3 차의료기관에서진단된원발성폐암의임상적특성 인하대학교의과대학내과학교실 1, 사회의학교실 2, 산업의학교실 3, 병리학교실 4, 진단방사선학교실 5 흉부외과학교실 6, 방사선종양학교실 7, 의과학연구소 8. 류정선 1, 이훈재 2, 임종한 3, 김루시아 4, 이경희 5, 조재화 1, 윤용한 6, 곽승민 1, 이홍렬 1, 김광호 6, 노준규 7, 정수경 8 Clinical Charicteristics of Primary Lung Cancer Patients in a Tertiary Hospital Jeong-Seon Ryu 1, Hun-Jae Lee 2, Jong-Han Leem 3, Lucia Kim 4, Kyung-Hee Lee 5, Jae-Hwa Cho 1, Young-Han Yoon 6, Seung-Min Kwak 1, Hong-Lyeol Lee 1, Kwang-Ho Kim 6, John-Kyu, Loh 7, Soo-Kyung Jung 8 Department of Internal Medicine 1, Social and Preventive Medicine 2, Occupational and Environmental Medicine 3, Pathology 4, Diagnostic Radiology 5, Chest Surgery 6, and Radiation Oncology 7, Institute of Medical Science 8, College of Medicine, Inha University, Incheon, South Korea Background : To evaluate the clinical characteristics of lung cancer patients in Korea, where there is a higher number of smokers than in Western countries. Methods : A retrospective study was performed on 1655 lung cancer patients, who were diagnosed at a university hospital between September 1996 and August 2005. Age, gender, cell types and clinical stage were analysed. Of 941 patients, who responded to a questionnaire at the time of diagnosis, the smoking habits, occupational history, family history of lung cancer in the first-degree relatives, coexisting diseases (diabetes mellitus and cardiovascular disease), body weight loss, ECOG performance status and presenting symptoms, were examined prospectively. In addition, coexisting diseases including chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis and active pulmonary tuberculosis were evaluated. Results : Of the 1655 patients, the male to females ratio was 3.6. Squamous cell carcinoma was the most common cancer whereas adenocarcinoma was more common in lifetime nonsmokers or women. 19.9% of the patients were non smokers and 80.1% ever smokers. Since 2000, there was an increase in the incidence of adenocarcinoma with a corresponding decrease in the incidence of squamous cell carcinoma. 