On Gastric Cancer. Jun Haeng Lee, M.D. Department of Medicine,Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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1 On Gastric Cancer Jun Haeng Lee, M.D. Department of Medicine,Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
2 AGC Borrmann IV - initial endoscopic examination
3 Fold thickening - 5 개월 전 내시경 함
4 Hg 7.5로 오신 Borrmann type IV
5 Fold thickening - Epigastric soreness (F/29) AGC, signet ring cell carcinoma, 17 x 12 cm, subserosa, 2/42, perineural invasion
6 Borrmann type IV gastric cancer is the most important disease in EGD
7 Borrmann type IV 1 st endoscopy 2 nd endoscopy
8 Borrmann type III-like Borrmann type IV - signet ring cell carcinoma, peritoneal seeding
9 Borrmann type IV, antral type
10 Borrmann type IV, antral type (M/46)
11 EGC Jun Haeng Lee, M.D. Department of Medicine,Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
12 조기위암의 내시경 소견 조기 위암 초기 위암 조기 위암 작은 위암 조기위암 = superficial lesion 내시경 소견에 따라 치료방침이 달라진다. 조기위암의 내시경 분류는 40여년 전에 만들어진 것이다. (in vivo, real-time, 내시경적 분류) 가능하면 단순한 형태로 분류한다. 자세한 글보다 좋은 사진이 정보가치가 높다. 크기에 대한 정확한 평가가 필수적이다.
13 Cancer diameter (mm) Clinical symptoms related to cancer size Death (10 12 cells) Palpable (10 9 cells = 1 cm) Visible with X-ray (10 8 cells) Cancer cell doublings Tumors will grow to about 1 mm diameter in the absence of new capillaries (angiogenesis) but further expansion requires the production of angiogenic growth factors by the cancer cells.
14 Classification of EGC Type 0 I Protruded type Type 0 IIa Superficial elevated type Type 0 IIb Flat type Type 0 IIc Superficial depressed type Type 0 III Excavated type
15 Gross type에 따라 위암의 위벽내 분포를 어느 정도 알 수 있을까? 김영채. 대한소화기내시경학회세미나 1995
16 김영채. 대한소화기내시경학회세미나 1995
17 Paris classification for EGC Type O Polypoid Non-polypoid elevated flat depressed excavated 0-I (Ip, Is) 0-IIa 0-IIb 0-IIc 0-III
18 EGC type I 과 type IIa의 경계는? - Update on the Paris classification The cut-off limit is 2.5 mm in the columnar epithelium and 1.2 mm in the stratified epithelium of the esophagus. Endoscopy 2005;37:
19 어디까지가 flat인가? - Update on the Paris classification The cut-off limit is 1.2 mm in the columnar epithelium and 0.5 mm in the stratified epithelium of the esophagus. Endoscopy 2005;37:
20 Ulcer가 있으면 type III 그러나 여전히 애매함 - Update on the Paris classification Endoscopic appearance of a superficial neoplastic lesion on the surface of the digestive-tract mucosa: excavated type (0 - III). An ulcer is seen. Endoscopy 2005;37:
21 Depressed type에서는 fold 변화가 중요하다
22 김영채. 대한소화기내시경학회세미나 1995
23 악성궤양에서 관찰되는 비정상적 점막주름 집중
24 Depth of invasion 함 요 형 1) 점막주름의 중단 2) 계단모양의 함요 3) 변색 4) 불규칙한 가늘어짐 m 5) 펜끝모양 가늘어짐 6) 점막주름주행의 함요내에 흔적이 남음 7) 점막주름 끝의 곤봉상 융기 결절모양의 융기 8) 점막주름사이에의 연결형성 9) 결절모양끝이 융합 10) 제방모양의 융기, 주위제방형성 11) 함요내 요철이 불규칙한 것이 현저함 섬형성, 결절성 융기, 두터운 백태부착, 출혈성 미란백태 등의 다재성 pm~s m에서는 흔하다 sm III B-II 함요(Iic)내의 III의 축소소실을 보이는 것은 m이 많다. 불규칙한 깊은 분화구 형성, 주위제방의 경화, 결절형성 B-III 분화구 형성, 주변의 미란출혈, 요철부정
25 전형적인 BGU의 fold 변화
26 EGC IIc + BGU
27 급성기 BGU에는 fold가 없다
28 조기위암에서 보이는 fold abnormality 1. Interruption 2. Tapering 3. Clubbing 4. Fusion 5. Moth-eaten
29 전형적인 위암의 fold change (1) Signet ring cell carcinoma, diffuse type, 1.9x1.2cm, SM3, 0/23
30 전형적인 위암의 fold change (2) Signet ring cell carcinoma, 1.6x1.2cm, SM3, 0/32
31 전형적인 위암의 fold change (3)
32 전형적인 위암의 fold change (4) - signet ring cell carcinoma, SM1
33 공기에 따라서 이렇게 달라 보이니
34 Typical fold changes of depressed type EGC
35 Fold 관찰과 적절한 공기주입의 중요성
36 EGC fold 연습
37 경미한 fold change를 보이는 경우가 많다
