, 복막결절에서시행한동결생검에서전이된선암이관찰되어고식적우측결장반절제술을시행하였다. 수술로절제된장의길이는 20 cm이었으며, 상행결장에 7.5 6.0 1.

5 cm in size, is noted in the ascending colon and it penetrates visceral peritoneum. At the distal portion of the tumor, superficial ulcers with atrophic mucosa are noted (arrows).

고 궤양성대장염이나크론병과같은만성염증성장질환이장기간지속된환자에서대장암발생의위험이증가한다는것은비교적잘알려져있지만, 1,2 장결핵은대장암과동반된증례보고들이있었음에도불구하고그인과관계가불분명하다. 3-8 대장암과장결핵이공존할수있는가능성으로는우연히두질환이공존하거나한질환이다른질환을유발했을가능성을고려할수있다.

3 차재명외 : 장결핵에동반된대장암 1 예 371 기가어려웠고, 지속적인복통을호소하고있었기때문에수술을하기로결정하였다. 수술소견에서는간, 복막, 장간막, 난소에미만성암파종을동반한복수와직장선반이관찰되었으며, 복막결절에서시행한동결생검에서전이된선암이관찰되어고식적우측결장반절제술을시행하였다. 수술로절제된장의길이는 20 cm이었으며, 상행결장에 cm 크기의궤양성종괴가관찰되었고이종괴는내장복막을통과하고있었고, 궤양성종괴의원위부에서장결핵성병변들이관찰되었다 (Fig. 4). 병리조직학적검사에서상행결장의궤양성종괴는점액분비를동반한중등도 Figure 4. Gross finding. An ulcerofungating lesion, measuring cm in size, is noted in the ascending colon and it penetrates visceral peritoneum. At the distal portion of the tumor, superficial ulcers with atrophic mucosa are noted (arrows). 분화도를보이는선암으로판명되었으며 (Fig. 5A), 궤양성종괴의원위부상행결장에서육아종이일부관찰되었다. 절제된 42개의국소림프절들중 22개의림프절에서전이된선암이관찰되었으며, 일부림프절에서는건락성육아종과상피양세포들이관찰되어결핵성림프절로판명되었다 (Fig. 5B). 수술후환자는항암화학요법을하며외래로추적관찰중이다. 고 궤양성대장염이나크론병과같은만성염증성장질환이장기간지속된환자에서대장암발생의위험이증가한다는것은비교적잘알려져있지만, 1,2 장결핵은대장암과동반된증례보고들이있었음에도불구하고그인과관계가불분명하다. 3-8 대장암과장결핵이공존할수있는가능성으로는우연히두질환이공존하거나한질환이다른질환을유발했을가능성을고려할수있다. 대장암에의한장관폐쇄가결핵균에의한이차감염을조장할수도있고, 9 암에의한세포면역약화와불완전한점막방어때문에결핵균에쉽게감염될수도있기때문에대장암이장결핵을유발할수있다는가설이있다. 10 Cooper 등 11 은회장결핵과회장암이동반된증례를통해결핵이전암성병변이라고주장하였으며, Dorai 등 9 은장결핵과대장암이구불결장에공존하는증례보고에서회맹부의침범없이구불결장에만장결핵이발생했기때문에대장암의장관폐쇄에의해이차적으로장결핵이발생했을것이라고주장하였다. 하지만, 이번증례와같이대장암의원위부에도장결핵이공존하는경 찰 Figure 5. Microscopic findings. (A) A finding of the mass showing adenocarcinoma with irregular shaped glands (H&E stain, 100). (B) A finding of a lymph node showing caseous granulomas composed of epithelioid cells and multinucleated giant cells (H&E stain, 100).

