대한세포병리학회제 21 차봄학술대회 The 21th Annual Spring Meeting of the Korean Society for Cytopathology 10:00-10:50 특강 I Current Status of Cytopathology in Mongolia 연자 : Galtsog London Prof. Ph.D (Dept. of Pathology & Forensic Medicine, Health Science University of Mongolia) 좌장 : 고일향교수 ( 전회장인제의대상계백병원 ) 10:50-11:40 특강 II WHO Classification of Breast Tumors 연자 : 정우희교수 ( 연세의대영동세브란스병원 ) 좌장 : 이동화교수 ( 대한세포병리학회회장, 순천향대학교병원 ) 13:30-15:40 심포지움 : FNAC in Breast Lesions 좌장 : 윤혜경교수 ( 인제의대부산백병원 ) Diagnostic approach to FNAC in breast lesions ( 울산의대공경엽 ) General cytologic characteristics of malignant lesions ( 부산의대김지연 ) Papillary lesions of the breast ( 아주의대임현이 ) Diagnostic pitfalls in breast FNAC: false positive and false negative ( 인제의대박경미 ) 일시 :2007 년 6 월 1 일 ( 금 ) 10:00 15:40 장소 : 가톨릭대학교강남성모병원의과학연구원후원 : 과학기술단체총연합회 대한세포병리학회 The Korean Society for Cytopathology
목차 특강 I : Current Status of Cytopathology in Mongolia 1 Galtsog London Prof. Ph.D (Dept. of Pathology & Forensic Medicine, Health Science University of Mongolia) 특강 II : WHO Classification of Breast Tumors 9 정우희교수 ( 연세의대영동세브란스병원 ) 심포지움 : FNAC in Breast Lesions Diagnostic approach to FNAC in breast lesions 12 ( 울산의대공경엽 ) General cytologic characteristics of malignant lesions 24 ( 부산의대김지연 ) Papillary lesions of the breast 49 ( 아주의대임현이 ) Diagnostic pitfalls in breast FNAC: false positive and false negative 54 ( 인제의대박경미 )
-1-
2
-3-
-4-
-5-
-6-
-7-
-8-
WHO Classification of Breast Cancer 정우희교수연세의대영동세브란스병원 침윤성유방암종 (invasive mammary carcinoma) 은임상적, 방사선학적, 병리학적, 생물학적특징에따라구분되는다양한질병군으로, 그분류는일반적으로세계보건기구 (World Health Organization: WHO) 질병분류제2개정판 (2003) 에따른다. 이분류체계는침윤성종양세포의성장형태와세포학적특징에따라정해진것으로, 그발생기원에근거하는것은아니며크게관암종과소엽암종으로대별한다. WHO histological classification of tumours of the breast Epithelial tumours Invasive ductal carcinoma, not otherwise specified Mixed type carcinoma Pleomorphic carcinoma Carcinoma with osteoclastic giant cells Carcinoma with choriocarcinomatous features Carcinoma with melanotic features Invasive lobular carcinoma Tubular carcinoma Invasive cribriform carcinoma Medullary carcinoma Mucinous carcinoma and other tumours with abundant mucin Mucinous carcinoma Cystadenocarcinoma and columnar cell mucinous carcinoma Signet ring cell carcinoma Neuroendocrine tumours Solid neuroendocrine carcinoma Atypical carcinoid tumour Small cell/oat cell carcinoma Large cell neuroendocrine carcinoma Invasive papillary carcinoma Invasive micropapillary carcinoma Apocrine carcinoma Metaplastic carcinomas Pure epithelial metaplastic carcinomas Squamous cell carcinoma Adenocarcinoma with spindle cell metaplasia -9-
Adenosquamous carcinima Mucoepidermoid carcinoma Mixed epithelial/mesenchymal metaplastic carcinomas Lipid-rich carcinoma Secretory carcinoma Oncocytic carcinoma Adenoid cystic carcinoma Acinic cell carcinoma Glycogen-rich clear cell carcinoma Sebaceous carcinoma Inflammatory carcinoma 1. 침윤성관암종 악성유방종양중가장흔한질환군으로유방암종의 65~80% 를차지한다. 이중반정도는일반형 (simple or usual, not otherwise specified NOS) 이라하여다른특수형이섞여있지않거나섞여있더라도 10% 미만인경우이고일반형이 50% 이상이면서특수형이 10% 이상 49% 미만섞여있는복합형 (mixed type) 이 25%, 종양의 90% 이상이특수형으로이루어진특수형 (special variant) 이나머지 25% 를차지한다. 일반형침윤성관암종은예후와연관하여 Elston과 Ellis(1991) 가제안한조직학적등급이가장널리사용되고있으며특수형인경우는특징적인성장형태와세포학적특징외에면역조직화학적특징을가지며이런것들이조직학적등급과더불어예후에영향을미치는것으로알려져있다. Semi-quantitative method for assessing histological grade in breast. From Elston and Ellis Feature Score Tubule and gland formation Majority of tumour(>75%) 1 Moderate degree(10-75%) 2 Little or none(<10%) 3 Nuclear pleomorphism Small, regular uniform cells 1 Moderate increase in size and variability 2 Marked variation 3 Mitotic counts Dependent on microscope field area 1-3 Examples of assignment of points for mitotic counts for three different field areas: Field diameter(mm) 0.44 0.59 0.63 Field area(mm2) 0.152 0.274 0.312-10-
