대한방사선의학회지 1992; 28(5) : 739~743 Journal of Korean Radiological Society. September. 1992 간암침습의담도내 CT 소견 울산대학교의과대학진단방사선과학교실 - Abstract- 김미영 이문규 오용호 임재훈 * 김기황 ** CT Feature of Bile Duct Invasion in Hepatocellular Carcinoma Mi Young Kim, M.D., Moon-Gyu Lee, M.D., Yong Ho Auh, M.D., Jae Hoon Lim, M.D*. Ki Whang Kim, M.D. ** Department 01 Diagnostic Radiology, A saη Medical Center. College 01 Mediciη e, Uni versiη 01 Ulsaη Intra- and extrahepatic bile duct can be invaded by hepatocellular carcinoma (HCC). This is infrequent in HCC, but it can directly affect the clinical m anifestation and prognosis. W e present eight cases of HCCs with emphasis on the incidence and features of bile duct invassion on computed tomography (CT). Over a period of 22 months, abdominal CT was performed in 186 with HCC patients. Out of these, fì ve cases of bile duct invasion by HCC were confìrmed in our hospital and three in other hospitals. The eight cases were evaluated for the type, size and location. CT features of intraductal m ass and ductal dilatation were evaluated. The incidence of bile duct invasion in HCC was 2.6%. Infìltrative type of HCC was seen in seven cases and six of these had mass 5-11 cm in size. The characteristic CT fìndings of bile duct invasion in HCC are mass in common hepatic duct with bulging contour (8/8), multiple intraductal masses in the intrahepatic ducts (5/8), and diffuse dilatation of intrahepatic ducts (7/8) Index Words: Hepatocellular carcinoma, CT Neoplasm, Bile duct 관내결석증등도유사한소견을보일수있으며그감별 서 론 이용이하지않다. 간암과동반된폐쇄성황달은 1-10% 미만의다양한 빈도로서보고된바있으나, 직접적인담관침습이외에도 간암의담관침습은임상적으로황달과, 증가된빌리루간실질병변, 임파선비대, 간경화등에의한영향을포 빈, 알칼라인포스포타제등의혈액검사소견을동반하함한경우였다 ( 1, 2 ). 부검으로확인된간암의담관침습 고, 복부전산화단충촬영 ( 이하 CT 로함 ) 또는초음파상빈도는 L 4-2.1% 또는 1. 9% 내외로보고되었다 ( 3, 4). 간암주변에동반된간내담관확장이종괴의담관침습을 저자들은본원에서수술로확인된간암의담관침습빈 시사하는것으로알려져있다. 그러나수술로확인된예도를알아보고, 복부 CT 상당관침습을호발하는간암의 가적고주변조직에의한압박, 담관종양, 전이암, 담형태, 침습된담관의 CT 소견및빈발하는담관의위치와 * 경희대학교의과대학방사선과학교실 * Depa rtm eη t 01 Radiology, Kyung Hee University College 01 Me diciη e ** 연세대학교의과대학방사선과학교실 ** Depa1τm eη t 01 Radiology. Yoη sei University College 01 Medicine 이논문은 1992 년 4 월 22 일접수하여 199 2 년 7 월 22 일에채택되었음. - 739 -
gν대한방사선의학회지 1992; 28 (5) : 739~743 간내담관의확장소견을분석하고자한다. 대상및방법 1989년 8월부터 22개월간본원에서임상소견또는세침홉인생검사상간암으로진단된환자가운데복부 CT 를시행한 186명을대상으로하였고, 그중 5예가수술로써담관침습이확인되었다. 외부병원에서병리조직이확인된 3예를포함하여전체 8예의복부 CT를분석하였다. 간암종괴는형 ( type ) 을결절형 ( nodu l ar) 과침습형 ( infi ltrative) 으로대별하고크기를측정하였으며, 종괴 의위치를중심부 ( 간문맥에서간표면까지직경의반이내 거리를임으로정함 ) 와주변부로구분하였다. 간암침습 담관의호발부위와간내담관확장의 CT 소견을알아보 a 았다. 결 과 본원에서확인된간암의담관침습빈도는 2. 6% 였다. 간암종괴의형분류상침습형이 7예였고종괴형이 1 예였다. 크기는 6예가 5 - llcm 의범주에속하였고 2예는 5 cm이하의소종괴였으며, 전예에서간실질중심부를침범한종괴가있었고그중 5예는주변부에도병변의파급이있었다. C 1' 상 8예모두에서공히총간담관을막는종괴가있었고, 간실질과동등하거나약간의저밀도를지니는병변에의해총간담관직경은폐쇄위치에서팽창되어있었다 (Fig. 1). 5 예에서간내담관안으로침습된종괴를인지할수있었다 ( Fig. 2) 간내담관은간암종괴의위치, 크기와일치하지않는전반적인확장이있었다 ( Fig. 3), (Table 1). 