대한초음파의학회지 2008;27: 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 연세대학교의과대학신촌세브란스병원영상의학과교실, 병리학교실 * 김지연 홍순원 * 김은경 김민정 곽진영 문희정 김기황 = 초록 = 갑상선의결절질환을평가하는데있어초음파유도하세침흡

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1 대한초음파의학회지 2008;27: 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 연세대학교의과대학신촌세브란스병원영상의학과교실, 병리학교실 * 김지연 홍순원 * 김은경 김민정 곽진영 문희정 김기황 = 초록 = 갑상선의결절질환을평가하는데있어초음파유도하세침흡인세포생검법은 1 차적진단기법으로인식되고있다. 세침흡인세포생검법은적합한검체를채취하였을경우진단의정확도가약 95% 정도로높은검사이나약 10-20% 에서부적합검체의채취로인해정확한진단이어려운경우가발생한다. 뿐만아니라약 10-30% 에서는세포병리학검사상불확실한결과를얻을수있으며림프종등의아형등의추가적인정보를제공하기어려운한계점이있다. 일반적으로초음파유도하중심부바늘생검은세포의조직구조적형태를볼수있는큰검체를얻을수있어정확한조직병리학적진단을가능케한다. 따라서 1) 세침흡인세포생검법상에서부적합검체가채취된경우, 2) 세침흡인세포생검법의결과가불확실하거나불충분한정보를주는경우, 3) 정확한병변의조준이어려운미만성갑상선질환인경우, 4) 영상소견과세침흡인세포생검법의결과가불일치하는경우등에서는중심부바늘생검을시행하는것이정확한진단에보다도움을줄수있다. 따라서이화보에서는갑상선결절질환에서중심부바늘생검이유용한경우들에관한조명을하고자한다. 색인단어 : Head and neck neoplasm, diagnosis; Thyroid; Thyroid, biopsy; Thyroid, neoplasm; Ultrasound (US), guidance 서론갑상선의결절은매우흔하게발견되는질환으로일반성인에서만져지는결절은약 4-7% 의유병율을갖는다 [1-3]. 특히최근고해상도초음파기기가발달하면서갑상선우연종 (incidentaloma) 의발견율이더욱증가하여최근에는갑상선결절의유병율이약 13-27% 로보고되고있다 [3]. 그러나이들중대부분은비종양성결절 (nonneoplastic nodule) 이며약 5-30% 만이악성으로수술적치료를필요로한다 [4]. 따라서갑상선결절이발견된환자에서세포병리학적인검사는수술적치료가필요한갑상선암의발견율을향상시키고 양성병변에대한불필요한수술을피하기위해필수적인과정이되었다 [4]. 이러한갑상선결절의평가및진단에이용되는기법에는초음파유도하세침흡인세포생검법 (ultrasonography-guided fine needle aspiration) 이대표적인방법이다. 세침흡인세포생검법은 게이지 (gauge) 의바늘을이용하는최소침습적이고안전한검사로별다른전처치나준비가필요하지않아외래에서도시행할수있는장점이있다. 또한적절한검체를얻었을경우진단의정확도 (accuracy) 가약 95% 에이르는방법으로현재갑상선결절의평가에대한 1차적진단기법 (diagnostic technique of choice) 로가장널리받아들여지고있으며, 대부분의갑상선병변의진단과치료방 논문접수 : 2008 년 10 월 16 일, 수정제의 : 2008 년 10 월 24 일, 수정논문접수 : 2008 년 10 월 29 일, 논문게재결정 : 2008 년 10 월 31 일통신저자 : 김민정, ( ) 서울시서대문구신촌동 134, 연세대학교의과대학세브란스병원영상의학과, 방사선의과학연구소 Tel. (02) Fax. (02) mines@yuhs.ac

대한초음파의학회지제 27 권제 4 호 2008 향결정은세침흡인세포검사만으로도충분하다 [3, 4].

이어려운병변이나영상소견과세침흡인세포생검법결과가불일치하는경우등에서도추가적인검사가필요시된다. 이와같은경우, 보완적으로시행할수있는진단기법에초음파유도하중심부바늘생검 (ultrasonography-guided coreneedle biopsy) 이사용될수있다.

이때중심부바늘생검바늘의주행경로는주변의주요구조를손상시키지않는범위안에서검사자가정한다. ㅇ. 한손으로탐촉자를잡고초음파유도하에다른한손으로바늘의끝이대상이되는결절의끝부분 (edge) 에위치하도록한다. ㅈ. 용수철활성화절단캐뉼라 (spring activated cutting cannula) 를발사시켜약 10-20 mm 정도길이의조직을얻는다. ㅊ.

