담도암의 항암치료

우상명 ( Sang Myung Woo ) 대한소화기학회 2017 대한소화기학회지 Vol.69 No.3

The term of biliary tract cancer (BTC) refers to all tumors that arise from the biliary tract or the biliary drainage system, including the intra- and extra-hepatic bile ducts as well as the gallbladder. BTCs are aggressive tumors with limited treatment options and poor overall survival. Currently, surgery remains to be the only potentially curative treatment, and most patients develop recurrence. For advanced tumors, only limited effective treatment modalities exist today. Gemcitabine plus cisplatin is considered as a standard option for advanced biliary cancer. A randomized phase III trial (ABC-02 trial) showed superiority of gemcitabine plus cisplatin over gemcitabine alone. In that study, they showed that after a median follow-up of 8.2 months, the median overall survival was 8.1 months in the gemcitabine-only group and 11.7 months in the gemcitabine plus cisplatin group (p<0.001). However, while this is a definite advancement, a 3-month survival extension among patients with BTC is modest at best. Moreover, this regimen has not been compared head-to-head with other gemcitabine based combinations. Gemcitabine monotherapy, 5-fluorouracil plus leucovorin, and single- agent capecitabine are all reasonable options for patients with a borderline performance status. Recent advancements have provided new insight into the genomic landscape of BTCs, and thus, it remains unclear whether combined treatment with molecular targeted agents or other cytotoxic chemotherapeutic agents may also be effective against advanced BTC. (Korean J Gastroenterol 2017;69:172-176)

Adjuvant Chemo-Radiation therapy for IHCC

Sang Myung Woo(우상명) 대한외과학회 2014 대한외과학회 학술대회 초록집 Vol.2014 No.11

전이성 췌장암의 치료

이보영,우상명,Bo Young Lee,Sang Myung Woo 대한소화기암연구학회 2018 Journal of digestive cancer reports Vol.6 No.2

Pancreatic ductal adenocarcinoma is a dismal prognosis and 5^th leading cause of cancer related death in Korea. A large proportion of patients are diagnosed at advanced or metastatic stage. Therefore systemic chemotherapy has become the mainstay of treatment for pancreatic cancer. For most patients advanced or metastatic pancreatic cancer that has a good Eastern Cooperative Oncology Group performance status (ECOG PS) 0 or 1, we can recommend for FOLFIRINOX (leucovorin, 5-fluorouracil [5-FU], irinotecan and oxaliplatin) and gemcitabine plus nanoparticle albumin-bound paclitaxel (nab-paclitaxel). Currently, steps towards improved therapeutic efficacy of palliative chemotherapy have been made by introducing these regimens. For patients with an ECOG PS of 2, gemcitabine monotherapy or S1 alone is recommended. The second-line therapy for patients initially treated with gemcitabine-based chemotherapy includes provide FOLFOX (leucovorin, 5-FU, and oxaliplatin), capecitabine plus oxaliplatin, and 5-FU plus liposomal irinotecan. The gemcitabine-based chemotherapy is a reasonable choice for patients treated with FOLFIRINOX. Currently, studies on selecting patients for biomarkers related to molecular biologic features of tumors are underway for the realization of precise medicine, and the development and verification of preclinical models for the development of new therapeutic agents are being carried out continuously.

분지췌관형 췌관내유두상점액종양의 자연 경과

이상협 ( Sang Hyub Lee ),박주경 ( Joo Kyung Park ),우상명 ( Sang Myung Woo ),유지원 ( Ji Won Yoo ),류지곤 ( Ji Kon Ryu ),김용태 ( Yong Tae Kim ),윤용범 ( Yong Bum Yoon ) 대한소화기학회 2007 대한소화기학회지 Vol.49 No.1