Mitotic count* 1 point 0-5 0-9 0-11 2 points 6-10 10-19 12-22 3 points >11 >20 >23 2. 침윤성소엽암종전체침윤성유방암종중두번째로흔한형태로 5~15% 를차지한다. 8~19% 에서양측성으로나타나는특징이있으며소엽내암종과함께나타나는경우가매우흔하다. 종양세포는접착력이떨어지는작은세포들이개개로또는일렬로서서간질내로침윤하는특징적인모습을취하며 80~100% 에서 E-cadherin expression 이소실되어침윤성관암종과의감별에도움이된다. 3. 비정형관상피증식증과관내암종비정형관상피증식증은암의발생과정에서저등급관내암종의전구병변으로서저등급관내암종과유사한유전적결함을보이므로일반적관상피증식증과조직학적인감별이필요하며관내암종은과거의성장유형에따라분류하는고형, 사상형, 면포형, 유두형, 미세유두형은종양의생물학적성상과뚜렷한연관이없어서 Black의기준에의한핵등급과괴사유무에따라분류한 VanNuys 분류법이예후와연관된치료방침결정에유용하다고인정되어널리사용되고있다. Nuclear greading for DCIS Nuclear Nuclear Nuclear Grade 1 Grade 2 Grade 3 Nuclear size 1-1.5 1.5-2.5 >2.5 Nucleoli - Rare ++/+++ Mitotic activity - +/- +/+++ Pleomorphism + ++ +++ Chromatin Diffuse Clumped Vesicular Van Nuys Classification DCIS Non-High Grade High Grade Group 3 without Necrosis with Necrosis Group 1 Group 2-11-
Diagnostic Approach to Fine Needle Aspiration of Breast Lesions 공경엽울산의대 현재우리나라병리과의실정을고려해보면만져지는유방병변인경우, 직접병리의사가세침흡인검사 (fine needle aspiration, 이하 FNA) 를시행하고진단하는병원, 임상에서 FNA를시행하고판독만하는경우로나누어진다. 물론만져지지않는병변인경우는방사선중재를필요로하므로방사선과에서시행하는경우가대부분이다. 실제 FNA를시행하고진단해보면그유용성을피부로느끼기도하지만위음성및위양성진단때문에괴로움을느낄때도종종있다. 그러나조직진단또한절대적으로완벽할수없고, FNA가가지는여러가지장점때문에이검사의이용이날로늘어가고있다. 본과정에서는유방의 FNA 에있어서병리의사가고민할수있는여러가지문제점중다음세가지를주제로하여서술하고자한다. Ⅰ. How credible the breast FNA as an effective diagnostic procedure and whether FNA can reliably replace biopsy? Ⅱ. How can we approach to interpret and report? Ⅲ. How can we start FNA in our department? I. How credible the breast FNA as an effective diagnostic procedure and whether FNA can reliably replace biopsy? 1930년대 FNA가시작된이후로전세계적으로주목을받으면서이검사가널리시행되고있음에도불구하고이검사의가치에대해서논란이있는것이사실이다. 특히유방의 FNA에있어서는그논의의강도가변함이없다는것이다. 가장큰이유로병원마다진단정확도의편차가다른검사에비해서너무크다는것인데각기다른기관에서발표된 29개의논문을보면 sensitivity 는 0.65 에서 0.98 이고 specificity 0.31에서 1.0 이었다. 또한 Masood 등은 3,000 예의유방병변의 FNA 진단정확도를 68 100% 로보고하였다. 이처럼진단정확도가다양한것은여러가지인자가작용을할수있으며이중에는검체의채취에서처리, 염색, 판독까지전과정에연관이있다할수있다. 검체의채취는병리과, 임상과등여러과에서시행할수는있지만저자는병리의사가직접시행하는것을권하고싶다. Darson 등의보고에의하면병리의가채취한것의검체적절성이 6 배나높다는보고를했다. 단사람및경험에따라검채채취능력이다른것은사실이지만누구에게나처음은존재하는것이며, 능력을향상시키는데는본인의노력이따라야함은당연한사실이다. 검체의처리과정도병이의사가직접도말을했을때양질의도말표본을제작할수있다. 염색과정도병리의사조금만더관심을갖고있으면항상일관된좋은염색을유도할수있다. 판독에는어느정도경험이필요하며전공의때부터꾸준히이런검체를접하고, 조직 세포간 correlation 을해오면전문의가된후진단하기가한결쉬울수있다. 진단의정확도만상승시킬수있다면, 이검사가조직검사를전부는아니라하더라도상당수대치할수있을것이다. 일례로 1987년 Dixon 등이발표한논문에 FNA를시행한후유방수술이 83% 에서 41% 로양성병변의유방조직검사빈도가 74% 에서 -12-
23 % 로감소했음을보고한적이있는데이를통해볼때, 불필요한조직검사를줄이는데 FNA의공헌도가큼을알수있다. II. How can we approsach to interpret and report? 1. Adequacy 유방병변에따라검체의적합성이달라질수있지만, 1994년 Sneige 등의보고에따르면검체채취시한병소당 3 4회시행할것을권하고크기가 3 4 cm 이상일땐그횟수를추가할것을권하고있다. 실제 FNA를시행해보면어떤예들은한번만에도좋은검체를얻을수있는반면, 어떤예들은사람손을바꿔가며해도검체채취에실패할수있으므로 case by case 적용을하는것이필요하다. Sneige 등은부적절한검체로 obscuring blood/ distortion artifact 가있어판독이불가능한경우로하였다. 외부에서검체를받아판독할때가능하면진단을낼려고무리를할수있는데이로인해오진을초래할수있으므로과감히부적절한검체로표기를하고그원인을설명해주는것이바람직하다고할수있다. 또한이들은적합한검체로 4 6개의세포군집이있어야하며이군집이소엽의형태일경우는최소한 6개의세포가있어야하며, flat sheet 일때는 10개의세포가있어야한다고했다. 하지만 Stanley, Links, Kline (Fig.1) 등은최종조직진단의결과와세포밀도간의상관관계를조사하여보고하였는데조직진단이소위 nonproliferative breast disease 인경우는세포가거의나오지않기때문에 Sneige 의 criteria 를일괄적으로적용하기에는무리가있으며 clinicopathologic 및 pathologic radiologic correlation 이중요하다하겠다. 