The Korean Journal of Pathology 2006; 40: 대장암병리보고서기재사항표준화 장희진 박철근 김우호 김영배김윤화 김호근 배한익 송규상장미수 장희경 채양석 대한병리학회소화기병리학연구회 A Standardized Pathology R

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1 The Korean Journal of Pathology 2006; 40: 대장암병리보고서기재사항표준화 장희진 박철근 김우호 김영배김윤화 김호근 배한익 송규상장미수 장희경 채양석 대한병리학회소화기병리학연구회 A Standardized Pathology Report for Colorectal Cancer Hee Jin Chang, Cheol Keun Park, Woo Ho Kim, Young Bae Kim, Youn Wha Kim, Ho Guen Kim, Han Ik Bae, Kyu Sang Song, Mee Soo Chang, Hee Kyung Chang and Yang Seok Chae The Gastrointestinal Pathology Study Group of the Korean Society of Pathologists, Seoul, Korea 접수 : 2006 년 3 월 7 일게재승인 : 2006 년 4 월 10 일 책임저자 : 박철근우 서울시강남구일원동 50 성균관대학교의과대학삼성서울병원병리과전화 : Fax: ckpark@smc.samsung.co.kr Background and Methods : For standardizing the pathology report and diagnosis of colorectal cancers, the Gastrointestinal Pathology Study Group of the Korean Society of Pathologists has developed a pathology reporting format for colorectal cancer in collaboration with the Korean Society of Coloproctology. Results : The diagnostic parameters are divided into two parts: the standard part and the optional part. The standard part contains most of the items listed in the Japanese classification, the TNM classification by AJCC, and the WHO classification. We included detailed descriptions on each item. Conclusions : The standardized pathology report for colorectal cancers is adequate for its application to routine surgical pathology reports, and it is also helpful to decrease the discrepancies that occur during the pathologic diagnosis of colorectal cancer. Furthermore, this reporting format could encourage nationwide multi-center collaborative studies. Key Words : Colorectal neoplasm; Pathology report; Surgical pathology; Neoplasm staging; Histologic type 대장암은국내에서네번째로자주발생하는암으로국내전체암발생의 11.2% 를차지한다. 1 최근식생활의서구화와대장내시경검사의보급확대로대장암발생률이높아지고있다. 그러나서구와일본의사들간에대장의상피성병변을병리학적으로진단하는기준이다르기때문에, 2 우리나라에서는어느쪽기준을따르느냐에따라병리의사들의진단이달라질수있으며, 대장암의병리보고서양식이병원마다다르기때문에, 병리보고서를표준화해야한다는요구가높아지고있다. 일본에서는이미 1977년에일본대장암연구회를중심으로대장암취급규약을제정하여대장암진단을표준화하였으며, 3 미국병리학회 (CAP, College of American Pathologist) 와병리과장협회 (AASP, Association of irectors of Anatomic and Surgical Pathology) 도 2003년각종암보고서에포함해야할항목에대한규약을제정하여발표하였다. 4,5 일본과미국에서각각제정한대장암의병리보고서기재항목에큰차이는없다. 그러나암의 T ( 침윤깊이 ) 와 N ( 림프절전이 ) 병기, 그리고육안분류등에대한기준이다르고, 더욱이이형성증과암종의진단기준및체계가다르기때문에어느한쪽의기준을그대로따르기는적절치않다. 