목적: 췌관내유두상점액종양은 주췌관형과 분지췌관형이 있는데 분지췌관형은 주췌관형보다 임상 경과가 양호하다. 분지형 췌관내유두상점액종양은 주췌관형보다 더 흔히 발견되는데 이들의 정확한 자연 경과가 잘 알려져 있지 않다. 따라서 이번 연구에서는 분지췌관형 췌관내유두상점액종양의 자연 경과를 알아보고자 하였다. 대상 및 방법: 1997년 7월부터 2005년 9월까지 서울대학교병원에서 췌관조영술로 주췌관과 연결되어 있는 것이 확인된 분지형 췌관내유두상 점액종양 환자 중 6개월 이상 2회 이상의 영상 검사로 경과 관찰을 시행하였던 환자들을 대상으로 하였다. 이들의 인구 특성과 낭종의 크기, 주췌관의 확장 및 벽 결절에 대한 변화와 경과 관찰 중 수술 절제를 받은 환자들의 병리 소견을 후향 분석하였다. 결과: 총 45명의 분지췌관형 췌관내유두 상점액종양 환자들의 자연 경과를 평균 27.4±18.8개월 동안 관찰하였다. 나이는 평균 62.9±8.3세이고 남녀는 각각 26명, 19명이었다. 관찰 중 낭종 크기가 10명에서 증가하였는데 단변량 분석에서 진단 당시 낭종 크기가 작은 군에서 크기가 증가하는 경향이 있었다(p<0.01). 다변량 분석에서는 1.0 cm 이하의 낭종 크기는 교차비 4.48로 크기 증가와 관련이 있었다. 10명의 환자들에서 경과 관찰 중 수술 절제를 시행 했는데 상피내암종과 침습 암종이 각각 1명에서 나타났고, 벽 결절의 동반된 경우 악성일 확률이 높았다 (p=0.02). 수술을 하지 않고 계속 경과 관찰 중인 35명의 환자들에서는 낭종으로 인한 다른 문제는 발생하지 않았다. 결론: 분지췌관형 췌관내유두상점액종양은 비교적 양호한 자연 경과를 취하며, 벽 결절이 발생되는 경우 악성으로 이행될 가능성이 높으나 낭종의 성장 속도는 낭종의 초기 단계에서 오히려 빠를 수 있어 이 소견만을 가지고 악성으로 판단해서는 안 된다고 생각한다. Background/Aims: Intraductal papillary mucinous neoplasms of the pancreas (IPMNs) are consisted of two types; branch-duct type and main-duct type. Branch-duct type is more common and follows a better course than main-duct type. However, the natural history of branch-duct type IPMN has not been exactly verified yet. The aim of this study was to investigate the natural course of branch-duct type IPMN. Methods: The medical records of 45 patients with branch-duct type IPMN diagnosed by pancreatogram were reviewed retrospectively. The mean age was 62.9±8.3 years old and the mean follow-up duration was 27.4±18.9 months. Demographic, clinical and radiologic characteristics were evaluated. The histological findings of specimens resected during the follow-up period were also analyzed. Results: Ten (22.2%) out of 45 patients showed enlargement of the cysts during follow-up. Initial size of the cyst in patients with cyst enlargement were smaller than in patients without it in univariate analysis (p<0.01). Cysts less than 1.0 cm were significantly associated with cyst enlargement with odds ratio of 4.48 in multivariate analysis. Ten patients underwent surgical resection and pathologic examination revealed one carcinoma in situ and one invasive adenocarcinoma. The presence of mural nodule was associated with malignant change of IPMNs (p=0.02). None of unresected cases showed metastasis or disease-related death. Conclusions: Natural history of branch-duct type IPMNs is generally good. The occurrence of mural nodule is associated with the malignant change of the cyst but not the speed of size increment. (Korean J Gastroenterol 2007;49:24-30)

췌장암 절제 후 잔여췌장에 발생한 췌장암에 대한 반복절제를 시행한 2례 - 췌장암의 반복절제 -

김영일,우상명,이우진,Young-Il Kim,Sang Myung Woo,Woo Jin Lee 대한소화기암연구학회 2013 Journal of digestive cancer reports Vol.1 No.1

There have been very few reports related to pancreatic cancer developing in the remnant pancreas after a resection for pancreatic cancer. We report two cases of repeated pancreatectomy for second primary pancreatic cancer. A 58-year-old man with a 2.3 cm sized low attenuated pancreatic tail mass on abdomen CT scan, received a distal pancreatectomy (adenosquamous carcinoma, stage IIB) and adjuvant chemoradiotherapy. A follow-up abdomen CT scan revealed a 2.0 cm sized pancreatic head mass in the remnant pancreas at 35 months after the distal pancreatectomy. He received a pancreaticoduodenectomy and diagnosed as ductal adenocarcinoma (stage IIA). Another 62-year-old female was declared pancreatic head mass on a regular health examination. An abdomen CT scan revealed a 3.6 cm sized mixed solid and cystic mass. She received a pylorus-preserving pancreaticoduodenectomy (ductal adenocarcinoma, stage IB) and adjuvant chemoradiation therapy. At 20 months after the resection, a 1.8 cm sized ill-defined low attenuated mass developing in the tail of remnant pancreas was detected on a follow-up abdomen CT scan. The patient received a distal pancreatectomy and diagnosed as ductal adenocarcinoma (stage IIA).

