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1 293 pissn : , eissn : Review J Korean Orthop Assoc 2019; 54: 연부조직종양의진단적접근 전영수 송승현 경희대학교의과대학정형외과학교실, 강동경희대학교병원정형외과 Diagnostic Approach to a Soft Tissue Mass Young Soo Chun, M.D., Ph.D. and Seung Hyun Song, M.D. Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea Soft tissue masses of the extremities and torso are a common problem encountered by orthopaedic surgeons. Although these soft tissue masses are often benign, orthopaedic surgeons need to recognize the key features differentiating benign and malignant masses. An understanding of the epidemiology and clinical presentation of soft tissue masses is needed to develop a practical approach for evaluation and surgical management. Size and depth are the two most important factors on which triage decisions should be based. In a differential diagnosis of a tumor, it is important to know the characteristics of the soft tissue mass through detailed history taking and physical examinations before the diagnostic procedures. A variety of imaging studies, such as simple radiography, ultrasound, magnetic resonance imaging, positron emission tomography, computed tomography, bone scan, and angiography can be used to diagnose tumors. Know the ledge of advantages and disadvantages of each imaging study is essential for confirming the characteristics of the tumor that can be observed in the image. In particular, ultrasonography is convenient because it can be performed easily in an outpatient clinic and its cost is lower than other image studies. On the other hand, the accuracy of the test is affected by the skill of the examiner. A biopsy should be performed to confirm the tumor and be performed after all imaging studies have been done but before the final treatment of soft tissue tumors. When a biopsy is to be performed, careful attention to detail with respect to multidisciplinary coordination beforehand, cautious execution of the procedure to minimize complications, and expedient follow-up and referral to a musculoskeletal oncologist when appropriate, are essential. Key words: soft tissue neoplasm, diagnostic approach, biopsy 신체진찰 연부조직종양에서의이학적검사는매우중요하다. 우선적으로 연부조직종양이양성이냐악성이냐의감별보다만져지는종양 이실제종양인지의여부를확인감별하는것이중요하다. 결절 종이나신경섬유종증, 흑색종등의경우에는특징적으로보이는 피부병변의시진을통해의심할수있다. 연부조직종양의경우 압통이나염증의소견이없는경우가대부분이나종양이신경주 Received September 19, 2017 Revised February 14, 2018 Accepted June 14, 2018 Correspondence to: Young Soo Chun, M.D., Ph.D. Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea TEL: FAX: mozart13@khu.ac.kr ORCID: 위에위치하거나신경에서발생한종양의경우는통증과함께신경증상을유발할수있으며, 혈관종이나섬유종증에서도통증을동반하는경우도있다. 종양의위치가천부인지심부인지, 크기가어떠한지 (Fig. 1), 가동성인지판단하는것또한중요하다. 육종의경우대부분심부에위치하며, 5 cm 이상이고고정되어있는경우가많다. 1,2) 농양인경우통증과염증소견이함께관찰되고, 동맥류나가성동맥류인경우박동성이며, 소음 (bruit) 이청취될수있다. 결절종인경우관절주위에서관찰되며, 단단하고불빛을투과시킬경우투조현상 (transillumination) 이관찰된다. 신경초종인경우 Tinel s sign이주로관찰되나특별한신경증상이없는경우도있다. 1-4) 육종의경우피하지방층에존재하는경우는드물지만일부종양은발생할수있어크기가작고가동성이있으며단단하지않게만져지는등확실한양성의확신이있다면추적관찰할수있으나증상이있거나크기가점점커지는경우나크기 The Journal of the Korean Orthopaedic Association Volume 54 Number Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Homogenous extremely dense, lobulated calcific masses about the joint Amorphous calcification with or without ossification (greater in periphery) 가 5 cm 이상인경우에는생검하는것이추천된다.

