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1 중심성폐암환자에서악성기도폐쇄에서전기탐침과투열올가미를사용한전기소작술의효과 고신대학교내과학교실호흡기내과, 왈레스기념침례병원호흡기내과 1 유홍준, 최평락, 박은호, 양재홍, 김형준, 김주훈, 옥철호, 조현명 1, 장태원, 정만홍 Bronchoscopic Electrocautery with Electroprobe and Diathermic Snare in Patients with Malignant Airway Obstruction Hong Jun You, M.D., Pyoung Rak Choi, M.D., Eun Ho Park, M.D., Jae Hong Yang, M.D., In Su Choi, M.D., Hyoung Jun Kim, M.D., Joo Hoon Kim, M.D., Chul Ho Oak, M.D., Hyun Myung Cho, M.D. 2, Tae Won Jang, M.D., Maan Hong Jung, M.D., Department of Internal Medicine, College of Medicine, Kosin University, Busan, Korea, Department of Internal Medicine, 1 Wallace Memorial Baptist Hospital, Busan, Korea Background : Endobronchial tumors cause life-threatening dyspnea and can lower the quality of life due to central airway obstruction. In those cases with an intraluminal tumor, various bronchoscopic techniques are available for tumor debulking. The therapeutic effect of bronchoscopic electrocautery for palliation in patients with a symptomatic tumor obstruction was studied. Method : Nineteen patients with bronchogenic carcinomas (n=15) and metastatic tumors affecting the bronchi (n=4), between March 2002 and March 2005, were enrolled in this study. Electrocautery was performed under local anesthesia using an electroprobe and diathermic snare. Using flexible bronchoscopy, a follow-up bronchoscopic examination was performed 3-4 days later. Symptom improvement was evaluated by FEV 1, FVC and dyspnea score (Modified Borg Category Scale (0 10)), both before and after the electrocautery. Results : The success rate of electrocautery on the follow up examination was 84%. Patients with endoluminal airway lesions had a mean overall decrease in the size of the obstruction to 47.8±15.7%. The mean Improvement in the dyspnea score immediately after the endobronchial tumor debulking was 2.78±1.42. The average improvements in the FEV 1 and FVC after electrocautery were 0.32±0.19L and 0.5±0.22L, respectively. There were 2 cases of complications related with electrocautery (one each of pneumothorax and pneumonia). Conclusion : Electrocautery using an electroprobe and diathermic snare was an effective and safe palliative treatment for a symptomatic endoluminal airway obstruction in lung cancer. (Tuberc Respir Dis 2005; 59: ) Key words : Lung cancer, Airway obstruction, Electrocautery 서 근치적절제가불가능한진행성비소세포폐암이나전이성폐암의경과중기관이나주기관지등의중심성기도폐쇄에의한심한호흡곤란은환자의삶의질을저하시키는중요한요인이다 1. 