동반소견으로서임파절비대가 4예, 간문맥혈전이 2 Table 1. C hatracteristic CT Findings of the HCC with Bile Duct Invasion C T findings Iso-or low-attenuation mass in CHD Bulging CHD w ith intraductal mass Multiple in traductal m asses in the IHDs DifTu se dilatation of IHDs C HD: common hepatic duct IHDs: intrahepati c ducts N no RJ -/ b Fig. 1. A 44-year old man with HCC and progressive jaundice a. C T scan of the upper abdomen shows a n eccentricall y located intraductal mass in common hepati c duct (arrows) with bulging contour b. C holangiogram shows fillin g defects in common he patic duct (arrows) and movable m ass in distal common bi le duct (asterisk) - 740-
김미영외. 간암침습의담도내 CT a Fig 3. A 55-year old m a n with HCC and obstructive jaundice. A percutaneous transhepatic bile drainage tube was inserted in common hepa tic duct CT scan shows an irregula r low attenuation masses in right hepatic lobe, multiple nodular masses in right intra hepati c ducts (arrowheads), and diffuse dilatation of intrahepatic ducts 예, 부신전이가 l 예, 복수가 2 예있었다. 고 :>:J E 므 간암의담관침습은빈도나 C1' 소견에대해알려진바가적교임상적으로황달, 발열, 상복부통증등을주소로내원하게된다는점이일반간암증상과차이가있으며혈액검사소견상증가된빌리루빈, 알칼라인포스포타제, SGOT, SGPT 등의이상을통반한다 ( 3, 5-7 ). 환자의예후는일반적으로간암의크기, 형태, 위치가관련되며동반된간문맥혈전, 임파선전이, 간경화퉁이영향을줄수있다. 그러나담관을침범하는간암자체가임상적예후에직접, 간접으로이떤영향을미치는가에대해서 b Fig 2. A 61-year old woman with HCC and recently developing jaundice. She had a previous history of common bile duct exploration due to HCC with bi le duct invasion. a. CT scan shows ill -defìn ed low attenuation m asses in caudate and ri ght hepati c lobe Multiple intraductal masses are noted in dilated ri ght and left intrahepatic ducts (arrowheads) a nd common hepatic d uct (arrows). b. C holangiogram shows multiple fil ling defects in the common hepatic a nd in trahepati c ducts with bulgin g co ntour 는아직논란의여지가많다. 이러한간암은침습성이강 한병리적특성이있거나자체내다수의담관침습으로 인해진행되는황달로써증상을악화시키는경향이있으 나 간암을절제하고담관내종괴를제거한뒤지속적인 담즙배액이가능할때좋은경과를보였다 ( 5, 6, 8-10). 섬 유층판형 (fibrolamellar type ) 간암은담관내동반된종 괴가있는경우에서도다른간암보다좋은예후가보고되 었다 (4, 11 ). 간암으로인한황달은일반적으로동반된간경화, 간실 질내파급된종양, 종괴나임파선에의한외적압박, 담 741 -
대한방사선의학회지 1992; 28(5) : 739~743 관내들어있는작은종양부스러기나혈전등으로설명하 고있다 (1, 2, 3, 9, 12, 13). 본원에서수술한총간담관안의 종괴들은병리조직소견상부서지기쉬운회색빛섞인갈 색의괴사찌꺼기로서간암세포가있었고, 담관조영시 조영제가차지않고떠다니던병변에서도간암세포가확 인되어부서진간암조각의이동가능성을시사하였다 (Fig. 1). 이와같이주병변에서떨어진위치의총간담관 이종괴로인해폐쇄를일으킨것은간암이담관내로침 습성이강히고, 조각으로잘부수어지며, 비중을지녀이동이가능하고, 담즙과유사한 다른담관내로의착상능 력이있음을전제로하게된다. 총간담관의폐쇄는 간내담관의전반적인확장을초래하게되며, 역으로간 암종괴와인접하지않는전반적인담관확장시총간담관 을막는종괴의유무를확인하여간암의담관침습을감 별해야할것이다. 그러나이러한 CT 소견은간암의담관침습에국한된 것은아니다. 좌우간내담관이만나는위치에서의담관 암은대부분담관이좁아지거나갑자기단절되는형태로 나타나며 (1 4, 15) 주병변에서멀리떨어진여러개의담관 을침습하는경우는드물지만, 밖으로자라나는종괴를 형성하거나담관내종괴를동반할때간암의담관침습과 감별이어렵고, 확진을위하여동반된간경화유무, AFP(a - fetoprotein), 세침홉인생검술이필요하다. 또 한간암과동반된간문맥혈전이문맥중심에서떨어진주 변부작은저음영들로보일때늘어난담관과구별이용이 하지않다 ( 16 ). 그밖에도통등혹은저밀도의담관결석 이불분명한저음영의주위염증을동반하여간암의담관 침습과유사하게보일수있고, 간문맥임파절비대또한 늘어난담관내종괴가찬소견으로오인될수있다. 담도 내전이암, 간홉충증도드물게감별을요한다 (13, 17, 18). 결론적으로담관을침벙한간암의대부분은침습형이었 고크기가 5cm 이상의큰종괴로서그빈도는 2. 6% 였다. 총간담관내공히폐쇄위치의담관을팽창시키는종괴가 있었고, 동반하였다. 