이의 correlation 이안될때는생검을유도하는방향이좋다. 아래에 NCI 에서제안한 specimen adequacy guideline 이비교적합리적이라생각되어이를정리하였다. - Adequacy of FNA samples of solid nodules A. An adequate specimen obtained by aspiration is one that leads to resolution of a problem presented by a lesion in a particular patient s breast. There is no specific requirement for a minimum number of ductal cells to be present for specimen adequacy. B. Adequacy is determined by two judgments: 1. Opinion of the aspirator that the cytologic findings based on the reports are consistent with the clinical findings and that the lesion was adequately aspirated. 2. Opinion of the pathologist examining the smears that the slides do not have significant distortion or artifacts. C. Specimen description should include quantity of epithelial cells 1. Few (occasional clusters) 2. Moderate (clusters easy to find) 3. Abundant (epithelial cells in almost every field) D. Other cellular components should also be in specimen description E. Laboratories may choose to require a given number of cells be present for specimen -13-
adequacy. F. There is no national standard that requires a given number of cells be present for specimen adequacy _ Adequacy of FNA sample from a cyst Adequacy of a benign cyst 1. When contents consist of thin, watery, green grey fluid and there is no residual mass palpable following evacuation of the cyst contents, the fluid from such a lesion may be examined or discarded at discretion of an experienced aspirator. 2. Any residual clinically significant mass requires further evaluation. 3. Any brown or red discoloration in the aspirate not considered to be traumatic warrants careful clinical and cytologic evaluation. ADEQUACY IN BREAST FNA CELLUARITY & HISTOLOGY 47-82% OF FCC SCANTY OR ABSENT +++ ++ + 0 FIBROFATTY LIPOMA ATROPHY MILD --- MODERATE --- FLORID DUCTAL HYPERPLASIA FAC ADH CA LINSK J. ACTA CYTOL 16:130-138, 1972 KLINE t. HANDBOOK. CV MOSBE, 1988 STANLEY M. DIAGN CYTOPATH 13:473-485, 1995. 2. Terminology 병원마다사용하는진단용어가다른것이현실이지만병리의사는임상의에게정확한의미전달이되는진단을해야하는의무가있으므로, 적어도한병원에서는통일된진단을쓰는것이바람직하다고하겠다. 가급적 FNA의진단은조직진단과연관을지을수있는용어가좋을것으로생각되어 NCI가제안한 benign, atypical/indeterminate, suspicious/probably malignant. malignant, unsatisfactory 등의 screening 성세포진단의용어는가급적사용하지않을것을권하고싶다. Page 등이제안한안은 Table 1에, Sneige 등이제안한것은 Table 2에 Massod 등이제안한안은 Table 3 에정리하였다. 각자병원정서에맞는것을사용하면되지만, 개인적으로는 Masood 안을가장선호하여본병원에서도이안을기본으로하고있으며, Masood 안을선호하는이유는 proliferative diseases 에있어서조직진단과의일치율이높고 (Table 4) 이에대한 follow up 특히 atypical hyperplasia with atypia 의의미 (Table 5) 가조직의의미와거의비슷하므로임상에유용한정보를줄수있다고생각하기때문이다. 또한유방암의등급을세포학적으로나누어보고자하는보고들이있어 Table 6,7 에인용은했으나, 실제이런정도까지의보고는필요하지않으리라생각된다. -14-
Table 1. FNAC Breast Diagnostic Categories and Their Predictions Diagnosis Tissue diagnosis Clinical outcomes Definite carcinoma Intermediate and high grade invasive carcinomas Probable carcinoma (and other terms) Uncertain, likely benign Benign 90+% invasive carcinomas, more in situ and lower grade Few carcinomas (low grade), many hyperplasias, and fibroadenomas Regularly benign, rare low grade DCIS, and lowest grade carcinomas, especially lobular and tubular Inadequate, etc. FNAC; fine needle aspiration cytlogy, DCIS; ductal carcinoma in situ. (Page et al, Cancer cytopathology, 81:6,1997) Poor; certainty adequate for neoadjuvant chemotherapy Intermediate to low malignant potential carcinomas predominate Benign, similar to benign, same as category