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1. ¹ßº´·ü ¹× ¿ªÇÐ
    • ÃéÀå¾ÏÀº ¿ì¸®³ª¶óÀÇ ¾Ï ¹ß»ý Åë°è¿¡ ÀÇÇϸé Àüü ÁÖ¿ä ¾ÏÁ¾ ¹ß»ý·ü¿¡¼­ 2.4%¸¦ Â÷ÁöÇÏ°í ÀÖÀ¸¸ç, Àüü ¾Ï Áß ¼ºº° ºñÁßÀº ³²¼º¿¡¼­ 2.6%, ¿©¼º¿¡¼­ 3.2% ·Î º¸°íµÇ°í ÀÖ´Ù. ÃéÀå¾ÏÀÇ ¹ß»ýÀº ±¹°¡ ¹× Áö¿ª¿¡ µû¶ó Â÷ÀÌ°¡ ÀÖÁö¸¸ º¸Åë 10¸¸¸í´ç 1~10¸íÁ¤µµÀÇ ¹ß»ý·üÀ» º¸ÀÌ°í, 90% ÀÌ»óÀÌ ¼±¾Ï(ductal adenocarcinoma)ÀÎ °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù. ¼±¾Ï ÀÌ¿ÜÀÇ ÃéÀå¾ÏÀº »ù²Ê¸®¼¼Æ÷ Á¾¾ç(acinar cell tumor)°ú ½Å°æ³»ºÐºñ Á¾¾ç(neuroendocrine tumor)ÀÌ Æ÷ÇԵdzª, ¼±¾Ï¿¡ ºñÇØ µå¹°´Ù. ¹Ì±¹¿¡¼­´Â ¿¬°£ 4¸¸6õ¸íÀÇ ÃéÀå¾Ï ȯÀÚ°¡ ¹ß»ýÇÏ¿© ¸Å³â 4¸¸¸íÀÌ ÃéÀå¾ÏÀ¸·Î »ç¸ÁÇÑ´Ù°í Çϸç, ¿ì¸®³ª¶ó¿¡¼­´Â 2014³â Åë°è º¸°í¿¡ µû¸£¸é ¿¬°£ ¾à 5,000¸íÀÇ ÃéÀå¾Ï ȯÀÚ°¡ ¹ß»ýÇÏ´Â °ÍÀ¸·Î º¸°íµÇ¾ú´Ù.

2. ¹ß»ý ¹× ¿øÀÎ
    • ÃéÀå¾ÏÀÇ Àß ¾Ë·ÁÁø À§ÇèÀÎÀÚ´Â Èí¿¬, ¿À·¡µÈ ´ç´¢º´, ¸¸¼º ÃéÀå¿°, ºñ¸¸ µîÀÌ ÀÖ´Ù. Èí¿¬ÀÚÀÇ °æ¿ì ÃéÀå¾ÏÀÇ À§Çèµµ´Â Èí¿¬·®ÀÌ ¸¹À»¼ö·Ï Áõ°¡ÇÏ°í, ±Ý¿¬ÇÏ¸é °¨¼ÒÇÏ´Â °ÍÀ¸·Î º¸ÀδÙ. ±× ¿Ü ³í¶õÀÌ µÇ°í ÀÖ´Â À§Çè ÀÎÀڷδ °íÁö¹æ, °í¿­·® ½ÄÀÌ, À½ÁÖ µîÀÌ ÀÖ´Ù. ±× ¿Ü À¯ÀüÀûÀÎ ¿¬°ü¼ºµµ º¸°íµÇ°í ÀÖÀ¸¸ç, ƯÈ÷ À¯Àü¼º ÃéÀå¿°ÀÇ °æ¿ì ÃéÀå¾ÏÀÇ ¹ß»ý À§ÇèÀÌ ¸Å¿ì Áõ°¡ÇÏ´Â °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù. ¾à 10% Á¤µµ¿¡¼­ À¯ÀüÀûÀÎ ¿äÀÎÀÌ ÃéÀå¾ÏÀÇ ¹ß»ý¿¡ ¿µÇâÀ» ¹ÌÄ¡Áö¸¸ °¡Á··Â¿¡ ´ëÇؼ­´Â ¾ÆÁ÷ ¸íÈ®ÇÏ°Ô ¾Ë·ÁÁø ¹Ù°¡ ¾ø´Ù. ±× ¿Ü Peutz-Jeghers ÁõÈıº, Von Hippel-Lindau ÁõÈıº, Gardner ÁõÈıº, Lynch ÁõÈıº II ¿Í °°Àº ƯÁ¤ ÁõÈıº¿¡¼­ ÃéÀå¾ÏÀÇ ¹ß»ý À§Çèµµ°¡ Áõ°¡ÇÑ´Ù. ÃéÀå¾ÏÀÇ ´ëºÎºÐÀ» Â÷Ä¡ÇÏ´Â ¼±¾ÏÀÇ °æ¿ì ÀúÇ÷°ü¼º Àú»ê¼Ò¼º ¹Ì¼¼È¯°æ¿¡¼­ ±¤¹üÀ§ÇÑ °áÇÕÁ¶Á÷Çü¼º µîÀÌ Æ¯Â¡ÀûÀÌ´Ù. ÃéÀå »óÇdz» Á¾¾ç¿¡¼­ ÀúºÐÈ­¿¡¼­ °íºÐÈ­·Î ÁøÇàÇÏ¸ç ¾Ç¼ºÁ¾¾çÀ¸·Î ¹ßÀüÇÏ°Ô µÇ¸ç K-rasÀÇ º¯ÀÌ°¡ ÃéÀå »óÇdz» Á¾¾çÀÇ 90% À̻󿡼­ È®ÀεȴÙ. ±× ¿Ü¿¡µµ p53 pathway ³ª SMAD4, TGF-¥â pathway µîÀÌ ÃéÀå¾ÏÀÇ ¹ß»ý °úÁ¤°ú ¿¬°üÀÌ ÀÖ´Â °ÍÀ¸·Î º¸ÀδÙ. ÃéÀå¿¡¼­ Àü¾Ï¼º º´º¯Àº ÃéÀå»óÇdz»Á¾¾ç(pancreatic intraepithelial neoplasia, PanIN), ÃéÀåÀ¯µÎ»óÁ¡¾×Á¾(intraductal papillary mucinous neoplasm, IPMN), Á¡¾×¼º³¶Á¾(mucinous cystic neoplasm, MCN) µîÀÌ ÀÖ´Ù.

