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만석 종
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1 online ML omm OI /kjorl-hns 비강및부비동악성종양의내시경적절제술 영남대학교의과대학이비인후 - 두경부외과학교실 우현재 배창훈 송시연 김용대 Endoscopic Resection of Sinonasal Malignant Tumors Hyun-Jae Woo, M, hang Hoon ai, M, Si-Youn Song, M and Yong-ae Kim, M epartment of Otorhinolaryngology-Head and Neck Surgery, ollege of Medicine, Yeungnam University, aegu, Korea STRT ackground and Objectives:Endoscopic surgery largely replaced the traditional external approach in the treatment of sinonasal inflammatory diseases and most benign tumors. However, there is much debate about its applicability to resection of sinosal malignancy. In this study, we demonstrate the efficacy of the endonasal endoscopic approach in the treatment of highly selected sinonasal malignant tumors. Subjects and Method:We retrospectively reviewed the medical records and radiologic findings of 11 patients who had underwent transnasal endoscopic excision for sinonasal malignancy from 1998 to ll patients were treated with curative intent. Results:The mean age was 60.6 (31-75 years) years and the mean follow-up period was 69 months ( months). Eight cases consisted of T1 and three cases were T2. The pathologic diagnosis was malignant melanoma (4 cases), plasmacytoma (2 cases), adenoid cystic carcinoma, olfactory neuroblastoma, cylindrical cell carcinoma, squamous cell carcinoma and neuroendocrine carcinoma. In ten cases, the tumor was removed by transnasal endoscopic excision with adequate free margin of normal mucosa. In one case, aldwell-luc operation was combined with the endoscopic excision. uring the follow-up, only one case of malignant melanoma had recurred at the lateral neck and retropharyngeal lymph node, but the other ten cases have kept up well without recurrence of primary tumor and significant complication. onclusion:onsidering oncological results and surgery-related morbidities, transnasal endoscopic resection can be used as a good modality in the highly selected early T stage of sinonasal malignancies. () KEY WORS:Nasal cavity Paranasal sinuses Tumor Endoscopy. 서 론 1900 년대초 Hirschmann 이방광경을변형한비강및부비동내시경을발명한이래, 1) 비내시경은발전을거듭하여현재비과질환의진단과치료에광범위하게이용되고있다. 비내시경은초기에는비강점막의변화와비강내종양의진단에국한하여사용되었으나, 기능적부비동내시경수술이라는개념이도입되면서발전을거듭하여비강과부비동에생기는많은질환의치료에사용되고있다. 최근에는비강과부비동의종양수술에도이용되고있다. 1-5) 작고국소적인양성종양에대해서는전통적인비외접근법을대신하여보편화되고있으나, 광범위한병변이나특히악성병변에대해서는아직도그치료효용성에대한논란 논문접수일 :2007 년 6 월 27 일 / 심사완료일 :2007 년 8 월 31 일교신저자 : 김용대, 대구광역시남구대명동 영남대학교의과대학이비인후과학교실전화 :(053) 전송 :(053) ydkim@med.yu.ac.kr 과이견이있다. 현재까지악성비 부비동질환의내시경적치료에관한연구와보고는소수에불과하며, 또한장기간추적관찰한예는많지않다. 1,5-9) 따라서이연구는비강및부비동악성종양중내시경을이용한비내종양절제술을받고장기간추적관찰이가능하였던환자를후향적으로분석하여치료결과와내시경수술의효용성을알아보고자하였다. 대상및방법 1998 년 1월부터 2003 년 1월까지본원이비인후과에서비강및부비동의악성종양으로진단되고완치를목적으로내시경적비내종양절제술을받은환자중, 적어도 52개월이상추적관찰이가능하였던 11예를대상으로하였다. 남자 4명, 여자 7명이었고평균연령은 60.6세 (31~75세 ) 였다. 병기설정은후각신경모세포종과신경내분비암에대해서는 1992년 UL(University of alifornia, Los 1118