below Benign, or excellent prognosis neopla 는 (fewer than in category above) Table 2. Diagnostic Categories of FNA and Recommendations Adequacy/Diagnostic Category Recommendation Specimen adequacy Satisfactory for evaluation (see diangostic categories 1 4) Insufficient for evaluation due to scant cellularity (< 4 6 cell groups) Unsatisfactory for evaluation due to distortion artifact/obscuring blood (1) Benign Specify as to lesion type (e.g., fibroadenoma, fibrocystic change, adenosis, papilloma, etc; benign phyllodes cannot be distinguished from fibroadenoma on FNA) (2) Proliferative A. Identified by cytologic atypia (e.g., crowded, enlarged, pleomorphic, overlapping nuclei, three dimensional groups or sheets, loss of cohesion, few single cells, homogeneous cell population and hyperchromasia) B. Idenetified by cytologic features combined with architectural pattern Proliferative lesions may be further classified as: (1) ductal hyperplasia (2) atypical ductal or lobular hyperplasia / low grade carcinoma in situ (3) Suspicious for carcinoma Includes cases with: Insufficient cellularity for diagnosis of carcinoma Low grade carcinomas that are admixed with benign ductal elements or present on one slide only (4) Malignant Breast carcinoma; Specify as to type (e.g., ductal, lobular mucinous, papillary or tubular) and nuclear grade (1 3); in situ cannot be distinguished from invasive carcinoma based on FNA. Others (i.e., sarcoma, lymphoma, metastasis, etc.) (Sneige et al Acta Cytol 38:971, 1994) Surgical (core or excisional) biopsy, if clinically indicated Repeat FNA; obscuring blood may be lysed by immersing smears in Carnoy s solution prior to staining Correlation with clinical/ mammographic findings is needed Atypia in premenopausal women may be due to cyclic secretory changed and may disappear on repeat FNA after two weeks (1) Correlation with clinical/ mammographic findings (2) Excisional biopsy to exclude carcinoma Excisional biopsy to confirm carcinoma Tumor invasion should be documented in: (1) nonpalpable cancer prior to axillary dissection (excisional biopsy) (2) preoperative chemotherapy (cutting needle biopsy or FBA of lymph node metastasis) -15-
Table 3. Criteria for Masood Cytolgic Grading System for Interpretation of Breast Fine Needle Asprates* Score Cellular arrangement Cellular pleomorphism Myoepithelial Cells Anisonucleosis nucleoli Chromatin Clumping 1 Monolayer Absent Many Absent Absent Absent 2 Nuclear overriding Mild Moderate Mild Rare micronucleoli Rare 3 Nuclear overriding and clustering 4 Loss of cohesion Moderate Few Moderate Frequent micronucleloi Conspicuous Absent Conspicuous Predominantly macronucleoli Occasional Frequent Total score : Nonproliferative breast disease 6 10; Proliferative breast disease without atypia 11 14; proliferative breast disease with atypia 15 18,; cancer 19 24 ( Masood et al. Diagn Cytopathol 7:581,1991) Table 4. Concordance between cytologic evaluation versus hisotlogic diangosis in 100 mammographically guided fine needle aspirates Diangosis No. of cases Concordance % 95% CI Nonproliferatve 29/34 85 0.69 0.95 Proliferative breast disease without atypia 15/17 88 0.64 0.99 Proliferative breast disease with atypia 21/23 91 0.72 0.99 Cancer 17/20 85 0.62 0.97 (Masood et al. Cancer 66:1480,1990) Table 5. Relative risk of breast cancer in subjects diagnosed with proliferative breast disease with atypia Cytopathology 4.9 fold Wrensch et al., Am J Epidemiology; > 2,300 women with 12.5 years follow up: fine needle aspiration biopsy. 