3,4 국내에서도 1988년에대한대장항문학회와대한외과학회주관으로 < 한국인대장암취급지침서 > 를만들어서임상적으로나병리학적으로통일된대장암취급방법을보급하려했다. 6 그러나당시제정한병기분류는일본의대장암취급규약을따르고있었으며, 그동안개정이이루어지지않았기때문에, 현재국내에서표준화지침서로사용하기에는부적절하다. 대한병리학회소화기병리학연구회에서는대한대장항문학회와함께대장암병리보고서를표준화하는작업을하였다. 2005년 3 월부터 11월까지소화기병리학연구회산하의위장관상피성종양소위원회모임을세차례갖고, H&E 슬라이드의회람및연구회전체의논의를거쳐, 본 < 대장암병리보고서기재사항표준화 > 를완성하였다. 이를위해현재국내대형병원에서사용하는병리보고서양식을참고하였으며, 일본의 扱い規, 3 미국병리학회의프로토콜, 4 미국병리과장협회의체크리스트, 5 AJCC 분류법 ( 제6판 ), 7 WHO 분류 (2000), 8 종양학국제질병분류 (IC-O) 9 등을참고하였다. 최근에는대장내시경생검술과용종절제술을시행하는빈도가늘어나면서적절한치료를위하여환자들의전원이늘어나고있는현실이다. 이러한현실을감안할때, 표준화된대장암병리 193

2 194 장희진 박철근 김우호외 8 인 보고서는환자의적절한진료를위해반드시필요하며, 앞으로국내에서다기관간임상시험에서동일한환자군을선택하는데도움이될것이다. 본병리보고서는 2005년에발표한위암병리보고서와형식을같이하였다. 10 따라서대장암의병리진단에서암의기본적인병리학적소견과예후판정혹은치료에필요한최소한의기본사항들을필수기재사항으로분류하였고, 그외의예후관련인자들이나보조치료에필요한사항들은선택기재사항으로분류하였다. 각병원에서는특성에맞추어선택기재사항이외의항목을추가하여사용할수있다. 또한병리보고서의국제화를위하여영어로기재하도록하였으며, 앞으로각항목의판정기준이나분류법이바뀌더라도추후에추적할수있도록약자나숫자로된분류법의사용을제한하였다. 본병리보고서도위암병리보고서와마찬가지로병원에서사용하기쉽도록판독용양식을본논문에첨부하였다. 또한대한병리학회소화기병리학연구회의홈페이지에서도본병리보고서의판독용양식파일을다운받아사용할수있다. 절제대장의표준기재사항 결과및고찰 Specimen type right hemicolectomy transverse hemicolectomy left hemicolectomy anterior resection low anterior resection abdominoperineal resection subtotal/total colectomy total proctocolectomy endoscopic mucosal resection transanal excision transanal endoscopic microsurgery (TEM) other 해설 : 본기재사항은수술로절제한대장암뿐아니라내시경절제혹은경항문절제표본에서도동일하게적용할수있도록하였다. Main diagnosis Multiple carcinomas 해설 : 종양이두개이상있는경우에는 multiple carcinomas 로표시하고, 가장깊은종양부터각각의종양에대한모든항목을적되, lymph node metastasis, associated findings, separate lesions은가장깊은종양에만적는다. 10 주진단명은대장암의조직학적유형을기재한다. Histologic type Adenocarcinoma well differentiated moderately differentiated poorly differentiated Mucinous adenocarcinoma Signet-ring cell carcinoma Small cell carcinoma Squamous cell carcinoma Adenosquamous carcinoma Medullary carcinoma Undifferentiated carcinoma Other 해설 : 조직학적유형은 WHO 의분류 (2000) 를따른다. 8 선구조를만드는면적이 95% 를초과하면고분화형샘암종, 50-95% 면중분화형샘암종, 5-49% 면저분화형샘암종, 5% 미만이면미분화암종으로분류한다. 점액샘암종과인환세포암종은세포외점액과인환세포가각각종양의 50% 이상일때진단하고, 샘편평세포암종은분명한편평상피분화를보이는부분이 WHO 분류기준대로 more than just occasional small foci 일때진단하며, 수질암종은암세포내림프구침윤이현저할때진단한다. 8 Others에는 Spindle cell carcinoma (Sarcomatoid carcinoma), Carcinosarcoma, Pleomorphic carcinoma, Pigmented carcinoma, Clear cell carcinoma, Stem cell carcinoma, Paneth cell-rich carcinoma, Choriocarcinoma, Carcinoid (Well differentiated endocrine neoplasm) 등이포함된다. 