3. ÀÓ»ó Áõ»ó
    • ÃéÀå¾ÏÀº ¾à 60-70% ÀÇ ÃéÀå¾ÏÀÌ ÃéÀåÀÇ µÎºÎ¿¡¼­ 20-25%´Â üºÎ ¹× ¹ÌºÎ¿¡¼­ ¹ß°ßµÇ´Â °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù. ¹«Áõ»óÀÎ °æ¿ì°¡ ¸¹°í Áõ»óÀÌ ÀÖ´Â °æ¿ìµµ ºÎÀ§¿¡ µû¶ó Â÷ÀÌ°¡ ÀÖ¾î, ÀÓ»ó Áõ»óÀ» ÅëÇÑ Á¶±â Áø´ÜÀÌ ¾î·Á¿î °æ¿ì°¡ ¸¹´Ù. ÃéÀå¾ÏÀÇ Áõ»óÀº º¸Åë º¹Åë, üÁß°¨¼Ò, ½Ä¿åÀúÇÏ µîÀÇ ºñƯÀÌÀûÀÎ Áõ»óÀ» º¸À̸ç, ÃéÀå µÎºÎ¾ÏÀÇ °æ¿ì ´ã°ü ħ½ÀÀ̳ª ¿ÜºÎ ¾Ð¹ÚÀ¸·Î ÀÎÇØ È²´ÞÀÌ µ¿¹ÝµÇ´Â °æ¿ì°¡ ÀÖ´Ù. ¶ÇÇÑ ¾à 50% Á¤µµÀÇ ÃéÀå¾Ï¿¡¼­ ´ç´¢°¡ ³ªÅ¸³ª±â ¶§¹®¿¡ ÃéÀå¾ÏÀÇ °íÀ§Ç豺 ȯÀÚ¿¡¼­ »õ·ÎÀÌ Áø´ÜµÈ ´ç´¢ÀÇ °æ¿ì, ÃéÀå¾ÏÀÇ °¡´É¼º¿¡ ´ëÇÑ ÁÖÀÇ°¡ ÇÊ¿äÇÏ´Ù. 1 cm ÀÌÇÏÀÇ ÃéÀå¾ÏÀº ´ëºÎºÐ ¹«Áõ»óÀÌ°í, Á¾±«·Î °üÂûµÇ´Â °æ¿ìµµ ¾à 25% ¿¡ ºÒ°úÇÑ °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù. Ãé°ü È®À常 º¸ÀÌ´Â °æ¿ìµµ ¾à 50% Á¤µµÀ̸ç, ÃéÀå¾ÏÀÇ Å©±â°¡ 1-2 cmÀÏ ¶§¿¡µµ ´ëºÎºÐ Áõ»óÀÌ ¾ø°Å³ª ºñƯÀÌÀûÀ̱⠶§¹®¿¡ ¿ì¿¬È÷ ¹ß°ßµÇ´Â °æ¿ì°¡ ¸¹´Ù. Áõ»óÀÌ ÀÖ´Â ÃéÀå¾ÏÀº ´ë°³ 2 cm ÀÌ»óÀÌ°í Ç÷°ü ħ¹üÀ̳ª ÀüÀÌ°¡ µ¿¹ÝµÈ ÁøÇàµÈ »óÅ·Π¹ß°ßµÇ±â ¶§¹®¿¡ ¼ö¼úÀû Ä¡·á°¡ ºÒ°¡ÇÑ °æ¿ì°¡ ´ëºÎºÐÀÌ´Ù. Ȳ´ÞÀÌ ¹ßÇöµÈ °æ¿ì ¿ìÃø ´Á°ñ °æ°è¿¡¼­ ¹«Å뼺ÀÇ ´ã³¶ÀÌ ÃËÁøµÉ ¼ö ÀÖÀ¸¸ç(Courvoisier ¡ÈÄ), ÁÂÃø ¼â°ñÀ§ ¸²ÇÁÀýÀÌ Á¾¾çÀ¸·Î ħ¹üµÇ¾î ÃËÁøµÇ±âµµ ÇÑ´Ù(Virchow ¸²ÇÁÀý). ÇöÀç±îÁö ÃéÀå¾ÏÀÇ È¿°úÀûÀÎ Á¶±âÁø´ÜÀ» À§ÇÑ ¼±º°°Ë»ç(screening test)´Â È®¸³µÇ¾î ÀÖÁö ¾Ê´Ù. ¸î¸î Á¾¾çÇ¥ÁöÀÚ, CEA(carcinoembryonic antigen) ³ª CA19-9(carbohydrate antigen 19-9) °¡ ÃéÀå¾Ï°ú ¿¬°ü¼ºÀ» º¸À̳ª ÃéÀå¾ÏÀÇ Á¶±âÁø´ÜÀ» À§ÇÑ ¼±º°°Ë»ç·Î ÀÌ¿ëµÇ±â¿¡´Â ¹Î°¨µµ¿Í ƯÀ̵µ°¡ ³·´Ù. ÃéÀå¾ÏÀº Ãʱ⿡ Áõ»óÀÌ ¾ø°í ¼±º°°Ë»ç°¡ ¾î·Á¿ö, Áø´Ü ½ÃÁ¡¿¡¼­ ÀÌ¹Ì ÁøÇàµÈ °æ¿ì°¡ ¸¹´Ù. ÃéÀåÀÇ Á¾±«´Â ´ëºÎºÐ º¹ºÎ CT ȤÀº ÃÊÀ½ÆÄ µîÀ» ÅëÇØ ¹ß°ßµÇ¸ç, ¼¼Ä§ÈíÀΰ˻糪 Á¶Á÷°Ë»ç°¡ È®ÁøÀ» À§ÇØ ÁÖ·Î ÀÌ¿ëµÈ´Ù. ÃÊÀ½ÆÄ ³»½Ã°æÀº ÀÛÀº º´º¯(Á÷°æ 2-3cm ÀÌÇÏ)ÀÇ ¹ß°ß°ú, ÁÖ¿ä Ç÷°üÀÇ Ä§¹ü ¿©ºÎ¿Í °°Àº ±¹¼Ò º´±â È®Àο¡ À¯¿ëÇϸç ÃÊÀ½Æij»½Ã°æÇÏ ¼¼Ä§ÈíÀμúÀ» ½ÃÇàÇÒ ¼ö ÀÖ´Ù´Â ÀåÁ¡ÀÌ ÀÖ´Ù. ³»½Ã°æ ¿ªÇ༺´ãÃé°üÁ¶¿µ¼ú(endoscopic retrograde cholangiopancreatography, ERCP) ¶ÇÇÑ ÃéÀå¾ÏÀÇ Áø´Ü¿¡ ³Î¸® »ç¿ëµÇ´Âµ¥, ƯÈ÷ Àü»êÈ­ ´ÜÃþÃÔ¿µÀ̳ª ÃÊÀ½ÆÄ °Ë»ç¿¡¼­ Á¾±«°¡ º¸ÀÌÁö ¾ÊÀ» ¶§¿¡µµ, Ãé°ü ¶Ç´Â ÃÑ´ã°üÀÇ ÇùÂøÀ̳ª Æó¼â¸¦ È®ÀÎÇÔÀ¸·Î½á ÃéÀå¾ÏÀÇ Áø´ÜÀ» °¡´ÉÇÏ°Ô ÇÑ´Ù. ÀÚ±â°ø¸í ´ãÃé°üÁ¶¿µ¼ú(magnetic resonance cholangiopancreatography, MRCP)Àº Ãé°üÀ̳ª ´ã°ü ÇüÅÂÀÇ ÇغÎÇÐÀû ±¸Á¶¸¦ ±¸ºÐÇÏ°í Ãé°ü Àüü¿¡ °ÉÃÄ ±¹¼Ò ÇùÂøÀ̳ª È®Àå µîÀÇ ¸ð¾çÀ» Àß È®ÀÎÇÒ ¼ö ÀÖ´Ù´Â Á¡¿¡¼­ CT¿¡ ºñÇØ ÀåÁ¡ÀÌ ÀÖ´Ù. °æÇÇ ¼¼Ä§ÈíÀμúÀº ¼¼Æ÷ÇÐÀû °Ë»çÀÇ ¾ç¼º·üÀÌ ³·°í, ½Ã¼ú·Î ÀÎÇØ º¹°­ ³» ¾ÏÀÇ ÆÄÁ¾ÀÌ À¯¹ßµÉ ¼ö ÀÖÀ¸¹Ç·Î ±ÙÄ¡Àû ÀýÁ¦°¡ °¡´ÉÇÏ´Ù°í ÆǴܵǴ °æ¿ì ½ÃÇàÇÏÁö ¾Ê´Â °ÍÀÌ ÁÁ´Ù. ÇÏÁö¸¸ ÃÊÀ½Æij»½Ã°æÇÏ ¼¼Ä§ÈíÀμúÀº º¹°­ ³» ¾ÏÀÇ ÀüÆÄÀ§ÇèÀÌ ³·¾Æ ÃéÀå¾ÏÀÇ Áø´Ü¿¡¼­ Á¡Á¡ ³Î¸® ½ÃÇàµÇ°í ÀÖ´Ù.