5.1 fold Masood et al., Acta Cytol 1999; 869 women with 5.5 years follow up: fine needle aspiration biopsy. 4.0 fold Fabian et al., J Natl Cancer Inst 2000; 580 women with 45 months, follow up: fine needle aspiration biopsy Table 6. Cytologic Criteria for Black s Nucelar Grading System (Fisher s Modification) Nuclear grade Nuclear size in relation to normal duct 3 (poor) Three fold variation in nuclear diameter 2 (moderate) Two fold variation; uniformity is the rule, with only silight variation 1 (well) Similar, minimal enlargement Nuclear membrane Irregular Round, Smooth Chromatin Nucleoli Mitotic figures Hyperchromatic, Macro +/ Frequent coarse Uniform, fine Macro +/ Moderate Table 7. Guidlford Grading System; Criteria for Cytologic Grading of Fine Needle Aspirates of Breast Carcinomas Based on Wet Fixed Papanicolaou Stained Smears, Criteria Score 1 Score 2 Score 3 Dissociation Cells mostly in clusters Mixture of single cells and cell clusters Cells mostly single Cell size 1 2 RBC size 3 4 RBC size > 5 RBC size Cell uniformity Monomorphic Mildly pleomorphic Pleomorphic Nucleoli Indistinct Noticeable Prominent or pleomorphic Nuclear margin Smooth Folds Buds or clefts chromatin Vesicular Granular Clumped and clear (Robinson et al., Diagn Cytopathol 16:295:1997) -16-
1. Microscopy guidelines 유방병변중양성인경우세포학적특징을요약하면 normochromatic, round to oval cell 이 acinar like group, mono/bilayered sheets 형태로관찰되며 naked, oval monomorphic nuclei 가배경에보이고 fat, phagocyte 등이보인다. 폐경이후여성은세포밀도가현저히떨어진다. 악성인경우는세포밀도가높고혈성배경을동반할때가많고 hyperchromatic/ pleomorphic nuclei 가특징이다. 주형태는 tubular, solid, cluster 등이다. 세포밀도가높은병변중주의해야할것은 fibrodenoma 와 papillary neoplasm 인데 fibroadenoma 는 branching mono/bilayered sheets, free cells mainly naked, fragments of loose, poorly cellular stroma 가특징적으로관찰된다. Papillary neoplasm 의특징은 cylindrical cells with nuclear enlargement/ hyperchromasia, clusters with smooth(papillary borders), debris/cystic proteinous precipitate, apocrine cells/ macrophage 등의존재로요약할수있다. 특히 papillary neoplasm 인경우는양성악성의분류를삼가하고조직검사를통한확진을유도하는것이바람직하다. 또한임신과관련된세포학적변화가흔히악성과의감별을요하는데 N/C ratio가낮고핵막이균일하며 chromatin pattern이얌전한데비해 nucleoli만이너무뚜렸하다고생각될때, 세포질을보면대개 bubbly 한양상이관찰된다. 아래의 comment 는지금은고인이되셨지만, FNA의세계적인보급에혁혁한공로를한 Loewhagen 이강의한내용인데위음성과위양성의오류를피하기위한안전장치와같은것이므로되새길필요가있다고생각되어정리하였다. Comments to FNA guidelines of breast lesions by Torsten Loewhagen - Benign features showed in general overrule occasional abnormal findings and should restrain one from conclusive diagnosis of cancer - Papillary features from small tumors should be signed out as papillary neoplasm and further classification should depend on histopathology. - Occasional free cells with well preserved cytoplasm may be seen in an breast aspirate and often numerous in aspirates from fibroadenoma - In pregnancy and lactation an aspirate often yields highly cellular smears with non cohesive enlarged acinar cells with prominent nucleoli and finely vacuolated cytoplasm. - Inflammatory aspirated including those from fat necrosis and post operative cases may contain a mixture of neutrophils, necrosis and histiocytes. Histiocytes may appear in clusters, closely simulating cancer cells. one should use extreme caution in evaluating cells from inflammatory smear. - Never diagnose breast cancer on a single feature. There must be a combination of incredients in favor of the diagnosis. -17-