6.2% of patients were asymptomatic. A coincident diagnosis of chronic obstructive pulmonary disease, cardiovascular disease, diabetes mellitus, active pulmonary tuberculosis, and idiopathic pulmonary fibrosis was made in: 44.1%, 22.2%, 10.7%, 3.9%, and 1.6% of patients, respectively. A positive family history of lung cancer in the first-degree relatives was identified in 4.4% of patients. An occupational history relevant to lung cancer was identified in 12.2% of patients. Conclusion : There is a high proportion of cigarette smokers in Korean lung cancer patients. The most common cell type was squamous cell carcinoma. However, a more detailed, prospective study of the clinical characteristics will be needed to better characterize lung cancer in Korea. (Tuberc Respir Dis 2006; 60: 321-329) Key words : Lung cancer, Clinical characteristics, Symptom, Smoking 서 2000 년에들어와폐암은우리나라암사망원인질 론 이논문은인하대학교의지원에의하여연구되었음. This study was supported by INHA university Research Grant (INHA) Address for correspondence : Jeong-Seon Ryu, M.D., Associate Professor, Pulmonary Division, Dept. of Internal Medicine, Inha University Hospital 7-206, 3-Ga, Shinheung Dong, Jung Gu, Inchon, 400-103, Korea Phone : 82-32-890-3738 Fax : 82-32-882-6578 E-mail : jsryu@inha.ac.kr Received : Jan. 17. 2006 Accepted : Mar. 22. 2006 환중 1위가되었으며, 2004년에암사망원인질환중폐암에의한것이 20.6% 를차지하였고, 13,325예 ( 남자 : 9,874예, 23.9%; 여자 : 3451예, 14.7%) 환자가사망하였다 1. 현재우리나라에서흡연인구가많아향후폐암에의한암사망률은지속적으로증가할것으로예측되어지고있다 2. 지난 50여년간눈부신생명과학의발전에도불구하고, 현재까지아직진행된병기의폐암환자를완치시킬수있는효과적인치료법은없는실정이다. 최근표적치료제개발에따른후속연구및흡연이폐암발병에미치는영향에대한연구들에서인종간유전적특성의차이, 생활환경이미치 321
JS Ryu et al. : Clinical charicteristics of primary lung cancer patients in a tertiary hospital 는영향등이부각되기도하였다 3,4. 이는향후폐암연구에서폐암환자의임상적특성에대한보다세밀한데이터시스템의구축이필요함을시사해주는것으로생각한다. 이와같은측면에서볼때우리나라폐암환자의임상적특성에대한연구는 1970년초부터몇몇보고들이있어오다가, 1997년에결핵및호흡기학회에서전국규모의폐암실태조사가시행되었다 5-9. 그러나이에대한연구는아직미흡한실정이다. 따라서저자등은단일 3차의료기관에서지난 9년간확진된폐암환자의임상적특성을알아보고자한다. 대상및방법 1996년 9월부터 2005년 8월까지 9년간본원에내원하여세포학적혹은조직학적진단을받았던 1655예의폐암환자를대상으로연구하였다. 모든대상환자에서연령, 성별, 세포형, 임상적병기를분석하였다. 폐암세포형은세계보건기구의분류기준을참고하여편평상피세포암, 선암 ( 기관지폐포암포함 ), 대세포암, 소세포암, 선-편평상피세포암, 세포형이결정되지않은비소세포암으로분류하였다 10. 임상적병기의판정은 Mountain 에의하여 1997년에개정된폐암병기를이용하였다 11. 폐암진단당시설문에동의하였던 941예환자를대상으로폐암가족력, 직업, 흡연력, 임상증상, 체중감소, 수행상태등을조사하였다. 폐암가족력은부모, 형제중폐암병력이있는경우로하였다. 직업력은환자직업의종류와기간을조사하였으며, 이데이터를본원산업의학과에의뢰하여폐암발병과관련성을평가하였다. 평가방법은 1) 의사에의하여질병이진단되었는가? 2) 질병과작업사이의관련성이의심되는가? 3) 업무관련성평가로 1업무관련성에대한객관적인증거 ( 기존의역학적증거 ) 2 업무관련성에대한객관적인증거를기준으로하였고 ( 당해근로자의역학적증거 ) 를기준으로하였다. 여기에서 1), 2) 를만족하는상태에서 3-1과 3-2 두가지기준을모두만족시키면 "definite" 로, 두가지기준중어느하나를만족시키면 probable", 두가지기준중어느하나도충분히 만족시키지못하면 "possible", 두가지기준중어느하나도만족시키지못하면 "suspicious" 구분하였다 12-13. 평생흡연력이설문조사되었으며흡연자, 비흡연자, 과거흡연자로구분하였다. 