4. ÀÓ»óº´±â¿Í ¿¹ÈÄ
    • ÃéÀå¾ÏÀº Ä¡·á Àü·«¿¡ µû¶ó ÀýÁ¦°¡´ÉÇü(resectable), ±¹¼ÒÁøÇàÇü(locally advanced), ÀüÀÌÇü(metastatic)ÀÇ 3´Ü°è ÀÓ»ó º´±â·Î ±¸ºÐÇÑ´Ù. AJCC (The American Joint Committee on Cancer) TNM (Tumor, Nodes, Metastasis) ºÐ·ù¿¡ µû¸£¸é ±¹¼Ò ÁøÇàÇüÀÎ stage III°ú ÀüÀÌÇüÀÎ stage IV´Â ¼ö¼úÀÌ ºÒ°¡´ÉÇÑ º´±â·Î ºÐ·ùµÈ´Ù. ºñ·Ï AJCC º´±â¿¡ ±Ù°ÅÇÏ¿© ¼ö¼ú Ä¡·á °¡´É¼º¿¡ ´ëÇÑ »ó´çÇÑ ÇÕÀÇ°¡ ÀÌ·ç¾î Áø °ÍÀº »ç½ÇÀ̳ª ƯÈ÷ ÃéµÎºÎ³ª üºÎ¾ÏÀÇ °æ¿ì ÁÖº¯ Ç÷°ü ħ½À Á¤µµ¿¡ µû¶ó °æ°è¼º ÀýÁ¦°¡´ÉÇü ÃéÀå¾Ï(borderline resectable pancreatic cancer, BRPC) Àӻ󺴱⸦ »õ·Ó°Ô ±ÔÁ¤ÇÏ°í ÀÖ´Ù. º¸Åë »óÀå°£µ¿¸Æ(superior mesenteric artery, SMA)°ú º¹°­µ¿¸Æ(celiac artery, CA)¿¡ Á¾¾çÀÌ Ä§¹üµÈ °æ¿ì T4º´±â¿¡ ÇØ´çÇÏ¿© ±¹¼ÒÁøÇàÇüÀ¸·Î °£ÁֵǾú´Ù(±×¸² 1). ÇÏÁö¸¸ ÃÖ±Ù¿¡´Â µ¿¸Æ Àç°Ç¼úÀ» °áÁ¤Áþ´Â Á¾¾ç ¸Â´êÀ½ Á¤µµ(180µµ ±âÁØ)¿¡ µû¶ó Á¾¾ç ÀýÁ¦°¡´É¼º ºÐ·ù¿¡ ´ëÇØ BRPCÀÇ °³³äÀÌ ¼Ò°³µÇ¾ú´Ù. BRPCÀÇ Á¤È®ÇÑ ±ÔÁ¤¿¡ ´ëÇؼ­´Â ¿¬±¸ ±×·ì¸¶´Ù ¾à°£ÀÇ ÀÌ°ßÀÌ ÀÖ´Ù. SMAÀÇ °æ¿ì °ÅÀÇ ´ëºÎºÐ ¿¬±¸ ±×·ì¿¡¼­ 180µµ ¹Ì¸¸ÀÇ ¸Â´êÀ½ÀÌ ÀÖ´Â °æ¿ì BRPC·Î ±ÔÁ¤ÇÏ°í ÀÖ°í CA °æ¿ì¿¡´Â ¿¬±¸ ±â°ü¸¶´Ù Á¶±Ý¾¿ ´Ù¸¥ ±ÔÁ¤À» º¸ÀδÙ. ´ëºÎºÐ ¼ö¼úÀû Ä¡·á °¡´É¼ºÀ» °í·ÁÇÏ¿© ¿µ»ó Áø´Ü¿¡ ±Ù°ÅÇÑ ÇغÎÇÐÀûÀÎ °ßÇØ°¡ ÁÖ·Î ¹Ý¿µµÇ¾úÁö¸¸ ÀϺΠ¿¬±¸ ´Üü¿¡¼­´Â ºñÇغÎÇÐÀû ±âÁصµ Æ÷ÇÔÇÏ°í ÀÖ´Ù.


