양성으로오인하기쉬운 악성위병변 성균관대학교의과대학내과이준행
양성으로오인하기쉬운악성위병변 보만 4형진행성위암과내시경교육 놓치기쉬운상부식도암 식도 SMT와위 SMT 위식도접합부 - 암같은용종과용종같은암 MALT 림프종
보만 4 형진행성위암과 내시경교육 성균관대학교내과이준행
Age-adjusted gastric cancer incidence in Korean male 1999 2013 Yearly Change Stomach 68.4 56.8-0.8% Colon 27.0 46.9 5.0% Lung 51.9 44.9-0.9% Liver 48.5 33.7-2.3% Thyroid 2.3 28.8 23.4% Prostate 8.5 26.2 10.5%
National screening program - started in 1999 Stomach cancer 40 years old Lifetime Screening Screening by Recommendation Both males and females Biennial Endoscopy or barium study Stomach 77.9 70.9* Liver 69.9 21.5 Colon 65.8 44.7 Breast 82.9 70.9 Cervix 77.1 67.9 *: EGD 63.3%, UGI 36.4% APJCP 2013;14:6459-6463
0.25% (65/25,536) Kim. APT 2008;27:173-185
넓은병소인데일부만관찰되었음 - ESD: 24mm mucosal cancer arising from 44mm adenoma with HGD
AGC Borrmann type IV (2013)
AGC Borrmann type IV
Stomach, total gastrectomy: Advanced gastric carcinoma 1. Location : upper third, middle third, lower third, Center at fundus, body, and greater curvature 2. Gross type : Borrmann type IV 3. Histologic type : tubular adenocarcinoma, poorly (poorly cohesive) differentiated 4. Histologic type by Lauren : diffuse 5. Size : 20x18 cm 6. Depth of invasion : invades serosa (pt4a) 7. Resection margin: free from carcinoma 8. Lymph node metastasis : no metastasis in 31 regional lymph nodes (pn0) 9. Lymphatic invasion : not identified 10. Venous invasion : not identified 11. Perineural invasion : present 12. Peritoneal cytology : negative 13. AJCC stage by 7th edition: T4a N0
1 년전내시경
2 년전내시경
주름은두꺼워지고골짜기는얕아진다
Shoulder by shoulder
정상과비정상의경계
함몰병소를보일수있습니다.
Antral type (M/46)
감별진단 : Diffuse large B cell lymphoma
감별진단 : Mantle cell lymphoma
감별진단 : 위매독
감별진단 : 비후성위염
Box summary (4) 보만 4 형진행성위암 보만 4형진행성위암은상부위장관내시경검사에서가장중요한질환입니다. 모든내시경검사에서가장먼저생각해야할것은 보만 4형진행성위암은아닌가? 입니다.
두글자 ( 혹은세글자 ) 로배우기 해봐 넣어봐
누구에서배우셨습니까? 미선생님
Fellow 생활을마치며마지막발표 실기가중요한것같지만마지막에는역시질병에대한지식으로돌아옵니다.
술기 기본지식 기본지식 술기 내시경기본지식없이무조건삽입부터배우는것은더이상타당하지않습니다.
Basic endoscopy course 2017/18
기본동영상및다양한강의동영상 동영상강의자료는핸드폰으로도보실수있고 PC 에서도보실수있습니다.
Description 연습 + feedback http://endotoday.com/endotoday/learning.html
Box simulator 훈련
逸院內視鏡倉庫敎室
Continuous endoscopy education 월요점심 소화기집담회 목요점심 내시경집담회 저널클럽 오전 8 시이전, 오후 6 시이후교육과정을폐지하고대신점심시간을활용합니다.
Segovis. BMC Med Edu 2007;7:22 소화기내과의국에서점심을제공하고있습니다. 시간을아끼기위하여.
과거의방법 최근의방법 2-3 번 observation 상세한이론교육과 book-reading 삽입 Description 연습 with feedback Simulator training Clinical observation 감독하시술 CEE ( 집담회, EndoTODAY)
함께발전하는내시경술기
파트너즈병원과함께하는내시경훈련
On-line 을통하여함께공부합시다.