과거흡연자는진단 1년전에금연을하였던경우로하였다. 진단당시임상증상은무증상과기침, 객담, 발열, 흉통, 호흡곤란, 객혈, 애성등의증상과두통, 어지럼, 기력감퇴, 식욕감소등과같은전신증상의유무로구분하여조사하였다. 체중감소는진단당시체중이 6개월전과비교하여 5% 이상감소가있었던경우로하였다. 수행상태는 ECOG 기준을이용하여조사하였다. 진단당시다음질환들의동반유무를조사하였다. 당뇨, 고혈압을포함한심장혈관질환, 만성폐쇄성폐질환, 특발성폐섬유화증및활동성폐결핵등을조사하였다. 당뇨와심장혈관질환의유무는설문에의존하였다. 특발성폐섬유화증유무는 chest CT 소견과폐기능검사소견을참고하여정하였으며, 만성폐쇄성폐질환의동반유무는 GOLD 기준에의하여폐기능검사에서 FEV 1 /FVC<0.7이었던경우로하였다 14. 활동성폐결핵의동반유무는진단당시시행한항산균객담배양결과를기준으로하였다. 통계처리는 SAS 프로그램 (ver 8.12) 을이용하였으며, 연구대상자의흡연력에따른폐암세포형분포차이등은카이제곱검정으로유의성을평가하였다. 결과 1. 성별연령분포및세포형전체대상폐암환자의나이는평균 64.4세이었고, 남여간의성비는 3.6 이었다 (Table 1). 전체환자에서편평상피세포암이제일흔하였고, 여자에서는선암이흔한세포형이었다. 2. 성별흡연력 941예의설문에응답한환자중평생흡연력을가지고있었던경우가 80.1% 이었고, 흡연력이없는경우는 19.9% 이었다 (Table 2). 여자의 71.7% 와남자의 322
Tuberculosis and Respiratory Diseases Vol. 60. No. 3, Mar. 2006 Table 1. Age distribution and cell types according to gender in 1655 patients of lung cancer Total N, (%) Men N, (%) Women N, (%) Total 1655(100) 1294(78.2) 361(21.8) Age, year <40 28(1.7) 15(1.2) 13(3.6) 40-49 130(7.9) 99(7.6) 31(8.6) 50-59 308(18.6) 242(18.7) 66(18.3) 60-69 616(37.2) 495(38.2) 121(33.5) 70-79 473(28.6) 367(28.4) 106(29.4) 80 100(6.0) 76(5.9) 24(6.6) Cell type Squamous 745(45.0) 660(51.0) 85(23.6) Adenocarcinoma 530(32.0) 319(24.7) 211(58.5) Bronchoalveolar 6(0.4) 2(0.2) 4(1.1) Large cell 24(1.5) 19(1.5) 5(1.4) Adenosquamous 22(1.3) 17(1.3) 5(1.4) NSCLC, not specified 39(2.4) 34(2.6) 5(1.4) Small cell 289(17.5) 243(18.8) 146(12.7) Table 2. Smoking habits according to gender in 941 patients of lung cancer responded to the questionnaire. Total N, (%) Men N, (%) Women N, (%) Total 941 736(78.2) 205(21.8) Smoking Current 524(55.7) 482(65.5) 42(20.5) habits Ex 230(24.4) 214(29.1) 16(7.8) Never 187(19.9) 40(5.4) 147(71.7) Pack-year 40.6±20.1 (1~180) 41.7±19.8 (2~180) 27.5±18.9 (1~100) 5.4% 가비흡연자이었다. 3. 연도별임상적특성의변화비소세포폐암환자에서임상적병기는일반적으로절제가가능할것으로판단하는병기 IA에서병기 IIIA가 447예 (33.0%) 이었고, 절제불가능병기 IIIB와 IV가 907예 (67.0%) 이었다 (Table 3). 비소세포폐암에서병기결정이어려웠던 12예가있었고이들의병기는표 3. 에제시하지않았다. 조사기간을 4.5년단위로하여 1996년부터 2000년까지와 2001년부터 2005 년까지두단위기간으로나누어보았을때, 비소세포폐암중선암이차지하는빈도가 29.5% 에서 33.7% 로증가한반면, 편평상피세포암은 49.9% 에서 41.8% 로감소하였다 (P<0.001)( 데이터미기재 ). 두단위기간 에서비소세포폐암과소세포폐암이차지하는비율의차이는관찰할수없었다 (P=0.15). 또한두단위기간에서임상적병기의차이도관찰할수없었다 (P=0.749). 4. 진단당시증상설문에응답한환자 941예중병기결정이불분명하였던 5예가있었다. 936예중무증상은 58예 (6.2%) 에서관찰되었다 (Table 4). 진단당시흔한증상으로는기침, 객담, 호흡곤란등이었다. 병기 IA-IIIA- (n=275) 와병기 IIIB-IV (n=484) 로나누어보았을때객담 (P=0.0031), 흉통 (P=0.024), 객혈 (P=0.005), 호흡곤란 (P<0.001), 애성 (P=0.020), 폐외증상 (P<0.001) 은진행병기에서흔히관찰되었다 ( 데이터미기재 ). 323