4 372 대한소화기내시경학회지 2008;37: Reference number Table 1. Clinical Characteristics of Reported Patients with Coexisting Tuberculosis and Carcinoma of the Colon Age/Sex Presentation Cases reported in the Korean literature Previous TB history Location of TB Location Features of colon cancer Histopathology Operative procedure /M 77/F 49/F 48/M 60/M 53/F Abdominal pain Pain*, constipation Diarrhea, pain* Abdominal pain ICV,, DC HF Distal Distal M/D adenocarcinoma P/D adenocarcinoma Extended Subtotal colectomy Inoperable Current case Abdominal pain Palliative Cases reported in the English literature /M 65/F 76/F 35/F 50/F 62/F 47/F 63/M 81/F 20/F Hematochezia Abdominal distension Pain*, diarrhea Pain*, fever Pain*, constipation, Ileum,, HF, Ileum, HF M/D adenocarcinoma Extended M, male; F, female; ICV, ileocecal valve;, ascending colon; HF, hepatic flexure;, transverse colon; DC, descending colon;, sigmoid colon; W/D, well differentiated; M/D, moderately differentiated;, not mentioned;, right hemicolrectomy; TB, tuberculosis. *It means abdominal pain. 우가있기때문에이러한주장은설득력이떨어진다. 12 다른한편으로는, 장결핵이대장암을유발했을수도있는데장기간지속된만성염증에서이형성변화가초래되어대장암이병발할수있다는가설이다. 6 Maruta 등 13 은장결핵이동반된대장암증례에서결핵성궤양반흔에동반된비정형적재생세관과선상선은대장암의전구병변일수있다고보고하였다. 13 하지만, 일반적으로장결핵환자에서대장암이빈발한다는역학적증거가없고, 12 장결핵과대장암이동반된환자에서만성결핵의특징적인소견인림프절내석회화병변이나병변부위의섬유화가관찰되지않기때문에이러한가설을뒷받침하지못하고있다. 12,14 이번증례에서는장결핵이대장암의원위부에발생하였고장결핵주위점막에서이형성과같은병리조직학적소견이관찰되지않았기때문에두병변은우연히동반되었을가능성이높다. 장결핵과대장암이공존할경우대장암의진단은내시경이나수술을통한조직검사로확진할수있지만장결핵의진단은상대적으로어려울수있다. 장결핵의진단은결핵균이나건락성육아종을병변에서증명해야 하지만진단기준을만족하지못하는증례들이있기때문이다. 8 이번증례의대장내시경생검에서결핵균이나건락성육아종이증명되지는않았지만, 점막위축, 반흔, 환상궤양등과같은대장내시경소견들이관찰되었고내시경생검에서비건락성육아종이관찰되어장결핵을의심할수있었다. 저자들은 KoreaMed 및 PubMed 컴퓨터검색을통하여장결핵과대장암이동시에발생한증례들을조사하여, 1988년이래국내에서보고된 6예의증례들과 1970년이래국외영어문헌에서보고된 10예의증례들을찾을수있었다 (Table 1). 3-12,14-16 본증례를포함하여 17예를분석한결과, 남녀성비가 5:12로여성의비율이많고주로우측대장에호발하였다. 환자들의평균나이는 56 세였으며, 폐결핵의과거력이있거나 3,8 흉부단순촬영에서폐결핵을앓은흔적이있는경우 6,16 는 4예에불과하였다. 이번증례를포함한 9예는처음부터장결핵과대장암의공존을진단하였으나, 4,6,8-11,14,16 장결핵을먼저진단하고항결핵제를복용했음에도불구하고전신상태가악화되어동반된대장암을진단한경우도있었고, 5,7,15