간내담관내종괴와전반적인간내담관확장을 참고문헌 1. Kiev J, Dyslin DC, Vitenas P, Kerstein MD Obstructive jandice cau sed by hepatoma fragments in the common hepatic duct. J clinical gastroenterology 1990; 12: 207-21 3 2. Araki T, Itai Y, Tasaka A. Compu ted tomography of localized dilatation of intrahepatic bile ducts. R adiology 198 1;141 773.776 3. Nonomura A, Ohta G, K anai M, Kobayahi K. H epatocellula r carcinoma presenting extrahepatic biliary obstruction. Acta pathology J apanese 1983 ;33: 789-806 4. Eckstein RP, Bambach C P, Stiel D, R oche J, Goodman BN. Fibrolamell ar carcinoma as a cause of bile duct obstruction. Pathology 1983;20:326-33 1 5. Tsuzuki T, Ogata Y, Iida S, K asajima M, Takahashi S. H epatoma with obstructive jaundice due to the migration of a tumor mass in bili ary tract: R eport of a successful resection Surgery 1979;85 :593-598 6. Joehl RJ, Abt AB. Obstructive ja undice caused by hepatocellular carcinoma. J orunal ofsurgical Oncology 1984;27 80-84 7. VanSonnenberg E, Ferrucci J T. Bile duct obstruction in h e patocellula r carcinoma ( H epa toma)-c linical and cholangiographic characteri stics. R adiology 1979; 130 :7-1 3 8. G illen P, Peel ALG. Failure to improve survival by improved diagnostic techniques in patients w ith malignant j a undice. B r. J. Surg 1986; 73 :63 1-633 9. Lee NW, Wong KP, Siu KF, W ong J. C holangiography in hepatocellular carcinoma with obstructi ve jaundice. C linical R adiology 1984;35: 11 9-1 23 10. Lau WY, Leung JWC, Li AKC. M anagement of hepatocellular carcin oma presenting as obstructi ve jaundice. The American J ournal of Surgery 1990; 160 :280-282 11. Albaugh J S, K effe EM, Krippaehne WW R ecurrent obstructi ve j aundice caused by fibro lamellar hepa tocellula r carclnoma Digestive diseases and sciences 1984;29: 762-767 12. Lau WY, Mok SD, Leung JWC, Li AK C Migrated tumour fragments in common bile ducts from hepatocellular carcinoma. Au st. N.Z.J. Surg. 1990;60 :995-997 13. Sarma DP, W eilbaecher TG, Deipairine EM H epatocellular carcinoma causing obstructi ve jaundice. J ournal of Surgical Oncology 1987;34: 192-1 93 14. Takayasu K, Ikeya S, Mukal K, Muramatsu Y, Makuuchi M, H asegawa H. CT of hilar cholangiocarcinoma: Late contrast enhancement in six patients. AJR 1990;154:1203-1206 - 742-
김미영외 간암침습의담도내 CT 15. C hoi BI, Lee JH, H an M C, Kim SH, Yi JG, Kim CW. Hila r cholangiocarcinoma :Com pa rative study with sonography and CT R adiology 1989; 1 72: 689-692 16. lmaeda T, Yam awaki Y, Hirota K, Suzuki M, Seki M, D oi H. Tumor thrombus in the branches of the di stal portal ve in :C T demonstra ti on J CAT 1989; 13:262-268 17. Rhoe BS, Kim H,Jin SY, J ang W I. H epatoma presenting as extrahepati c biliary obstruction due to hemobilia. Yonse i M edical J ournal 1989;30 (4) 383-386 18. \ 시 e in b re n K, Adam A, Bilumgart H, Banks LM. Appa ren t ex trahepatic in vaslon by metastatlc tumors in the li ver. C linical radiology 1987;38:357-362 -743 -