2 대한초음파의학회지제 27 권제 4 호 2008 향결정은세침흡인세포검사만으로도충분하다 [3, 4]. 세침흡인세포생검법의결과는대개양성 (benign), 미결정 (indeterminate), 악성 (malignant), 비진단적 (nondiagnostic/inadequate) 의 4가지범주로구분되는데이중미결정병변과비진단적인병변의경우에는치료방침의결정을위하여추가적인검사가필요하고그외에도조준 (targeting) 이어려운병변이나영상소견과세침흡인세포생검법결과가불일치하는경우등에서도추가적인검사가필요시된다. 이와같은경우, 보완적으로시행할수있는진단기법에초음파유도하중심부바늘생검 (ultrasonography-guided coreneedle biopsy) 이사용될수있다. 본화보에서는갑상선중심부바늘생검의개념및시술방법, 그리고세침흡인세포생검법에추가적으로중심부바늘생검이유용한경우에대해조명하고자한다. 1. 초음파유도하중심부바늘생검 (1) 개념중심부바늘생검은세침흡인세포생검법시사용하는 게이지의바늘보다큰 16-21게이지의바늘 (Fig. 1, 2) 을사용하여조직을얻는다 [4, 5]. 입한다. 필요에따라피부에절개를시행할수있다. 이때중심부바늘생검바늘의주행경로는주변의주요구조를손상시키지않는범위안에서검사자가정한다. ㅇ. 한손으로탐촉자를잡고초음파유도하에다른한손으로바늘의끝이대상이되는결절의끝부분 (edge) 에위치하도록한다. ㅈ. 용수철활성화절단캐뉼라 (spring activated cutting cannula) 를발사시켜약 mm 정도길이의조직을얻는다. ㅊ. 한결절에대하여대개 1-3번의검사를반복한다. ㅋ. 채취한검체를포르말린액에고정한다. ㅌ. 바늘을뽑은후바로알코올솜으로눌러준후거즈를대고 15분정도압박하여지혈시키며관찰한다. (3) 합병증이전에초음파유도를하지않은상태에서시행한중심부바늘생검의경우되돌이후두신경의손상, 출혈, 바늘이지나가는길 (biopsy track) 을따른암세포의파종 (implantation) 등의합병증이보고되었으나, 최근초음파유도를통한중심부바늘생검의경우에는약간의혈종이나객혈등입원치료를필요치 (2) 중심부바늘생검의검사방법및순서 (Fig. 3.) ㄱ. 환자를앙와위로눕힌다. ㄴ. 어깨밑을베개또는수건등으로받쳐목이신전될수있도록한다. ㄷ. 검사도중침을삼키거나말을하지않도록주의시킨다. ㄹ. 검사시행부위의피부를베타딘및알코올로소독하고무균적드래핑을한다. ㅁ. 7 MHz 이상의고해상도직선형탐촉자의표면에젤리를바르고감염방지용소독비닐로감싼다. ㅂ. 젤을바르고탐촉자를움직여목표가되는결절을찾아모니터의중간에결절이위치하도록한다. ㅅ. 피부에국소마취를시행한다 게이지의바늘을사용하여피부를뚫고그곳을통하여생검용바늘을삽 Fig. 2. Comparison of core biopsy needle (: 16 gauge, : 18 gauge) and aspiration needle (C: 23 gauge). Fig. 1. The examples of biopsy needles used for core needle biopsy : STERICUT Semi-automatic biopsy system, in which the stylet containing a biopsy specimen slot is advanced manually and the cutting cannular is then fired. / : CECUT utomatic iopsy System, in which the spring-activated stylet and the cutting cannula are fired in succession

김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 않는경한합병증만이간간히보고되고있다 [4, 6]. 숙련도가높은검사자가시행하거나시행전자세한초음파검사와도플러검사를통하여주변조직과혈류정도를세밀하게조사하여가장안전하고짧은경로로접근하면이러한합병증의발생위험을더욱낮출수있다 [7, 8].

을이용하는것보다주변조직의손상을입힐가능성을줄일수있는방법중한가지이다 [7]. 그밖에도검사후환자를약 30-60분간충분히안정시키면서관찰하는것도위험한출혈합병증의발생을낮출수있다 [8]. 됨을알수있다. 각검사의검체적합성 (adequacy rate) 의경우세침흡인세포생검법이약 70.3%, 그리고중심부바늘생검이 82.

세침흡인세포생검법과중심부바늘생검 기존의보고들에따르면적절한검체가채취되었을경우에세침흡인세포생검법과중심부바늘생검의민감도 (sensitivity) 는각각약 83% 와 84% 로보고되었으며특이도 (specificity) 의경우각각약 92% 와 95% 로나타났다 [3, 7-16].