      ±×¸² 1. ÃéÀå¾ÏÀÇ º´±â(Pancreatic cancer staging. AJCC 7th edition)

      ÇöÀç Àüü ÃéÀå¾Ï ȯÀÚÀÇ 10-20%¸¸ÀÌ Áø´Ü ´ç½Ã ¼ö¼úÀû ÀýÁ¦°¡ °¡´ÉÇϸç ÀÌ °æ¿ì 13~20°³¿ùÀÇ Áß¾Ó »ýÁ¸±â°£À» º¸ÀδÙ. ¸¹Àº ȯÀÚµéÀº Áø´Ü ½Ã ÀüÀÌ°¡ Á¸ÀçÇÏ¸ç »ýÁ¸±â°£ÀÌ 3~6°³¿ù Á¤µµ·Î ¸Å¿ì ºÒ·®ÇÑ ¿¹Èĸ¦ º¸ÀδÙ. ±×¸®°í ÀüÀ̼º º´º¯ÀÌ ¾øÀÌ ±¹¼ÒÀûÀ¸·Î ±¹ÇÑµÈ ¾Ï º´º¯À» º¸À̳ª ¼ö¼úÀûÀÎ ÀýÁ¦°¡ ºÒ°¡´ÉÇÑ °æ¿ì, ±¹¼Ò ÁøÇ༺ ÃéÀå¾Ï(locally advanced pancreatic cancer)À̶ó Çϸç ÀüÀ̼º(metastatic) ÃéÀå¾Ï°ú ÇÔ²² ¼ö¼úÀÌ ºÒ°¡´ÉÇÑ ÁøÇ༺ ÃéÀå¾ÏÀ¸·Î Á¤ÀÇÇÒ ¼ö ÀÖ´Ù. ¿ì¸®³ª¶ó º¸°Çº¹ÁöºÎ Åë°èÀÚ·á¿¡ µû¸£¸é ÃéÀå¾ÏÀÇ 5³â »ýÁ¸·üÀÌ 8.7%·Î ¾Ë·ÁÁ® ÀÖÁö¸¸ Àü ¼¼°èÀûÀ¸·Î´Â 5³â »ýÁ¸·üÀÌ 5% ¹Ì¸¸ÀÌ°í, ±ÙÄ¡Àû ÀýÁ¦¼ú ÈÄ¿¡µµ 5³â »ýÁ¸·üÀÌ ¾à 10-20% ¹Û¿¡ µÇÁö ¾Ê´Â °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù.