2 294 Young Soo Chun and Seung Hyun Song Figure 1. Size description of soft tissue masses (baseball 7.2 cm, golf ball 4.6 cm, table tennis ball 4 cm). Table 1. Radiographic Findings of Soft-Tissue Masses and Suggested Diagnoses Phleboliths Radiographic finding Juxta-articular osteocartilaginous masses Mature peripheral calcifications Central calcifications Homogenous extremely dense, lobulated calcific masses about the joint Amorphous calcification with or without ossification (greater in periphery) 가 5 cm 이상인경우에는생검하는것이추천된다. 또한심부에 위치한경우는악성의가능성이높기때문에위에서언급한확실 한양성소견이아니라면추가검사를하는것이권장된다. 1,3,4,5) 1. 단순방사선검사 영상검사 Suggested diagnosis Hemagioma Synovial chondromatosis Myositis ossificans Extraosseous osteosarcoma Tumoral calcinosis Synovial sarcoma 단순방사선검사는골의이상유무와석회화, 연부조직의음영 등을확인할수있으며이를통하여혈관종, 연골종, 지방종등을 진단하는데도움이된다 (Table 1). 천천히자라는연부조직종양 인경우이에의한국소적인압력의증가로인접골의변화가명 확히구분되는반응성변연부또는경계와함께관찰할수있으 며, 빨리자라는악성의경우에는비대칭적인피질골파괴가보 일수있다. 최근의디지털화된영상에서는더많은정보를얻을 수있어대부분경우단순방사선검사와함께다른영상검사를 시행한다. 2. 초음파검사 (ultrasonography) 초음파는종물의깊이, 밀도또는경도 (consistency, 고체성또는낭종성 ), 크기등을확인하는데매우유용하다. 초음파는비침습적이고상대적으로다른영상검사에비해비용이낮아널리사용되고있으며방사선에노출이없고실시간으로영상을보면서생검을시행할수있다는장점이있다. 그러나깊은위치의종물을검사하는경우, 특히골조직근처에존재하는병변의검사시에는오류가발생할수있으며, 컴퓨터단층촬영 (computed tomography, CT) 이나자기공명영상 (magnetic resonance imaging, MRI) 과비교하면해부학적정확성에차이를보인다. 초음파는항암화학요법이나방사선치료등의비수술적인치료에서종양이반응하는정도를종양의크기등을측정하여판단할수있으며, 이러한정보는치료의방침을결정하는데도움이되기도한다. 6) Color, power Doppler 초음파검사를이용하면근골격계종양에서의혈류의상태나변화를알수있다. 전반적으로초음파는상대적으로깊지않은곳에위치하는종양의생검을안내하는데유용하며, 종양이고체성인지낭종성인지구별하는데유용하게사용될수있다 (Fig. 2). 2) 1) 연부조직초음파검사의가이드라인덩어리, 열감, 부종, 통증등의증상이있는부위에대해초음파검사를시행할수있으나초음파검사를시행하기에앞서반드시상세한병력조사및신체검사가선행되어야한다. 병력조사를통하여종양의발현기간및크기변화, 통증동반유무 ( 휴식, 활동, 만질때방사통 ) 를확인하여야하며, 외상 ( 혈종, 근육파열 ) 과의연관성과전신증상 ( 열, 체중감소 ) 동반유무

295 Diagnostic Approach to a Soft Tissue Mass A B Figure 2. Ultrasonography findings of soft tissue masses. (A) These appearances are characteristic of lipoma.

Ultrasound image shows an encapsulated subcutaneous mass isoechoic to the adjacent subcutaneous fat and fine internal echogenic striations parallel to the long axis of the

(A) Longitudinal forearm ultrasound shows a fusiform heterogeneous, hypoechoic mass in continuity with the ulnar nerve with posterior acoustic enhancement.

(B) Transverse color Doppler ultrasound of the same lesion shows a moderate degree of intralesional hypervascularity. Note the moderate posterior acoustic enhancement.

(D) Well-defined, lobulated, low echoic mass ulnar to the 5th distal interphalangeal joint with no increased vascularity. 를확인하여야한다.

다음으로신체검사를통해크기, 위치 (superficial, deep), 움직임, 경도, 압통, 박동 (pseudoaneurysm, vascular lesion), 피부색깔변화, 열감, 발적등을확인해야한다.