3 김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 않는경한합병증만이간간히보고되고있다 [4, 6]. 숙련도가높은검사자가시행하거나시행전자세한초음파검사와도플러검사를통하여주변조직과혈류정도를세밀하게조사하여가장안전하고짧은경로로접근하면이러한합병증의발생위험을더욱낮출수있다 [7, 8]. 또한검체홈 (specimen slot) 이있는탐침 (stylet) 을직접손으로밀어넣는단발성용수철활성화바늘 (single-action spring-activated needle) 을이용하는것이탐침과절단캐뉼라 (cutting cannula) 가모두용수철에의해발사되는양발성용수철활성화바늘 (doubleaction spring-activated needle) 을이용하는것보다주변조직의손상을입힐가능성을줄일수있는방법중한가지이다 [7]. 그밖에도검사후환자를약 30-60분간충분히안정시키면서관찰하는것도위험한출혈합병증의발생을낮출수있다 [8]. 됨을알수있다. 각검사의검체적합성 (adequacy rate) 의경우세침흡인세포생검법이약 70.3%, 그리고중심부바늘생검이 82.2% 로중심부바늘생검에서세침흡인세포생검법에비하여높게보고되고있다 [4, 5, 11]. 바꾸어말하면, 중심부바늘생검도약 17.8% 의검체부적합성을보일수있으므로, 갑상선병변의진단에있어두가지검사중어느한쪽이월등하 2. 세침흡인세포생검법과중심부바늘생검 기존의보고들에따르면적절한검체가채취되었을경우에세침흡인세포생검법과중심부바늘생검의민감도 (sensitivity) 는각각약 83% 와 84% 로보고되었으며특이도 (specificity) 의경우각각약 92% 와 95% 로나타났다 [3, 7-16]. 각검사의정확도는세침흡인세포생검법과중심부바늘생검에서각각약 95% 와 96% 으로비슷하게보고되고있으며, 일단세침흡인검사에서적절한검체가채취된경우는중심부바늘생검과견줄만한정확도를가진다할수있다 [7]. 이전연구에서도적절한검체가채취된경우두검사의정확도는거의차이를보이지않았다 [7]. 그러나, 이는검체가적합한경우에한한것이므로실제로는검체적합성이상당히중요한역할을하게 Fig. 3. The procedures of core needle biopsy.. Position the tip of the needle at the edge of the lesion using freehand technique under ultrasonogram guidance.. Manually advance or fire the stylet with a biopsy specimen s- lot and then fire spring-activated blade(=spring-loaded cutting cannula) to acquire approximately mm size tissue. C. Fix the acquired tissue specimen in Formalin. Fig. 4. The transverse scan of thyroid ultrasonography of a 50-year-old woman.. There was no definitely visible nodular lesion, but the bilateral lobes of the thyroid gland were heterogeneous and diffusely decreased in parenchymal echogenicity. The fine needle aspiration biopsy was performed at the right lobe of the thyroid gland, but cytologic result revealed cell paucity, meaning inadequate sampling.. Core needle biopsy was performed at the right lobe of the thyroid gland, and pathologic result revealed Hashimoto s thyroiditis in the fibrosing stage

현재세침흡인세포생검법에비하여비용과시간이많이들고더침습적인점등을고려하였을때중심부핵생검을갑상선결절질환을가진환자에서초기진단검사로이용하는것에대해서는여전히회의적인의견이많다 [4, 13, 18, 19].

4 대한초음파의학회지제 27 권제 4 호 2008 다기보다는상호보완적인역할을수행할수있다. 실제로두가지검사를동시에이용하였을경우민감도가약 97.3% 그리고검체적합성이약 88.9% 로어느한가지검사만을시행한경우보다의미있게증가한다는것이보고되었다 [5, 17]. 두가지검사는모두출혈, 감염, 되돌이후두신경의손상, 암세포의파종등유사한합병증을동반할수있는데최근연구들에따르면대부분입원치료를요하는중요합병증의발생률은세침흡인세포생검법에서약 0.13%, 그리고중심부바늘생검에서약 0.16% 로매우낮은빈도로보고되고있다 [4, 7]. 현재세침흡인세포생검법에비하여비용과시간이많이들고더침습적인점등을고려하였을때중심부핵생검을갑상선결절질환을가진환자에서초기진단검사로이용하는것에대해서는여전히회의적인의견이많다 [4, 13, 18, 19]. 따라서보다간단한방법인세침흡인검사로일차적인검사를시행하고, 좀더명확한갑상선병변의평가를위해서는어떠한경우에중심부바늘생검을이용할것인지에관해서는이러한사례들의이해와적절한적용이필수적이다. 3. 세침흡인세포생검법에추가적으로시행하는중심부바늘생검이유용한경우 (1) 세침흡인세포생검법상의부적합검체채취 (inadequate sampling) 현재까지세침흡인세포생검법은일반적으로약 10-20% 에이르는검체부적합율이보고되고있다 [5]. 특히 1회의세침흡인세포생검법을시행하는경우검체부적합율은약 28% 까지도보고되어있으며부적합검체가검출된환자에서세침흡인세포생검법시최대 4회까지흡인을재시행한다고하더라도 약 6% 이상의부적합검체가채취될수있다 [6]. 검체부적합율의원인으로는여러가지가알려져있다. 기존에시행되던세침흡인세포검사는강제적인음압을가하여세포를흡인함으로써검체를채취하는방법을사용하였다. 이방법은더많은세포를얻으려는데그목적이있으나세포나조직에손상을입혀조직학적형태의변화를유발하거나혈액에의한오염의빈도를증가시켜세포병리학적인진단이어려운경우들이발생할수있다. 또한시술자의숙련도역시검체부적합율의원인이될수있는데미숙련된시술자의경우약 70% 까지도부적합검체가채취될수있으며, 숙련된시술자라할지라도약 17% 까지검체부적합율이보고된다 [6, 20]. 그러나무엇보다도검체부적합율은병변자체의특성과밀접한연관을보이고특히경화 (sclerosis) 또는섬유화 (fibrosis) 가심한병변이거나석회화 (calcification) 를가지는병변, 혹은넓은부위가낭종성변성 (cystic degeneration) 을한병변등에서는세침흡인세포생검법을통해적절한검체를채취하는것이어렵다 [5, 11]. 이렇게세포흡인이어려운병변에서반복적으로검체부적합이보고되면다시세침흡인세포생검법을시행하는것보다는중심부바늘생검과같은다른진단기법을이용하여조직을얻는것이보다효과적일수있다 [5] (Fig. 4, 5). 실제로세침흡인세포생검법에서반복적으로검체부적합율을보이는병변에서중심부바늘생검을시행하면약 48.8% 에서조직학적인진단이가능할수있다 [6]. (2) 세침흡인세포생검법결과가미결정형 (indeterminate) 이거나불충분한정보를주는경우세침흡인세포생검법의결과가불확실한경우는여포성병변 Fig. 5. The transverse scan of thyroid ultrasonography of an 82-year-old man.. mass with heterogeneous echogenicity involving the entire right lobe of the thyroid gland was noted. Partial cystic change was demonstrated within the mass. few atypical cell, which concur with inadequate sampling, was reported on cytology of fine needle aspiration biopsy.. Core needle biopsy was performed on the same mass, and pathologic result of core needle biopsy was revealed as anaplastic carcinoma

