췌장의 관강내 유두상 점액 종양: 췌장절제방법을 결정하는 데 있어 관강내 세경초음파 단층촬영술의 역할
Intraductal Papillary Mucinous Neoplasm of the Pancreas: The Role of Intraductal Ultrasonography in Selection of Resection Method of Pancreas
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목적: 췌관내유두상점액종양은 췌장 선암과 비교하여 예후가 좋아 정확하고 신속한 진단과 적극적인 치료가 필요하다. 또한 악성여부를 정확하게 알 수 있는 표지자나 검사 방법이 없으므로 췌관내유두상점액종양이 의심될 때에는 수술적 요법을 고려해야 한다. 그러나 병변의 특징상 췌관을 미만성으로 침범하여 어떠한 수술 술식을 해야할지 결정하기 어려운 경우가 많은 문제점이 있다. 이에 저자들은 췌관내유두상점액종양의 수술 술식을 결정하는 데 있어 관강내세경초음파단층촬영술(intraductal ultrasonography, IDUS)의 역할을 평가하고자 본 연구를 시행하였다. 대상 및 방법: 1997년 1월부터 2001년 8월까지 영상학적 검사를 통하여 췌관내유두상점액종양으로 의심된 17예 중 12예에서 췌장절제술을 시행하였다. 췌장절제술을 시행한 12예(남：녀=5：7, 평균연령: 54.6세)의 환자 모두에서 수술 전에 IDUS를 시행하였으며, IDUS의 결과에 따라 술식을 사전에 결정, 수술을 시행하였고, 수술 중 절제면의 동결절편 조직검사를 통하여 수술범위를 최종 결정하였다. 수술 전의 IDUS소견 및 수술 후 병리소견을 비교분석하였다. 결과: 모든 예에서 주췌관 내로 초음파탐촉자의 삽입이 가능하였으며 전체 12예 중 8예에서 췌미부까지 관찰할 수 있었다. IDUS에 의거하여 췌장절제술을 시행하였을 때 최초 췌장절단면에서 종양세포 양성 소견을 보인 예는 2예였고, 이 2예에서는 절제범위를 변경하였다. 수술시 동결 절편에서 종양세포 음성을 보였던 10예 중 1예에서 최종 수술표본의 절제면에서 종양세포가 관찰되어 수술 전 췌관내유두상점액종양의 위치 및 침습정도를 평가하는데 있어 IDUS의 진단의 정확도는 75%였다. 결론: 췌관내유두상점액종양환자에서 외과적 절제를 고려할 때 수술 전 IDUS의 시행은 췌장절제술식 및 절제면을 결정하는데 매우 유용한 검사방법으로 생각한다.
Abstract
Background/Aims: The treatment of choice of intraductal papillary mucinous neoplasm (IPMN) is partial pancreatic resection with complete excision of this potentially malignant lesion, thus preserving sufficient pancreatic tissue to ensure endocrine and exocrine functions. This strategy, however, requires a reliable preoperative assessment of the highly variable extension of IPMN. We performed this study to determine the role of intraductal ultrasonography (IDUS) in predicting the extension of IPMN and selecting the resection methods of pancreas. Methods: A preoperative assessment of IPMN by IDUS was performed in 12 patients who underwent a surgical resection of IPMN. According to the preoperative localization of IPMN by IDUS, various types of limited pancreatic resections were planned. The histologic examination of the frozen section of the pancreatic cut surface was performed in all patient. In the cases of tumor involvement as cut surface margin, a modification of the planned pancreatic resection was done. Results: Technical success was achieved in all 12 cases (100%). There were positive tumor margin of cut surfaces in 2 patients. Of 10 cases whose frozen tissue evaluation of the pancreatic cut surface had been negative at first, one patieat has turned out to be margin positive in permanent section examination, finally. Overall accuracy of IDUS in predicting the continuous extension of IPMN was 75%. Conclusions: IDUS is a reliable diagnostic modality to guide the resection extent of the pancreas in patients with IPMN.
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