7 Malignant lymphoma, stromal tumor 등은포함하지않는다. Location cecum ascending colon hepatic flexure of colon transverse colon splenic flexure of colon descending colon sigmoid colon overlapping lesion of colon ( ) rectosigmoid junction rectum other 해설 : 위치는 IC-O의분류를따른다. 9 대장전체의길이를 150 cm로가정할때, 맹장의길이는대략 6 cm, 상행결장은 15 cm, 횡행결장은 50 cm, 하행결장은 25 cm, 에스자결장은 40 cm이며, 직장은항문연 (anal verge) 의 cm 상방부터 dentate line의 1-2 cm 상방까지다. 11 종양이대장의두부분을침범하였을때는더많이침범한부위로분류하며, 두부분을똑같은범위로침범하였을때는중복병변 (overlapping lesion) 으로분류한다. 9 Gross type superficial fungating / polypoid

3 대장암병리보고서기재사항표준화 195 ulcerofungating ulceroinfiltrative infiltrative unclassifiable 해설 : 미국병리학회에서는육안형태를 exophytic, ulcerative, infiltrative, other로나누고있으나, 12 일본에서는 type 0 부터 type 5까지나누고있다. 3 Type 0는 superficial type 이고, type 1부터 type 4는진행위암의 Borrmann의분류법과동일하며 type 5는 unclassifiable에해당한다. 본연구회에서는일본의육안분류와동일한분류법을채택하였다. Superficial type은점막또는점막하층에국한된조기대장암에만사용하며, 3 정의는 flat adenoma와마찬가지로종양의두께가주변점막의 2배이하일때로하였다. 13 일본의분류에서는 type 0를 type 0-I (protruded), type 0-II (superficial), type 0-III (excavated) 로세분하고, type 0-I과 type 0-II를각각세가지아형 (type 0-I: pedunculated, semipedunculated, sessile; type 0-II: superficial elevated, superficial flat, superficial depressed) 으로나누고있다. 3 본연구회에서는 fungating/polypoid type에서두가지용어를모두사용하기로하였다. 분류용어의통일을위해서는 fungating type을사용하는것이더좋으나, 용종에서생긴작은크기의대장암에서는 fungating type보다는 polypoid type이더적합하기때문이다. Tumor size x x cm 해설 : 종양의크기는가장긴축의길이와이에수직인길이의곱으로표시한다. 종양의깊이는가장두꺼운곳에서현미경으로측정한다. epth of invasion intraepithelial carcinoma (ptis) invades lamina propria (ptis) invades submucosa (pt1) invades proper muscle (pt2) invades subserosa or pericolic/perirectal tissue (pt3) directly invades adjacent organs or structures (including levator ani muscle) and/or penetrates visceral peritoneum (serosa) (pt4) 해설 : 침윤깊이의분류는소위원회에서가장논란이많았던항목가운데하나였다. 일본의분류에서는 carcinoma in situ를인정하지않고점막내암종 (intramucosal carcinoma) 에포함시 키는반면에, 3 WHO 분류에서는상피내암종 (intraepithelial carcinoma) 과점막내암종모두전이될위험성이사실상없다는이유때문에고도이형성증으로분류한다. 8 따라서병리의사가어떤기준을따르느냐에따라점막내병변의진단에이견이생길수있으며, 이로인해문제가발생할수있다. 본연구회에서는, AJCC/UICC의원발종양병기기준을따르기로하였다. 이기준에서는고유판 (lamina propria) 을침윤 하지않는상피내암종과고유판을침윤하나점막에국한된점막내암종으로나누고, 두병변모두 ptis에포함시키고있다. 7 따라서이분류기준을적용하면, 일본과 WHO 분류기준의차이점을완충시킬수있을뿐아니라, 위를비롯한타장기암의침윤깊이분류체계와도통일성을유지할수있다. 상피내암종은심한핵의비정형 (loss of polarity) 과심한구조이상 (cribriform: gland within gland, bridging or back to back, budding without intervening stroma) 을보이나, 고유판을침윤하지않는경우에국한시킨다 (Fig. 1A). 