김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 (follicular lesion) 이나악성이의심스러운병변 (suspicious for malignancy) 등을포함하는결과로모든세침흡인세포생검법결과의약 15-30% 를포함하며이중악성이약 10-20% 가량으로보고되고있어보다정확한진단이필요하다 [21-24].

림프종의아형을아는것은환자의치료방침결정이나치료약제의선택, 예후예측등에영향을주게되므로이에대한추가적인정보를얻기위하여중심부바늘생검이유용하게사용될수있으며, 진단적인목적의수술을피할수있다는장점이있다 [19] (Fig. 6).

5 김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 (follicular lesion) 이나악성이의심스러운병변 (suspicious for malignancy) 등을포함하는결과로모든세침흡인세포생검법결과의약 15-30% 를포함하며이중악성이약 10-20% 가량으로보고되고있어보다정확한진단이필요하다 [21-24]. 그외에도림프종의경우세침흡인세포생검법에서림프종자체의진단이용이하지않고특히림프종의아형 (subtype) 의진단은거의불가능하다 [19]. 이에반해중심부바늘생검은충분한조직을얻어여러슬라이드를만들수있어조직에대한특수염색을시행할수있으므로아형을진단이가능하다. 림프종의아형을아는것은환자의치료방침결정이나치료약제의선택, 예후예측등에영향을주게되므로이에대한추가적인정보를얻기위하여중심부바늘생검이유용하게사용될수있으며, 진단적인목적의수술을피할수있다는장점이있다 [19] (Fig. 6). 세침흡인세포생검법으로얻은검체의경우세포의형태로진단을내려야하므로주로핵의특성에기초하고있고따라서가끔내분비세포에서의악성의가능성을예측하기힘들수도있으며세포병리학자의경험이필수적이다. 그러나중심부바늘생검을시행하는경우에는 게이지의바늘을이용하여보다큰검체를얻을수있으므로세포의형태뿐만이아니라병변의조직구조적형태 (tissue architecture) 가유지된조직학적인표본을얻을수있다. 특히일반적인병리학자의경우세포학적인형태단독만으로진단을내리는것보다조직학적표본을통한진단에더욱익숙하므로진단의정확도가증가 할수있다 [4]. 또한세포학적인형태만으로는감별진단이어려운휘슬세포선종 (Hurthle cell adenoma) 과여포암 (follicular carcinoma), 유두암 (papillary carcinoma) 의여포변종 (follicular varient), 수질암 (medullary carcinoma) 등의진단에도유용하게쓰일수있다 [15] (Fig 7). 또한, 원발성갑상선암과전이성갑상선암의감별이나전이성갑상선암의원발암의종류또한면역조직화학염색을통해감별이가능하다 [4, 18, 19] (Fig. 8). (3) 정확한목표설정및조준이어려운경우 : 미만성갑상선질환그레이브스병 (Grave s disease), 다결절성갑상선종대 (multinodular goiter) 및몇몇염증성질환은미만성으로갑상선을침범하게되는데이들중다결절성갑상선종대의경우약 1-10% 에서갑상선암이발견되고하시모토갑상선염의경우드물게림프종이병발할수있으므로초음파검사시에는동반된암이있는지를밝히는것이중요하다. 그렇지만미만성갑상선질환을가진환자의갑상선은많은경우에초음파상에서비균질한에코를보이고특히다결절성갑상선종대나하시모토갑상선염인경우에국소적인병변의발견은어려운일이다. 또한국소적으로의심스러운부분을발견했다고하더라도경계가모호하거나그부위가넓은경우에는세침흡인검사를시행함에있어조준 (targeting) 이쉽지않은경우가있다. 이러한경우에세침흡인세포생검법을시행하면부적합검체가 Fig. 6. The ultrasonography of a 57-year-old man.. The transverse scan of the thyroid gland shows heterogeneous parenchymal echogenicity. n ill-defined area with marked hypoechogenicity (arrowheads) is visualized in the right lobe of the thyroid gland. The cytologic result of fine needle aspiration biopsy from the hypoechoic area was confirmed as lymphoma.. In order to determine the subtype of the lymphoma, the immunohistochemical s- tain (L26/CD79a,TTF,chromogranin,cytokeratin) was additionally performed with the tissue, which was obtained by core needle biopsy (arrow: core biopsy needle). The subtype of the lymphoma was determined as diffuse large cell lymphoma