38 병소보다 fold가 현저한 경우도 있다
39 Dam formation은 진행성 위암의 sign이다 AGC, signet-ring cell carcinoma, diffuse, 3x2.5 cm, SS, 0/42, perinural invasion
40 Benign or malignant? - Screening EGD for asymptomatic 49 YO male Biopsy: H. pylori-negative, chronic gastritis
41 Benign or malignant? - follow up 4 weeks later Biopsy: H. pylori-positive, chronic gastritis
42 What is the clue in the left picture? - Epigastric discomfort (M/59) EGC. signet ring cell carcinoma. 4.2 x 1.7 cm. extension to lamina propria, LN 0/48
43 EGC with spontaneous bleeding
44 EGC type I Tubular adenocarcinoma (W/D), 3.6x1.6 cm, in LP
45 EGC type I Tubular adenocarcinoma (W/D), 2.5x2.4 cm, SM2, L(+), 0/38
46 EGC type I
47 EGC type IIa
48 EGC type IIa + BGU
49 EGC type IIb Signet ring cell carcinoma, 1.2x0.9cm, SM1, 0/30
50 EGC type IIb
51 EGC type IIb
52 EGC type IIb signet ring cell carcinoma
53 EGC type IIb in the gastric fundus
54 EGC type IIc
55 EGC type IIc
56 EGC type IIc Adenocarcinoma (M/D), 2.8 x 2.2cm, Extension to SM3, 1/36, endolymphatic thrombi
57 EGC type IIc
58 EGC type IIc Adenocarcinoma (M/D), 0.6cm x 0.4cm, Confined within lamina propria, 0/16
59 EGC type IIc signet ring cell carcinoma
60 EGC type IIc - M cancer (P/D), node mets (+) 1/18
61 Erosive gastritis??? - biopsy: well differentiate adenocarcinoma
62 EGC IIc or EGC type III Adenocarcinoma (P/D), Submucosal, No node mets
63 EGC type III는 드물다 - BGU와 감별진단에 특히 주의해야 한다 Adenocarcinoma (P/D), lamina propria, 0/39
64 EGC type III EGC, signet ring cell carcinoma, 4.8x2.8 cm, MM, 0/43
65 EGC type III 중에 AGC가 상당히 많다 AGC, adenocarcinoma (P/D), 3.6x2.2 cm, PM cancer, 0/25
66 Mixed type은 되도록 많이 쓰지 않도록 하자. 그러나 일부에서는 꼭 필요하다. EGC IIa + IIc
67 EGC type IIa + IIc
68 EGC type IIc + IIa
69 EGC type IIc + IIa Adenocarcinoma (P/D), 4.8x2.0cm, MM, 0/36
70 이런 EGC는 어떻게 분류할 것인가
71 Superficial spreading EGC - EGC가 작은 위암은 아니다 Adenocarcinoma (M/D), 7.4 x 7.2cm, Extension to muscularis mucosa, 1/40
72 Intractable ulcer로 의뢰되어 진단한 위암
73 AGC-like EGC EGC, tubular adenocarcinoma (P/D) with lymphoid stroma, 3.3x3 cm, SM3, 0/36
74 Is it a sentinel polyp or cancer? (1/4)
75 Is it a sentinel polyp or cancer? (2/4)
76
77 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 Lymphatic invasion : present 10. Venous invasion : not identified 11. Perineural invasion : not identified
78 AGC Jun Haeng Lee, M.D. Department of Medicine,Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
79 AGC Borrmann type I
80 AGC Borrmann type I (F/76) - adenocarcinoma (P/D), PM invasion, LN 1/47
81 AGC Borrmann type II
82 AGC Borrmann type II
83 Advanced Gastric Cancer, B-II
84 Adenocarcinoma (P/D), SS, 0/46
85 2년 전 내시경을 했는데
86 AGC
87 AGC Borrmann type III
88 AGC Borrmann type III
89 AGC Borrmann type III
90 AGC B-III
91 Diagnosis of ulcerative lesions EGC AGC AGC DLBL DLBL GIST
92 EG junction cancer Jun Haeng Lee, M.D. Department of Medicine,Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
93 조유경. 대한소화기내시경학회지 2008;37(Suppl. 1):16-23
94 건강검진 발견 접합부 암 (남 72) - adenocarcinoma (M/D). 3.5 cm. esophageal adventitia and gastric subserosa invasion. LN 4/23
95 식도암 의심으로 의뢰된 cardia cancer Biopsy: adenocarcinoma (moderately differentiated)
96 EG junction cancer
97 Cardia cancer
98 AGC with adreanal and kidney metastasis
99 EG junction cancer
100 Angle of His cancer Bx #1. adenocarcinoma, M/D Bx #2. suspected malignancy
101 GC side of the fundus a blind spot (1) (2) 1 2 Blind area
102 Difficult location 1 2 Blind area
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