3 295 Diagnostic Approach to a Soft Tissue Mass A B Figure 2. Ultrasonography findings of soft tissue masses. (A) These appearances are characteristic of lipoma. (B) Well differentiated liposarcoma. Ultrasound image shows an encapsulated subcutaneous mass isoechoic to the adjacent subcutaneous fat and fine internal echogenic striations parallel to the long axis of the mass. Lipoma and well differentiated liposarcoma are difficult to differential diagnosis completely by ultrasound. Figure 3. Sonographic images of schwannoma. (A) Longitudinal forearm ultrasound shows a fusiform heterogeneous, hypoechoic mass in continuity with the ulnar nerve with posterior acoustic enhancement. Note the entering and exiting components of the ulnar nerve. (B) Transverse color Doppler ultrasound of the same lesion shows a moderate degree of intralesional hypervascularity. Note the moderate posterior acoustic enhancement. (C) Oval shaped mass with heterogeneous echogenicity with no continuity with the nerve of shoulder lesion. (D) Well-defined, lobulated, low echoic mass ulnar to the 5th distal interphalangeal joint with no increased vascularity. 를확인하여야한다. 7) 또한기타다른암과의연관성, 수술또는 anticoagulation의연관성과도확인이중요하다. 그외병력 ( 신부전, 간경변 ) 을확인하는것도감별에중요하다. 다음으로신체검사를통해크기, 위치 (superficial, deep), 움직임, 경도, 압통, 박동 (pseudoaneurysm, vascular lesion), 피부색깔변화, 열감, 발적등을확인해야한다. 병력조사와신체검사를충분히시행한후초음파검사를시행하게되는데병변의위치에따라환자및검사자가편한자세를취하도록하며환자로하여금증상이있는위치를손으로정확하게가리키도록한다. 초음파검사는보통 5-15 MHz 선형탐촉자 (linear transducer) 를사용하게되며병변의위치에맞게깊이 / 초점을조절하고 transverse/longitudinal scan을시행해야하며초음파검사를하는동안병변이눌리지않도록주의하여야한다 (Fig. 3). 병변의크기가큰경우 panoramic view/extended field-of-view 와 subcutaneous tissue, muscle, bone cortex까지깊은위치의연부 조직도확인하는것이필요하다. 근육및건 (tendon) 을검사할때에는 anisotropy artifact를주의를하여야하며, muscle hernia의경우에는근육을수축한상태에서초음파검사를하거나증상이있는부위가하지라면서있는자세에서초음파검사를하는것이도움이되며부종이있는환자에서는심부정맥혈전증 (deep vein thrombosis) 여부도함께조사하여야한다. 또한팔다리의경우증상이없는반대편을검사하는것이도움이되기도한다. 전반적인연부조직종괴의평가는크게위치, 크기, echogenicity, 경계, 모양, effect on ultrasound (US) beam, compressibility, vascularity, plain radiograph로세분화할수있으며각각의기술은다음과같다 (Table 2). 3. 자기공명영상 MRI는연부조직종양을진단하는가장유용하고정확한진단방

296 Young Soo Chun and Seung Hyun Song Table 2.

Echogenicity: anechoic, hypoechoic, isoechoic, hyperechoic, mixed (compared with subcutaneous fat) Margin Well-defined, ill-defined Shape Round, oval, lobulated, irregular Effect on ultrasound beam

Calcification, hemangioma with phleboliths, osteochondroma A B C Figure 4. Magnetic resonance imagings of leiomyosarcoma.