2,14 간혹샘종에서일부선구조가점막하층으로이탈하는경우, 샘종내암종성분의점막하침윤과감별하기어려울수있으나, 점막하층내상피세포가분명한암세포이고, 주변에섬유성결합조직의증식 (desmoplasia) 이함께나타나면, 암종의점막하침윤으로판정한다 (Fig. 1B). 14 암세포가장막을뚫고인접한장기를침윤하였을때는침범장기를기록한다. 암세포가복강으로노출되어있거나 (Fig. 1C), 암세포가장막면에붙어있으면서중피세포의증식이나염증등의반응을동반하는경우도 pt4로분류한다 (Fig. 1). 4,15 궤양에의해근육층이소실된부위에종양이있으면장막하침윤으로판정한다. 림프관혹은정맥혈관내에국한된암세포는침윤깊이에해당하지않으며별도로괄호안에기록한다 (invades proper muscle [invades subserosa by lymphatic emboli]). Skip metastasis (multiple tumor foci in mucosa or submucosa of adjacent bowel) 는원격전이로분류하지않는다. [Endoscopic or Transanal Excision only] invades submucosa (sm1, sm2, sm3) (pt1) For sessile lesion: depth of submucosal invasion: cm For pedunculated lesion level of invasion: depth of submucosal invasion in stalk: cm 해설 : EMR검체는핀을박아고정판에고정하고 10% 포르말린을충분히넣은용기에 8시간이상고정한다음, 폭 0.2 cm 의연속평행절편을만든다 (Fig. 2A, B). 근육층이포함된검체에서점막하층침윤이있는경우, 점막하층을 3등분하여침윤깊이를 sm1, sm2, sm3로기록한다. 점막하층침윤이있는경우에는, 종양의육안형태에따라점막하층내침윤된깊이를달리표현해야한다. 16 무경성 (sessile) 병변은점막하층내에침윤된깊이를소수점두자리까지기록하며 (Fig. 2C), 점막내근육이암세포의침윤이나궤양에의해파괴된경우에는침윤부위의표층부로부터점막하층내침윤깊이를기록한다. 16 유경성 (pedunculated) 병변은 stalk의길이가다양하기때문에점막하층내침윤깊이를일률적으로기록하는것은임상적으로의의가없다. 유경성병변에서침윤깊이를표기하는방식은구

4 196 장희진 박철근 김우호외 8 인 A B C Fig. 1. The histologic features of intraepithelial carcinoma (A), invasive carcinoma (B), and pt4 carcinoma showing penetration of visceral peritoneum (C) or attachment of visceral peritoneum (). 미와일본의사들간에차이가있다. 구미에서는 Haggitt 등이제안한 level of invasion (head, neck, stalk, submucosa of bowel wall) 을따르는반면에, 17 일본에서는여러기관에서공동연구한결과에따라 stalk 내점막하층침윤깊이를표기할것을제안하고있다. 16 두가지기준중, Haggitt level만선택할경우, stalk내침윤이있을때는침윤깊이가어느정도인지알수없는반면, 일본기준을선택할경우에는 stalk내침윤이없을때점막하침윤이용종의어느 level인지알수없다는단점이있다. 따라서본연구회에서는두가지기준을모두표기하기로하였으며, stalk내점막하층침윤깊이는용종의 neck을기준으로하여소수점두자리까지기록하기로하였다 (Fig. 2, E). 16 [after treatment] ( 예 ) invades proper muscle after treatment (ypt2) 해설 : AJCC/UICC 병기분류에따르면수술전항암, 방사선치료를한경우에는병기앞에 y 를붙이도록되어있다. 7 따라서치료후의침윤깊이는 ypt로기록하며, 국소림프절병기도 ypn로표기한다. [recurrent cancer] ( 예 ) invades subserosa, recurred cancer (rpt3) 해설 : 재발암의침윤깊이는 rpt 로기록한다. 7 Resection margin involved by carcinoma free from carcinoma safety margin; proximal cm distal cm radial cm 해설 : Involved by carcinoma인경우에는 safety margin을 0 cm으로적는다. Visceral peritoneum으로둘러싸여있지않은직장하부는 radial (circumferential) margin의침범여부가수술후재발을결정하는가장중요한요소중하나이므로 radial margin에종양이침범했는지여부와 safety margin을표기하여야한다. 4,15 Radial safety margin이 1 mm 미만일때는 (by direct spread, lymph node metastasis, vascular invasion, or tumor satellite)

