위선종 / 이형성 Gastric adenoma/dysplasia Jun Haeng Lee. Department of Medicine Sungkyunkwanuniversity School of Medicie, Seoul, Korea
Dysplasia in Barrett s esophagus Ideally, the management of a disorder is based on an unequivocal diagnosis, a firm understanding of the natural history, and definitive data regarding the risks and benefits of the treatment options. Unfortunately, none of these prerequisite factors may be available to guide the management of patients with dysplasia in Barrett s esophagus. Spechler SJ. Am J Gastroenterol 2005;100:927-935
Issues regarding gastric adenoma/dysplasia Jun Haeng Lee. Department of Medicine Sungkyunkwanuniversity School of Medicie, Seoul, Korea
Problem 1: What is dysplasia? Abnormality of development; in pathology, alteration in size, shape, and organization of adult cells (Dorlands dictionary 24 th ed.) Unequivocal neoplastic transformation of the epithelium (Riddell RH. Hum Pathol 1983) Histological expression of genetic alterations that favor cell growth and neoplasia (Spechler. Gastroenterology 2001) In Japan, some authorities defined biopsies with marked reactive and regenerative histological features as dyplasia (Goldstein NS. Hum Pathol 1997)
What is adenoma? - Adenoma = dysplasia 소화기병리학연구회. 위암병리보고서기재사항표준화. 대한병리학회지 2005;39:106
Regenerating atypia vs. dysplasia Changes in epithelial cells (e.g. increased N/C ratio +/- structural disarray) may occur in two situations. Regenerating atypia - when the eithelium has been injured and is undergoing repair Dysplasia - when genetic alterations have transformed the cells in a neoplastic growth Significant overlap exist between the two.
Conceptual model Regenerating atypia Dysplasia
In clinical practice Regenerating atypia Dysplasia
위궤양 scar 의조직검사에서 adenoma with low grade dysplasia
관찰자간차이에대하여
Atypia 에대한설명 (2017/3) 비전형적세포 (Atypia) 는세포의모양이비전형적이라는, 즉정상이아니라는뜻입니다. 여기에는많은원인이있습니다. 좋은것부터나쁜것까지상당히다양합니다. 먼저좋은쪽을보자면단순한위염또는위궤양때문에세포의모양이비전형적 (atypical) 으로변할수있습니다. 반대로전암성병소또는위암의조직검사에서비전형적이라는결과가나오는경우도있습니다. 그비율을정확히말하기는어렵지만보통암과관련되지않은것 ( 위염이나궤양 ) 이절반, 암과관련된것 ( 선종이나암 ) 이절반정도입니다. 외부슬라이드재판독과내시경재검을권합니다. 첫평가에서큰이상이아닌것으로나와도재검이필요합니다.
현실적인접근 Adenoma의진단에는모양은고려하지않습니다. 융기형, 평탄형, 함몰형이모두포함됩니다. 광의의 adenoma = adenoma with LGD + adenoma with HGD 좁은의미의 adenoma = adenoma with LGD 병리과의사가 dysplasia라고만보고한경우 : dysplasia = adenoma ( 광의 )
Problem 2: Inter-continental variation Normal Superficial Gastritis Atrophic Gastritis Intestinal metaplasia Dysplasia Stomach Cancer Correa. Scand J Gastroenterol Suppl 1984;104:131-136
Dysplasia 에대한다양한분류법 Rugge. Eur J Gastroenterol Hepatol 2005;17:1191-1196
Group classification of JRSGC since 1971 Group Group I Group II Group III Group IV Group V Diagnosis Normal mucosa and benign lesions with no atypia Lesions showing atypiaa but are diagnosed as benign (non-neoplastic) Borderline lesions between benign (nonneoplastic) and malignant Lesions strongly suspected of carcinoma Carcinoma Nagano T. Gann Monogr Cancer Res 1971;11:245-256 Kato. Stomach & Intestine 2004;39:1443-1447
Japanese 1. normal and benign lesion with no atypia 2. benign nonneoplastic lesion 3. borderline lesion 4. lesions strongly suspected of carcinoma 5. carcinoma Western negative for dysplasia indefinite for dysplasia low grade adenoma/dysplasia high grade adenoma/dysplasia suspicious for invasive carcinoma invasive carcinoma Vienna, 1998 1. negative for neoplasia/dysplasia 2. indefinite 3. noninvasive low-grade neoplasia 4.1 high-grade adenoma/dysplasia 4.2 carcinoma in situ 4.3 suspicion of invasive carcinoma 5. invasive carcinoma Schlemper. Gut 2000;47:251-255
Western vs. Japanese view - pathologic diagnosis of 35 cases Schlemper RJ. Lancet 1997;349:1725-1729 Willis & Riddell. Gastrointest Endosc 2003;57:369-376
우리나라의고도선종은아마도일본에서는암으로분류되고있는것같습니다. Korean endoscopists are treating a lot of patients with gastric adenomas, and some of them may be considered as well-differentiated gastric adenocarcinomas in Japan.