대한초음파의학회지제 27 권제 4 호 2008 채취되거나위음성의결과를얻을수있으므로중심부바늘생검을통하여보다큰크기의검체를얻으면진단의정확도를올릴수있다. (4) 영상소견과세침흡인세포생검법의결과가불일치 (discordant) 한경우대부분의갑상선결절질환이있는환자에서세침흡인세포생검법이나중심부중심부바늘생검등을시행하기전초음파검사를시행한다.

또한그외에도주변림프절종대나달걀껍질모양의석회화를포함한주변부석회화가있는때석회질의바깥쪽으로불규칙한모양의종괴가있는경우에도악성을의심할수있는소견으로보고되고있다 [16, 18]. 만일결절이등에코이거나난원, 구형혹은불규칙한모양인경우, 경계가분명하고부드러운경우혹은불분명한경우, 둘레석회화를보이는경우등에서는악성결절이보고되는경우도있으므로역시주의를요하는소견들이다.

6 대한초음파의학회지제 27 권제 4 호 2008 채취되거나위음성의결과를얻을수있으므로중심부바늘생검을통하여보다큰크기의검체를얻으면진단의정확도를올릴수있다. (4) 영상소견과세침흡인세포생검법의결과가불일치 (discordant) 한경우대부분의갑상선결절질환이있는환자에서세침흡인세포생검법이나중심부중심부바늘생검등을시행하기전초음파검사를시행한다. 갑상선의결절질환의초음파검사에서악성을강력히의심할수있는소견으로는결절내의미세및거대석회화, 결절내부의현저한저에코, 앞뒤가긴모양 (taller than wide), 경계가분명하면서침상인경우 (well-defined spciulated) 등이대표적이다 [14, 18]. 또한그외에도주변림프절종대나달걀껍질모양의석회화를포함한주변부석회화가있는때석회질의바깥쪽으로불규칙한모양의종괴가있는경우에도악성을의심할수있는소견으로보고되고있다 [16, 18]. 만일결절이등에코이거나난원, 구형혹은불규칙한모양인경우, 경계가분명하고부드러운경우혹은불분명한경우, 둘레석회화를보이는경우등에서는악성결절이보고되는경우도있으므로역시주의를요하는소견들이다. 초음파검사상위와같은소견들을바탕으로악성이강력히의심되었던병변이었음에도불구하고세침흡인세포생검법상양성의결과를얻는다면이는위음성의가능성을고려해야하는결과이다. 실제로세침흡인세포생검법에관한연구들에따르면약 % 정도의위음성율이보고되고있으므로임상및영상소견과세침흡인세포생검법의결과가불일치한다 고판단되는경우에는재검사를통한확인이필요하다 [3] (Fig. 9). 일반적으로위음성의원인으로는여러가지가있으나검체채취시의오류 (sampling error) 또는병리학적판독의오류 (interpretive mistake) 등이대표적인데중심부바늘생검을통하여큰조직학적검체를얻는것이보다정확한진단에도움을줄수있다 [3]. 4. 중심부바늘생검의한계점비록위와같은경우들에서중심부바늘생검이세침흡인세포생검법에비하여유용하게사용될수있으나중심부바늘생검에도한계점들이존재하는데, 예를들어, 중심부바늘생검은세침흡인세포생검법에비해굵은바늘을사용하고더침습적이며바늘이움직일수있는범위가제한되어있고시야범위가상대적으로좋지않을수있다. 또한, 바늘이병변을관통하여조직을얻게되므로병변의위치가주변장기에손상을줄수있는위치라면신중한계획과숙련된영상의학과의사의전문지식과풍부한경험이필수적이다 [17]. 또한병변의크기나매우작은경우에는조준이어렵고부적절한검체가채취될가능성이높다. 그밖에도대상이되는병변의위치가갑상선의상하부, 내외측, 후방부피막부위에위치하여혈관및주요기관과인접한경우등에서는접근이어려울수있다 [5]. 뿐만아니라결절에매우심한석회화가동반되어있을경우에는세침흡인세포검사와마찬가지로중심부바늘생검시에도제한을받을수있다 [18]. 이러한검사과정상의문제뿐아니라세침흡인세포생검법과 Fig. 7. The transverse scan of thyroid ultrasonography of a 64-year-old man.. bout 2.5-cm-size nodule with microcalcification and indistinct margin is noted in the right lobe of the thyroid gland. This nodule also shows taller than wide appearance. The cytologic result by fine needle aspiration biopsy of the nodule was suspicious for oncocytic medullary carcinoma, however, confirmative diagnosis was difficult.. Core needle biopsy was performed on the same nodule and the pathologic result was comfirmed as Hurthle cell neoplasm. Immunohistochemical stain, using the markers for oncocytic medullary carcinoma, was performed, but the results were all negative. The patient underwent thyroidectomy and the surgical specimen was diagnosed as Hurthle cell neoplasm

