부산대학교병원 CASE PRESENTATION 전임의이현정 2013.10.02
CASE PRESENTATION F/79 C.C) Epigastric soreness P.I) 2011년 4월외부병원시행한 EGD 상병변보여본원의뢰됨 P.Hx) HT / DM / Hepa / Tbc - / - / - / - S.Hx) smoking (-), alcohol (-) F.Hx) N-S
ROS) N-S P/Ex) N-S Lab) CASE PRESENTATION WBC 4.57 * 10 3 E/ul (seg 41.2%) Hb 12.2 g/dl PLT 228K/ul AST/ALT 24/12 IU/L BUN/Cr 24.5/0.73 mg/dl ALP/LDH 235/395 IU/L TC/UA 229/2.6 mg/dl TB/DB 0.38/0.10 mg/dl Ca/P 9.2/3.6 mg/dl TP/Alb 7.6/4.8 mg/dl Na/K/Cl 144.6/4.08/109.6 mmol/l PT(INR)/aPTT 10.6 (0.94)/29.4 CEA 1.05 ng/ml CA19-9 33.17 U/mL CA-125 8.33 U/mL CRP 0.06 mg/dl
외부병원 EGD (2011.04.07)
본원 EGD (2011.04.13)
진단은?
본원 EGD (2011.04.13)
ESD (2011.04.21)
Post-ESD CT
Poorly differentiated area
PATHOLOGIC FINDING Stomach, antrum, anterior wall, endoscopic submucosal dissection : Early gastric carcinoma 1. Location : antrum, anterior 2. Gross type : EGC type 0-IIa+IIc 3. Histologic type : tubular adenocarcinoma, moderately to poorly differentiated 4. Histologic type by Lauren : intestinal 5. Size : 1.6x0.8 cm 6. Depth of invasion : invades submucosa (pt1b) depth of sm invasion : 2050um/dissected sm depth: 2750um 7. Growth pattern : mixed expanding and infiltrative growth patern 8. Resection margin : free from carcinoma (LM(-)/VM(-)) -safety margin to the closest LM: 3mm 9. Lymphatic invasion : present, mild 10. Venous invasion : not identified 11. Perineural invasion : not identified 12. Associated findings 1) peritumoral lymphocytic infiltration, moderate
FOLLOW-UP_EGD 6 MONTHS LATER (2011.10.05) vs 14 MONTHS LATER (2012.06.21) 6 MONTHS LATER 14 MONTHS LATER Bx ; Chronic gastritis
FOLLOW-UP_CT 6 MONTHS LATER (2011.10.05) vs 14 MONTHS LATER (2012.06.21) 6 MONTHS LATER 14 MONTHS LATER
FOLLOW-UP 28 MONTHS LATER (2013.08.05)
진단은?
FOLLOW-UP 28 MONTHS LATER (2013.08.05)
submucosa mucosa Muscularis propria subserosa
Mesothelial lining
PATHOLOGIC FINDING Stomach, subtotal gastrectomy : Advanced gastric carcinoma (recurred after ESD) 1. Location : lower third, center at pylorus 2. Gross type : Borrmann type 4 (localized) 3. Histologic type : adenocarcinoma, tubular well differentiated (tub1) 4. Histologic type by Lauren : intestinal 5. Growth pattern: diffusely infiltrative growth pattern 6. Size : 2.6x2.0cm 7. Depth of invasion : Tumor invades serosa (pt4a) 8. Resection margin: free from carcinoma safety margin: distal 0.8cm, proximal 16.2cm 9. Lymph node metastasis : metastasis to 9 out of 52 regional lymph nodes (pn3a) (9/52) (lesser curvature 7/34, greater curvature 2/17, "LN" 0/0, "12P" 0/1 ) 10. Lymphatic invasion : present, mild 11. Venous invasion : not identified 12. Perineural invasion : present, moderate. (Muc2(-)/Muc5AC(+/-)/Muc6(-)/CD10(+)/cERB2(++),GI(I) type)
FINAL DIAGNOSIS Advanced gastric cancer, recurred after ESD
REVIEW Local recurrence of EGC after ESD
빈도 Local recurrence of EGC after ESD 0-0.2%(curative resection) 10-15%(noncurative resection) 위험인자 involved or uncheckable lateral/vertical resection margin, piecemeal resection, lymphovascular invasion tumor size, tumor location
Macroscopic pattern of local recurrence Several reports Just ulcer scars, healing stage ulcers, subtle erythematous changes > ulcerofungating mass ulcer scar(47%) Possibility of overlooking significant portion of local recurrence ER scar 에 abnormal feature 가없더라도 routine biopsy 시행 주변점막변화관찰
Routine follow-up biopsy after endoscopic resection 과거 curability 여부와무관 첫 1년동안 2-4회 매년 1회내시경및 Post-ER scar에서조직검사최근 Complete resection은국소재발가능성이낮음 - Metachronous cancer를배제하기위해매년시행 Incomplete resection, Noncurative resection - Few reports - 국소재발의위험인자에따라개별화하여내시경간격을결정
수술 Management of Noncurative resection 궤양이있는 3cm 이상의점막암, deep submucosal invasion, LVI 수술이가능한 clinical submucosal invasive EGC 의경우 ESD 후추적관찰하는것이수술보다 ineffective 하다는보고가있음 Classic vs Extended indication in Japan 1526 patients, F/U (> 36 mo) Stom Intest 2008;43:73 ESD in elderly patients ( 80 years old) 440 patients, Median F/U (41 mo) overall 5YSR; curative resection vs noncurative resection with op.vs without op. (80.3% vs 100% vs 66.7%) Gastric Cancer 2011
Management of Noncurative resection 추가적내시경적절제, APC Observation No report
1. Endoscopy 2013;45:93-97 2. J Gastric Cancer 2012;12(2):88-98 3. Korean J Med 2013;85:285-293 4. Gastrointest Endosc 2008;68:887-94 5. Clin Endosc 2013;46:235-238 6. J Gastric Cancer 2011;11(3):162-166 REFERENCES