JS Ryu et al. : Clinical charicteristics of primary lung cancer patients in a tertiary hospital Table 3. Annual trends of clinical characteristics of 1655 patients of lung cancer Year at diagnosis N, (%) 1996 (N=49) 1997 (N=128) 1998 (N=130) 1999 (N=168) 2000 (N=182) 2001 (N=219) 2002 (N=208) 2003 (N=177) 2004 (N=241) 2005 (N=153) Gender Man 33(67.4) 100(78.1) 102(78.5) 129(76.8) 147(80.8) 173(79.0) 173(82.2) 142(80.2) 188(78.0) 107(69.9) Women 16(32.6) 28(21.9) 28(21.5) 39(23.2) 35(19.2) 46(21.0) 35(16.8) 35(19.8) 53(22.0) 46(30.1) Age, yr Cell type <60 19(38.8) 37(28.9) 44(33.9) 57(33.9) 48(26.4) 68(31.1) 53(25.5) 44(24.9) 57(23.6) 39(25.5) 60 30(61.2) 91(71.1) 86(66.2) 111(66.1) 134(73.6) 151(68.9) 155(74.5) 133(75.1) 184(76.4) 114(74.5) All NSCLC (N=1366) 38(77.6) 114(89.1) 108(83.1) 141(83.9) 152(83.5) 184(84.0) 169(81.3) 145(81.9) 188(78.0) 127(83.0) Squamous 17(34.7) 70(54.7) 58(44.6) 89(53.0) 94(51.7) 109(49.8) 98(47.1) 74(41.8) 92(38.2) 44(28.8) Adenocarcinoma 16(32.7) 37(28.9) 42(32.3) 44(26.2) 55(30.2) 64(29.2) 64(30.8) 63(35.6) 81(33.6) 64(41.8) Bronchoalveolar 2(4.1) 3(2.3) 1(0.8) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) Large cell 2(4.1) 3(2.3) 1(0.8) 3(1.8) 2(1.1) 0(0.0) 3(1.4) 2(1.1) 2(0.8) 6(3.9) Adenosquamous 1(2.0) 0(0.0) 4(3.1) 3(1.8) 0(0.0) 4(1.8) 1(0.5) 2(1.1) 3(1.2) 4(2.6) NSCLC, not specified 0(0.0) 1(0.8) 2(1.5) 2(1.2) 1(0.6) 7(3.2) 3(1.4) 4(2.3) 10(4.2) 9(5.9) Small cell (N=289) 11(22.5) 14(10.9) 22(16.9) 27(16.1) 30(16.5) 35(16.0) 39(18.8) 32(18.1) 53(22.0) 26(17.0) Stage IA, N=46(3.4) 1(2.6) 1(0.9) 5(4.7) 7(5.1) 4(2.6) 4(2.2) 7(4.2) 7(4.9) 7(3.7) 6(4.7) IB, N=136(10.1) 5(13.2) 9(7.9) 10(9.4) 16(11.7) 15(9.9) 13(7.1) 22(13.1) 16(11.1) 17(9.0) 13(10.2) IIA, N=3(0.2) 0(0.0) 1(0.9) 0(0.0) 1(0.7) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 1(0.5) 0(0.0) IIB, N=84(6.2) 2(5.3) 5(4.4) 3(2.8) 8(5.8) 12(7.9) 11(6.0) 18(10.7) 8(5.6) 13(6.9) 4(3.2) IIIA, N=178(13.1) 5(13.2) 16(14.0) 17(15.9) 17(12.4) 19(12.5) 30(16.5) 19(11.3) 17(11.8) 21(11.2) 17(13.4) IIIB, N=357(26.4) 9(23.7) 35(30.7) 29(27.1) 35(25.6) 41(27.0) 47(25.8) 34(20.2) 38(26.4) 55(29.3) 34(26.8) IV, N=550(40.6) 16(42.1) 47(41.2) 43(40.2) 53(38.7) 61(40.1) 77(42.3) 68(40.5) 58(40.3) 