5. Ä¡·á

    • 1) 1±â, 2±â ÀýÁ¦°¡´ÉÇü ÃéÀå¾Ï

    • (1) ¼ö¼ú


      ÃéÀå¾ÏÀÇ Ä¡·á´Â ¼ö¼úÀû ÀýÁ¦¸¦ ÅëÇÑ ¿Ü°úÀû ¼ö¼úÀÌ, ¿ÏÄ¡¸¦ ±â´ëÇÒ ¼ö ÀÖ´Â À¯ÀÏÇÑ Ä¡·á¹ýÀÌ´Ù. 1±â ȤÀº 2±âÀÇ ÃéÀå¾Ï¿¡¼­´Â °¡´ÉÇÑ °æ¿ì ¼ö¼úÀû Ä¡·á°¡ ¿ì¼± °í·ÁµÇ¾î¾ß Çϸç, ÃéÀå¾ÏÀÇ ÀýÁ¦ °¡´É¼º¿¡ ¿µÇâÀ» ÁÖ´Â ÀÎÀÚ¿¡ ´ëÇÑ È®ÀÎÀÌ ÇÊ¿äÇÏ´Ù. ±¹¼ÒÇ÷°ü ħ¹üÀ̳ª º¹°­µ¿¸Æ(celiac artery), Àå°£¸· µ¿¸Æ°ú Á¤¸Æ(superior mesenteric artery & vein), °£¹®¸Æ(portal vein), °£µ¿¸Æ(hepatic artery)ÀÇ Ä§¹ü ¿©ºÎ µîÀÌ ÀýÁ¦°¡´É¼º°ú ¹ÐÁ¢ÇÑ ¿¬°üÀÌ ÀÖÀ¸¸ç, ƯÈ÷ µ¿¸ÆÀÇ Ä§¹üÀÌ ÀÖ´Â °æ¿ì ¼ö¼úÀû Ä¡·áÀÇ °¡´É¼ºÀÌ ³·¾ÆÁø´Ù.
      ÃéÀå¾ÏÀÇ ¼ö¼úÀû Ä¡·á´Â Á¾¾çÀÇ À§Ä¡¿¡ µû¶ó ¼ö¼ú ¼ú±â°¡ ´Þ¶óÁö°Ô µÇ´Âµ¥, ÃéÀå µÎºÎ¾ÏÀº Ãé½ÊÀÌÁöÀåÀýÁ¦¼ú(pancreaticoduodenectomy), ÃéÀå üºÎ¾Ï ¹× ¹ÌºÎ¾ÏÀÇ °æ¿ì ºñÀåÀýÁ¦¼úÀ» Æ÷ÇÔÇÑ ¿øÀ§ºÎ ÃéÀåÀýÁ¦¼ú(distal pancreatectomy)ÀÌ ½ÃÇàµÈ´Ù. ÃéÀå µÎºÎ¾Ï¿¡ ºñÇØ ÃéÀå ¹ÌºÎ¾ÏÀÌ ¼ö¼úÀû Ä¡·á°¡ ¿ëÀÌÇÏ°í º¹°­°æÀ» ÅëÇÑ Á¢±Ù µîµµ °¡´ÉÇÏ¿© ÁÁÀº ¿¹Èĸ¦ ±â´ëÇÒ ¼ö ÀÖÀ¸³ª, Á¶±â¿¡ ¹ß°ßµÇ´Â °æ¿ì°¡ Àû¾î ¼ö¼úÀû Ä¡·á°¡ °¡´ÉÇÑ °æ¿ì´Â µå¹°´Ù. ¼ö¼úÀû Ä¡·á°¡ °¡´ÉÇÑ °æ¿ì´Â Àüü ȯÀÚÀÇ 15-20%¿¡ ºÒ°úÇÏ´Ù. ¸²ÇÁÀý ÀüÀÌ°¡ ¾ø°í Á¾¾çÀÇ Å©±â°¡ 3cm ¹Ì¸¸À̸ç ÀýÁ¦¸éÀÌ À½¼ºÀÎ °æ¿ì, Á¶Á÷ÇÐÀû ºÐÈ­µµ°¡ °íºÐÈ­ÀÎ °æ¿ì ´õ ÁÁÀº ¿¹Èĸ¦ º¸ÀδÙ.


      (2) ¼ö¼ú ÈÄ º¸Á¶Ä¡·á(Adjuvant Therapy)


      ±ÙÄ¡Àû ÀýÁ¦¼úÀ» ½ÃÇà ¹ÞÀº ȯÀÚ¿¡¼­ º¸Á¶ Ä¡·áÀÇ À¯¿ë¼º¿¡ ´ëÇؼ­´Â ¾ÆÁ÷ ³í¶õÀÌ ÀÖ´Ù. ÇÏÁö¸¸ ÃéÀå¾ÏÀº ¼ö¼úÀû Ä¡·á¸¸À¸·Î´Â ºÒ·®ÇÑ ¿¹Èĸ¦ º¸ÀÌ´Â °æ¿ì°¡ ¸¹°í ¼ö¼ú ÈÄ Á¶Á÷°Ë»ç¿¡¼­ ¸²ÇÁÀý ÀüÀÌ°¡ ÀÖ´Â °æ¿ì 5³â »ýÁ¸À²ÀÌ ¾à 10%¿¡ ºÒ°úÇÏ¿© ÀÓ»óÀûÀ¸·Î´Â ¼ö¼ú ÈÄ º¸Á¶Ä¡·á°¡ ¸¹Àº °æ¿ì¿¡¼­ °í·ÁµÈ´Ù. ÃéÀå¾ÏÀÇ º¸Á¶Ä¡·á´Â ¿ø°ÝÀüÀÌÀÇ À§ÇèÀ» °¨¼Ò½ÃÅ°´Â Àü½ÅÇ×¾ÏÈ­ÇÐÄ¡·á¿Í ±¹¼ÒÀç¹ßÀÇ À§ÇèÀ» °¨¼Ò½ÃÅ°´Â ¹æ»ç¼± Ä¡·á°¡ Æ÷ÇԵȴÙ. ÇÏÁö¸¸ Àü½ÅÇ×¾ÏÈ­ÇÐÄ¡·áÀÇ È¿°ú¿¡ ´ëÇؼ­´Â ¿©·¯ ¿¬±¸¸¦ ÅëÇØ ±× È¿°ú¿Í Á߿伺ÀÌ ÀÔÁõµÇ¾úÁö¸¸, ¹æ»ç¼± Ä¡·áÀÇ È¿°ú¿¡ ´ëÇؼ­´Â ¾ÆÁ÷ ³í¶õÀÌ ¸¹´Ù. ÃéÀå¾ÏÀÇ º¸Á¶Ä¡·á·Î½áÀÇ Ç×¾ÏÈ­ÇÐÄ¡·á´Â gemcitabine ȤÀº fluorouracil ÀÌ Àüü »ýÁ¸À²À» ³ôÀ̴µ¥ È¿°úÀûÀÎ °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù.
      ¼ö¼ú Àü Æò°¡¿¡¼­ ¸²ÇÁÀýÀÇ ¾ç¼º¼Ò°ßÀ» º¸ÀÌ´Â °æ¿ì°¡ ¸¹°í ÀÎÁ¢ Àå±â ¹× Ç÷°üÀÇ Ä§¹ü¿©ºÎ µîÀ¸·Î ÀÎÇØ ¼ö¼úÀû Ä¡·á°¡ ¿ëÀÌÇÏÁö ¾Ê´Â »óÅ°¡ ¸¹¾Æ ÀÌ¿¡ ´ëÇÑ »õ·Î¿î Á¢±Ù¹ýÀ¸·Î ¼ö¼ú Àü Ç×¾ÏÈ­Çпä¹ý(neoadjuvant chemotherapy) µîÀÇ Á߿伺ÀÌ ´ëµÎµÇ°í ÀÖ´Ù. ÃÖ±Ù Ç×¾ÏÁ¦ÀÇ ¹ß´Þ µî¿¡ ÈûÀÔ¾î º¹ÇÕÇ×¾ÏÈ­Çпä¹ýÀ» ÅëÇÑ ¿¬±¸ ¹× Ä¡·á°¡ ½ÃµµµÇ°í Àִµ¥, ±× Áß ´ëÇ¥ÀûÀÎ °ÍÀ¸·Î´Â fluorouracil, irinotecan, oxaliplatin, ¹× leucovorin À» ÀÌ¿ëÇÑ FOLFIRINOX regimenÀÌ ÀÖÀ¸¸ç, gemcitabine °ú albumin bound paclitaxel particles (nab-paclitaxel) À» ÅëÇÑ ¼ö¼ú Àü/ÈÄ Ç×¾ÏÈ­ÇÐÄ¡·áµµ ÁÁÀº È¿°ú¸¦ º¸ÀÌ°í ÀÖ´Ù.