2 우현재외 ngeles) 병기체계를사용하였고, 나머지는 2002 년 J (merican Joint ommittee on ancer) 병기체계에준하였다. 전이유무를확인하기위해서경부초음파, 골스캔, 간담도초음파, 식도조영술등을같이실시하였다. 철저한병기결정과수술계획을세워전신마취하에 1:100,000 epinephrine이섞인 2% 의 lidocaine 거즈를사용하여충분히점막을수축시킨후, 내시경을사용하여철저하게비강내를관찰하였다. 충분한안전절제연을확보하기위하여종물의경계와정상점막의범위를확인하였다. 종물을일괴로절제하기위해노력하였으며이를위해절제연이가능한연결될수있게계획하고, 종양이침범한점막과인접한뼈를가능한한충분한절제연 (0.5~1.0 cm) 을두고내시경적종양절제술을시행하였다. 전비공을한번에통과할수없는크기의종양은불가피하게여러조각으로나누어제거하였다. 상악동내측벽의침범이있는경우에는비내로접근하여상악동의내측벽전체, 사골동의일부, 중비갑개일부와하비갑개전체, 비루관의하부를절제하는변형된내시경적내측상악절제술을시행하였다. 필요한경우내시경을이용하여광범위한비내사골동전절제술도시행하였다. 절제연의안전성은동결절편조직검사로확인하였고, 절제연확보를위해두개저또는안와의일부를제거해야하는경우는없었다. 충분한지혈후비강내팩킹을시행하고 2~3일유치한다음모두제거하였다. 수술후 3~4개월마다정기적인외래방문시내시경을이용해수술부위를철저히관찰하였고두경부및전신의이학적검사를하였다. 필요한경우전산화단층촬영, 자기공명영상촬영과양성자방출단층촬영등을시행하여국소재발과원격전이여부를검사하였다. 평균외래추적관찰기간은 69 개월 (52~112 개월 ) 이었다. 통계학적인분석은 SPSS ver 을사용하였으며생존율을분석하기위해서는 Kaplan- Meier 법을이용하였다. 결과 병리조직학적으로는악성흑색종이 4예로가장많았으며이외에골수외형질세포종이 2예, 선양낭성암종, 후각신경모세포종, 원주세포암, 편평상피세포암, 신경내분비암이각 1예였다 (Table 1). 악성흑색종 4예중 2예는각각 3년과 2년전타병원에서악성흑색종으로진단받고수술단독혹은수술및항암약물치료후재발한경우였으며나머지 9예는초발암이었다. 1예의편평상피세포암은수술전조직검사상반전성유두종으로진단되어수술을시행하였으나수술후조직검사결과종괴중일부에서상피내편평상피세포암 (squamous cell carcinoma in situ) 으로보고되었다 (Fig. 1). TNM 병기는 11예중 1병기 7예, 2병기 3예, 3병기 1 예였다 (Table 1). 모든환자들의원발암은 T1, T2였으며각각 8예, 3예였다. 그러나 1명의악성흑색종환자는림프절전이 (N1) 로인해서 T1임에도불구하고전체병기는 3 병기로판정되었다. 시행한수술적방법으로는, 10예의비강및비강외측벽에국한된종양에대해서는내시경을이용한비내종양절제술을시행하였는데, 경우에따라사골동전절제술을같이시행한경우도있었고, 증례 1, 4 및 8의경우상악동내측벽의침범이의심되어변형된내시경적내측상악절제술을시행하였다. 좌측상악동에서기원한원주세포암 1예 Table 1. Summarized data of patients with sinonasal malignancy managed by endoscopic excision ase Sex/ ge iagnosis Site Stage Treatment F/U (Mo) dditional treatment 01 M/54 IP containing S in situ Lt MS/N II (T2N0M0) E (R) NE Present state 02 F/40 Plasmacytoma Rt LNW I (T1N0M0) E 112 RT NE 03 F/59 Plasmacytoma Lt LNW I (T1N0M0) E 072 RT NE 04 F/59 denoid cystic carcinoma Rt LNW I (T1N0M0) E (R) 094 RT NE 05 F/31 Neuroendocrine carcinoma Lt NS I (T1N0M0) E 056 T+RT NE 06 M/73 ylindrical cell carcinoma Lt MS I (T1N0M0) E+-L NE 07 F/71 Olfactory neuroblastoma Rt OF I (T1N0M0) E NE 08 F/72 Malignant melanoma Lt ES/LNW II (T2N0M0) E NE 09 M/75 Malignant melanoma Rt NS II (T2N0M0) E NE 10 F/66 Malignant melanoma Rt LNW I (T1N0M0) E NE 11 M/67 Malignant melanoma Lt LNW III (T1N1M0) E+SN (I, II, III, V) 060 Neck recur SN+T+RT Neck recur -L:aldwell-Luc operation, T:chemotherapy, R:dacryocystorhinostomy, E:endoscopic excision, ES:ethmoid sinus, IP: inverted papilloma, LNW:lateral nasal wall, MS:maxillary sinus, N:nasal cavity, NE:no evidence of disease, NS:nasal septum, Lt:left, Rt:right, OF:olfactory fissure, RT:radiotherapy, S:squamous cell carcinoma, SN:selective neck dissection 1119