74(39.4) 53(41.7) Table 4. Presenting symptoms at the time of diagnosis in the patients responded to the questionnaire Cell type Clinical stage N Presenting symptoms N, (%) Cough Sputum Fever Chest pain Hemoptysis Dyspnea Hoarsness Extrapulmonary Asymptomatic NSCLC IA 39 17(43.6) 15(38.5) 3(7.7) 4(10.3) 4(10.3) 7(18.0) 0(0.0) 12(30.8) 7(18.0) IB 88 47(63.4) 52(59.1) 10(11.4) 19(21.6) 25(28.4) 27(30.7) 5(5.7) 36(40.9) 10(11.4) IIA 2 1(50.0) 0(0.0) 0(0.0) 0(0.0) 0(0.0) 1(50.0) 0(0.0) 0(0.0) 1(50.0) IIB 52 29(55.8) 32(61.5) 7(13.5) 22(42.3) 12(23.1) 19(36.5) 3(5.8) 25(48.1) 1(1.9) IIIA 94 63(67.0) 62(66.0) 6(6.4) 26(27.7) 23(24.5) 47(50.0) 10(10.6) 33(35.1) 5(5.3) IIIB 193 118(61.1) 103(53.4) 23(11.9) 73(37.8) 34(17.6) 107(55.4) 28(14.5) 97(50.3) 15(7.8) IV 291 158(54.3) 141(48.5) 41(14.1) 90(30.9) 39(13.4) 141(48.5) 29(10.0) 158(54.3) 8(2.8) Total 759 433(57.1) 405(53.4) 90(11.9) 234(30.8) 137(18.1) 349(46.0) 75(9.9) 361(47.6) 47(6.2) SCLC Limited 61 35(57.4) 32(52.5) 4(6.6) 19(31.2) 13(21.3) 26(42.6) 8(13.1) 17(27.8) 7(11.5) Extensive 116 71(61.2) 69(59.5) 6(5.2) 31(26.7) 22(19.0) 62(53.5) 20(17.2) 66(56.9) 4(3.5) Total 117 106(59.9) 101(57.1) 10(5.7) 50(28.3) 35(19.8) 88(49.7) 28(15.8) 83(46.9) 11(6.2) 무증상은병기 IA-IIIA에서흔히관찰되었다 (P= 0.029)( 데이터미기재 ). 0-2도 ECOG 수행상태보다 3-4도수행상태와체중감소가있었던경우가병기 IIIB-IV에서흔히관찰되었다 ( 각각 P<0.001, P< 0.001)( 데이터미기재 ). 324
Tuberculosis and Respiratory Diseases Vol. 60. No. 3, Mar. 2006 Table 5. Smoking habits and gender according to cell type in the patients responded to the questionnaire Men Smoking habit, N (%) Women Smoking habit, N (%) Current Ex Never Total Current Ex Never Total N=429 N=245 N=21 N P N=44 N=15 N=136 N P Squamous cell 212(49.4) 133(54.3) 1(4.8) 346 <0.001 19(43.2) 8(53.3) 19(14.0) 46 <0.001 Adenocarinoma 103(24.0) 71(29.0) 17(81.0) 191 18(40.9) 6(40.0) 102(75.0) 126 Small cell 114(26.6) 41(16.7) 3(14.3) 158 7(15.9) 1(6.7) 15(11.0) 23 Table 6. Coexisting diseases in the patients of lung cancer No. investigated No. (% of total) Chronic obstructive pulmonary disease by FEV1/FVC<70 1067 471 (44.1) Cardiovascular disease 941 209 (22.2) Diabetes mellitus 941 101 (10.7) Pulmonary tuberculosis by AFB culture positive 1374 53 (3.9) Idiopathic pulmonary fibrosis by Chest CT scan 1655 27 (1.6) 5. 세포형에따른남여흡연습관 6. 진단당시동반질환 세종류의주요세포형 ( 편평상피세포암, 선암및소세포암 ) 을보였던환자 890예에서세포형에따른성별흡연력을조사하였다 (Table 5). 