김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 C D E F Fig. 8.

. 4.5-cm-sized hypoechoic mass(arrowheads), with indistinct margin and invasion of the

This mass shows taller than wide appearance.

. The cytology of this mass shows hypercelluarity with papillary structured epithelial

7 김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 C D E F Fig. 8. The transverse scan of thyroid ultrasonography of a 49-year-old woman with breast cancer cm-sized hypoechoic mass(arrowheads), with indistinct margin and invasion of the outer normal thyroid gland tissue, is noted in the right lobe of the thyroid gland. This mass shows taller than wide appearance. Fine needle aspiration of this mass was performed.. The cytology of this mass shows hypercelluarity with papillary structured epithelial cell clusters and nonfollicular cytologic characters, suggesting metastatic carcinoma (Papanicoloaou 200). C. To confirm whether the thyroid mass was metastasis from breast or from other sites, core needle biopsy was performed. D. The core needle biopsied thyroid tissue shows unusual tumor emboli in the blood or lymphatic vessels in the background of thyroiditis, suggesting metastatic carcinoma (H & E 200). E & F. With CE (E, arrows) and C-erb2 (F, arrowheads) immunoreactivity, this case was diagnosed as breast ductal carcinoma (Immunohistochemical s- tain 200)

대한초음파의학회지제 27 권제 4 호 2008 공통적인몇몇한계점들도존재한다.

에이르는세침흡인세포생검법의위음성율보다는낮으나환자의예후에중요한영향을미칠수있으므로중심부바늘생검상양성의결과를얻었다고할지라도반드시추적검사를 C E D Fig. 9.

. On the transverse scan of thyroid ultrasonography, not only was the volume of the left lobe of the thyroid gland larger

Fine needle aspiration biopsy of the left lobe was performed.

8 대한초음파의학회지제 27 권제 4 호 2008 공통적인몇몇한계점들도존재한다. 예를들어, 두가지검사모두가초음파유도하에시행하지않는다면시술자가병변자체를정확히조준하는것이어려운것은물론이고병변을정확히조준하였다하더라도해당병변에서가장의심스러운부분또는고형부분이채취되었는지확신하기어렵다. 따라서두가지검사모두보다정확한결과를 위해서는초음파유도가필수적이다. 두번째로, 초음파유도하에실시한다고해도약 0-8% 정도의위음성율이중심부바늘생검에서보고되고있는데이것은 1-19% 에이르는세침흡인세포생검법의위음성율보다는낮으나환자의예후에중요한영향을미칠수있으므로중심부바늘생검상양성의결과를얻었다고할지라도반드시추적검사를 C E D Fig. 9. The ultrasonography of a 78-year-old man with a history of renal cell cancer.. On the transverse scan of thyroid ultrasonography, not only was the volume of the left lobe of the thyroid gland larger than that of the right lobe, but also, the left lobe demonstrated irregular hypoechogenicity. Fine needle aspiration biopsy of the left lobe was performed.. The cytology of this case shows hypocelluarity with rare epithelial clusters with bland looking cytological characters, diagnosed as negative for malignancy (Papanicoloaou 200). C. However, the axial PET scan of the left lobe revealed markedly increased FDG uptake(arrow). D & E. Therefore, core needle biopsy (D) was performed for confirmation. The core needle biopsied thyroid tissue (E) shows a well defined nonfollicular mass, showing bland looking renal cell carcinoma, diagnosed as metastatic renal cell carcinoma (H & E 200)

김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 C D E F Fig. 10.

thyroidectomy for a benign lesion and has recent chief complaint of thyroid enlargement with associated

. The left lobe of the thyroid gland shows diffuse enlargement in size and marked parenchymal

ased on ultrasonographic findings, lymphoma was suspected rather than simple thyroiditis, and fine needle

. The cytology shows hypocelluarity with lymphocytes with rare follicular cells, suggesting lymphocytic

ecause the possibility of lymphoma still existed based on ultrasonography findings, core needle biopsy (C)