inhomogenous mass (*) in left maxillary sinus

or recurrent tumor 24 months after endoscopic

Preoperative axial () and coronal () images show

3 비 부비동악성종양의내시경수술 Fig. 1. Paranasal sinus MRI, and postoperative endoscopic view of case 1 with inverted papilloma containg carcinoma in situ. inhomogenous mass (*) in left maxillary sinus and nasal cavity is noted on T2 axial () and enhanced T1 coronal image (). En block resection of the tumor and lateral nasal wall was performed (). Postoperative endoscopic view shows no residual or recurrent tumor 24 months after endoscopic medial maxillectomy (). Fig. 2. Paranasal sinus T scans of case 3 with plasmacytoma. Preoperative axial () and coronal () images show a mass (*) located on left lateral nasal wall and right maxillary sinusitis. Postoperative image 31 months after surgery;mucosal thickening of maxillary sinuses is noted in axial () and coronal () view. 1120

show a relatively well-circumscribed mass

slightly enhanced mass (*) which seems to

4 우현재외 Fig. 3. Paranasal sinus T scans of case 5 with neuroendocrine carcinoma. Preoperative axial () and coronal () view show a relatively well-circumscribed mass (*) in both nasal cavities and sphenoid sinuses destructing the bony septum. Postoperative images 26 months after surgery ( and );there is no evidence of residual or recurrent lesion. Fig. 4. Paranasal sinus MRI of case 7 with olfactory neuroblastoma. In preoperative enhanced T1WI ( and ), right nasal cavity is filled with a slightly enhanced mass (*) which seems to originate from right olfactory fissure. t 56 month after surgery, there is no evidence of recurrent or residual lesion in T2WI ( and ). 1121

비 부비동악성종양의내시경수술 는내시경적비내절제술만으로는종양의완전한적출이불가능하여 aldwell-luc 수술을동시에시행하였다. 좌측악하부에경부림프절전이가동반된악성흑색종 1예에서는선택적경부절제술 (level I, II, III, V) 을함께시행하였다.

후각신경모세포종 1예의경우수술후방사선치료를계획하였으나환자의거부로시행할수없었다 (Fig. 4). 내시경을이용한내측상악절제술을시행한 3예중 2예는누관의손상으로수술중에비내누낭비강문합술을시행하였는데, 이중 1예에서는수술후누관의협착이발생하여누낭비강문합술을다시실시하였다. 그외모든예에서수술후특별한합병증이나후유증은발견되지않았다.

5). 이환자를제외한나머지 10예에서는현재까지재발소견없이추적관찰중이며, 표본의수가적어큰의미를부여하기는어려우나 5년재발률은 9.1%, 평균재발기간은 105.4 개월이었다. 고찰 비강및부비동악성종양의치료원칙은일반적인모든악성종양에서와같이정상조직을포함하여충분한절제연을두고일괴절제술을시행하는것이다.

Slightly enhanced homogenous mass (*) is noted at left nasal cavity on axial () and coronal () view.