평생흡연력이없었던환자의남여모두에서선암이제일흔한세포형이었다. 흡연력이있었던환자에서는편평상피세포암이흔한세포형이었다. 설문에응하였던환자에서심장혈관질환및당뇨가각각 209예 (22.2%), 101예 (10.7%) 로관찰되었다 (Table 6). 전체 1655예의폐암환자중항산균객담검사를하였던 1374예중배양양성이 53예 (3.9%) 에서관찰되었다. 특발성폐섬유화증은 27예 (1.6%) 에서관찰되었다. 진단당시폐기능검사를시행하였던환 Table 7. Clinical characteristic of forty patients having family history in first degree relative among the patients responded to the questionnaire Family history N (%) Yes, 40 (4.4) No 901 (95.6) P Father/Mother/Sibling, 9/ 11/ 20 Gender Men 31(77.5) 705(78.3).911 Women 9(22.5) 196(21.8) Age <60 12(30.0) 247(27.4).720 60 28(70.0) 654(72.6) Cell type Squamous 14(35.0) 378(42.0).314 Adenocarcinoma 14(35.0) 302(33.5) Large cell 1(2.5) 12(1.3) Adenosquamous 0(0.0) 13(1.4) NSCLC, not specified 0(0.0) 26(2.9) Small cell 11(27.5) 170(18.8) Smoking Never 8(20.0) 155(17.2).953 habits Ex 11(27.5) 271(30.1) Current 21(52.5) 475(52.7) 325
JS Ryu et al. : Clinical charicteristics of primary lung cancer patients in a tertiary hospital Table 8. Occupational relationship in lung cancer patients Criteria by IARC* No. (% of 941 patients) Presumed carcinogens(no.) Definite 1(0.1) Asbestos(1) Probable 42(4.5) Metal fume(26) Inorganic dust(11) Asbestos(4), PAH + (1) Possible 70(7.4) PAH+(37), Paint pigment(9), Wood preservative(8), Metal fume(5), Inorganic dust(4), Asbestos(2), Heavy metal(2), Glass fiber(1), Chrome(1), PAH + +Wood preservative(1) Suspicious 2(0.2) Wood preservative(1), PAH + +metal fume(1) *International Agency for Research on Cancer, +polycyclic aromatic hydrocarbon 자는전체 1655예중 1067 예 (64.4%) 이었으며이들중 471예 (44.1%) 가 GOLD 기준에따른만성폐쇄성폐질환이었다. 만성폐쇄성폐질환동반유무에따른임상적특성의비교에서동반이된경우남자, 60세이상, 편평상피세포암및흡연력을보였던경우가유의하게흔하였다 (P=0.001, 데이터미기재 ). 특발성폐섬유화증의동반유무에따른비교에서성, 연령, 세포형, 흡연력등임상적특성의유의한차이는관찰되지않았으나, 동반이된경우에 60세이상과편평상피세포암에서흔한경향을보였다 ( 각각 P=0.053, 0.057, 데이터미기재 ). 7. 폐암환자의가족력과직업력부모, 형제, 자매중폐암병력이있었던환자는 40 예 (4.4%) 이었고부모가폐암이었던경우 20예 (5-0.0%), 형제, 자매가폐암이었던경우 20예 (50.0%) 이었다 (Table 7). 폐암가족력의동반유무에따른성, 연령, 세포형, 흡연력의유의한차이는관찰되지않았다. 직업력조사에서 suspicious 2예를제외한 113예 (12.2%) 의환자에서폐암발병이직업과관련성이있었을것으로추정한다 (Table 8). 그러나전체환자중비흡연자는 probable, possible, suspicious에서각각 2예씩있었다 ( 데이터미기재 ). 고찰본연구의임상적으로절제가능병기인 IA에서 IIIA까지가 33% 이었으며, 이는 1997년시행되었던전국폐암실태조사의 34.6% 와유사하였다 8. 최근폐 암조기진단에대한국민의관심이증가되고있음에도불구하고 2000년이전과이후두단위구간간에임상적병기의차이가없었다. 본연구를시행한병원에서 2000년-2004년까지모든진단되는폐암환자를대상으로뇌핵자기공명영상을상용하였으며, 2004년부터현재까지임상의사의판단에따라서 PET를진단에이용하여오고있다. 