5 대장암병리보고서기재사항표준화 197 B A C Head Neck Neck Stalk E Fig. 2. Management of EMR specimen. The resected specimen should be pinned to a flat plate (A). After fixation, the margin of the pinned out specimen should be stained in different colors, and the mucosal tissue should be sectioned serially in 2-mm thickness (B). In a flat or sessile lesion, depth of submucosal invasion should be measured (C). In a pedunculated lesion, the depth of submucosal invasion should be checked in two ways ( and E). One is Haggitt s level of polyp () and the other is depth of submucosal invasion in stalk (E). positive 로판정한다. 12 직장하부뿐아니라직장의중1/3 양측방과후방, 직장의상 1/3 후방및상행결장과하행결장의후방도 peritonealization 이되어있지않다. 그러므로이부위에서발생한암종에대해서도 radial safety margin을기록하는것이원칙이다. 7,12 [Endoscopic or Transanal Excision only] involved by carcinoma free from carcinoma safety margin; proximal cm distal cm right cm left cm deep cm (SM invasion only) 해설 : 방향이표시되어있지않은경우에는가장가까운 lateral margin과 deep margin만기록한다. Carcinoma in an adenoma에서절제연이 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 1-3 LN pn2: metastasis in 4 or more LN

6 198 장희진 박철근 김우호외 8 인 해설 : 미국병리학회의프로토콜에따르면 12개이상의림프절을검사하여, 전이가없을때만 pn0로판정하도록되어있다. 4 그러나수술전항암, 방사선치료를한경우에는박리되는림프절수가적을수있다. 5 대장직장주변지방조직내에서종양결절이관찰될경우, 결절내림프조직이남아있지않아도결절의형태가림프절처럼둥글고경계가매끈할때는림프절전이로간주하고, 경계가불규칙할때는 pt 병기로분류한다. 7 Isolated tumor cells ( 전이된종양의크기가 0.2 mm 이하 ) 는원칙적으로전이숫자에포함하지않으나, 크기가 0.2 mm 이하더라도 HE염색으로발견되는림프절전이의대부분은 malignant activity (gland formation, stromal reaction, proliferation) 가동반되어있으므로전이숫자에포함한다. 7 Regional lymph node 이외의림프절 (external iliac 또는 common iliac LN) 내전이는원격전이로판정하고, pn 병기를결정하기위한림프절전이숫자에는포함시키지않아야한다 ( 예 : pericolic LN, 2/12; common iliac LN, 2/3; pn1m1). 7 [Lymph node groups] ( 예 ) pericolic LN,3/5; IMA LN,0/4;... 해설 : 별도로표시되어접수된림프절의결과는별도로기록한다. Lymphatic invasion not identified present Venous invasion not identified present 해설 : HE 염색으로 lymphatic vessel과 blood vessel을구별할수없는경우가흔하기때문에작은 vessel 침범은 lymphatic invasion으로, 근육층이있는큰 vessel 침범은 venous invasion 으로간주한다. 10 A B C Fig. 3. The gross feature of pedunculated tubular cdenoma (A) and the histologic features of tubular adenoma (B), villous adenoma (C), and serrated adenoma (). Serrated adenoma rests mainly on the uniform population of abnormal epithelial cells with mild nuclear pseudostratification and eosinophilic cytoplasm.