5 비 부비동악성종양의내시경수술 는내시경적비내절제술만으로는종양의완전한적출이불가능하여 aldwell-luc 수술을동시에시행하였다. 좌측악하부에경부림프절전이가동반된악성흑색종 1예에서는선택적경부절제술 (level I, II, III, V) 을함께시행하였다. 형질세포종으로진단된 2예의경우골수생검, 혈청및요의단백전기영동검사, 면역영동검사상특이소견이없어골수외형질세포종으로최종진단을받았으며수술후방사선치료를병행하였고 (Fig. 2), 선양낭성암종 1예도수술후방사선치료를시행하였다. 신경내분비종양으로진단된 1예의경우수술후항암약물요법과방사선치료를추가로시행하였다 (Fig. 3). 후각신경모세포종 1예의경우수술후방사선치료를계획하였으나환자의거부로시행할수없었다 (Fig. 4). 내시경을이용한내측상악절제술을시행한 3예중 2예는누관의손상으로수술중에비내누낭비강문합술을시행하였는데, 이중 1예에서는수술후누관의협착이발생하여누낭비강문합술을다시실시하였다. 그외모든예에서수술후특별한합병증이나후유증은발견되지않았다. 추적관찰과정에서, 림프절전이로선택적경부절제술을 받은악성흑색종 1예의경우, 수술후 39개월째에좌측악하부에다시림프절재발이발생하여경부절제술및항암화학요법그리고방사선치료를하였으나, 1년뒤우측경부및후인두림프절에재발이되었고, 환자의연령과전신상태상추가적인치료는보류하고경과관찰중이다. 그러나원발부위의재발은현재까지없는상태이다 (Fig. 5). 이환자를제외한나머지 10예에서는현재까지재발소견없이추적관찰중이며, 표본의수가적어큰의미를부여하기는어려우나 5년재발률은 9.1%, 평균재발기간은 개월이었다. 고찰 비강및부비동악성종양의치료원칙은일반적인모든악성종양에서와같이정상조직을포함하여충분한절제연을두고일괴절제술을시행하는것이다. 비강과부비동악성종양의일괴절제를위하여다양한외부접근법이시행되었으며이러한접근법은충분한시야를확보할수있다는장점이있었으나, 여러가지심각한합병증을야기하였다. 오랜기간동안사골동암의치료를위해선택되었던외측 Fig. 5. Paranasal sinus T scans of case 11 with malignant melanoma. Slightly enhanced homogenous mass (*) is noted at left nasal cavity on axial () and coronal () view. This lesion seems to originate from left lateral nasal wall, but definite bony septal destruction or invasion to surrounding soft tissue is not seen. Metastatic cervical lymph node (N) is noted in left level II (). Postoperative image 25 months after surgery shows metastatic retropharyngeal lymph node (RN)(). 1122