5 차재명외 : 장결핵에동반된대장암 1 예 373 대장암을수술한후혈변이발생하여시행한대장내시경검사에서장결핵을진단한예도있었다. 3 그러므로, 장결핵에대해충분히항결핵제를복용했는데도불구하고임상적으로호전되지않을경우약제내성결핵균외에대장암과같은다른질환의중복을고려해야한다. 장결핵과대장암이다른분절에있었던증례는 4예 3,6,12 에불과한반면, 그외 13예 (76%) 에서는장결핵과대장암이같은분절에서관찰되었으며, 이들중이번증례를포함한 7예에서는대장암에의한장관폐쇄가관찰되었다. 4,7,8,10,14,16 장결핵과대장암이공존하는많은증례들에서대장암에의한장관폐쇄가동반되며두병변들이같은분절에서관찰되었기때문에대장암에의한장관폐쇄가두질환의공존에기여할가능성을고려할수있다. 대장암과장결핵이공존하는경우병리조직학적으로오진을할수있을뿐만아니라, 5,7,15 영상의학적으로장결핵에의한림프절종대를대장암의림프절전이로오인하여수술전에정확한병기판정이어려울수도있다. 4,6 실제로, 수술전에는원격림프절전이가의심되었으나, 수술후원격림프절에서암전이는없고림프절결핵만관찰된증례도있었다. 6 이번증례에서도영상의학검사만으로원격림프절종대에대해대장암의림프절전이유무를구분하기어려워수술을시행하였으며, 수술결과대부분이대장암의림프절전이로판명되었다. 저자들은복통으로내원한 45세여자의상행결장에서대장암과장결핵이중복된 1예를경험하여이를보고하며, 문헌고찰을통하여국내외에서보고된유사한증례들의임상적인특징에대해보고한다. ABSTRT Patients with chronic inflammatory bowel disease have a potential risk for developing colorectal cancer. Simultaneous occurrence of tuberculosis and colon cancer at the same segment of the colon has been reported; however, there is little causal relationship between the two disorders. The occurrence of tuberculosis and an adenocarcinoma at the same segment of the colon may lead to a histological misdiagnosis of either lesion. Furthermore, it may be difficult to determine the correct radiological cancer staging before surgery, as tuberculous lymphadenitis may be misinterpreted as a lymph node metastasis of colon cancer. We report here a rare case of colon cancer coexisting with colonic tuberculosis at the same segment of the colon. In addition, we review the clinical characteristics of reported patients with similar conditions following a computerized search of KoreaMed and PubMed. (Korean J Gastrointest Endosc 2008;37: ) Key Words: Colon cancer, Intestinal tuberculosis 참고문헌 1. Ekbom A, Helmick C, Zack M, Adami HO. Ulcerative colitis and colorectal cancer. A population-based study. N Engl J Med 1990;323: Ekbom A, Helmick C, Zack M, Adami HO. Increased risk of large-bowel cancer in Crohn s disease with colonic involvement. Lancet 1990;336: Hwang LS, Nam SW, Lee SE, et al. A case of pancreaticobiliary duct obstruction due to pancreatic tuberculosis combined with a colon adenocarcinoma and tuberculosis colitis. Korean J Gastrointest Endosc 2007;35: Yun, Shin EJ, Song OP, et al. A case of colon cancer associated with colonic tuberculosis. J Korean Soc Coloproctol 2007;23: Ha CY, Jung HK, Ryu JH, et al. A case of diffuse infiltrative colon cancer coexisting with colonic tuberculosis. Korean J Gastrointest Endosc 2004;29: Han MS, Kim JS, Kim WS, Jang HJ, Kang GH. Colon cancer and polyposis associated with colon tuberculosis. J Korean Soc Coloproctol 2000;16: Seong SG, Ryu CS, Kim DK, Park KH, Cho BS, Choi HS. A case of colon cancer associated with tuberculosis colitis. Korean J Gastroenterol 1996;28: Ahn TH, Kim JW, Kang DH, Ryu SK, Hyun JH. Colon cancer associated with tuberculous colitis, report of a case. Korean J Gastroenterol 1988;20: Dorai CR, Harun ZB. Colonic tuberculosis with colonic carcinoma--a rare association. Postgrad Med J 1991;67: Sane SY, Nimbkar SA. Carcinoma colon with tuberculosis. J Postgrad Med 1980;26: Cooper MJ, Williamson RC, Smith JH. Ileal carcinoma and tuberculosis ileitis. Postgrad Med J 1987;63: Jain BK, Chandra SS, Narasimhan R, Ananthakrishnan N, Mehta RB. Coexisting tuberculosis and carcinoma of the colon. Aust N Z J Surg 1991;61: Maruta K, Tanaka S, Nakamura T, Hagio S, Sato E, Nishi M. Carcinoma of the colon coexisting with tuberculosis-report of 2 cases. Gan No Rinsho 1983;29: Barson AJ, Kirk RS. Colonic tuberculosis with carcinoma. J Pathol 1970;101: Isaacs P, Zissis M. Colonic tuberculosis and adenocarcinoma: an unusual presentation. Eur J Gastroenterol Hepatol 1997; 9: Tandon HD, Kapoor BM. Carcinoma of the colon associated with tuberculosis: report of a case. Dis Colon Rectum 1974; 17:

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untitled The Korean Journal of Gastrointestinal Endoscopy Case Report 구불결장의동일부위에발생한선암과결핵성림프절염 1 예 류성호ㆍ신운건ㆍ이승민ㆍ박소연ㆍ김성준ㆍ유종진ㆍ조성진 * ㆍ김학양 한림대학교의과대학내과학교실, * 병리학교실 Adenocarcinoma and Tuberculous Lymphadenitis on the Same