    • 2) °æ°è¼º ÀýÁ¦°¡´ÉÇü ÃéÀå¾Ï


    • ºñ·Ï ¼ö¼ú Àü º¸Á¶Ä¡·á¿Í ¼ö¼ú ÈÄ º¸Á¶Ä¡·á¸¦ ÀüÇâÀûÀ¸·Î ºñ±³ÇÑ ÀÓ»ó 3»ó ¿¬±¸µéÀº ¾øÁö¸¸ ¿©·¯ ÈÄÇâÀû ¿¬±¸µé¿¡¼­´Â BRPC º´±â¿¡¼­ ¼ö¼ú Àü º¸Á¶Ä¡·á°¡ º¸´Ù È¿°úÀûÀÓÀ» ½Ã»çÇÏ°í ÀÖ´Ù. ´ëºÎºÐÀÇ ÃéÀå¾Ï ȯÀÚ¿¡¼­´Â ÀÌ¹Ì Áø´Ü ´ç½Ã¿¡ Çö¹Ì°æÀû ÀüÀ̸¦ °®°í ÀÖ´Ù°í º¸°íÇÏ°í ÀÖ´Ù. ¼ö¼ú Àü º¸Á¶Ä¡·á¸¦ ½ÃÇàÇÒ °æ¿ì °üÂû ±â°£À» Á¦°øÇÒ ¼ö ÀÖÀ¸¹Ç·Î Ãʱâ Àẹ ÀüÀÌ(occult metastasis)¸¦ ¹ß°ßÇÒ ¼ö ÀÖ°í ºÒÇÊ¿äÇÑ ¼ö¼úÀ» ÇÇÇÒ ¼ö ÀÖ´Ù. ¶ÇÇÑ Ãʱ⿡ ¼ö¼úÀû Ä¡·á¸¦ ¿ì¼± ½ÃÇàÇÑ È¯ÀÚÀÇ °æ¿ì ¾à 20%°¡·®¿¡¼­ ¼ö¼ú ÈÄ ÇÕº´Áõ°ú ´õµò ȸº¹·Â, ¶Ç´Â ÀüÀÌ·Î ÀÎÇØ ¼ö¼ú ÈÄ Ç×¾ÏÄ¡·á¸¦ ¹ÞÁö ¸øÇÏ´Â °ÍÀ» °í·ÁÇÒ ¶§ ¼ö¼ú Àü º¸Á¶Ä¡·á°¡ º¸´Ù ÇÕ¸®ÀûÀÎ Ä¡·á ¹æ¾ÈÀ¸·Î ÀÎÁ¤¹Þ°í ÀÖ´Ù. ¶ÇÇÑ, BRPC ȯÀÚÀÇ ÈÄÇâÀû ºñ±³¿¬±¸ °á°ú ¼ö¼ú Àü º¸Á¶Ä¡·á ÈÄ¿¡ ¼ö¼úÄ¡·á¸¦ ¹ÞÀº ȯÀÚ±º¿¡¼­ ¼ö¼ú´Ü¸é¿¡ Á¾¾ç¼¼Æ÷ ¾ç¼º·üÀÌ ÈξÀ ³·¾Ò´Ù´Â °á°úµµ ¼ö¼ú Àü º¸Á¶Ä¡·áÀÇ ÇÕ¸®¼ºÀ» µÞ¹ÞħÇÏ°í ÀÖ´Ù.