경계절제성 또는 국소진행성 췌장암에서 수술 전 보조치료의 역할

이우진 ( Woo Jin Lee ),우상명 ( Sang Myung Woo ) 대한췌담도학회 2016 대한췌담도학회지 Vol.21 No.3

췌장암의 가장 효과적인 치료는 수술적 절제이나 10-20%에서만 가능하다. 그 이유는 췌장은 복막 후강에 위치하고 있어 암이 발생하더라도 초기에 특이적인 증상이 없고, 암조직이 빠르게 성장하여 진단 당시 이미 진행된 경우가 많기 때문이다. 절제 후에도 재발이 흔하여 근치적 절제수술후에도 5년 생존율이 20% 이하이다. 절제 이외의 치료 방법은 효과가 적어 전체 췌장선암종 환자의 5년 생존율은 5%이하로 매우 예후가 나쁜 종양이다. 정확하고 엄격한 수술 전 병기 판정과 절제가능성 평가에 따른 병기별 치료는 필수적이다. 절제가 불가능하나 원격전이가 없는 국소진행성 췌장암은 30-40%에서 관찰되며 중앙생존기간은 치료를 안 한 경우 6-8개월, 치료한 경우 10-12개월 정도이다. 이들 국소진행성 췌장암은 생존율 향상의 여지가 많아서, 보다 나은 치료 효과를 얻기 위해 가장 적극적이고 집중적인 관심이 필요한 상태의 췌장암이라 할 수있다. 췌장암의 절제술에 있어서 경계성 절제가능성 췌장암의 개념의 등장의 배경은 낮은 R0 절제율과 힘든 절제 후의 나쁜 예후에 있다. 최근 다중검출 CT의 발전으로 새로이 분류된 경계성 절제가능성 췌장암군은 절제연 양성의 위험성이 높아 다학적 치료법의 좋은 적용군이라 할 수 있다. 최근R1이나 R2 절제의 가능성이 높은 경우 무리한 수술보다는 수술 전 항암요법과 방사선요법 후 영상학적으로 진행하지않거나 개선되어 혈관침습이 국소적인 경우 혈관 절제나 재건을 포함한 근치적 수술을 시도하여 비교적 좋은 결과들이 보고되고 있다. 수술 전 화학요법 또는 화학방사선치료는 수술 후 치료에 비해 미세원격전이가 있어 나중에 진행하여 명백한 원격전이가 보이는 환자들에게는 불필요한 절제수술을 막을 수 있다. 또한 수술 후 보조요법을 못하는 환자가 1/3에 달하는 상황에서 전신상태가 비교적 좋을 때 여러 다양한 치료를 시도할 수 있다. 최근 췌장암에 효과적인 몇몇 약제들이 소개되면서 이들 약제의 방사선치료와의 병합치료에 대한 기대 역시 증가하고 있다. 하지만 아직 그 정의에서 각 병원마다 차이가 많고 치료 및 효과의 판정에서도 확립되지 않은부분이 많아 잘 짜여진 기준을 가진 전향적 무작위 대조 연구가 필요하다. 또한 수술 전 항암 또는 방사선치료 효과를 정확히 평가할 수 있는 영상 검사나 병리학적 기준이 필요하며 향후 개개인에 맞는 맞춤형 치료의 개발 및 효과를 볼 수 있는 환자군을 선택하는 것이 필요하겠다. Surgical resection offers the only chance of cure for nonmetastatic exocrine pancreatic cancer. However, only 15 to 20 percent of patients have potentially resectable disease at diagnosis; approximately 40 percent have distant metastases, and another 30 to 40 percent have locally advanced unresectable tumors. Typically, patients with locally advanced unresectable pancreatic cancer have tumor invasion into adjacent critical structures, particularly the celiac and superior mesenteric arteries. The optimal management of these patients is controversial, and there is no internationally embraced standard approach. Therapeutic options include chemoradiotherapy or chemotherapy alone. While it is reasonable to restage and reevaluate the potential for resectability after neoadjuvant therapy, the frequency of a complete resection and long-term survival is low for patients who initially have categorically unresectable tumors. Others have disease that is categorized as “borderline resectable.” While these patients are potentially resectable, the high likelihood of an incomplete resection has prompted interest in strategies to “downstage” the tumor or to increase the likelihood of a margin-negative resection prior to surgical exploration using neoadjuvant therapy. The rationale for neoadjuvant therapy is as follows. First, it is to improve the selection of patients for whom resection will not offer a survival benefit (i.e., those who rapidly progress to metastatic disease during preoperative therapy). Second, it is to increase rates of margin-negative resections, which is the major goal of surgery. Third, it is to start an early treatment of micrometastatic disease. Initial attempt at downstaging with chemotherapy, chemoradiotherapy, or a combination followed by restaging and surgical exploration in responders rather than upfront surgery is suggested. Korean J Pancreas Biliary Tract 2016;21(3):117-127