4 296 Young Soo Chun and Seung Hyun Song Table 2. Assessment of Soft-Tissue Masses Location Skin, subcutaneous, fascial, intramuscular, intermuscular, juxta-articular, tendon/paratendon/tendon sheath, nerve, vessel Size 3 dimensions Echogenicity Echogenicity: anechoic, hypoechoic, isoechoic, hyperechoic, mixed (compared with subcutaneous fat) Margin Well-defined, ill-defined Shape Round, oval, lobulated, irregular Effect on ultrasound beam Posterior acoustic enhancement, posterior acoustic shadowing, calcification Compressibility Compressive, non-compressive Vascularity Color Doppler, power Doppler, spectral Doppler Plain radiograph Calcification, hemangioma with phleboliths, osteochondroma A B C Figure 4. Magnetic resonance imagings of leiomyosarcoma. Relatively well-defined superficial soft tissue mass in the posterolateral aspect of the right buttock at the greater trochanteric level, (A) T1 weighted image with intermediate signal intensity (higher signal to the muscle), (B) T2 weighted fat suppressed image with bright high signal and intermediate signal intensity, (C) T1 weighted fat suppressed contrast enhancement image with strong enhancement (no enhancement in the bright high signal portion on T1 weighted image. 법이다. 5 cm 이상의크기를가진심부에위치한종양이 MRI에서 heterogenous signal을나타내면악성일가능성이높으며, MRI 에서피하지방 (subcutaneous fat) 과동일한 signal을 homogenous 하게나타낸다면대부분지방종일가능성이크다. 최근더욱발전된기술로인해종양과신경혈관구조물과의관계를확인할수있으며, 8) 이로인해서수술전계획이더정확해지고육종일경우더안전하게사지구제술을시행할수있으며예측가능한술식을시행할수있게되었다. 2) 따라서 MRI는종양의병기설정에필수적인검사로인정되고있다. MRI는 CT와비교해볼때더나은해상도와다방면의영상을얻을수있으며방사선의영향이없다는것이장점이다. 그러나골에침범된병변이나무기질화, 석회화가진행되는병변에서는 CT가여전히좋은해상력을보인다. 축면 (axial) T1 weighted image (T1WI) 에서는수술전계획을위해정확한영상을얻을수있으나 T2 weighted image (T2WI) 에서는주변부의부종때문에종양의크기가과대측정되는경우가발생한다. 대부분의연부조직종양은 T1WI에서는저강도또는중등도의신호강도를나타내며, T2WI에서는고강도의신호강도를보여진단적인특이도자체는높지않은편이다. 9-11) 혈종, 지방종, 저등급의지방육종, 혈관종, 출혈이동반된종양등은 T1WI에서고강도를보이기 도한다. Gadopentetate dimeglumine이나다른 gadolinium chelate 등은 MRI의조영제로유용하게사용되는데, 종양과주변부종을감별하는데도움이된다. 고식적인 MRI의단점을보완하기위해 dynamic contrast enhancement (DCE)-MRI가사용되기시작하였는데, 수용성의 paramagnetic 조영제를주입하여혈관의관류 (perfusion) 와확산 (dffusion) 을측정할수있어, viable tumor 와술후 / 회복기의조직또는 nonviable tissue를감별하는데유용하다. 9,11) 따라서생검시에종양중에서가장공격적인부분을확인하거나항암화학요법의효과를판정할때, 염증성가성종양으로부터재발을감별할때많이사용된다. 11,12) 그러나 DCE-MRI를시행하는데있어서노력이나시간을많이필요로하고, 영상촬영에필요한시간이길며, 여러가지기술적인면이많이필요하다는단점이있다 (Fig. 4, 5). 4. 양전자방출단층촬영술지난 10년간양전자방출단층촬영술 (positron emission tomography, PET) 의활용이비약적으로증가, 발전되었다. 이로인해조직의대사를측정할수있게되어림프종이나악성흑색종의분화나병기를확인할수있게되었고, 재발성, 전이성결장암을일찍발견할수있게되었으며, 비소세포성폐암의병기결

297 Diagnostic Approach to a Soft Tissue Mass A B a a b c b Figure 5. Magnetic resonance imagings (MRIs) of lipoma (A), liposarcoma (B, pleomorphic).

The mass has the same signal intensity as the adjacent subcutaneous fat. No nodules or thick septa can be seen. A blood vessel is present along the deep border of the mass.

homogeneously low. The single high signal focus is vascular.

(B-b) Axial T2WI shows mixed signal intensity. (B-c) T1WI FS MRI shows heterogeneous enhancement. A malignant finding in MRI, pleomorphic liposarcoma in the pathology examination. 정이나고립성폐결절을감별할수있게되었다.

이과정에서주요관심부위의 maximum과 average standardized uptake value (SUV) 를측정하게된다. 증가된에너지필요양을추정하면일반적인근육이나정상연부조직, 다른기관들에비해고등급의연부조직육종에많은양의 FDG가축적된다. 일부연구자들은 FDG 축적의양이종양의세포질 (cellularity) 이나분화도와관련성이있다고생각하기도한다.