      ¼ö¼ú Àü º¸Á¶¿ä¹ý¿¡ ´ëÇÑ Ä¡·á ¼ø¼­(treatment sequencing)´Â Å©°Ô 1) Ç×¾ÏÈ­Çпä¹ý ÈÄ Ç×¾ÏÈ­Çйæ»ç¼±Ä¡·á ÈÄ ¼ö¼ú, 2) Ç×¾ÏÈ­Çйæ»ç¼±Ä¡·á ÈÄ ¼ö¼ú, 3) Ç×¾ÏÈ­Çпä¹ý ÈÄ ¼ö¼ú, 4) Ç×¾ÏÈ­Çйæ»ç¼±Ä¡·á ÈÄ Ç×¾ÏÈ­Çпä¹ý Áö¼Ó ¹æ¹ýÀÌ Àִµ¥, ÇöÀç±îÁö´Â Ä¡·á ¼±Åÿ¡ µû¸¥ ºñ±³ ¿ìÀǸ¦ Áõ¸íÇÒ ¸¸ÇÑ ¹«ÀÛÀ§ ºñ±³ ¿¬±¸¿¡ ´ëÇÑ ÀÚ·á´Â ¾ø´Â ½ÇÁ¤ÀÌ´Ù.


    • 3) 3±â, 4±â ÃéÀå¾Ï

    • (1) Àü½ÅÇ×¾ÏÈ­ÇÐÄ¡·á


      ±¹¼ÒÁøÇàÇü ¶Ç´Â ÀüÀ̸¦ º¸ÀÌ´Â ¼ö¼ú ºÒ°¡´ÉÇÑ º´±âÀÇ ÃéÀå¾ÏÀº Àü½ÅÇ×¾ÏÈ­ÇÐÄ¡·á°¡ Ä¡·áÀÇ ±Ù°£À» ÀÌ·ç°í ÀÖ°í °¢ Ç×¾ÏÁ¦ÀÇ È¿´É°ú È¿°úÀûÀÎ ¾àÁ¦ Á¶ÇÕ¿¡ ´ëÇÑ ¿¬±¸°¡ ´Ù¼ö ÁøÇàµÇ°í ÀÖ´Ù. Áö±Ý±îÁöµµ gencitabineÀÌ Ç¥ÁØ Ä¡·áÁ¦·Î ÀÎÁ¤¹Þ°í ÀÖ°í gemcitabine °ú erlotinibÀÇ º´ÇÕ¿ä¹ýÀÌ ÀϺΠȯÀڵ鿡°Ô È¿°úÀûÀÎ °ÍÀ¸·Î ¾Ë·ÁÁ® ÀÖ´Ù.

      ´Ù¹ß¼º ÀüÀ̸¦ µ¿¹ÝÇÑ 4±â ÃéÀå¾ÏÀÇ °æ¿ì, ÅëÁõ Á¶Àý ¹× ¿µ¾ç °ø±Þ µîÀÇ ÁöÁö¿ä¹ý(supportive care)ÀÌ Áß¿äÇϸç, ȯÀÚ°¡ È£¼ÒÇÏ´Â Áõ»ó¿¡ ´ëÇÑ ´ëÁõ Ä¡·á¸¦ ½ÃÇàÇÔÀ¸·Î½á ȯÀÚÀÇ °íÅëÀ» °æ°¨ ½ÃÅ°°íÀÚ ÇÏ´Â ³ë·ÂÀÌ ÇÊ¿äÇÏ´Ù. ÀÌÀü ¿¬±¸¿¡¼­´Â fluorouracilÀ» ±âº»À¸·Î ÇÑ Ç×¾ÏÈ­ÇÐÄ¡·á°¡ ÁöÁö¿ä¹ý¸¸À» ½ÃÇàÇÑ È¯ÀÚ¿¡ ºñÇØ 3°³¿ù Á¤µµÀÇ »ýÁ¸¿¬Àå¿¡ È¿°úÀûÀ̾ú´Ù´Â º¸°í°¡ ÀÖÀ¸¸ç, gemcitabine °ú fluorouracil ÀÇ º´ÇÕ¿ä¹ý µîµµ µµ¿òÀÌ µÈ´Ù´Â ¿¬±¸°¡ ÀÖ´Ù. ÃÖ±Ù¿¡´Â FOLFIRINOX regimen À̳ª gemcitabine°ú nab-paclitaxelÀÇ º´ÇÕ¿ä¹ý µîÀÇ È¿°ú°¡ ¹ßÇ¥µÇ¾úÀ¸¸ç »ýÁ¸±â°£ Áõ°¡ ¹× »îÀÇ Áú Çâ»ó µî¿¡µµ ÁÁÀº È¿°ú¸¦ º¸°íÇÏ¿´´Ù. ÁøÇ༺ ÃéÀå¾Ï¿¡¼­ ÀÌÀü¿¡´Â 2³â ÀÌ»óÀÇ »ýÁ¸ÀÌ ±ØÈ÷ µå¹°¾úÀ¸³ª, ÀÌ·¯ÇÑ Ä¡·á¸¦ ¹ÞÀº ȯÀÚ¿¡¼­ ¾à 10% ¿¡¼­´Â 2³â ÀÌ»óÀÇ »ýÁ¸À» ±â´ëÇÒ ¼ö ÀÖ¾ú´Ù°í ÇÑ´Ù. µû¶ó¼­ ¼ö¼úÀÌ ºÒ°¡´ÉÇÑ ÁøÇàµÈ ÃéÀå¾ÏÀÇ Ä¡·á¿¡¼­µµ ÀûÀýÇÑ Ç×¾ÏÈ­ÇÐÄ¡·á¸¦ ÅëÇØ ÁÁÀº ¿¹Èĸ¦ ±â´ëÇÒ ¼ö ÀÖ´Ù. ÇÏÁö¸¸, ÀÌ·¯ÇÑ Ä¡·áÀÇ ÀÓ»ó Àû¿ë¿¡¼­ ºñ¿ëÀûÀÎ Ãø¸é°ú ºÎÀÛ¿ë µîÀÇ Ãø¸éµµ ÇÔ²² °í·ÁÇØ¾ß ÇÏ´Â ¹®Á¦°¡ ÀÖ´Ù. ÃÖ±Ù¿¡ °³¹ßµÈ ¾àÁ¦ Áß¿¡ ±¹³»¿¡¼­ ÃéÀå¾Ï Ä¡·áÁ¦·Î ½Ä¾àó Ç°¸ñÇã°¡¸¦ ¹ÞÀº ¸®¾Æ¹é½º(RIAVAX, GV1001)¶ó´Â ÅڷθӶóÁ¦(telomerase) À¯·¡ ÆéŸÀÌµå ¹é½ÅÀÌ ÀÖ´Ù. ¸®¾Æ¹é½º¿¡ ´ëÇÑ ¹ÝÀÀÀº ȯÀÚÀÇ Ç÷Áß ÀÌ¿ÀŹ½Å(eotaxin) ¼öÄ¡¿Í ¹ÐÁ¢ÇÑ °ü°è°¡ ÀÖÀ¸¸ç, ÀÌ¿ÀŹ½Å ¼öÄ¡°¡ ³ôÀº °æ¿ì »ýÁ¸À² ¶ÇÇÑ Áõ°¡ÇÏ´Â °ÍÀ¸·Î º¸°íÇÏ°í ÀÖ´Ù. ÃéÀå¾ÏÀÇ ¹ß»ý¿¡ ±â¿©ÇÏ´Â ´Ù¾çÇÑ ºÐÀÚ »ý¹°ÇÐÀû ±âÀüµéÀÌ ¹àÇôÁü¿¡ µû¶ó ÃÖ±Ù¿¡´Â ¼¼Æ÷µ¶¼º ½Å¾à(cytotoxic new drugs), Á¾¾ç ¼¼Æ÷ °ü·Ã Ç¥Àû Ä¡·áÁ¦(cancer cell related target agents), Á¾¾ç ±âÁú(cancer stroma) Ç¥Àû ¾à¹° ¹× ¸é¿ª Ä¡·áÁ¦ µîÀÇ »õ·Î¿î ¾à¹°µéÀÌ È°¹ßÇÏ°Ô °ËÁõµÇ°í ÀÖ´Ù. ±×·¯³ª ÁøÇ༺ ÃéÀå¾ÏÀ» ´ë»óÀ¸·Î ÇÏ´Â ´ëºÎºÐÀÇ ½Å¾à Àӻ󿬱¸´Â ¾ÆÁ÷±îÁö ÀÇ¹Ì ÀÖ´Â °á°ú¸¦ º¸ÀÌÁö ¸øÇÏ°í ÀÖ´Ù.


