대장 용종절제술을 시행한 환자에서 조기 대장암의 예측 인자 = Predictable Factors of Early Colorectal Cancer after Colonoscopic Polypectomy

국문 초록 (Abstract)

목적: 대장암은 국내에서 암 발생률 3위, 암 사망률 4위를 차지한다. 최근 대장내시경 검진과 대장 용종절제술로 인해 대장암의 발생률과 사망률이 감소하고 있다. 이번 연구는 대장 용종절제술 후 진행성 선종, 점막암, 점막하층암을 분석하여 조기 대장암을 예측할 수 있는 인자들이 있는지를 평가하고자 하였다.
방법: 2003년 8월부터 2012년 6월까지 제주대학병원에서 대장 용종절제술을 시행받은 총 1,001명의 환자 기록을 분석하였다.
결과: 대상 환자의 용종은 비진행성 선종 460명(50.1%), 진행성 선종 409명(44.5%), 점막암 38명(4.0%), 그리고 점막하층암 12명(1.4%)에서 관찰되었다. 평균 용종의 크기는 조기 대장암에서 유의하게 증가되어 있었고 (12.2 mm vs . 15.3 mm, P ＜0.01), 당뇨병을 가지고 있는 환자가 증가되어 있었다(13.1% vs . 25.0%, P =0.04). 또한 용종의 해부학적 위치는 원위부에 위치할수록 조기 대장암의 분포가 증가되어 있었다(39.3% vs . 52.0%, P=0.05). 다변량 회귀분석을 통해서 조기 대장암의 위험인자를 분석한 결과 당뇨병(odds ratio [OR], 2.10;95% confidence interval [CI], 1.07-4.33; P ＜0.01), 용종의 크기(＞15 mm; OR, 4.49; 95% CI, 2.40-8.38; P ＜0.001), 원위부 위치(OR,2.59; 95% CI, 1.33-5.05; P ＜0.01)가 위험 요인으로 확인되었다. 점막하층암의 환자에서 5명은 추가적인 수술을 시행하였고 암성조직은발견되지 않았다.
결론: 대장 용종절제술을 시행한 환자에서 조기 대장암의 예측인자는 크기가 15 mm 이상, 용종이 원위부에 분포하거나 당뇨병을 동반한 경우였다.

다국어 초록 (Multilingual Abstract)

Background/Aims: Colorectal cancer is the third most common cancer and the fourth leading cause of cancer death in Korea. Colonoscopic screening with removal of adenomas is an effective strategy for reducing the incidence and mortality of colorectal cancer. This study was conducted to investigate predictable factors of early colorectal cancer (ECC) in patients with advanced adenoma (AA), tumor in situ (Tis), and submucosal (SM) cancer diagnosed after colonoscopic polypectomy. Methods: Between August 2003 and June 2012, a total of 1,001 patients who underwent colonoscopic polypectomy in Jeju National University Hospital were enrolled in this study. Results: Patients were classified into four groups; non-AA, AA, Tis, and SM cancer. Compared to the AA group, the ECC group (n=50) had large adenoma size (12.2±5.9 mm vs. 15.3±6.5 mm, P<0.01), distal location (39.3% vs. 52.0%, P=0.05) and diabetes mellitus (13.1% vs. 25.0%, P=0.04). However, age, sex, body mass index, the mean number of polyps, and morphological features (polypoid vs. nonpolypoid lesions) were not significantly different between the AA and ECC groups. In multivariate analysis, adenoma size >15 mm (odds ratio [OR], 4.49; 95% confidence interval [CI] 2.40-8.38), distal location (OR, 2.59; 95% CI, 1.33-5.05), and diabetes mellitus (OR, 2.10; 95% CI, 1.07-4.43) were significantly associated with ECC. Of the 12 patients with SM cancer, 5 underwent additional operations and had no remnant carcinoma. Conclusions: Predictable factors of ECC after colonoscopic polypectomy may be adenoma size >15 mm, distal location and diabetes mellitus. (Intest Res 2013;11:169-177)