기관지경적전기 본연구는 2004년도고신대학교의과대학 2004년연구비지원에의하여시행되었음. Address for correspondence : Chul Ho Oak, M.D. Department of Internal Medicine, College of Medicine, Kosin University, 34 Amnam-dong Seo-Gu, Busan, Korea Phone : Fax : oaks70@dreamwiz.com Received : Jul Accepted : Sep 론 소작술 (bronchoscopic electrocautery) 은기관지경을통해조직에고주파전류를투과시켜발생한열에의해조직을파괴하여기도내강에존재하는종물을제거하는시술중의하나이다 2. 전기소작술은굴곡성기관지경을통해시술이가능하고전기탐침 (electro probe) 을직접병소에접촉시켜시술하므로방법이용이하고치료효과도레이져 (laser) 요법과비슷한장점이있다 3. 그러나결절성병변 (nodular lesion) 의경우, 소작된조직을겸자를통해제거해야하고용종성병변 (polypoid lesion) 의경우병소자체의파괴에필요한시술시간이길어져환자의순응도가떨어진다는단점이있었다 4. 이러한점을극복하기위해최근개량된전기탐침이나투열올가미 (diathermic snare) 를전기소작술에이용한연구가보고된바있다 5-8. 이에 504
2 Tuberculosis and Respiratory Diseases Vol. 59. No. 5, Nov 저자들은악성종물에의한중심성기도폐쇄로호흡곤란을호소하는환자들에서굴곡성기관지경을통해전기탐침과함께투열올가미를사용한전기소작술의치료효과를조사하였다. 대상및방법 1. 대상 2002년 3월부터 2005년 3월까지고신대학교복음병원에내원하여비소세포폐암이나그외악성종양으로진단받은후항암치료나방사선치료후진행성경과를취하여심한호흡곤란을호소하는환자에게서기관지경검사상종양에의한기관이나주기관지의폐쇄가있었던 19명을대상으로하였다. 이들은모두기도폐쇄의병변이결절성이나용종성인경우와성공적인소작술시행후환자의생존기대기간이 2개월이상인경우가소작술의적응이되었고외부압박으로인한기도폐쇄, 기도의연골파괴, 4-6주이상의오래된기도폐쇄, 폐쇄부위의길이가 4cm이상인경우, 엽기관지나분절기관지만의폐쇄가있는환자들은제외되었다. 조직학적으로는편평상피암이 14례, 선암이 1례, 전이성폐암이 4례였다. 평균나이는 61±10였으며남자가 17명, 여자가 2명이였다. 폐쇄부위는기관이 2례, 주기관지가 17례였다. 기도폐쇄를유발한병변은결절성병변이 11례용종성병변이 8례였다 (Table 1). 2. 시술방법시술전에흉부방사선검사, 폐활량측정 (FVC, FEV 1 ), 흉부전산화단층촬영을시행하였다. 그리고환자의주관적호흡곤란의정도를 modified Borg category scale(0~10) 을이용하여측정하였고기도폐쇄의정도는기관지내시경상내경의폐쇄를백분율로기록하였다. 시술전전처치로 meperidine 50mg과 atro pine 0.5mg을근육주사한뒤 lidocaine 으로구강내국소마취를시행하였으며시술직전 midazolam 5mg 을정맥주사하였다. 전기소작술은굴곡성기관지경 Table 1. Patients characteristics Characteristics Number Male 17 Female 2 Age 61.0 ± 10.0 Diagnosis Squamous cell carcinoma 14 Adenocarcinoma 1 Renal cell carcinoma 1 Hepatocelluar carcinoma 2 Gastrointestinal stromal cell tumor 1 Tumor shape Nodular 11 Polypoid 8 Site of obstruction Trachea 2 Left main bronchus 10 Right main bronchus 7 Previous treatment Chemotherapy 16 Radiotherapy 5 의삽입후시행하였으며투열올가미를사용하여각경을갖고있는종물이나폴립양종괴의기저부에삽입하여올가미를당기며 1-2초간 30와트로소작한뒤단계적으로 3-4회에걸쳐반복소작을시행하여종물을제거하였다. 투열올가미를이용할수없는결절성종물의경우에전기탐침을통해조직을응고시켜물리적으로제거하였다. 시술후 3-4일후에정화기관지경술 ( clean-up bronchoscopy) 을시행하여기도폐쇄의완화의정도를측정하였다. 정화기관지경술을받은다음날주관적호흡곤란의개선여부는 modified Borg category scale(0~10) 을이용하여측정하였고, 흉부방사선검사, 폐활량측정으로추적조사하였다. 시술의성공은기도폐쇄가호전되고폐기능의증가나호흡곤란점수가호전이되었을경우로정의하다. 시술은총 29회시행되었다. 3. 통계분석통계분석은 window 용 SPSS 프로그램 (SPSS 12.0 SPSS Inc, Chicago, Illinoi, USA) 를이용하였다. 모든통계값은평균전기소작술시행전후의기도폐쇄 505