      (2) ±¹¼Ò ÁøÇàÇü ÃéÀå¾Ï¿¡¼­ ±¹¼Ò Ä¡·á


      ¿­À̳ª ·¹ÀÌÀú¸¦ ÀÌ¿ëÇÑ ±¹¼Ò Á¾¾ç Á¦°Å¼úÀº ¿©·¯ °íÇü¾Ï Ä¡·á¿¡ ¸¹ÀÌ ÀÌ¿ëµÇ°í ÀÖ´Ù. ÃéÀå¾Ï¿¡ ´ëÇÑ ÀÌ·¯ÇÑ ±¹¼Ò Ä¡·á´Â Ãʱ⠿¬±¸ °á°ú Áß¿ä ÇÕº´Áõ ¹ß»ý°ú »ç¸Á·ü·Î ÀÎÇØ ³Î¸® ÀÌ¿ëµÇÁö ¸øÇÏ¿´´Ù. ÇÏÁö¸¸ ÃÖ±Ù µé¾î °íÈ­ÁúÀÇ ¿µ»ó±â¹ý°ú ³»½Ã°æ ¼ú±âÀÇ ¹ß´Þ, ´Ù¾çÇÑ Àû¿ë¿¡ ´ëÇÑ ½Ã¼ú °³¼±ÀÌ ÀÌ·ç¾îÁö¸é¼­ ÃéÀå¾Ï ±¹¼ÒÄ¡·á¿¡ ´ëÇÑ °ü½ÉÀÌ °íÁ¶µÇ°í ÀÖ´Ù. Áø´Ü ½Ã ¼ö¼úÄ¡·á·Î ¿ÏÄ¡°¡ °¡´ÉÇÑ ÃéÀå¾Ï ȯÀÚ°¡ ¸Å¿ì Àû°í ´ëºÎºÐ Ç×¾ÏÁ¦ Ä¡·á ¹ÝÀÀÀÌ Á¦ÇÑÀûÀ̶ó´Â Á¡ µîÀº »õ·Î¿î ±¹¼Ò Ä¡·á¿¡ ´ëÇÑ °¥¸ÁÀ» °®°Ô ÇÏ¿´´Ù. ÃÖ±Ù±îÁö º¸°íµÈ ¹®ÇåµéÀ» Âü°íÇØ º¼ ¶§ ¾ÆÁ÷ ÃéÀå¾Ï¿¡ ´ëÇÑ ±¹¼ÒÄ¡·á´Â ÁÖ·Î ÀýÁ¦ ºÒ°¡´ÉÇÑ ±¹¼Ò ÁøÇàÇü ÃéÀå¾Ï¿¡¼­ ½ÃµµµÇ°í ÀÖ´Ù. ÇöÀç ÀÓ»ó ¿¬±¸°¡ È°¹ßÈ÷ ÁøÇàµÇ°í ÀÖ´Â ±¹¼Ò Ä¡·á´Â ¿­À» ÀÌ¿ëÇÑ °íÁÖÆÄ ¼ÒÀÛ¼ú(radiofrequency ablation, RFA), ·¹ÀÌÀú¸¦ ÀÌ¿ëÇÑ ±¤¿ªÇÐÀû ¿ä¹ý(photodynamic therapy, PDT)°ú °í°­µµ Áý¼Ó ÃÊÀ½ÆÄ(high intensity focused ultrasound, HIFU) ¹× ºñ°¡¿ªÀû Àü±âõ°ø¼ú(irreversible electroporation, IRE) µîÀÌ ÀÖ´Ù.

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