9 김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 C D E F Fig. 10. The transverse scan of thyroid ultrasonography of a 54-year-old woman who had undergone right thyroidectomy for a benign lesion and has recent chief complaint of thyroid enlargement with associated hardness.. The left lobe of the thyroid gland shows diffuse enlargement in size and marked parenchymal hypoechogenicity. ased on ultrasonographic findings, lymphoma was suspected rather than simple thyroiditis, and fine needle aspiration biopsy was performed.. The cytology shows hypocelluarity with lymphocytes with rare follicular cells, suggesting lymphocytic thyroiditis (Papanicolaou 100). C & D. ecause the possibility of lymphoma still existed based on ultrasonography findings, core needle biopsy (C) was performed for confirmation. The core needle biopsied thyroid tissue (D) shows dense collagenous fibrosis with inflammation, suggesting Riedel s thyroiditis (H & E 100). E. The surgical specimen of thyroid shows lymphoid inflammation with dense collagenous fibrosing lobulations (H & E 12.5). F. Higher magnification of thyroid shows lymphoid germinal center and Hurthle cells, diagnosing Hashimoto s thyroiditis, fibrosing variant (H & E 100) which was identical with the result of fine needle aspiration biopsy

10 대한초음파의학회지제 27 권제 4 호 2008 실시하여야한다 [8]. 특히영상소견상악성이의심되는경우에는단기추적검사가반드시필요하다. 또한, 기존에세침흡인세포생검법의한계점으로지적되어왔던병변중중심부바늘생검으로극복되지못하는경우들이있다. 여포암과여포선종의감별의경우는중심부바늘생검으로감별이가능하다는연구들도있으나이에대해서는아직논란이있으며, 여전히수술만이정확한진단을가능하게하여중심부바늘생검의한계점으로도지적되고있다 [25, 26]. 뿐만아니라다결절성갑상선종 (multinodular goiter) 와여포선종 (follicular adenoma) 에서는여포선종과선종성증식 (adenomatous hyperplasia) 이혼동되는경우도약 22% 에서보고되어여포선종의진단에있어서는세심한주의가필요하다 [17]. 또한저자들이경험한하시모토갑상선염중일부는핵생검에서리델갑상선염 (Riedel s thyroiditis) 으로진단된사례도있었다 (Fig. 10). 결 초음파유도하세침흡인세포생검법은갑상선의결절성질환을가진환자의평가에있어비교적저렴하고안전하며정확한 1차적진단기법이다. 초음파유도하중심부바늘생검은세침흡인세포생검법을대체하는방법이라기보다는세침흡인세포생검법에서불확실한결과를얻었거나반복적으로비진단적인결과를얻은경우, 미만성갑상선질환으로조준이어려운경우, 영상소견과세포검사결과가불일치하는경우등에서보완적인방법으로사용할수있는유용한검사법이다. 그러므로영상의학과의사는위에서언급한초음파유도하중심부바늘생검의장점및한계점을충분히숙지하고초음파유도하중심부바늘생검의적응증이되는증례들에서세침흡인세포생검법의보완적인역할을할수있는초음파유도하중심부바늘생검을적절히활용하는것이필요하다. 론 References 1. Vander J, Gaston E, Dawber TR. The significance of nontoxic thyroid nodules. Final report of a 15-year study of the incidence of thyroid malignancy. nn Intern Med 1968;69: Rojeski MT, Gharib H. Nodular thyroid disease. Evaluation and management. N Engl J Med 1985;313: Gharib H, Goellner JR. Fine-needle aspiration biopsy of the thyroid: an appraisal. nn Intern Med 1993;118: Screaton NJ, erman LH, Grant JW. US-guided core-needle biopsy of the thyroid gland. Radiology 2003;226: Renshaw, Pinnar N. Comparison of thyroid fine-needle aspiration and core needle biopsy. m J Clin Pathol 2007;128: Carpi, Nicolini, Marchetti C, Iervasi G, ntonelli, Carpi F. Percutaneous large-needle aspiration biopsy histology of palpable thyroid nodules: technical and diagnostic performance. Histopathology 2007;51: Harvey JN, Parker D, De P, Shrimali RK, Otter M. Sonographically guided core biopsy in the assessment of thyroid n- odules. J Clin Ultrasound 2005;33: Taki S, Kakuda K, Kakuma K, et al. Thyroid nodules: evaluation with US-guided core biopsy with an automated biopsy gun. Radiology 1997;202: Hamming JF, Goslings M, van Steenis GJ, van Ravenswaay Claasen H, Hermans J, van de Velde CJ. The value of fine-needle aspiration biopsy in patients with nodular thyroid disease divided into groups of suspicion of malignant neoplasms on clinical grounds. rch Intern Med 1990;150: Pepper GM, Zwickler D, Rosen Y. Fine-needle aspiration biopsy of the thyroid nodule. Results of a start-up project in a general teaching hospital setting. rch Intern Med 1989;149: Mahar S, Husain, Islam N. Fine needle aspiration cytology of thyroid nodule: diagnostic accuracy and pitfalls. J yub Med Coll bbottabad 2006;18: Harsoulis P, Leontsini M, Economou, Gerasimidis T, Smbarounis C. Fine needle aspiration biopsy cytology in the diagnosis of thyroid cancer: comparative study of 213 operated patients. r J Surg 1986;73: Karstrup S, alslev E, Juul N, Eskildsen PC, aumbach L. USguided fine needle aspiration versus coarse needle biopsy of thyroid nodules. Eur J Ultrasound 2001;13: Khoo TK, aker CH, Hallanger-Johnson J, et al. Comparison of ultrasound-guided fine-needle aspiration biopsy with core-needle biopsy in the evaluation of thyroid nodules. Endocr Pract 2008;14: Mehrotra P, Hubbard JG, Johnson SJ, Richardson DL, liss R, Lennard TW. Ultrasound scan-guided core sampling for diagnosis versus freehand FNC of the thyroid gland. Surgeon 2005;3: Moon WJ, Jung SL, Lee JH, et al. enign and malignant thyroid n- odules: US differentiation--multicenter retrospective study. Radiology 2008;247: oey J, Hsu C, Collins RJ, Wong J. prospective controlled study of fine-needle aspiration and Tru-cut needle biopsy of dominant thyroid nodules. World J Surg 1984;8: Kim EK, Kwak JY. State of the rt Thyroid Sonography. 1st ed, Seoul: GON Medical ook Service, 2006; Kwak JY, Kim EK, Ko KH, et al. Primary thyroid lymphoma: role of ultrasound-guided needle biopsy. J Ultrasound Med 2007;26: urch H, urman KD, Reed HL, uckner L, Raber T, Ownbey JL. Fine needle aspiration of thyroid nodules. Determinants of insufficiency rate and malignancy yield at thyroidectomy. cta Cytol 1996;40: Miller JM, Hamburger JI, Kini S. Diagnosis of thyroid nodules. Use of fine-needle aspiration and needle biopsy. JM 1979;241: Ramacciotti CE, Pretorius HT, Chu EW, arsky SH, rennan MF, Robbins J. Diagnostic accuracy and use of aspiration biopsy in the