5 297 Diagnostic Approach to a Soft Tissue Mass A B a a b c b Figure 5. Magnetic resonance imagings (MRIs) of lipoma (A), liposarcoma (B, pleomorphic). (A-a) Axial T2 weighted image (T2WI) MRI shows a homogeneous, high signal, fatty mass along the medial aspect of the proximal arm. The mass has the same signal intensity as the adjacent subcutaneous fat. No nodules or thick septa can be seen. A blood vessel is present along the deep border of the mass. (A-b) Axial T1 weighted fat suppressed image (T1WI FS MRI) with contrast enhancement shows the signal intensity of the lipoma is entirely suppressed, similar to the subcutaneous fat, to become homogeneously low. The single high signal focus is vascular. (Ba) Axial T1WI MRI shows an irregular and lobulating intramuscular mass in the anterolateral portion of the midthigh, heterogeneously, iso to low signal intensity. (B-b) Axial T2WI shows mixed signal intensity. (B-c) T1WI FS MRI shows heterogeneous enhancement. A malignant finding in MRI, pleomorphic liposarcoma in the pathology examination. 정이나고립성폐결절을감별할수있게되었다. PET은양성과악성종양의감별, 종양병기의결정, 생검을위한위치결정, 항암화학요법의결과평가, 종양재발의발견등에중요하게사용되고있다. 2,13,14) 생체내에서 positron-emitting radionuclides ( 주로 fluorodeoxyglucose [FDG]) 를이용하여조직의활성도등을측정하게된다. 이과정에서주요관심부위의 maximum과 average standardized uptake value (SUV) 를측정하게된다. 증가된에너지필요양을추정하면일반적인근육이나정상연부조직, 다른기관들에비해고등급의연부조직육종에많은양의 FDG가축적된다. 일부연구자들은 FDG 축적의양이종양의세포질 (cellularity) 이나분화도와관련성이있다고생각하기도한다 ) PET이양성종양과악성종양을감별하는데도움이되기는하지만저등급의육종이나공격성을가진양성종양인경우감별하기가힘들다. SUV 값이 1.6 이상인경우는고등급, 1 이하는양성, 그사이는양성이나저등급의악성종양으로분류한다. 18) 골종양인경우도이와유사하다. 그러나지방육종과 desmoids, 거대세포종, 신경초종사르코이드증과는 mean SUV 값에유의한차이가없다. 하지만이러한단점에도불구하고 FDG-PET은저등급의병변과고등급의병변을구별하는데유용하게사용된다. PET은비 용, 다양한 false-positive나 false-negative, 흉부 (chest) CT와비교하면폐전이를찾아내는데좀미진한부분이있으나연부조직육종의진단, 관찰, 치료에유용하게사용된다. 2,13-16,19) 5. 컴퓨터단층촬영 CT는단순방사선사진후에시행할수있는영상검사중골조직의형태, 골의재형성, 골막반응을정확히살펴볼수있는검사법이다. 연부조직종양을검사하는데에는어느정도한계점이있지만연부조직에석회화가발생한경우나주위피질골의미묘한미란, 골막반응등을관찰하는데에는유용하다. CT는복부와같은지방이풍부한부위에서의연부조직종양을감별해내는데에도유용한검사법이다. 지방과비지방조직과의경계를비교적정확하게알아낼수있는장점이있고, MRI가금기인환자에게서도좋은검사법이다. 6,12) 또한폐전이에민감한검사법으로병기를결정하는데중요한역할을한다. 정맥내조영술을이용하는경우연부조직종양의혈관분포를측정하고주변조직과의경계를분명히하는데도움이된다. 12) CT guided needle biopsy는척추주위나골반부와같이심부에위치한복잡한구조물에병변이있을때유용하게사용될수있다.