III. How can we start FNA in our department? 실제 FNA를시행해보고자하는병리의사를위해어떤시설, 장비및재료들이필요한지, 어떻게시행하는지검체들을어떻게처리하는지에대해간략하게요약하였다. 1. 시설, 장비및기구 1) 침대및조명 : 환자를눕히거나앉게할수있는정도의침대면충분하고, 침대의폭은넓지않은것이좋다. 의사가환자주위를 360도돌면서관찰하고검사를할수있게침대를설치하는것이이상적이지만, 대개공간이여의치않을경우가많으므로한쪽벽면에침대를붙이고병변의위치에따라환자의위치를바꾸면된다. 조명은밝은형광등으로도충분하다. 2) 주사바늘 : 통상적으로쓰는피하주사바늘이면충분하고굵기는 22 27gauge ( 외경 0.65 0.5mm) 가좋다. 3) 주사기및주사기고정기구 (Syringes and Syringe Holders) : 바늘을끼웠다뺐다할수있는주사기가사용되어진다. 한손은병변을고정하는데사용되므로한손으로행위를할수있게끔고안된 syringe holder 가있다. 일단구입하면주사기를끼웠다뺐다하며계속사용할수있으므로영구사용이가능하다. syringe holder 는 10ml 용이취급이쉽고흡인하기도용이하다. 세침흡인시걸어주는음압은 1 2ml 이면충분하므로주사기가크다고좋을것은없다. 4) Slide : 양질의 slide를쓰는것이좋으며, frosted end slide가환자의 ID를기록하기좋고앞뒤의구분을쉽게할수있어서좋다. 면역세포화학염색은대개 frosted end slide로가능하며, ER및 PR같은고가의시약을사용할때에는 coating slide를쓰면된다. 5) 고정액 : 통상사용하는 95% ethanol 이면충분하다. 6) Fast stain set 및현미경 : 환자의검체물의적절성을확인할수있는 fast stain 시설이필요한데, diff quik 이나 HE 염색을간단하게할수있을정도면충분하다. 7) Sterile containers : 세침흡인검사가많이행해지면이를이용한여러가지검사를할수있는데, flow cytometry 나 cell culture 등을위한 RPMI 용액같은 sterile solution 이준비되어있으면된다. 8) 기타 : 피부소독제, 마취제, 장갑, 반창고 2. 환자에대한준비 흡인검사준비에서가장중요한것은, 환자에게검사에대한자세한설명및가능한부작용에대한이해를시키고, 환자의동의및협조를구하는것이순서이다. 때에따라서는환자의승낙서를받을필요가있다. 스웨덴에서는승낙서없이검사를하고변호사가많은미국에서는모든환자로부터승낙서를받는다. 모든환자로부터승낙서를받는것이원칙이긴하지만실제해본바위험성이높지않은검사임에도불구하고환자에게너무심한공포감을주게되고많은시간이소요되므로, 감염의우려가있는병변이나기흉의위험성이높은쇄골상부림프절검사정도로제한해도좋으리라생각한다. 또한시행횟수가많을수록진단율이높아지므로많이할수록좋지만실제환자를상대로무한정하는것은불가능하므로 2회정도하는것이좋고이를사전에환자에게잘설명 -18-
해주는것이좋다. 국소마취는대부분필요없다. 병변이작을경우국소마취를하게되면, 주입된마취액때문에촉진이더욱어렵다. 표층부를검사할때는알코올에적신탈지면으로피부를닦아내면이것으로충분한소독이된다. 3. 기본적수기 기본수기는어떤장기의검사에라도적용될수있는공통적인사항이고, 세침을이용한흡인검사법은경사진바늘끝이칼과같은역할로찌를때조직을잘라서바늘을전후좌우로움직여작은파편을만들어이를흡인해내는것이다. 액체인경우를제외하고는대부분의흡인물은주사기로나올정도의양은아니다. 적절한검체물을얻기위해서는병소의고정이정확해야하며바늘끝의위치및움직임이정확해야한다. 다음의순서대로하면된다. 1) 병소의촉진및고정 : 병소를조심스럽게만져서크기와피부에서부터의깊이를측정한다. 이런과정을통해서바늘의위치를결정한다. 1cm 이하크기인경우에는병변의중심을찌르는것이좋다. 큰병변 ( 5cm 이상인경우 ), 대개중심부에는괴사및낭성변화가있게마련이므로병변의변연부를하는것이더진단율이높다. 이사이의크기 (2 4cm) 인경우는두곳, 즉중심부를기준으로한쪽을하고거울을비춰보듯이그반대편을하는것이좋다. 충분한검체물을얻기위해서는, 병변이바늘을따라서안움직여야한다. 병변내로바늘을제대로넣기위해서는병소를잘고정시켜야한다. 3cm이상의크기인경우엄지와검지로병소를잡아서고정하면된다. 1 2.5cm크기정도의작은병변일경우검지와중지사이에병소를놓으면좀더효율적으로병소를고정시킬수있다. 손가락을병소에가깝게두어야한다. 병소위의피부를약간잡아당겨팽팽하게하면고정하기가더쉽다. 1cm이하의작은병변인경우는고정시키기가어려운데이를고정하기위해서는검지와중지끝으로병소를잘만져서한방향으로병소를민다. 그리고난뒤, 손가락끝을들어올리지말고, 병소위의피부를잡아당긴다. 이압력으로병소가피부위쪽으로튀어나오게된다. 손가락을움직이지말고소독한후흡인검사를시행하면된다. 2) 바늘찌르기, 흡인및바늘빼기 : 일단병소가확인되면, 주사기가끼워져있는 syringe holder 를들어서주사바늘을병소내로찌른다. syringe plunger 를뒤로잡아당기는데 1 2ml 정도면충분하다. 10ml정도의음압을걸어도되긴하지만결과는거의마찬가지이다. 제일바람직한것은음압을건상태에서 plunger 의위치를변화시키지않고검사하는동안흡인을하는것이며, 검사하는동안 plunger 를움직이는것은피해야한다. 일단흡인을하면병소내에서바늘끝을전후로움직인다. 충분한검체물을모으기위해서는바늘을빠르게 15 20회정도까지움직인다. 이렇게하면단시간내에충분한흡인물을얻을수있다. 충분한검체물이모여졌다고생각되면바늘을뽑기전에음압을천천히푼다. 이런과정은검체물을주사바늘과주사기끝에있게하기위함이다. 만약음압을건상태로바늘을뽑으면, 모여졌던흡인물이주사기의관내로빨려들어와버려, 다시슬라이드위에떨어뜨리기가불가능하다. 주사바늘을병변에서빼고난후, 주사바늘을주사기에서떼어낸다. 그리고나서 plunger 를뒤로당겨주사기내로공기를넣은후다시주사바늘을끼워 plunger 를밀어서유리슬라이드위에검체물을분출시킨다. 검체물이튀는것을피하기위해, 바늘끝의경사진면을아래로오게해서슬라이드위에 -19-
대고한다. 때로검사를하는도중에바늘의방향을바꿔야할경우가생긴다. 이때는바늘을다빼지말고피부아래에어느정도는바늘을꼽아둔채바늘의각도를바꾸어서병변내로다시찌르면된다. 이런과정중에음압을풀필요는없다. 방향을바꾸기전에주사바늘을반쯤빼야주사바늘의방향전환이가능하다. 환자쪽에서보면역시고통을더느끼게되고출혈도더많다. 또한주사바늘의방향전환은시간도더걸리고기술도필요하며, 대부분의경우검체물도만족스럽지못하다. 따라서통상의방법으로쓰기에는부적절하며, 폐경이후여성의유방검사때병변이잘안만져질경우에는시도해볼만한방법이다. 4. 부작용 만져지는표재성병변인경우정맥주사를하는정도의통증이고 5 10초면충분하다. 이검사는대부분의경우특이할만한부작용은없으므로환자들이기꺼이동의를한다. 가장흔한부작용은병소내또는주변의출혈이다. 멍드는것을방지하려면주사바늘을뽑고난직후잘눌러주는것이다. 환자에게누르라고하면엉뚱한곳을누를수도있고충분한압력을가하지않고누를수도있다. 일단출혈이되면병변이약간커지기도하고흡인후동통을호소하기도한다. 유방이작은사람의병변을검사할때기흉의위험성이있을수있다고되어있으나, 실제한예도없었고, 오히려쇄골상부림프절검사때 2예를경험하였는데대개소량이어서 2 3일정도후에저절로없어졌다. 5. 도말수기 도말과정의목적은잘보존된세포나작은조직파편들을슬라이드위에적절하게분배하는것이다. 