Problem 3: Inter-observer variation - Referred due to high grade dysplasia (M/71) Outside review: adenocarcinoma (W/D)
ESD using needle knife for EGC - W/D adenocarcinoma, SM2, RM(-), L(+), V(-)
자연사 Jun Haeng Lee. Department of Medicine Sungkyunkwanuniversity School of Medicie, Seoul, Korea
8 년간치료안한선종
History of gastric dysplasia - from a very famous textbook Mild Dysplasia 5 years 10% 5 years 10% Moderate Dysplasia 60% 10% High Grade Dysplasia 3 months 2 years 50-90% Gastric Cancer Luk GD. Sleisenger s. 6 th ed. page 736
Progression to invasive carcinoma (cat 5) - significant difference between authors Author LGD (Vienna category 3) HGD (Vienna category 4) % fraction interval % fraction Interval Saraga (1987) 2% (1/64) 4 years 81% (7/21) 4 months Lansdown (1990) 0% (0/7) 85% (11/13) 5 months Rugge (1991) 17% (12/69) 1 year 75% (6/8) 4 months Fertitta (1993) 23% (7/30) 10 months 81% (25/31) 5 months Di Gregorio (1993) 7% (6/89) 2 years 60% (6/10) 11 months Rugge (1994) 14% (13/90) 2 years 78% (14/18) 9 months Kokkola (1996) 0% (0/96) 67% (2/3) 1.5 year Yamada (2004) 0% (0/38) 10% (1/10) 4.6 year
자연사인지조직검사의한계인지명확하지않습니다. Resected Biopsy LGD HGD Total LGD 83 3 86 HGD 12 12 24 Carcinoma 1 7 8 Total 96 22 118 Park DI. Endoscopy 2001;33:501-506
저도선종 ESD 후위암 (LP 암 )
위선종의진단과치료 Jun Haeng Lee. Department of Medicine Sungkyunkwanuniversity School of Medicie, Seoul, Korea
저도선종 2 개
고도선종
Endoscopic or surgical resection of gastric neoplasms in SMC (2012) - Excluding palliative surgeries Adenoma with LGD (141) Adenoma with HGD (122) Absolute indication EGC (327) AGC (505) Beyond absolute indication EGC (949) EGCs among all gastric cancers: 71.6% (327/1,781) Absolute indication EGCs among all EGCs: 25.6% (327/1,276)
Diagnostic group classifications before and after the treatment Pre-treatment diagnostic groups LGD HGD AI-EGC EI-EGC BEI-EGC AGC ESD or surgery Post-treatment diagnostic groups LGD HGD AI-EGC EI-EGC BEI-EGC AGC
Post-treatment analysis of EI-EGCs (2012) LGD 1 HGD 12 AI-EGC 67 EI-EGC 31 BEI-EGC AGC ESD 111 LGD HGD AI-EGC EI-EGC 111 BEI-EGC AGC Lee JH. Surg Endosc 2016;30:3987-93
Pre-treatment analysis of AI-EGCs (2012) LGD HGD AI-EGC 396 EI-EGC BEI-EGC AGC ESD 355 LGD 1 HGD 4 AI-EGC 229 EI-EGC 67 BEI-EGC 53 AGC 1 Lee JH. Surg Endosc 2016;30:3987-93
Absolute indication EGC by pre-treatment diagnostic groups Pre-Tx AI EGC 396 ESD 355 Operation 41 LGD 1 HGD 4 AI EGC 229 BAI EGC 120 AGC 1 LGD 1 AI EGC 29 BAI EGC 11 ESD 1 Surgery 53 Surgery 1 Reason for surgery (multiple) Suspicious lymphadenopathy on CT (18) Multiple lesions (6) Patient s wish (18) Difficult location (3) Suspicious SM invasion on EUS (2) * BAI: beyond absolute indications Lee JH. Surg Endosc 2016;30:3987-93
선종의 33% 는 upgrade 됩니다. Lee JH. Surg Endosc 2016;30:3987-93
먼과거에는선종으로수술하기도했습니다. Villous adenoma with high grade dysplasia, 4.0x3.6cm
거의전부내시경으로치료하고있습니다. Tubular adenoma, elevated type, 4x3.5cm, negative RM
작고납작한저도선종은소작술로치료
위선종의치료 High grade dysplasia는원칙적으로내시경적절제술을시행한다. 위암을동반하고있는경우가많으므로가급적 en bloc resection을위하여노력한다. ESD 등의방법을적극적으로이용한다. Low grade dysplasia의치료방침은 HGD 보다는 less invasive하게선택한다. 큰병소, 뚜렷한함몰부위나돌출부위가있는경우는내시경절제술을선택한다. 그러나, 작고납작한병소와전신상태가나쁜경우는 APC를이용한 ablation을하고선택적으로 follow-up도가능하다.
새로운접근법은없는가? Jun Haeng Lee. Department of Medicine Sungkyunkwanuniversity School of Medicie, Seoul, Korea
Genetic changes in early gastric carcinogenesis Min et al. investigated the genomic and transcriptomic landscape of adenoma with LGD, adenoma with HGD, and EGC. Several genetic changes have been identified in advanced gastric cancer, but the genetic alterations associated with early gastric carcinogenesis remain unclear. Min BH. J Pathol 2016;240:304-314
Genetic changes in early gastric carcinogenesis He found that the expression pattern clearly divided into normal, LGD, and EGC, whereas those of HGD overlapped with LGD or EGC. RNF 43 mutation were present only in HGD and EGC. Min BH. J Pathol 2016;240:304-314
Adenoma-carcinoma model of gastric multistep carcinogenesis Min BH. J Pathol 2016;240:304-314
결론 위선종 조직검사에서 dysplasia가있으면선종으로진단합니다. 선종중일부는 ( 저도선종의 10%, 고도선종의 33%) 절제술후암으로진단이바뀐다. 그중일부는수술이필요합니다. 작고납작한저도선종은소작술혹은경과관찰을선택할수있습니다.
감사합니다.