6 298 Young Soo Chun and Seung Hyun Song 6. 뼈스캔 (bone scintigraphy, bone scan) 99m Tc bone scan은연부조직종양을진단하는데에는한계가있으며, 병기를결정하는데에도특별히사용되는편은아니다. 연부조직육종은주로폐로원격전이되며드물게림프관으로전이되기도하지만다른골로의전이는극히드물다. 연부조직육종주위의골로의섭취가증가된경우는주로피질골에침범된경우관찰될수있으며이러한경우에는 CT나 MRI로판단할수있다. 7. 혈관조영검사 (angiographic studies) 혈관조영술은현재는자주사용되는검사법은아니지만, 종양이나그주변구조물의혈액공급이나구조물을살펴보는데유용한검사법이며, 해부학적인구조외에도국소효과, 동맥혈공급이나정맥혈배액등의상태를살펴볼수있다. 이러한장점들은수술을계획하거나중재술을시행할때에도움이되며, MRI나자기공명혈관조영술 (magnetic resonance angiography) 등을통해서더많은정보를얻을수있다. 일부에서는혈관조영술의양상에따라진단에도움이되기도한다. 예를들면혈관주위세포종 (hemagiopericytoma) 은혈관조영술에서매우독특한과다혈관성 (hypervascular) 양상을나타낸다. 그러나혈관조영검사는대부분의연부조직종괴에서특별한병리진단을내리기에는부족하여, 혈관중재술을통한수술전색전술을시행하여혈관이풍부한연부조직종괴의수술적치료시다량의출혈을방지하는데사용하고있다. 생검 (biopsy) 생검은심부에위치한큰크기의연부조직종양의최종치료시작전에, 모든영상검사가시행된이후에시행하여야한다. 중요한것은적절한검사나평가없이종양을양성으로판단하는것은위험한일이며, 생검이필요하지않다고강하게생각되는경우계획을수립하여정확히추시하는것이필요하며이경우종양에대해정확하게기술하여야추후에종양의성상을비교할수있다. 1-4,20,21) 1. 적응증환자가내원했을때처음부터종양의크기와위치, 성상등을정확히기술하는것이중요하며피하지방층에위치한종양도그크기가커지는경우적절하게평가하고검사하는것이중요하다. 우선적으로정확하게환자의병력과이학적검사를시행한후에영상검사를시행하게된다. 3,20) 단순방사선검사로골종양과의감별이가능하고, 석회화나골화, 주변골조직으로의영향과이물질등을관찰할수있다. MRI로종양이양성인지또는악성인지정확히감별하기는쉽지않지만해부학적경계, 주위신경혈관과의관계, 종양의 signal characteristics를알수있어서감별진단 이나적절한생검을위한계획을세우는데도움이된다. 부적절한생검을하는경우주위조직의오염이발생하고이로인해사지구제술이어려워지는경우가발생할수있어항상주의하여야한다. 1,20.21) Nononcologic biopsy 가시행되는경우이는국소재발, 광범위한방사선치료등의좋지않은결과로이어질수있기때문에근골격계종양치료의경험이풍부한의사가시행하는것이치명적인오류를줄일수있다. 생검시의통로는추후육종의최종적인수술시에모두 en bloc으로한번에제거되어야한다. 2. 생검의종류 1) 절개생검 (incisional biopsy) 근골격계연부조직종양조직채취방법의 gold standard이다. 종양외부에직접적인절개를가한후에단일구획이나근육을통해직접접근한다. 조직채취후에술후출혈에의한오염을방지하기위해철저한지혈이필수적이다. 생검방법중에서는제일정확한방법이며동결절편검사를함께시행하면 100% 가까운정확도를얻을수있다. 그러나 needle biopsy나 trochar biopsy에비해연부조직을오염시키는범위가증가한다는단점이있어최종수술시에는생검통로를함께제거해야한다. 또한경피적으로시행하는생검에비해비용이많이발생하여경피적생검을우선으로시행하는경우도많다. 2,4,20) 2) 영상유도생검 (radiographycally guided biopsy) 연부조직육종은주로대퇴부나 proximal limb girdle에발생하게되며, 많은수의종양들이심부에위치해있고, 촉진하기어려우며, 후복막강에위치하고있어 percutaneous needle biopsy를시행하는데있어어려움이많다. 종양의정확한위치를찾는데에도어려움이많으며종양의주위에신경및혈관이위치하는경우원하지않는합병증이발생할수도있다. 이러한경우안전을도모하고진단적정확성을높이기위해서 CT guided biopsy를시행할수있으며, 이런경우골반내에위치한악성종양의경우진단의정확성이 81% 에서 90% 로상승한다는보고가있다. 2) US guided biopsy 또한정확하고안전한방법이며악성과양성을감별하는정확성이 98% 로높은정확성을보고하고있다. MRI를이용하는방법도일부에서시도하고있으나비용적인측면에서경제적인부담이상승하여잘사용되고있지않다. 영상유도생검은생검시시행하는바늘의크기에따라세침흡인생검과중심부바늘생검으로나눌수있다. (1) 세침흡인생검 (fine needle aspiration biopsy, FNAB): 경피적으로종양에바늘을삽입하여조직을얻으며, 외래에서도시행할수있는장점이있다. 일반적으로널리사용되는술식으로술기가간편하며, 최소침습의술식이고, 주위조직의오염을최소화할수있어합병증이나질환율을줄일수있고상대적으로경제적이