참고문헌 (Reference)

1 김흥업, "한국인에서 조기 대장암의 형태적 특성" 대한소화기내시경학회 29 (29): 126-132, 2004

2 이석호, "대장폴립절제술 가이드라인" 대한소화기학회 59 (59): 85-98, 2012

3 허규찬, "대장암 조기 발견을 위한 전략" 대한내과학회 79 (79): 104-112, 2010

4 이보인, "대장암 선별과 대장폴립 진단검사 가이드라인" 대한소화기학회 59 (59): 65-84, 2012

5 이희정, "내시경 점막절제술로 치료된 조기 대장암의 추적 결과" 대한소화기학회 57 (57): 230-236, 2011

6 Kwon KA, "The clinicopathological characteristics and treatment results of the early colorectal cancer" 3 : 133-139, 2005

7 Schlemper RJ, "The Vienna classification of gastrointestinal epithelial neoplasia" 47 : 251-255, 2000

8 Winawer SJ, "Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps" 328 : 901-906, 1993

9 Markowitz SD, "Molecular origins of cancer: Molecular basis of colorectal cancer" 361 : 2449-2460, 2009

10 Cooper GS, "Management of malignant colonic polyps: a populationbased analysis of colonoscopic polypectomy versus surgery" 118 : 651-659, 2012

11 Bujanda L, "Malignant colorectal polyps" 16 : 3103-3111, 2010

12 Yuhara H, "Is diabetes mellitus an independent risk factor for colon cancer and rectal cancer?" 106 : 1911-1921, 2011

13 Vogelstein B, "Genetic alterations during colorectal-tumor development" 319 : 525-532, 1988

14 "General rules for clinical and pathological studies on cancer of the colon, rectum and anus. Part I. Clinical classification. Japanese Research Society for Cancer of the Colon and Rectum" 13 : 557-573, 1983

15 Lieberman DA, "Five-year colon surveillance after screening colonoscopy" 133 : 1077-1085, 2007

16 Ferlay J, "Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008" 127 : 2893-2917, 2010

17 Moss A, "Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia" 140 : 1909-1918, 2011

18 Kudo S., "Endoscopic mucosal resection of flat and depressed types of early colorectal cancer" 25 : 455-461, 1993

19 Minamoto T, "Early invasive colorectal carcinomas metastatic to the lymph node with attention to their nonpolypoid development" 88 : 1035-1039, 1993

20 Shimoda T, "Early colorectal carcinoma with special reference to its development de novo" 64 : 1138-1146, 1989

21 Mainprize KS, "Early colorectal cancer: recognition, classification and treatment" 85 : 469-476, 1998

22 Schlemper RJ, "Differences in the diagnostic criteria used by Japanese and Western pathologists to diagnose colorectal carcinoma" 82 : 60-69, 1998

23 Schlemper RJ, "Diagnostic criteria for gastrointestinal carcinomas in Japan and Western countries: proposal for a new classification system of gastrointestinal epithelial neoplasia" 15 : G49-G57, 2000

24 Wang HS, "Curative resection of T1 colorectal carcinoma: risk of lymph node metastasis and longterm prognosis" 48 : 1182-1192, 2005

25 Kitajima K, "Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma : a Japanese collaborative study" 39 : 534-543, 2004

26 Zauber AG, "Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths" 366 : 687-696, 2012

27 Kim MN, "Clinical features and prognosis of early colorectal cancer treated by endoscopic mucosal resection" 26 : 1619-1625, 2011

28 Jemal A, "Cancer statistics, 2008" 58 : 71-96, 2008

29 Statistics Korea, "Annual report on the cause of death statistics"

30 Hardy RG, "ABC of colorectal cancer. Molecular basis for risk factors" 321 : 886-889, 2000

31 Martínez ME, "A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy" 136 : 832-841, 2009

32 Ministry of Health and Welfare, "2008 National cancer registration and stastistics"