몇가지방법의도말수기대하여설명하고자한다. 각각에는장단점이있으며각기다른 artifact 가있을수있다. 도말방법의결정은기호의문제이지만, 시술자들은여러방법을쓰는것보다한방법을쓰는것이보통이다. 검체물은대개 dry aspirate 또는 wet aspirate 두가지범주에든다. Dry aspirate 이나오면 one step method 로하고 wet aspirate 이나오면액체의양이나종류에따라 two step method 로하면된다. 1) 1단계법 (One step technique) : 기본적인 1단계법은반고형성고형물을 1 2방울얻었을때하는방법이다. 소량의혈액이포함될수도있다. 슬라이드를집어서 frosted end가왼손의엄지와검지사이에오도록놓고, 다른세손가락은슬라이드아래에놓고슬라이드를지지한다. 오른손에새슬라이드를한장쥐고흡인물에 45 90도각도로가까이세워서댄다. 세운슬라이드의위쪽끝을아래로내려서흡인물을덮게끔해서오른손에쥐고있는슬라이드를회전시키는기분으로아래로부드럽게민다. 움직임은부드럽고빨라야하나서두르지말아야한다. 두슬라이드의평행을유지하는것이중요하며아래슬라이드를긁는방식은피해야한다. 도말슬라이드가완성되면즉시고정해야한다. 고정을할때조금이라도지체가되면 airdrying artifact 가생긴다. 흡인물이많을때나특수염색이필요한경우여러장의슬라이드를만들수있도록검체물을나눌수있다. 2) 혈액이나액체에의해희석된검체물의도말방법 : 너무많은액체흔히혈액에의해흡인물이희석될수있는데, 이것이도말을어렵게하는가장흔한원인의하나이다. 이런경우, 도말방법이몇가지가있다. 도말전에조직파편과액체를분리하는것이중요한데, 두가지방법 -20-
이있다. 첫째방법은다음과같다. 여러슬라이드에흡인물을뿌려놓은뒤가장많이조직파편을포함하고있는슬라이드를선택한다. 그슬라이드를집어서액체가아래로흐르도록기울인다. 슬라이드중심부에남아있는조직파편을다른슬라이드의끝으로걷어내서또다른슬라이드위에놓고민다. 두번째방법은이단계 (two step) 법인데다음과같다. 앞에방법과마찬가지로, 가장좋은슬라이드를선택하여왼손으로 frosted end 를잡아서 frosted end 쪽으로기울인다. 액체만흘러내리고, 조직파편만남게되면새슬라이드를옆으로세워서 frosted end쪽으로검체물을밀었다가다시반대편으로와서슬라이드의중심부에서멈추고위쪽슬라이드를떼어낸후, 아래쪽슬라이드를 frosted end 쪽으로다시기울여서액체를흘려보낸다. 슬라이드중심부에모여있는조직파편들을새슬라이드를가지고일단계법으로도말하면된다. 액체가너무많을경우에는거즈로액체를흡수시킨후도말을하는것도한방법이다. 흡인물의고정및염색법 가장흔히사용되는염색법은 Papanicolaou, Hematoxylin Eosin 및 Romanowsky 형염색인데이중에는 May Gruenwald Giemsa, Wright Giemsa및 Diff Quik염색법등이있다. Pap염색을하기위해서는검체물을재빨리고정시켜야한다. 95% ethanol 을고정액으로가장흔히사용한다. Romanowsky 염색을위한도말은염색과정전에실온에서잘말려야한다. Romanowsky 염색중에는 MGG 및 Diff Quik염색이좋다. 환자를보내기전에검체물의질을평가할수있는빠른염색법이필요하다. Pap, H E, Diff Quik 및 MGG의통상방법을약간씩변형시키면모든것이가능하다. 기타흡인물처리법 Cell Blocks : 검체물을처리하는데있어서, 나온조직의큰파편이흡인물로부터제거될수도있고고정액에넣어서 cell block을만들수도있다. 파라핀또는플라스틱포매가이용될수있다. 이런처리법이때때로도말에서관찰되지않는구조들을잘관찰할수있다. 또한 cell block은다른특수염색이나면역세포화학검사에이용할수있는장점이있다. 충분한검체물을얻지못한경우 1. 피가많이나오는경우 : 많은양의혈액으로희석된검체물은진단에부적절할경우가많다. 혈액의양을줄일수있는여러가지방법이있다. 어떤부분을검사할때첫번째검체물이가장좋을경우가많으므로, 처음에검사를할때면밀하게계획되어야한다. 검사를여러번시행할수록혈액의양이많아지는것은당연하다. 만약종괴가 1.5cm 이상이라면, 다른부분에서검사를해보는것이좋다. 바늘의움직임을 4 5회정도로제한하는것이좋고, 피가보이기시작하면검사를중단하고바늘을뽑는것이좋다. 흡인하지않고바늘을찔러서하는검사법도이용될수있다. 그래도피가나올경우, 특별한도말방법이필요하다. 2. 불충분한검체물 : 여러가지원인때문에불충분한검체물이나올수있다. 예를들면바늘끝의위치가잘못되었을경우이다. 또, 바늘의깊이가너무깊이들어가있거나너무얕게들어갔을경우도마찬가지이다. 어떤때는종괴가실제크기보다훨씬크게만져질때가있는데, -21-
예를들면유방종괴의직경이 3cm 정도로만져지나실제종양은그반도안되는경우가그좋은예이다. 좋은검체물을얻기위해서는바늘끝이실제종양의중심부내에들어가야만한다. 저항이증가되어있는부분에바늘이들어가는것을느끼면, 그것은병소에제대로들어간경우가맞다. 병소를정확하게고정시키지않으면, 불충분한검체물을얻을수있다. 병변이고정되지않고움직이면제대로검체물을뽑아낼수있다. 이것을피하기위해서는손끝을병소가까이에두고압력을가하는것이필요하다. 섬유화가많이진행된병소도또한같은문제를야기시킬수있다. 이런경우, 바늘이병소내로들어가면, 병소의경도가마치고무처럼느껴진다. 22 23G needle 이그런병소를통해왔다갔다한다는것은어렵다. 이런병소는대개세포성분이적고흔히 dry tap 이나세포성분이거의없는검체물만이나올뿐이다. 위에서언급했듯이가는바늘 (25G) 이더쉽게조밀한섬유조직을뚫을수있다. 침윤성소엽성암종경우에종괴의중심부가때때로세포성분이더적을경우도있다. 그러나, 종괴의변연부는대개세포밀도가더높아서진단에이르기가더쉽다. 3. 잘처리된검체물을얻지못하는경우 : 공기건조인공부산물은알코올고정이수초만늦어져도생긴다. 세포성분없는검체물은특히건조에민감하다. 공기건조를피하기위해, 고정액이들어있는용기는가까운곳에두어야하며, 즉시사용이가능해야한다. 도말슬라이드를공기중에건조시킬것인가는도말하기전에결정을해야한다. 슬라이드에세포가있는지의관찰은알코올고정을할것이라면고정후에보는것이좋다. 만약스프레이고정액을사용한다면보조자가필요한데보조자가도말이완성되자마자바로고정액을뿌려주는것이좋다. 혈액응고또한흔한문제이다. 세포군집의구조를변경시킬수도있고, 현미경적구조가잘안보일수도있다. 응고를피하기위해, 흡인방법이재빨라야한다. 흡인하는기술및도말하는방법에있어서많은훈련이있어야실제수기상에주저함이없이빨리이루어질수있다. 응고가발생했을경우, 알코올고정이공기건조시키는것보다세포를더잘관찰할수있으므로좋다. 도말과정중에너무많은압력을가하게되면발생하는 crushing artifact 도주의해야한다. 개개의세포또는세포군집이해석하기어려울정도로겹쳐있을경우, 도말과정에가해지는압력이불충분할수있다. 압력이지나친것도문제이지만이또한문제가될수있다. -22-