이들검사들에의한병기변화에대한분석이필요하겠지만, 이는윌로거씨현상과같은병기이동 (stage migration) 현상의가능성에의한것으로생각한다 15. 1983년부터미국등선진국에서는흡연력의감소와담배의변화에의하여선암이제일흔한암종으로변하고있다 16,17. 본연구에서대상환자의폐암세포형은아직편평상피세포암이가장흔한것으로조사되었다. 이는후향적으로조사되었던전국폐암실태조사의전체및남여간흡연율과비교하여볼때유사한결과를보였다 8. 본연구에서비흡연자는 19.9% 였고, 실태조사에서는 23.2% 로유사하였다. 미국등선진국과달리우리나라에서는폐암환자중비흡연자가차지하는비율이낮고, 편평상피세포암이많은소견은향후지속적이고강도높은금연운동의필요성을시사하는소견이다. 또한본연구의여자폐암환자에서비흡연자는 71.7% 이었다. 이는아시아인에서여자폐암발병요인으로흡연이외에환경적요인, 유전적요인등이중요한요인으로생각되고있어이에대한향후추가연구의필요성을지적해주는소견으로생각한다 3. 폐암진단당시증상에있어서전국폐암실태조사에서무증상은 7.2% 이었으며, 본연구에서 6.2% 로유사한빈도를보였다 8. 흔한증상의순서도본연구에서기침, 객담, 호흡곤란이었고이는폐암전국실 326
Tuberculosis and Respiratory Diseases Vol. 60. No. 3, Mar. 2006 태조사와같았다 8. 폐암증상이조기발견및진단에도움이되지는않는다고알려져있지만, 본연구에서무증상은낮은병기에, 폐외증상과호흡곤란등은진행된병기에서유의한차이를보이며흔히관찰되었다. 세포형에따라흡연습관이다른지를보았을때, 선암이기존의외국연구에서와같이성별에구분없이비흡연자에서흔히관찰되었고, 성에따라서는여자에서흔한것을알수있었다. 이와같은결과는 Shigematsu 등 18 의연구에서와같이흡연유무에따른폐암발병기전이다름을시사하는소견으로생각된다. 만성폐쇄성폐질환및심장혈관질환의동반은폐암진단과정및치료에어려움을주는것으로알려져있다. 본연구에서수술적절제가가능한병기에서만성폐쇄성폐질환의빈도와심장혈관질환의빈도는각각 40.8% 와 24.6% 이었다. Janssen-Heijnen등 19 이 3864예의폐암환자에서의무기록을검토한조사에서만성폐쇄성폐질환이 23% 에서동반되었다고보고하였다. 본연구에서의이와같은만성폐쇄성폐질환의높은동반율은유무를판정하는데있어 GOLD 기준을이용하였고, 우리나라의높은흡연률때문인것으로생각한다. 특발성폐섬유화증이폐암발병을증가시키는지에대한연구결과는아직결론에이르지못하고있으며, Hubbard등 20 은 7.3배의발병위험도가있다고하였지만, 다른연구에서는이를확인하지못하였다 21. 박등 22 의연구에서특발성폐섬유화증이동반된폐암의경우편평상피세포암의빈도가 30% 로높았지만, 동반되지않은폐암과세포형의차이가없었다고하였다 (P=0.151). 본연구에서도동반이된경우그렇지않은경우보다편평상피세포암에서흔한경향을보였다. 폐결핵의동반은폐암진단과정에서임상의사에게혼동을줄수있으며, 임상적병기결정에어려움을줄수있다. 활동성폐결핵환자의약 1% 에서폐암이동반되었고, 폐암환자의 2-4% 에서활동성폐결핵이동반되는것으로알려져있다 23,24. 국내에서최등 25 과유등 26 은각각 4286예와 1044예의폐결핵 환자의후향적조사에서각각 24예 (0.6%), 18예 (1.7 %) 에서폐암이동반되었다고보고하였다. 본연구에서는폐암환자를대상으로활동성폐결핵의동반을조사하였고, 동반빈도는 3.9% 로이전에시행된일본에서의연구와유사한빈도를보였다. 폐암의가족적발병에대하여 1960년대에처음으로 Tokuhata 등 27 이발표하였다. 그후몇개의환자- 대조군연구가있었으며, 가족력을보였던가계의폐암발병위험도가 1.8배에서 2.8배까지증가하는것으로알려져있다 28,29. 그러나폐암환자에서의높은흡연률과흡연습관에가족성집합 (familial aggregation) 경향때문에가족성폐암에대하여아직정확히정의되어있지않다. 그임상적특성에대하여 Shaw등 30 은가족력이있는경우발병연령이낮음을보고하였다. 본연구에서는환자-대조군연구가아니므로상대위험도를측정하기는불가능하였고, 가족력이있는군과없는군간임상적특성의차이를관찰할수없었다직업적유해물질노출이암과호흡기질환의발병에미치는영향에대하여 Ward등 31 과 Trupin 등 32 은암환자의 4-10% 와호흡기질환환자의 10-20% 가직업과관련이있다고보고하였다. 본연구에서직업적관련가능성을생각할수있는경우가전체대상환자의 12.2% 이었다. 폐암발병에있어서직업관련성에대하여연구원이평생직업및기간에대한설문조사를실시하였으나세밀한유해물질의노출정도, 노출시간등을조사하지못한결점이있다. 그러나이와같은결과는인천지역이공장등유해환경이많아이를반영해주는것으로생각한다. 따라서환경공해, 직업적유해물질노출등현재우리나라에서간과하고있는이들분야에대한보다체계적인연구가필요할것으로생각한다. 그러기위하여환자에대한보다세밀하고광범위한정보수집이필요할것이다. 본연구의제한점은지역혹은국가단위임상적특성조사한것이아닌한대학병원에서의조사로, 한국인폐암의임상적특성을대표하는데한계가있을것으로생각한다. 그러나흡연력, 증상등임상적특성에대한등의조사가전향적으로시행되었다는데장 327