6 우현재외 비절개접근법은피부와상악의구축과변형, 비골의방사선괴사, 유루증등의합병증을일으킨다. 10) 미용과기능보존을위해적용되는구순하상악노출절개법은종양의상부경계, 즉사골동상부, 사골판, 전두개저의접근이용이하지않다. 11) 두개안면절제술은대부분의경우에서종물의일괴절제가가능했지만접형동, 안와첨, 전두와로접근하기가기술적으로어려우며수술후사망률이 4~31% 나되었고, 12,13) 영구적인합병증인두통, 시력변화, 후각상실증등으로인해삶의질의심각한저하를야기한다. 14) 이러한여러가지접근법과치료법에도불구하고지난 30년동안비강및부비동암에대한생존율은크게향상되지않았으며수술에대한후유증을줄여삶의질을향상시키는것이중요하게되었다. 15) 따라서최대한정상적인해부학구조를유지할수있으며비침습적인내시경을이용하여비강및부비동암을치료하는시도가이루어졌다 년대후반부터내시경을이용한비 부비동수술이유두상선암종, 연골육종등에시행되고, 잘선택된환자에서비강및부비동악성종양에대한성공적인내시경적치료가보고되었으나그증례가많지않고추적관찰기간이짧았다. 1,5,6,16-18) 국내에서도비 부비동및비인강악성종양에서내시경수술이적용된 6예를보고한바가있으나, 7) 발표된증례가많지않고추적관찰기간도충분히길지않았다. 또한일부연구자들은악성종양에대한내시경적치료가전혀효과적이지않고진단적생검, 암종의절제후추적관찰, 지혈과고식적치료정도에만그가치가있다고하였다. 1,4) 최근에 T병기는알수없으나비강및사골동악성종양 15명에서근치목적으로내시경적비내종양절제술을시행한후평균 32개월동안추적관찰한결과국소재발률이 21.4%, 총생존율및무병생존율이 85.7% 이라는보고가있었다. 8) 그리고또다른연구에서는 T1에서 T3병기까지를포함하는비강및사골동악성종양 49 예를내시경적비내수술로치료한결과 5년생존율이 88%, 무병생존율이 68% 임을보고하였는데, 9) 고전적인두개안면부접근법에의한생존율이 50% 내외인것을감안하면, 19,20) 적어도 5년미만의단기추적결과에서는내시경적비내수술에서의생존율이낮지않다는것을알수있다. 이연구에서는비강및부비동에생긴제한된 T1 및 T2병기 11예에대해내시경을이용한종양절제술을시행하고추적관찰하였는데 69개월의평균추적관찰기간동안모두원발부위의재발은없었고, 1예의경부재발이발생하였다. 그리고심각한합병증은발생하지않았다. 이연구가최근에보고된다른연구 8,9) 보다재발률과생존율이우수한이유는두개저나안와를침범하지않은 T2 이하의 선택된환자를대상으로하였고, 수술시가능한충분한절제연을확보했기때문인것으로생각된다. 전통적인외비접근술을이용한악성종양의수술에비해내시경을사용한비내악성종양의절제는다음과같은장점이있다. 외부절개를가하지않으므로안면구축, 반흔형성, 절개부의감염등을피할수있고입원기간도단축시킬수있으며, 정상적인구조물과코점막을최대한보존할수있으므로비강의기능을유지하는데도움이된다. 그리고, 내시경으로밝고확대된영상을보면서수술하게되므로종양의절제연을결정하는데유리하고주위구조물의손상을피하는데도움을준다. 또한, 다양한각도의내시경을이용하여전방에서는보이지않는공간을관찰할수있으므로종양의정확한범위를파악하기에도유리하다. 외비접근법을통한광범위한절제술보다종양학적인측면에서불리할것이라는의견도있다. 하지만, 영상진단기법이발전하여수술전에종양의범위를비교적정확히판단할수있어내시경적비내절제술이가능한환자를선별해내는데큰어려움이없을것이며, 수술과정중에동결절편조직검사로완전절제유무를확인할수있다. 전비공을한번에통과할수없는크기의종양인경우, 전비공을통해일괴적출하기가사실상거의불가능해서종양을조각조각내어제거해야하는종양학적단점이있다. 그러나이런경우고식적인접근방법으로도일괴적출이쉽지않을것이며, 이연구에서비중격이나비강외측벽에국한된작은종괴는일괴적출이가능하였으므로이런경우에서는종양학측면의단점도없을것이다. 비 부비동암종에대한내시경적절제의효과를판정하기위해서는이연구의증례가부족한것이사실이다. 그리고병리조직학적분류에따라서도치료성적에많은차이가날수있으므로이에대한연구를위해서는여러기관과협력하여충분한증례를확보하여분석하는시도가이루어져야한다. 이연구의결과에서도알수있듯이조기진단, 적절한병기결정, 완전절제를위한수술전계획을바탕으로신중하게선택된악성저병기종양을대상으로한다면양호한수술성적뿐만아니라미관과기능상의장애및수술후합병증을줄이면서조기퇴원할수있는여러가지장점을얻을수있다. 결론 비강및부비동에생긴악성종양에서조기진단과신중한 수술전평가및계획을통해 T1, T2 병기의환자중특 1123