3 HJ You et al. : Bronchoscopic electrocautery with electroprobe and diathermic snare in patients with malignant airway obstruction Table 2. Result of electrocautery Pretreatment Posttreatment Mean change p value Obstruction(%) 84 ± ± ± 15.7 <0.01 Dyspnea score 7.10 ± ± ± 1.42 <0.01 FEV 1(L) 1.29 ± ± ± 0.19 <0.01 FVC(L) 2.04 ± ± ± 0.22 <0.01 modified Borg category scale(10-0) 의백분율과증상호전점수그리고 FVC와 FEV1의평균 ± 표준편차로표기하였으며, 각군사이의통계값비교는대응표본 T 검정을이용하였다. A B 결 시술후의미있는폐쇄의호전과증상호전이관찰된경우는 19례중 15례로 84.2% 였다. 호흡곤란의정도는 modified Borg category scale이치료전 7.1± 0.90에서 5.7±0.70 로, 기관지내시경상기도폐쇄정도는치료전 84 ± 24.9% 에서 69 ± 22.1% 로모두유의하게호전되었다 ( 각각 p<0.001, p<0.001). FEV 1 과 FVC 는각각 1.29±0.20 L, 2.04±0.34 L 에서치료후 1.72± 0.75 L, 2.4.±0.3L 로유의하게호전되었다 ( 각각 p<0.001, p<0.001), (Table 2). 시술시간은결절성병변의경우 과 Figure 1. A. Electroprobe and diathermic snare B. Electrosurgical unit. 평균시간이 30±15분이였고용종성병변의경우평균 50±25분으로유의하게길었는데 (p=0.05) 전기탐침만을사용했을경우평균 60±20분이였고투열올가미를사용하였을경우시술시간이평균 30±11분으로두기구에따른시술시간에유의한차이가있었다 (p=0.005). 시술에따른합병증으로는폐렴이 1례, 기흉이 1례였고그외심각한출혈, 발열, 부정맥, 사망등은없었다. 시술후전체평균생존기간은 60(20-90) 일이였다. 고찰진행성폐암환자에서호흡곤란은진단당시에 15% 의환자에서나타나고질병의경과중 65% 에서나타나는흔한증상이다 9. 종양에의한기관이나주기관지등의중심성기도폐쇄는심각한호흡곤란의원인이되고환자의삶의질의심각한감소를초래하는데침범된기도내의폐쇄정도와만성폐쇄성호흡기질환, 울혈성심부전, 선행된폐수술등의기왕력의유무에따라호흡곤란의정도가결정된다 1. 기도내종물에의한폐쇄인경우기관지경을통한레이져요법 (laser therapy), 전기소작술 (electrocautery), 한랭요법 (cryotherapy), 아르곤응고소작술 ( argon plasma coagulation), 기관지내방사선요법 (endobronchial brachytherapy) 등의고식적방법을통해기도폐쇄를완화시키게되는데보고자에따라서 75-80% 에서성공률을나타낸다 이중 Nd-YAG laser 가전세계적으로가장많이사용되고있지만장비를운용하는데많은경비가들고경직성기관지경시술이보조적으로사용되기때문에국내에서는널리사용되고있지않다. 506
4 Tuberculosis and Respiratory Diseases Vol. 59. No. 5, Nov A B C D Figure 2. Bronchoscopic findings and chest reontgenograms of patients with central airway obstruction. A. Polypoid mass obstruting trachea and right upper bronchus. B. Remnant mass at the main bronchus after electrocautery. C. Total hazziness of right lung field. D. Restoration of right lung field after electrocautery. 전기소작술은굴곡성기관지경을통해비교적용이하게사용될수있고전기소작술에필요한전기수술기가레이져장비에비해가격이저렴한장점이있다 14. 그리고 Nd-YAG laser의원리와작용기전이유사해시술효과가 Nd-YAG laser와동일한것으로알려지고있는데 Boxem 등 15 은중심성기도폐쇄를보인 31명의원발성폐암환자에서 Nd-YAG laser 와전기소작술의치료효과를비교한연구에서시술후호흡곤란의호전이각각 71% 와 76% 로치료효과가대등함을보고하였고 Coulter 등 16 도 47명의환자에게서소작술을시행하여 89% 의성공률과그에따른부작용이없음을보고하면서전기소작술이 Nd-YAG laser 시술의대안이될수있다고하였다. 국내에서정등 7 은 10명의중심기도폐쇄로인한호흡곤란을호소하는환자에서우수한증상호전을보인경우가 50% 였고주관적증상의일부호전이 40% 로보고하였다. 본연구의경우전체환자의 84%(19명중 16명 ) 에서전기소작술이성공적이였는데주관적증상과내시경상내강폐쇄의평균호전율이각각 2.78±1.42 과 47.8±15.7% 로향상되었고시술후 FEV 1 과 FVC 도각각 0.32± 0.19과 0.5±0.22로호전되어환자의삶의질이개선되었다. 증상호전이유지된기간은연구가되지않았고 2회이상전기소작술을받은환자에서다음소작술까지의평균기간은 20±10일이였다. 그러나대부분의전기소작술은굴곡성내시경을통한시술이기때문에시야확보가어려워정밀한시술이어렵고, 용종성병변의경우제거에소요되는시술시간이 Nd-YAG laser에비해서길어서의식하마취를시행한환자에서수용성이떨어지는단점이있다 4. Hooper 등 3 은용종성병변의경우투열올가미 507