췌장내분비종양의 임상 양상과 생존과 연관된 예후 인자

백우현 ( Woo Hyun Paik ),윤용범 ( Yong Bum Yoon ),이상협 ( Sang Hyub Lee ),박주경 ( Joo Kyung Park ),우상명 ( Sang Myung Woo ),양기영 ( Ki Young Yang ),서정균 ( Jeong Kyun Seo ),류지곤 ( Ji Kon Ryu ),김용태 ( Yong Tae Kim ) 대한소화기학회 2008 대한소화기학회지 Vol.52 No.3

Background/Aims: Since pancreatic endocrine tumors (PET) are rare and heterogeneous diseases, their survival and prognosis are not well known. Due to recent advances in CT/MRI technology, incidentalomas of the pancreas are detected with increasing frequency. This study presents results of clinical manifestations of PET and predictive factors associated with survival. Methods: From year 1990 through 2006, medical records of 98 patients (56 men, 42 women) who were diagnosed as PET pathologically at Seoul National University Hospital were reviewed retrospectively. Results: Ages ranged from 17 to 76 years (mean 51.6±1.3 years) with a mean follow-up of 3.6±0.4 years (range 0-10.1 years). Overall 5-year survival rate was 68.1%, and 5-year survival rate of the patients who had distant metastases at initial diagnosis was 43.9%. Functioning tumors [hazard ratio (HR) 0.229, 95% confidence interval (CI) 0.056-0.943, p=0.041] and lymph node or liver metastases (HR 5.537, 95% CI 2.106-14.555, p<0.001) were the significant prognostic factors associated with survival rate. However, tumor size and pathology showed no significant association with survival. Conclusions: Because small and pathologically benign nature do not predict good prognosis in PET, aggressive treatment such as curative resection would be considered initially even in the case of incidental PET. (Korean J Gastroenterol 2008;52:171-178)

담췌관 확장을 동반한 바터 팽대부의 선근종

김선아 ( Seon A Kim ),우상명 ( Sang Myung Woo ),홍은경 ( Eun Kyung Hong ),한성식 ( Sung Sik Han ),박상재 ( Sang Jae Park ),고영환 ( Young Hwan Koh ),이주희 ( Ju Hee Lee ),이우진 ( Wo Jin Lee ) 대한췌장담도학회 2016 대한췌담도학회지 Vol.21 No.1

Adenomyoma is a non-neoplastic lesion that frequently occurs in the gallbladder, but it’s rarely found at the ampulla of Vater. When it develops at the ampulla of Vater, it may be mistaken for a periampullary malignancy. A 64-year-old asymptomatic male patient visited to our hospital with abnormal sonogram findings. Abdominal computed tomography and magnetic resonance cholangiopancreatography showed dilatations of common bile duct and main pancreatic duct. However, there was no definite ampullary mass. We performed endoscopic biopsies and endoscopic ultrasonography-guided fine needle aspiration. But the results were negative for malignant cells. Because we could not completely rule out malignancy, pylorus preserving pancreato-duodenectomy was performed. Histologically, hyperplastic components are intermixed with smooth muscle fibers in the subepithelial portion of ampulla of Vater. Awareness of adenomyoma of the ampulla of Vater is very important because of their clinical and endoscopic similarities to ampullary tumors.