7 299 Diagnostic Approach to a Soft Tissue Mass 다. 그러나종양의이질성 (heterogenisity) 으로절개생검법에비해진단적정확성이떨어지고, 검사를위해근골격계종양을전공한숙련된영상의학과전문의가필요하며검사를시행하는영상의학과전문의에게주치의는환자에대한세세한정보를제공해야한다는단점이있다. 숙련된병리학자의경우양성과악성의감별은 84% 에서 95% 의정확성을보이며등급이나조직학적분류의경우는더낮은정확성을보인다. 최근의보고에의하면질환을판단하는데에는 88%, 정확한진단은 64%, 등급결정은 78%, 조직학적아분류는 90% 의정확성을나타낸다. FNA는연부조직종양의재발을평가하는데유용하며, 재발과주위조직의염증성변화를감별하는데에도유용하게사용된다. 1,2,20) (2) 중심부바늘생검 (core needle biopsy): Wide needle biopsy나 Trochar biopsy로불리우기도하며, 크기가큰구멍의바늘로시행한다. Tru-cut needle을이용할경우가장많은조직을얻을수있으며, FNA에비해진단의정확도를높일수있다. 20,21) 일부에서는절개생검의정확도에근접한결과를보인다고보고하기도한다. 장점으로는 FNA와유사하여술기가간편하며, 최소침습의술식이고, 주위조직의오염을최소화할수있어합병증이나질환율을줄일수있으며, 수술실이외의장소에서행해질경우상대적으로경제적이다. 절개생검에비해상대적으로얻을수있는조직의양이적다는단점이있어많은경험이필요하다. 3) 절제생검 (excisional biopsy) (1) 변연절제술 (marginal excision): 종양을진단하기위해종양의반응층에서절제하는술식이며, 반응층에서절제를시행하기에부적절한치료및오염을초래할수있어일부의경우에서만사용될수있으며, 경험있는술자에의해시행되는것이안전하다. MRI상지방종으로진단된경우, 손가락이나발가락의종양인경우, 피하지방층의작은종양등에서시행할수있으며, 추후육종으로진단될경우에대비하여수술을시행하여야한다. (2) 일차적광범위절제술 (primary wide excision): 일차적광범위절제술은종양주위에서일정한간격을유지하면서정상조직에절개를가하여종양을절제하는방법으로절제연이정상조직이어야한다. 이러한방법은육종의최종수술적치료시시행하는방법과같은방법으로서육종이강력히의심되는경우, 정상조직을절제하여도기능적으로큰문제가발생하지않는경우, 생검시행후생검통로의오염으로인해최종수술시사지구제술이불가능해질것이예상되는경우에시행할수있으며, 육종의치료에많은경험이있는술자에의해매우선택적으로시행되어야한다. 요약 신체의사지및체간에발생하는연부조직종양은정형외과의사 가일상에서마주할수있는흔한질환중하나이다. 대부분연부조직종양은양성종양일가능성이높지만반드시악성종양과의감별진단을필요로한다. 정형외과의사는양성종양과악성종양의감별진단에필요한핵심적인요소들을알고있어야하며, 이를통하여위에서설명한병력조사와신체진찰, 영상검사및생검등을시행하여양성종양과악성종양을감별진단할수있어야한다. 또한종양의진단을위하여생검을시행할때에는의심되는종양과관련이있는진료과와의긴밀한협력진료가필요하며생검시행시발생할수있는여러합병증들을최소화할수있도록세심한주의를기울여야한다. 아울러추후종양의추적관찰방법의설정을위해근골격계종양전문의의협력진료도필요하다. 결국연부조직종양의평가와수술적치료의실제적인접근을위해서는정형외과의사개인이종양의역학및임상양상을이해하고, 주의깊게술기를시행해야하며, 타과및종양전문의의협력진료가동반되어야함을알아야한다. 22) CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Springfield D. Evaluation of soft tissue tumors. Instr Course Lect. 1999;48: Silverstein E, Gibbs CP. Classification and imaging of soft-tissue tumors. In: Schwartz HS, ed. Orthopaedic knowledge update. Musculoskeletal tumors 2. 2nd ed. Rosemont (IL): American Academy of Orthopaedic Surgeons; Frassica FJ, McCarthy EF, Bluemke DA. Soft-tissue masses: when and how to biopsy. Instr Course Lect. 2000;49: Frassica FJ, Thompson RC Jr. Evaluation, diagnosis, and classification of benign soft-tissue tumors. J Bone joint Surg. 1996;78: Sim FH, Frassica FJ, Frassica DA. Soft tissue tumors: diagnosis, evaluation, and management. J Am Acad Orthop Surg. 1994;2: Schuetze SM. Imaging and response in soft tissue sarcomas. Hematol Oncol Clin North Am. 2005;19:471-87, vi. 7. Manaster BJ. Soft-tissue masses: optimal imaging protocol and reporting. AJR Am J Roentgenol. 2013;201: Jones BC, Fayad LM. Musculoskeletal tumor imaging: focus on emerging techniques. Semin Roentgenol. 2017;52: Shapeero LG, Vanel D, Verstraete KL, Bloem JL. Fast magnetic resonance imaging with contrast for soft tissue sarcoma