5 HJ You et al. : Bronchoscopic electrocautery with electroprobe and diathermic snare in patients with malignant airway obstruction 를사용할경우신속하게종괴를제거할수있고레이져에저항성인연골이나골성분의제거가가능함을보고한바있다. 내시경부속기구가발달함에따라새롭게고안된칼모양의전기탐침이나투열올가미등을사용한연구가진행되었다. 국내에서정등 7 은칼모양의전기탐침을사용한전기소작술에대한연구에서용종성병변의제거시시술시간이 20-50분으로양호한성적을보고하였다. 본연구에서는 3례의용종성병변에서는기존의전기탐침을사용했을경우시술시간이평균 60분 (40-80분) 이였고 5례의용종성병변에서투열올가미 (diathermic snare) 사용하였을때시술시간의평균이 30분 (10-40 분 ) 으로정등 7 의성적과유사하였다. Sagawa 등 8 은 9명의용종성병병을가진폐암환자에서투열올가미를사용하여평균시술시간을 10분으로보고한바가있어, 모든병변에투열올가미가적응이되진않지만용종성병변인경우향후술기가향상되면시술시간이더단축됨으로써시술에관련된부작용줄이고환자의수용성을더높일수있을것으로생각된다. 투열올가미를사용한전기소작술의합병증으로종물의기저부에올가미가삽입된후전기수술기의출력이너무강하거나투열올가미를지나치게강한힘으로당길경우혈관의소작이불안정하여대량출혈을할수있다는단점이지적되어왔다 3. 투열올가미를사용한 5례의용종성병변중 3례 ( 간세포암 1례, 신세포암 1례, 육종 1례 ) 가전이성폐암이하엽에서발생하여주기관지로진행한경우였는데외견상괴사가심하여조직생검상출혈이잘일어나지않았고투열올가미를사용한시술과관련된심한출혈도없었다. 또한병변의기저부까지제거하지않고우상엽나좌상부기관지의개통만으로만족할만한증상의개선이있었다. 나머지 2례에서는올가미삽입후 1-2초간 30W로소작한후탄화된조직과의유착을피한뒤다시점진적으로올가미를당기면서같은과정을반복하여심각한출혈을방지할수있었다. Sagawa 등 8 의연구에서도투열올가미를사용한시술에따른의미있는출혈등의합병증은보고되지않았다. 따라서적절히선택된병변과시술방법을사용한다면심각한출혈을줄일수있을것으로보인다. 전기소작술의합병증으로기도의천공, 기흉, 출혈, 기관지경의발화, 감염의기관지경의전파등이알려져있다 17,18. 본연구에서시술에따른합병증으로기흉이 1례발생하였으나보전적인흉관삽입술로치료가되었다. 환자는용종성병변이였고전기탐침만으로소작술을시행받았다. Boxem 등 19 동물실험에서 30W로 3초간소작술을시행하였을때 0.9± 0.5mm 의궤양과조직의괴사가발생하고 5초이상시술시 1.9±0.8mm 의궤양과연골의소상을초래한다고보고하였다. 상기환자에서시술시간은 60분이였는데, 시술시기관지벽에전기탐침이접촉되는빈도와시간이길어져과다한에너지에의해기도파열이발생하였다고추정된다. 이상으로중심성기관지폐쇄가있는경우굴곡성기관지경을통해전기소작술을시행할경우전기탐침과투열올가미를사용하였을때효과적으로증상이호전되었고또한시술시간도상대적으로단축되었다. 요약배경 : 폐암의경과중종양에의한기도폐쇄로발생하는호흡곤란은환자의삶의질을저하시키는중요한요인이다. 이런환자들에서전기탐침과투열올가미를이용하여굴곡성기관지경을통해시행한전기소작술의치료효과를조사하였다. 방법 : 기도를침범한종괴로인해서호흡곤란을호소하는 19명의폐암환자 ( 편평상피암 14례, 선암 1례, 전이성폐암 4례 ) 를대상으로하였다. 평균나이는 61±10 세였으며남자가 17명여자가 2명이었다. 폐쇄부위는기관이 2례, 주기관지가 17례였다. 국소마취하에서굴곡성기관경을통해전기소작술을총 29회시행하였으며소작시 30W의전력을사용하였다. 치료전에 modified Borg category scale(0~10), 환기기능검사및기관지내시경검사를실시하였고시술후 3-4일후에 modified Borg category scale(0~10) 의변화및환기기능검사를시행하였고, 정화기관지경술 (clean- 508
6 Tuberculosis and Respiratory Diseases Vol. 59. No. 5, Nov up bronchoscopy) 을시행하여기도폐쇄의완화의정도를측정하였다. 결과 : 시술후호흡곤란의호전율은 84% 였고호흡곤란의정도는 modified Borg category scale가치료전 7.1±0.90에서 5.7±0.70로, 기관지내시경상기도폐쇄정도는치료전 84 ± 24.9% 에서 69±22.1% 로모두유의하게감소하였다. FEV 1 과 FVC는각각 1.29±0.20 L, 2.04±0.34 L 에서치료후 1.72±0.75 L, 2.4.±0.3L로유의하게호전되었다. 용종성병변의경우전기탐침을이용하였을때보다투열올가미를사용한때평균시술시간이의미있게감소하였다 ( 각각 60분, 30분 ). 시술과관련된위험한정도의출혈, 부정맥, 그리고사망은없었다. 결론 : 전기탐침과투열올가미를이용한굴곡성기관지경적전기소작술은종양에의한기도폐쇄로발생하는호흡곤란을완화시키는데효과적이고안전하며경제적인치료방법이었다. 