7 대장암병리보고서기재사항표준화 199 Perineural invasion not identified present 해설 : Intraneural invasion도 perineural invasion에포함시켜기록한다. Pre-existing adenoma (describe when present) histology, grade size and involvement of resection margin 해설 : Carcinoma in an adenoma (carcinoma component 가병변의 50% 미만 ) 와 carcinoma with adenomatous component (carcinoma component가병변의 50% 이상 ) 에해당하는경우에만기록하며, 3 암종과분리된샘종은 separate lesion에기록한다. 샘종의 histology는 tubular (Fig. 3A, B), tubulovillous, villous, serrated adenoma로나눈다. Villous adenoma는끝이뾰족한 leaf-like projection이 80% 이상인경우에 (Fig. 3C), serrated adenoma는 surface epithelial dysplasia가있고 serration 이 20% 이상있을경우에진단한다 (Fig. 3). Serrated adenoma는 uniform epithelium으로피복되어있고경도의핵중첩을보인다. 샘종의 grade는 low grade dysplasia와 high grade dysplasia로나누며, tubular, tubulovillous, villous, serrated adenoma 에모두적용한다. 중첩된핵의길이가세포길이의 2/3 이하이고구조이상이없을때는 low grade dysplasia로분류한다 (Fig. 4A). Regular chain 형태의선구조는구조이상에해당되지않는다 (Fig. 4B). 중첩된핵의길이가세포길이의 2/3 이상이거나 (Fig. 4C) 선구조의이상 (irregular budding 혹은 branching) 이있을때는 (Fig. 4) high grade dysplasia로분류한다. 2,14 그러나핵이세포의 base에닿아있지않은 tangential cutting 이많기때문에, 중첩된핵의길이가세포길이와거의같을경우 high grade dysplasia로진단하여야한다. Low grade와 high grade dysplasia가섞여있을때는 high grade dysplasia로분류하는것이원칙이다. 14 그러나 high grade component가어느정도있어야 high grade dysplasia의샘종으로진단할지에대한기준은아직정립되어있지않다. 그러나염증성장질환 (inflammatory bowel disease) 에서발생한 dys- A B C Fig. 4. The histologic feature of colorectal adenomas with low-grade dysplasia (A and B) and high-grade dysplasia (C and ).

8 200 장희진 박철근 김우호외 8 인 plasia에서는인접한세개이상의선구조가 high grade dysplasia의소견을보일경우 high grade dysplasia로진단한다는기준이있다. 18 예 ) Pre-existing adenoma: Tubular adenoma with high grade dysplasia ( cm, involvement of proximal resection margin) Associated findings Tumor perforation (pt4) Mesenteric/omental seeding (M1) Metastasis in other sites (M1) specify 해설 : 병변이있을때는기록하고, 없을때는기록하지않는다. Separate lesions Adenoma Polyp GIST Ulcerative colitis/crohn s disease Others specify 해설 : 병변이있을때는기록하고, 없을때는기록하지않는다. 절제대장의선택기재사항 해설 : 선택기재사항은병원의특성에따라필요한항목을선택하여사용할수있다. epth of invasion Optional subclassification of pt3 T3a (<1 mm beyond the border of proper muscle) T3b (1-5 mm beyond the border of proper muscle) T3c (5-15 mm beyond the border of proper muscle) T3d (>15 mm beyond the border of proper muscle) Optional subclassification of pt4 T4a (directly invades adjacent organs or structures) T4b (penetrates visceral peritoneum [serosa]) 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 : mm 크기거나그보다작더라도 malignant activity가있으면 micrometastasis로판정하고, 전이숫자에포함하며, 별도로기록한다 mm 이하의전이에서 malignant activity가없을때는 isolated tumor cell로판정하고, 전이숫자에포함하지않지만, 별도로기록한다. 7,12 Lymphatic invasion mural or extramural minimal or moderate or marked Venous invasion mural or extramural minimal or moderate or marked Perineural invasion mural or extramural minimal or moderate or marked 해설 : 장벽외 (extramural) 정맥침습은다변량분석에서대장암의불량한예후및간전이와연관있는독립적인예후인자이므로, 15 표기하는것을권장한다. 장벽외혈관침습이없다고판정하기위해서는, 검사한암종의파라핀블록이 5개이상이어야한다. 4,12 장벽내정맥침습을포함한다른소견의예후적중요성은아직완전히증명되지않았다. 따라서림프관및신경침습에대한자세한언급은선택기재사항으로분류하였다. 