진행성 바터팽대부 선암종에서 카페시타빈과 옥살리플라틴 병합요법의 효과

이정환 ( Jung Hwan Lee ),김경희 ( Kyung Hee Kim ),우상명 ( Sang Myung Woo ),박상재 ( Sang-jae Park ),한성식 ( Sung-sik Han ),홍은경 ( Eun Kyung Hong ),고영환 ( Young Hwan Koh ),이주희 ( Ju Hee Lee ),이우진 ( Woo Jin Lee ) 대한췌담도학회 2017 대한췌담도학회지 Vol.22 No.3

배경/목적: 바터팽대부에서 발생하는 선암종은 드문 질환으로 항암화학요법에 대한 연구가 부족하다. 본 연구에서 진행성 바터팽대부 선암종 환자에서 XELOX 병합요법의 효능 및 안전성을 분석하고자 한다. 방법: 2006년 10월부터 2014년 1월까지 국립암센터에서 XELOX 병합요법으로 치료한 바터팽대부 선암종 환자 28명을 대상으로 후향적으로 분석하였다. 모든 환자는 진단 당시 전이성 또는 재발한 바터팽대부 선암종 환자이었다. XELOX 병합요법은 외래에서 3주마다 다음과 같은 프로토콜에 따라 투여되었다. 치료 시작 1-14일에 하루 2회 카페시타빈 750mg/m²를 경구 투여하고, 1일에 옥살리플라틴 130 mg/m²을 정맥 주사하였다. 결과: 24.6개월(범위 4.8-78개월)의 중앙 추적관찰 기간에서 중앙 무진행 생존 기간은 4.8개월(범위 0.7-18.0개월)이었고, 중앙 생존 기간은 11.9개월(범위 2.0-26.1개월)이었다. 1명의 환자(4%)가 완전 관해를 얻었고, 5명의 환자(18%)는 부분 관해를 보였다. 무진행 생존 기간와 전체 생존 기간에서 항암화학요법 반응 여부에 따른 차이는 없었다. 환자에서 가장 흔한 3등급의 이상 반응은 메스꺼움과 구토였다(10.7%). 치료와 관련된 사망은 관찰되지 않았다. 결론: XELOX 요법은 전이 혹은 재발 바터팽대부 선암종에서 비교적 낮은 독성의 발현과 중등도 효과를 보이는 치료법이다. Background/Aim: Adenocarcinoma arising from the ampulla of Vater is a rare disease and has limited data regarding outcome of palliative chemotherapy. We investigated the efficacy and safety of capecitabine plus oxaliplatin (XELOX) in patients with advanced ampullary adenocarcinoma. Methods: From October 2006 to January 2014, we retrospectively analyzed 28 patients with advanced ampullary adenocarcinoma treated by XELOX regimen at single institution. All the patients had histologically confirmed stage IV or recurrent ampullary adenocarcinoma. XELOX was administered in outpatient clinic every 3 weeks according to the following protocol: oral administration of capecitabine 750 mg/m² twice a day on days 1-14 and intravenous injection of oxaliplatin 130 mg/m² on day 1. Results: With follow-up of median 24.6 months (range 4.0-78.0 months), median progression-free survival (PFS) was 4.8 months (range 0.7-26.1 months), and median overall survival (OS) was 11.9 months (range 2.0-36.0 months). One patient (4%) achieved complete response and 5 patients (18%) showed partial response. There were no significant differences for PFS and OS according to response by chemotherapy. The most common grade 3 adverse events in patients were nausea and vomiting (10.7%). There was no treatment-related mortality. Conclusions: XELOX regimen is well tolerated and show moderate activity against advanced ampullary adenocarcinoma.

증례 : 순환기; 위암 환자 급성 심막염에 NSAID 사용 후 발생한 위심막루에 의한 심낭기종

김영기 ( Yeong Gi Kim ),김학진 ( Hak Jin Kim ),박경선 ( Kyeong Seon Park ),홍아람 ( A Ram Hong ),이상진 ( Sang Jin Lee ),우상명 ( Sang Myung Woo ) 대한내과학회 2014 대한내과학회지 Vol.86 No.4

Here, we report a case of gastropericardial fistula associated with the treatment of acute pericarditis using non-steroidal anti-inflammatory drugs (NSAIDs) in the presence of gastric cancer. The patient presented with acute pericarditis with pericardial effusion that had progressed into definite gastropericardial fistula with pneumopericardium after the administration of NSAIDs. The patient improved after conservative management. Based on the current case, we advise caution when using NSAIDs to treat acute pericarditis in the presence of gastric cancer or possible gastropericardial fistula. (Korean J Med 2014;86:489-493)