11 김지연외 : 갑상선결절진단에서의초음파유도하중심부바늘생검의유용성 management of thyroid nodules. rch Intern Med 1984;144: Nunez C, Mendelsohn G. Fine-needle aspiration and needle biopsy of the thyroid gland. Pathol nnu 1989;24 Pt 1: Myeon Jun Yang MD, Jong Hwa Lee, M.D., Shang Hun Shin, M.D., Seong Hoon Choi MD, e Kyung Jeong, M.D., yeong Seong Kang, M.D., Woon-Jung Kwon MD, Yoong Ki Jeong, M.D. US Guided Fine-needle Non-suction Technique: Useful and Comfortable Method for Thyroid Nodule. J Korean Soc Ultrasound Med 2006: Jordan CD. Equanimity: synchronous fine-needle aspiration cytology and core biopsy of thyroid nodules. m J Clin Pathol 2007;128: Carpi, Nicolini, Righi C, Romani R, Di Coscio G. Large needle aspiration biopsy results of palpable thyroid nodules diagnosed by fine-needle aspiration as a microfollicular nodule with atypical cells or suspected cancer. iomed Pharmacother 2004;58: J Korean Soc Ultrasound Med 2008;27: = bstract = The Utility of US-Guided Core-Needle iopsy in the Diagnosis of Thyroid Nodules Ji Youn Kim, M.D., Soon Won Hong, M.D.*, Eun-Kyung Kim, M.D., Min Jung Kim, M.D., Jin Young Kwak, M.D., Hee Jung Moon, M.D., Ki Whang Kim, M.D. Department of Radiology, Yonsei University College of Medicine, Seoul, Korea *Department of Pathology, Yonsei University College of Medicine, Seoul, Korea Ultrasonography (US)-guided fine needle aspiration biopsy (FN) is widely considered to be the diagnostic technique of choice in the assessment of nodular disease of the thyroid gland. lthough the accuracy of FN analysis approaches 95% where there is an adequate sample, non-diagnostic sampling occurs in 10-20% of cases. dditionally, equivocal pathological results are obtained in 10-30% of cases, and there are limitations in detecting subtypes of certain diseases, such as lymphoma. Generally, US-guided core needle biopsy (CN) allows for the procurement of a large, grossly visible specimen and a more precise pathological diagnosis. Therefore, US-guided CN is indicated in the following situations: 1) when an inadequate specimen is obtained by FN, 2) when FN yields indeterminate or inadequate information, 3) when targeting of the lesion is difficult because it is diffuse, and 4) when there is a discrepancy between the imaging findings and the FN results. In this article, we describe the situations in which US-guided CN is useful for diagnosing thyroid lesions. ddress for reprints : Min Jung Kim, M.D., Department of Radiology & Research Institute of Radiological Science, Severance Hospital, College of Medicine, Yonsei University, 250 Seongsanno, Seodaemun-gu, Seoul , Korea. Tel Fax mines@yuhs.ac

Kbcs002.hwp

Kbcs002.hwp Does Real-time Compound Imaging Improve Evaluation of reast Cancer Compared to Conventional Sonography? o Kyoung Seo, M.D., Yu Whan Oh, M.D., Kyu Ran Cho, M.D., Young Hen Lee, M.D., Hyung Joon Noh, M.D.,