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9 301 pissn : , eissn : Review J Korean Orthop Assoc 2019; 54: 연부조직종양의진단적접근 전영수 송승현 경희대학교의과대학정형외과학교실, 강동경희대학교병원정형외과 사지와몸통의연부조직종양은정형외과의사가직면할수있는흔한문제이다. 비록연부조직종양은대부분양성이지만정형외과의사는양성과악성종양을구별할수있는특징을알고있어야한다. 연부조직종양의임상적특징및역학을이해하게되면올바른진단및수술적인치료를할수있게된다. 종양의크기와깊이는종양의진단을위해가장중요한요소이다. 종양의감별진단을하기위해서우선적으로상세한병력청취와자세한신체검사가필요하며, 이후단순방사선촬영, 초음파, 자기공명영상 (magnetic resonance imaging), 양전자방출단층촬영술 (positron emission tomography), 컴퓨터단층촬영 (computed tomography), 뼈스캔, 혈관조영술등의다양한영상촬영법을사용하여종양을진단하고진단된종양의특성을확인하여야한다. 특히초음파검사는외래에서도쉽게수행할수있어유용하다. 그러나검사자의숙련도에따라검사정확도의차이가발생할수있다는단점이있다. 종양의생검을통한조직검사는종양에대한모든영상검사를시행한후최종적으로시행하는것이원칙이다. 조직검사를시행할때는세심한주의를기울여야하며, 최종적인진단후에는치료를위해다각적인접근을시행하여야하며필요한경우에는경험있는근골격계종양전문의사에게의뢰하는것이필요하다. 색인단어 : 연부조직종양, 진단적접근, 생검 접수일 2017 년 9 월 19 일수정일 2018 년 2 월 14 일게재확정일 2018 년 6 월 14 일책임저자전영수 05278, 서울시강동구동남로 892, 경희대학교의과대학정형외과학교실, 강동경희대학교병원정형외과 TEL , FAX , mozart13@khu.ac.kr, ORCID 대한정형외과학회지 : 제 54 권제 4 호 2019 Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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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.,