놓치기쉬운상부식도암 성균관대학교의과대학내과이준행
Esophageal cancer s/p STG for EGC (M/70) 2002. 5. 20. Subtotal gastrectomy Adenocarcinoma (W/D), intestinal type 1.6x1.6 cm, muscularis mucosa, RM (-) 0/36 2002. 9. 1 st follow-up EGD 2004. 1. 2 nd follow-up EGD 2005. 1. 3 rd follow-up EGD 2005. 6. 4 th follow-up EGD: 식도암
Esophageal cancer after surgery for EGC
Esophageal cancer after surgery for EGC Invasive squamous cell carcinoma (M/D), 2.1x1.4 cm, extension to PM, RM (-), 0/24
Cervical esophageal cancer - Dysphagia 로한달전내시경검사
식도 SMT 와위 SMT 성균관대학교의과대학내과이준행
위식도점막하종양에대한설명서
Granular cell tumor
Lipoma
Esophageal SMT with calcified rim - r/o duplication cyst
Outside review: SCC with focal neuroendocrine component Repeat biopsy: acanthotic squamous epithelium
ESD 후수술 - Large cell neuroendocrine carcinoma - 수술을하였고림프절전이를확인
Esophageal LELC Korean J Gastrointest Endosc 2010;41:41-44
Esophageal leiomyoma - Leiomyoma; 10x7x4 cm, mitotic count: 0/10 HPF, SMA (+), CD34 (-), c-kit (-) 증례제공 : 민병훈교수님
SMT-like gastric cancer 빈도 : 절제된위암의 0.1 0.63% 남 : 녀 = 3 : 2 50세이상 : 75% 조기암 : 진행암 = 1 : 1 분화형선암 : 미분화형선암 = 1 :2 크기 : 80% 이상에서 2cm 이하 주로중부에발생한다.
M/60. SMT during screening EGD
Impression of r/o GIST Surgery Surgical findings: antrum, LC side의약 6 x 7 sized mass가있고주변에 inflammation, sever adhesion, multiple enlarged LNs가있고 pancreas inferior border에단단하게붙어있어 invasion 가능성있음 Frozen biopsy: moderately differentiated adenocarcinoma Distal pancreatectomy and total gastrectomy 최종병리 : Undifferentiated carcinoma. 5.4 x 3.5 cm, pancreas invasion, LN 0/50
62 세남자. Screening endoscopy ESD Layer: 3rd layer Echo level: hypoechoic Echo pattern: homogenous + hyperechoic spots Margin: undulated and somewhat clear Growth pattern: intraluminal/intramural Size: 1.5 cm * 1.2 cm 학회홈페이지 : 흥미로운내시경증례 ( 부산대학교김광하교수님 )
Adenocarcinoma, poorly differentiated, solid type (por1) 1) prominent lymphoid stroma (lymphoepithelioma-like carcinoma) 2) extension into submucosa (invasion depth: 6500 um) 학회홈페이지 : 흥미로운내시경증례
SMT-like gastric cancer - 1 st biopsy: gastritis, 2 nd biopsy: adenocarcinoma (M/D) - 수술후최종병리 : papillary adenocarcinoma
위식도접합부 - 암같은용종과용종같은암 성균관대학교의과대학내과이준행
무증상역류성식도염 + sentinel polyp 2 년 2 년
용종의심했는데조직검사에서암이라니
내시경에서는 sentinel polyp 같은데조직검사에서 sentinel polyp + squamous cell carcinoma
Sentinel polyp after PPI (low dose) - initially SCC was suspected in pathology 2010-3 2010-5 2010-2 2011-7 2012-5
Is it a sentinel polyp or cancer? (1/4)
Is it a sentinel polyp or cancer? (2/4)
Early gastric carcinoma 1. Location : upper third, center at cardia (Siewert II) 2. Gross type : EGC type IIc 3. Histologic type : tubular adenocarcinoma (P/D) 4. Histologic type by Lauren : mixed 5. Size : 2.2x1.5 cm 6. Depth of invasion : invades submucosa (sm3) (pt1b) 7. Resection margin: free from carcinoma safety margin: proximal 2.3 cm, distal 16 cm 8. Lymph node metastasis : no metastasis in 21 9. Lymphatic invasion : present 10. Venous invasion : not identified 11. Perineural invasion : not identified
