Very low-risk Low-risk Intermediate-risk High-risk Appendiceal mucinous tumours Mucinous adenoma Mucinou

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1 I. Workshop 결과에대한설문조사결과 A. 종양의행태 (behavior) 코드부여에이견이있는소화기계암에대한설문조사결과 Organ or Subject Stomach Colon Diagnosis 응답자수 ( 총 240 명 ) Low grade adenoma/dysplasia 무응답 High grade adenoma/dysplasia in-situ Adenoma, low grade dysplasia Ademona, high grade dysplasia Intraslandualr carcinoma =adenocarcinoma in-situ Intramucosal carcinoma Carcinoid tumour > submucosal invasion All except appendix and rectum Carcinoid tumour = well differentiated neuroendocrine tumour : Size < 1cm, no invasion Appendix Carcinoid tumour =well differentuated neuroendocrine carcinoma : Any size, Mesoappendix invasion, metastasis, angioinvasion Carcinoid tumour = well differentiated neuroendocrine tumor : Size < 1cm, no invasion Rectum Pancreas Carcinoid tumour =well differentuated neuroendocrine carcinoma : Any size, Muscle invasion, angioinvasion, node or distant metastasis Well-differentiated endocrine tumour Well-differentiated endocrine tumour Gastrointestinal stromal tumour (GIST)

2 Very low-risk Low-risk Intermediate-risk High-risk Appendiceal mucinous tumours Mucinous adenoma Mucinous neoplasm, uncertain malignant potential (UMP) Mucinous neoplasm, low malignant potential (LMP) = Extremely well-differentiated adenocarcinoma Mucinous adenocarcinoma Pseudomyxoma peritonei * 비고 1. Carcinoid tumor 설문전체에대한응답 ( 의견코드는제시하지않았음 ) : 부위에상관없이 lung 과같이진단하고 (4 types), 그다음부위에다라악성, borderline, 으로나눔 2. Appendiceal mucinous tumors : Pseudomyxoma peritonei 에대해 6 번을준뒤 상피존재할경우 라고조건을제시함 : Mucinous neoplasm low malignant potential 에대해 3 번준뒤, peritoneal implant 가어떤지에따라 1~3 을구분해야할것같다. 라고조건제시 : Pseudomyxoma peritonei 에대해 6 번을준뒤 epithelium 있어야함 이라고조건제시 B. 암등록대상결정에중요한용어의사용에대한의견 ( 응답자수총 200명 ) 사용수식어 암진단간주 암진단아님 암진단과무관 무응답 Apparent(ly), Appears to Malignant appearing Presumed, Probable Suspect(ed), Suspicious (for) Possible Potentially malignant Suggests

3 대한병리학회회원과대한세포병리학회회원을대상으로한설문조사결과는 Workshop 결과와대체적으로일치하였지만 Workshop 과정에서가장논란이되었던 stomach 과 colon 의 high grade dysplasia 와 colon 의 intramucosal carcinoma 가설문조사에서도역시가장낮은일치율을보였다. 추후진단기준에대한 consensus 와교육이있어야하지만우선적으로이번 workshop 과설문조사의결과를토데로질병의행태코드부여시에아래와같은지침서사용을제안하고자한다. A. 소화기계암의행태 (behavior) 코드부여지침서 Organ or subject Stomach Colon Diagnosis Low grade adenoma / dysplasia /0 High grade adenoma / dysplasia ( 본회에서제시한등급체계 ) ; Nuclear loss of polarity, round nuclei, irregular chromatin pattern, prominent nucleoli, no anastomozing glandular pattern in-situ Noninvasive intraglandular carcinoma Intramucosal carcinoma 포함 Adenoma, low grade dysplasia /0 Adenoma, high grade dysplasia ( 본회진단기준 : Nuclear length; >2 of cell length, irregular budding or branching of glandular architecture, not focal, more than 3 continuous glandular change) Intraglandular carcinoma =adenocarcinoma in-situ (Nuclear loss of polarity, severe cribriform; gland within gland, bridging or back to back, budding without intervening stroma) Intramucosal carcinoma with lamina propria invasion >submucosal invasion ICD-O3 behavior code 비고 용어의사용과진단기준에이견이많으므로본회에서제시한등급체계의기준을따르는것을원칙으로하며 low to high grade adenoma는 /0으로하고 adenocarcinoma in situ와구별이어려운예로제한한다. Vienna Classification에서 category 4.1에해당함. 본회에서제시한이형성등급체계시안에는기술이없으나 Vienna Classification에서 category 4.2에해당함 대장과차이가있음 ICD-O3 의 glandular intraepithelial neoplasia, grade III (M8148) 에해당함 AJCC와 UICC에서구분한병기에따라 Tis로분류하기로함. 위암과차이가있음. Submucosal invasion : Stage T1 Carcinoid tumor (=well differentiated neuroendocrine tumor)