7 비 부비동악성종양의내시경수술 별히선택된경우에서내시경적비내절제술을시행한다면, 환자의이환율을줄이고미용적인효과뿐만아니라비 부비동의생리적기능을보존하는데도움이될수있을것이다. 중심단어 : 비강 부비동 종양 내시경. REFERENES 1) Homer JJ, Jones NS, radley PJ. The role of endoscopy in the management of nasal neoplasia. m J Rhinol 1997;11(1): ) radley PJ. Paranasal sinus malignancy: review-what is the current role of ESS? ENT News 2005;14(4): ) ohen N, Kennedy W. Endoscopic sinus surgery: Where we areand where we re going. urr Opin Otolaryngol Head Neck Surg 2005;13(1): ) anhiran W, asiano RR. Endoscopic sinus surgery for benign and malignant nasal and sinus neoplasm. urr Opin Otolaryngol Head Neck Surg 2005;13(1): ) Poetker M, Toohil RJ, Loehrl T, Smith TL. Endoscopic management of sinonasal tumors: preliminary report. m J Rhinol 2005; 19(3): ) Kühn UM, Mann WJ, medee RG. Endonasal approach for nasal and paranasal sinus tumor removal. ORL J Otorhinolaryngol Relat Spec 2001;63(6): ) Lee H, Mo JH, Kwon SK, Lee SS, Oh SJ, Rhee JS. pplication of endoscopic surgery on sinonasal and nasopharyngeal malignancy. Korean J Otolaryngol-Head Neck Surg 2004;47(9): ) Roh HJ, atra PS, itardi MJ, Lee J, olger WE, Lanza. Endoscopic resection of sinonasal malignancies: preliminary report. m J Rhinol 2004;18(4): ) Lund V, Howard J, Wei WI. Endoscopic resection of malignant tumors of the nose and sinuses. m J Rhinol 2007;21(1): ) ernard PJ, iller HF, Lawson W, Leenger J. omplications following rhinotomy. Review of 148 patients. nn Otol Rhinol Laryngol 1989;98(9): ) Maniglia J, Phillips. Midfacial degloving for the management of nasal, sinus, and skull-base neoplasms. Otolaryngol lin North m 1995;28(6): ) Shah JP, Sundaresan N, Galicich J, Strong EW. raniofacial resections for tumors involving the base of the skull. m J Surg 1987;154(4): ) Shah JP, Kraus H, ilsky MH, Gutin PH, Harrison LH, Strong EW. raniofacial resection for malignant tumors involving the anterior skull base. rch Otolaryngol Head Neck Surg 1997;123(12): ) Jones E, Lund VJ, Howard J, Greenberg MP, Mcarthy M. Quality of life of patients treated surgically for head and neck cancer. J Laryngol Otol 1992;106(3): ) Ketcham S, Van uren JM. Tumors of the paranasal sinuses: therapeutic challenge. m J Surg 1985;150(4): ) Shah UK, Hybels RL, ugan J. Endoscopic management of low-grade papillary adenocarcinoma of the ethmoid sinus: ase report and review of the literature. m J Otolaryngol 1999;20(3): ) Matthews, Whang, Smith S. Endoscopic resection of a nasal septal chondrosarcoma: First report of a case. Ear Nose Throat J 2002;81(5): ) arrau RL, ydogan, Hunt JL. hondrosarcoma of the sphenoid sinus resected by an endoscopic approach. m J Otolaryngol 2004; 25(4): ) Lund VJ, Howard J, Wei WI, heesman. raniofacial resection for tumors of the nasal cavity and paranasal sinuses- 17-year experience. Head Neck 1998;20(2): ) entz G, ilsky MH, Shah JP, Kraus. nterior skull base surgery for malignant tumors: multivariate analysis of 27 years of experience. Head Neck 2003;25(7):

Kaes017.hwp

Kaes017.hwp 갑상선의 Poorly Differentiated (Insular) Carcinoma Insular Carcinoma: An Aggressive Subtype of Differentiated Thyroid Neoplasms Seok-Jin Nam, M.D., Sang-Dal Lee, M.D., Hal-lin Park, M.D., Young-Ryun Oh, M.D.