참고문헌 Masood G: Expanding role of breast cytopathology as a risk predictor. Adv Ana Pathol 8; 255 263,2001 Fabian CJ, Kimler BF Zalles CM et al: Short term breast cancer prediction by random periareolar fine needle aspiration cytology and the gail risk model. J Natl Cancer Inst 92:1217 27, 2000 Masood S, Rasty G: Potential value of cytology in the detection of breast cancer precursors by fine needle aspiration cytology: the future pap smear for breast cancer:. Acta Cytol 43:890, 1999 Abati A, Mckee G: Grading of breast carcinoma in fine needle aspiration cytology. Diag Cytopathol 19:153 154, 1998 Sidawy MK, Stoler MH, Frable WJ, Frost AR, Masood S, Miller TR, Silverberg SG, Sneige N, Wang HH. Interobserver variability in the classification of proliferative breast lesions by fine needle aspiration: results of the Papanicolaou Society of Cytopathology Study. Diag Cytopathol 18:150 165,1998 Page D, Johnson J, Dupont W: Probabilistic approach to the reporting of fine needle aspiration cytology of the breast. Cancer Cytopathol 81: 6 9, 1997 Layfield L, Mooney E, Glasgoe B, Hirchowitz S, Coogan A: What constitutes an adequate smear in fine needle aspiration of cytology of the breast? Cytopathol 81:16 21, 1997 The uniform approach to breast fine needle aspiration biopsy. Diag Cytopathol 16:295 311, 1997 Sneige N, Staerkel G, Caraway N, Fanning T, Katz R: A plea for uniform terminology and reporting of breast fine needle aspirates The M.D. Anderson Cancer Center proposal Acta cytol 12 :971 972, 1994 Wrench M, Petrakis NL, King EB et al. Breast cancer risk associated with abnormal cytology in nipple aspirates of breast fluids and prior history of breast biopsy. Am J Epidemiol 137: 829 833, 1993 Masood S, Fryberg E, Mclellan G et al: Cytologic differentiation between proliferative and nonproliferative breast disease in mammographically guided fine needle aspirates.diag Cytopathol 7:581 590, 1991 Masood S, Fryberg E, Mclellan G et al: Prospective evaluation of radiollogically directed fine needle aspiration biopsy of nonpalpable breast lesions. Cancer 66:1480 1487, 1990 Abele JS, Miller TR, King EB and Lohagen T: Smearing techniques for the concentration of particles from fine needle aspiration biopsy. Diagn Cytopathol 1:59 65, 1985 Bobbit D, Lief RC, Silverman M, Temple W, Thomson RV and Ng ABP: Centrifugal cytology of fine needle aspiration cells. Acta Cytol 25:443, 1981 Coley BL, Sharp GS, and Ellis EB: Diagnosis of bone tumors by aspiration. Am J Surg 13:215 224, 1931 Frable WJ: Fine needle aspiration biopsy. A review. Hum Pathol 14:9 28, 1983 Karnaauchow PN and Bonin RE: Cell Block" technique for fine needle aspiration biopsy. J Clin Pathol 35:688, 1982-23-
Layfield LJ, Glasgow BJ and Cramer H: Fine needle aspiration in the management of breast masses. Pathol Ann Part II 24:23 62, 1989 Lee KR, Foster RS and Papillo JL: Fine needle aspiration of the breast. Importance of the aspirator. Acta Cytol 31:281 284, 1987 Pak HY, Yokota S, Teplitz RL, Shaw SSL and Werner JL: Rapid staining techniques employed in fine needle aspirations of the lung. Acta Cytol 25:178 184, 1981 Zajdela A, Zillhardt P and Voillemot N: Cytological diagnosis by fine needle sampling without aspiration. Cancer 59;1201 1205, 1987 Frable WJ: Needle aspiration biopsy. Past, present and future. Human Pathol 20:504 517, 1989 Johansson B and Zajicek J: Sampling of cell material from human tumors by aspiration biopsy. Nature 200:1333 1334, 1963 Koss LG: Aspiration Biopsy. Cytologic interpretation and histologic bases. 2nd ed. Igaku Shoin, New York, 1992 Orell SR: Manual and Atlas of Fine Needle Aspiration Cytology, Churchil Livingstone, 1992-24-