참고문헌 1. Smith EL, Hann DM, Ahles TA, Furstenberg CT, Mi tchell CT, Meyer L et al. Dyspnea, anxiety, body con sciousness, and quality of life in patients with lung cancer. J Pain Symptom Manage 2001;21: Sutedja G, Postmus PE. Bronchoscopic treatment of lung tumors. Lung Cancer 1994;11: Hooper RG, Jackson FN. Endobronchial electrocautery. Chest 1985;87: Wallace JM. Electrocautery via the fibroptic broncho scope: a useful therapeutic technique? Chest 1985;87: Gerasin VA, Shafirovsky BB. Endobronchial electro surgery. Chest 1988;93: Themelin D, Duchatelet P, Boudaka W, Lamy V. End oscopic resection of an endobronchial hypernephroma metastasis using polypectomy snare. Eur Respir J 1990;3: Chung HS, Han SG, Shim YS, Kim KY, Han YC. Endobronchial electrosurgery: application of a newlydesigned probe in malignant airway obstruction. Tuberc Respir Dis 1990;37: Sagawa M, Sato M, Takahashi H, Minowa M, Saito Y, Fujimura S. Electrosurgery with a fibroptic broncho scope and a snare for endotracheal/endobronchial tu mors. J Thorac Cardiovasc Surg 1998;116: Muers MF, Round CE, Palliation of symptoms in nonsmall cell lung cancer: a study by the Yorkshire regional cancer organisation thoracic group. Thorax 1993;48: Natalini G, Cavaliere S, Seramondi V, Foccoli P, Vitacca M, Ambrosino N, Candiani A. Curative bronchoscopic laser therapy for surgically resetable tracheobronchial tumors. Personal Experience J Bronchol 2002;9: Methur PN, Wolf KM, Busk MF, Briete WM, Datzman M. Fiberoptic bronchoscopic cryotherapy in the mana gement of tracheobronchial obstruction. Chest 1996;110: Morice RC, Ece T, Ece F, Keus L. Endobronchial argon plasma coagulation for treatment of hemoptysis and neoplastic airway obstrucion. Chest 2001;119: Villanueva AC, Lo TC, Beamis JF Jr. Endobronchial brachytherapy. Clin Chest Med 1995;16: Sutedja G, van Kralingen K, Schramel FM, Postmus P. Fibroptic bronchoscopy electrosurgery under local anesthesia for rapid palliation in patients with central airway malignancies: a preliminary report. Thorax 1994; 49: Boxem T, Muller M, Venmans B, Postmus P, Sutedja G. Nd-YAG laser vs bronchoscopic electrocautery for palliation of symptomatic airway obstruction. Chest 1999;116: Coulter TD, Mehta AC. The heat is on: impact of end obronchial electrocautery on the need for Nd-YAG laser photoresection. Chest 2000;118: Cavaliere S, Venuta F, Foccoli P, Toninelli C, la Face B. Endoscopic treatment of malignant airway obstruc tions in 2008 patients. Chest 1996;110: Sutedja G, van Boxem T, Schramel F, et al. Endobro nchial electrocautery is an excellent alternative for Nd:YAG laser to treat airway tumors. J Bronchol 1997;4: van Boxem TJ, Westerga J, Venmans BJ, Postmus PE, Sutedja TG. Tissue effects of bronchoscopic electroca utery. Chest 2000;117:
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