15 Tumor border expanding infiltrative Lymphocytic response intratumoral or peritumoral mild or moderate or marked 해설 : 종양의경계부는대장암의독립적인예후인자로인정받지못하고있으나, 침윤성성장을보이는종양의침습면에서 5개미만의암세포군들 (tumor budding) 이중배율 ( 250배) 시야에서 10개이상관찰될때는유의하게예후가나쁘다는연구결과가있다. 19 침윤성성장은종양이간질반응없이전근육층을 dissection 하거나, 작은선이나불규칙한암세포의군집이장간막을 dissection하거나, 신경침습이있는경우로한다. 종양내림프구침윤은현미부수체불안정성 (microsatellite instability) 과연관있는인자로, 암세포내의림프구 (tumor infiltrating lymphocytes) 가하나의고배율시야당 4개이상관찰될때는현미부수체불안정성과유의한상관성을보인다는보고가있다. 4 Therapeutic response No regression Minimal regression Moderate regression Near total regression Total regression 해설 : 진행된병기의하부직장암에서항문괄약근을보존하고, 근치적절제율을높이기위하여수술전항암, 방사선보조치료를시행하는경우가늘어나고있다. 그러나대장에서항암, 방사선치료효과를병리학적으로판정하는기준은아직까지국제적으로공인된바없다.

9 대장암병리보고서기재사항표준화 201 A B C Fig. 5. Pathologic grading of therapeutic response for chemoradiation therapy: minimal regression (A), moderate regression (B), near total regression (C), and total regression (). 일본에서는전체병변에남아있는암세포의양에따라다음과같이나누고있다 ; grade 0 (no change); grade 1 (necrosis or disappearance of tumor in less than 2/3 of tumor); grade 2 (necrosis or disappearance of tumor in more than 2/3 of tumor); grade 3 (severe change: no viable cells evident). 3 이분류법은치료후절제된표본에서는치료전병변의크기를알기어렵기때문에병리의사가결정하기힘들다는단점이있다. 이밖에도 worak 등 20 과 Mandard 등 21 이제안한병리학적치료반응분류법이있다. 이두가지분류법은모두치료후남아있는암세포양과방사선조사후변화 ( 섬유화, 괴사, 혈관변화등 ) 정도에따라 no regression, minimal regression, moderate regression, near total regression, total regression의다섯가지체계로나눈다. 적용되는등급은 worak 분류에서는 no regression이 0등급, total regression이 4등급인반면에, 20 Mandard 분류에서는각각 5등급과 1등급에해당된다. 21 본연구회에서는위의다섯가지등급체계를숫자를사용하지않고그대로적용함으로써, 여러기관에서연구할때다른분류체계를사 용하더라도쉽게전환할수있도록하였다. 등급기준은아래와같다 (Fig. 5). No regression: no evidence of irradiational change (fibrosis, necrosis, vascular change) Minimal regression: dominant tumor mass with obvious irradiational change Moderate regression: dominant irradiational change with residual tumor (easy to find) Near total regression: microscopic residual tumor (difficult to find) in fibrotic tissue Total regression: No residual tumor cells, only fibrotic mass 내시경생검의표준기재사항 Location cecum ascending colon hepatic flexure of colon transverse colon

10 202 장희진 박철근 김우호외 8 인 splenic flexure of colon descending colon sigmoid colon rectosigmoid junction rectum other Specimen type endoscopic biopsy Histologic type Adenocarcinoma well differentiated moderately differentiated poorly differentiated Mucinous adenocarcinoma Signet-ring cell carcinoma Small cell carcinoma Squamous cell carcinoma Adenosquamous carcinoma Medullary carcinoma Undifferentiated carcinoma Other 대장암판독용양식 (Colon, Rectum), (right hemicolectomy, transverse hemicolectomy, left hemicolectomy, anterior resection, low anterior resection, abdominoperineal resection, subtotal/total colectomy, total proctocolectomy), (endoscopic mucosal resection, transanal excision, transanal endoscopic microsurgery):. Multiple carcinomas, carcinoma in an adenoma, carcinoma with adenomatous component. Adenocarcinoma, (well, moderately, poorly) differentiated, Mucinous adenocarcinoma, Signet-ring cell carcinoma, Small cell carcinoma, Squamous cell carcinoma, Adenosquamous carcinoma, Medullary carcinoma, Undifferentiated carcinoma, Other 1. Location : cecum, ascending colon, hepatic flexure of colon, transverse colon, splenic flexure of colon, descending colon, sigmoid colon, overlapping lesion, rectosigmoid junction, rectum, other 2. Gross type : superficial, fungating/polypoid, ulcerofungating, ulceroinfiltrative, infiltrative, unclassifiable 3. Size : X X cm 4. epth of invasion : intraepithelial carcinoma (ptis), invades lamina propria (ptis), invades submucosa (sm1, sm2, sm3) (pt1), [for sessile lesion: depth of SM invasion : cm ], [for pedunculated lesion: level of invasion : head, neck, stalk /depth of SM invasion in stalk : cm], invades proper muscle (pt2), invades subserosa or pericolic/perirectal adipose tissue (pt3), directly invades adjacent organs or structures or penetrates visceral peritoneum (pt4) 5. Resection margin: involved by carcinoma, free from carcinoma safety margin: proximal cm, distal cm, radial cm [right cm, left cm, deep cm (SM only)] 6. Regional lymph node metastasis : no metastasis in all regional lymph nodes (pn0), metastasis to out of regional lymph nodes (pn_) (pericolic/perirectal /, IMA root /, LN / ) 7. Lymphatic invasion : not identified, present 8. Venous invasion : not identified, present 9. Perineural invasion : not identified, present 10. Pre-existing adenoma : (tubular, tubulovillous, villous, serrated) adenoma (with high grade dysplasia) 1) size : X X cm 2) resection margin : free from adenoma, involved by adenoma 11. Associated findings : perforation, mesenteric seeding, metastasis 12.Separate lesions : adenoma (type and grade), polyp, GIST, ulcerative colitis/crohn s disease, others ( 이탤릭체는 EMR 검체에서만사용하는항목임.) 대장암병리보고서작성예 Colon, anterior resection:. Carcinoma with adenomatous component. Adenocarcinoma, moderately differentiated 1. Location : sigmoid colon 2. Gross type : fungating 3. Size : cm 4. epth of invasion : invades proper muscle (pt2) 5. Resection margins : free from carcinoma safety margins: proximal 3.2 cm, distal 6.6 cm 6. Regional lymph node metastasis : no metastasis in all 20 regional lymph nodes (pn0) (pericolic 0/ 10, IMA root 0/10) 7. Lymphatic invasion : present 8. Venous invasion : not identified 9. Perineural invasion : not identified 10. Pre-existing adenoma : tubular adenoma with high grade dysplasia 1) size : 1.5X1X0.5 cm 2) resection margin : free from adenoma Colon, transanal endoscopic microsurgery:. Carcinoma in an adenoma. Adenocarcinoma, well differentiated 1. Location : ascending colon 2. Gross type : polypoid 3. Size : 1.2X0.8X0.5 cm 4. epth of invasion : invades submucosa (sm1) (pt1) (for pedunculated lesion: level of invasion : stalk, depth of SM invasion in stalk : 0.01 cm) 5. Resection margins : free from carcinoma safety margins: proximal 2 cm, distal 1 cm, right 0.5 cm, left 1 cm, deep 0.02 cm 6. Lymphatic invasion : present 7. Venous invasion : not identified 8. Perineural invasion : not identified 9. Pre-existing adenoma : tubular adenoma with high grade dysplasia 1) size : cm 2) resection margin : free from adenoma Rectum, endoscopic biopsy: Adenocarcinoma, moderately differentiated

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