4 용어 : Carcinoid tumor보다는 well differentiated neuroendocrine tumor 사용을권장함 All GI carcinoid tumor except appendix and rectum Carcinoid tumor = well differentiated neuroendocrine tumor (Size < 1cm, no invasion) Appendix Carcinoid tumor (= well differentiated neuroendocrine carcinoma) (Any size, Mesoappendix invasion, metastasis, angioinvasion) Carcinoid tumor = well differentiated neuroendocrine tumor (Size < 1cm, no invasion) Rectum Carcinoid tumor (= well differentiated Angioinvasion의경우는 neuroendocrine carcinoma) 면역염색을통해증명하는 (Any size, Muscle invasion, angioinvasion, 것이필요함 node or distant metastasis) Well-differentiated endocrine tumor, Confined to the pancreas, no angioinvasion, size <2cm, <2 Ki-67 면역염색은선택사항 mitosis0hpf & <2% Ki-67 index Well-differentiated endocrine tumor, Confiened to the pancreas (one or more of Pancreas >2cm, 2-10 mitosis0hpf, >2% Ki-67 index Neuroendocrine carcinoma, welldifferentiated (atypical carcinoid) & poorly differentiated (Any size with metastasis or distinct malignant evidence) Gastrointestinal stromal tumor (GIST) : risk of aggressive behavior by NIH consensus meeting Very low-risk /0 (<2cm, <5/50HPF) Low-risk (2-5cm, <5/50 HPF) Intermediate-risk (<5cm, 6-10/50HPF) or (5-10cm, <5/50HPF) High-risk (>5cm, >5/5-HPF), (>10cm, any mitotic figure) or (Any size, >10/50HPF) Appendiceal mucinous tumors Human pathology 2007;38: 에장기별로세분화하여예후를예측하는 guideline 이제시되었으나우선은기존의 NIH consensus meeting 기준을적용하기로함. Mucinous adenoma 1) Cytologically bland 2) No epithelium in wall 3) No epithelium in extraappendiceal mucin 4) Clear proximal margin /0

5 Mucinous neoplasm, uncertain malignant potential (UMP) : 1) Cytologically bland 2) Mucin with epithelium in wall 3) Uncertainty of epithelium within extraappendiceal mucin 4) Proximal margin : + * 복강내소견을모를경우 pseudomyxoma peritonei의가능성을설명하는것이필요함 진단기준을정확히사용해야함. 현재 ICD-O3 에항목이없으므로지침서등을통해의견을개진할예정임 Mucinous neoplasm, low malignant potential (LMP) = not always extremely well-differentiated adenocarcinoma 1) Cytologically bland = extremely welldifferentiated adenocarcinoma에해당됨. 2) Epithelium in wall and peritoneal implants 4) Extensive peritoneal disease 5) No LN, lung, liver metastasis Mucinous adenocarcinoma 1) Destructive invasion 2) Architectural complexity 3) High grade atypia 4) Low grade cytologic atypia=extremely well differentiated adenocarcinoma에해당됨 Pseudomyxoma peritonei : 진단기준에대한논의가필요함 (Mucin 의양과상피존재여부 ) /6 수술소견과임상소견을참고하여야함. Appendix Gross 시 radial margin 을표시하여모두 embedding 해야함 B. 암등록대상결정에중요한용어의사용. 3 차에걸친설문조사결과 comparable with, consistent with, compatible with, favors, most likely, typical of 와함께 'malignant appearing' 과 suggests' 도암진단으로간주되는용어로생각할수있다. 가능하면암으로의심되는경우상기한용어를사용하도록권장하며, 그이외의용어에대해서는진단한병리의사와상의를할것을권장한다.

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내시경 conference 부울경소화기내시경학회 6월집담회 고신대학교복음병원소화기내과전임의서광일 F/63 CASE C.C) epigastric pain for 2 wks P. I) 2014.04.16 EGD at LMC adm via OPD for further evaluation. P. Hx) CASE HTN/DM/Hepatitis/Tbc (+/+/-/-) S. Hx) N-S ROS)