Epigastric pain for 2 months Loss of weight (10 kg) No abnormality Retroperitoneal mass Retroperitoneal & EG junction uptake
Biopsy: adenocarcinoma (M/D) Surgery: O & C (peritoneal seading)
추가증례 : Squamous cell carcinoma - much advanced stage than endoscopic impression Invasive squamous cell carcinoma (M/D), 2x1.5 cm extension to perimuscular adventitia, LN 1/33 12 months before surgery
양성궤양혹은악성궤양 성균관대학교의과대학내과이준행
Intractable ulcer for more than 1 year
Biopsy after referral: adenoca (M/D)
1. Location : upper third, Center at cardia (Siewert II) and posterior wall 2. Gross type : Borrmann type 2 3. Histologic type : mucinous adenocarcinoma (mucinous carcinoma portion: 90 %) 4. Histologic type by Lauren : intestinal 5. Size : 3x2.5 cm 6. Depth of invasion : invades serosa (pt4a) 7. Resection margin: free from carcinoma safety margin: proximal 1.2 cm, distal 15 cm 8. Lymph node metastasis : metastasis to 3 out of 27 (pn2) 9. Lymphatic invasion : present 10. Venous invasion : not identified 11. Perineural invasion : present 12. Peritoneal cytology : negative
Dysphagia, cardia mass (M/67) Biopsy: chronic gastritis, no cancer
1. Location : Center at upper body, lesser curvature 2. Gross type : Borrmann type, unclassifiable 3. Histologic type : tubular adenocarcinoma, M/D 4. Histologic type by Lauren : intestinal 5. Size : 7x6 cm 6. Depth of invasion : invades serosa (pt4a) 7. Resection margin: free from carcinoma safety margin: proximal 1 cm, distal 11 cm 8. Lymph node metastasis : metastasis to one out of 48 (pn1) 9. Lymphatic invasion : present 10. Venous invasion : present (extramural) 11. Perineural invasion : present 12. Peritoneal cytology : negative
MALT 림프종 성균관대학교의과대학내과이준행
Lymphoepithelial lesions Monocytoid B-cells
Personal protocol for MALToma Low-grade MALT lymphoma in the first endoscopic biopsy Staging work-up including CT (prn, EUS, BM) Stage E-I 2, II, III, IV or H. pylori (-) or high-grade HPE or ChemoRx H. pylori eradication (PCA 2 weeks ) + 2nd eradication, if necessary UBT 4-6 wks after completing antibiotic treatment Endoscopy, 3 months after completing eradication
Typical response to HPE Initial EGC 2 months later 6 months later
Typical response to HPE 2003. 2. 7. 2003. 4. 18 2003. 6.13 2003. 8. 22 (HPE 1 개월 ) (HPE 3 개월 ) (HPE 5 개월 )
Gastic MALToma (M/40) 2 months later
Gastric MALToma (F/32) - typical response to H. pylori treatment Initial EGC 2 months later 6 months later
MALToma mimicking EGC (F/49)
Gastric MALToma (F/46)
Gastric MALToma (F/57)
집으로가져가는메세지 내시경교육법의혁신이일어나고있습니다. Online, off-line을통하여배움을지속할길이있습니다. 보만 4형진행성위암을놓치지않는것이모든내시경검사의시작입니다. 식도는지나가는길이아닙니다. 위궤양이호전되지않으면위암을고려해야합니다. 증상을고려하면서검사하고결과를해석합시다.