JS Ryu et al. : Clinical charicteristics of primary lung cancer patients in a tertiary hospital 점이있으며, 또한연구자오류를줄이고자연구기간내진단되었던모든폐암환자를분석하여하였다. 향후우리나라폐암환자의임상적특성에대한연구에서비흡연여자에서의높은발병율에대한원인연구, 만성폐쇄성폐질환, 결핵등의동반질환이진단및치료에미치는영향에대한연구, 종양의가족력및직업적혹은환경적유해물질노출이발병에미치는영향등에대하여세밀한정보수집및유전적연구가필요할것으로생각된다. 요약연구배경 : 폐암은 2000년에들어와우리나라암사망원인질환중 1위가되었으며, 아직뚜렷한생존기간의향상이없는예후가불량한암이다. 최근표적치료제개발에따른후속연구및흡연이폐암발병에미치는영향에대한연구들에서인종간유전적특성의차이, 생활환경이미치는영향등이부각되기도하였다. 우리나라폐암환자의임상적특성에대한연구는아직미흡한실정이다. 저자등은단일 3차의료기관에서지난 9년간확진된폐암환자의임상적특성을알아보고자한다. 방법 : 1996년 9월부터 2005년 8월까지 9년간본원에입원하여폐암으로진단을받았던 1655예의환자를대상으로연구하였다. 모든대상환자에있어서연령, 성별, 세포형, 임상적병기를분석하였다. 폐암진단당시설문에응답하였던 941예의환자를대상으로폐암가족력, 직업, 흡연력, 임상증상, 체중감소, 수행상태등을조사하였다. 진단당시동반질환으로당뇨, 고혈압을포함한심장혈관질환, 만성폐쇄성폐질환, 특발성폐섬유화증및활동성폐결핵등을조사하였다. 결과 : 전체연구대상폐암환자의남여성비는 3.6:1 이었다. 세포형은편평상피세포암이제일흔하였고, 여자에서는선암이흔한세포형이었다. 흡연력이있었던경우가 80.1% 이었고비흡연자는 19.9% 이었다. 여자 72.3% 가비흡연자이었다. 비흡연자에서는남여모두 선암이제일흔한세포형이었고, 흡연력이있는환자에서는편평상피세포암이흔하였다. 1996년부터 2000년까지와 2001년부터 2005년까지두단위기간으로나누어보았을때, 비소세포폐암중선암이차지하는빈도의증가 (29.5% 에서 33.7% 로 ) 추세와편평상피세포암의감소 (49.9% 에서 41.8% 로 ) 추세를확인할수있었다. 환자중무증상은 6.2% 에서관찰되었고흔한증상으로는기침, 객담, 호흡곤란등순이었다. 동반질환으로만성폐쇄성폐질환, 심장혈관질환, 당뇨, 결핵, 특발성폐섬유화증은각각 44.1%, 22.2%, 10.7%, 3.9%, 1.6% 에서관찰되었다. 부모, 형제, 자매중폐암가족력이있었던환자는 4.4% 이었고, 환자직업력이폐암발병과관련성이있을것으로추정된경우는 12.2% 이었다. 결론 : 우리나라폐암환자에서높은흡연율이관찰되었 고아직편평상피세포암이제일흔한세포형이었다. 향후우리나라폐암환자의임상적특성에대한보다세밀한조사가필요하겠다. 참고문헌 1. 통계청. 2004 년사망원인통계연보. 2005. 2. Jee SH, Kim IS, Suh I, Shin D, Appel LJ. Projected mortality from lung cancer in South Korea, 1980-2- 004. Int J Epidemiol 1998;27:365-9. 3. Lam WK. Lung cancer in Asian women-the environment and genes. Respirology 2005;10:408-17. 4. Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto RA, Brannigan BW, et al. Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib. N Engl J Med 2004;350:2129-39. 5. Oh JK. Clinical aspects of lung cancer. Tuberc Respir Dis 1973;20:24-30. 6. Jung ET. Clinical survey of lung cancer in Korea. Tuberc Respir Dis 2000;49:137-48. 7. Kim HJ, Jeong MP, Heo DS, Bang YJ, Han SK, Shin YS, et al. Lung cancer in Korea (1980-1984). Korean J Med 1994;46:221-8. 8. Lee C, Kang KH, Koh Y, Chang J, Chung HS, Park SK, et al. Characteristics of lung cancer in Korea, 1997. Lung Cancer 2000;30:15-22. 9. Kim JS, Park JY, Chae SC, Shin MC, Bae MS, Son 328
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