췌장두부암의 주변 절제연에 대한 평가: 0 mm 대 1 mm R1 절제연 규칙을 비교한 전향적 연구

학위논문(석사) -- 서울대학교대학원 : 의과대학 의학과, 2022.2. 윤유석.Background: Although microscopic residual disease (R1 resection) has been reported as an independent prognostic factor for pancreatic ductal adenocarcinoma (PDAC), the prognostic significance of R1 resection for PDAC has varied in the literature. The numerous variations may be due to the following reasons: 1) a lack of consensus on the definition of R1 resection (1 mm rule vs. 0 mm rule), 2) a lack of consensus on the definition of various resection margins and surfaces (e.g. anterior, posterior, superior mesenteric vein/portal vein [SMV/PV] and superior mesenteric artery [SMA]), and 3) various grossing techniques in the pathology laboratory where pancreaticoduodenectomy (PD) specimens are being studied and analyzed. Materials and Methods: We performed a prospective clinicopathological analysis of 111 cases of PDACs that were resected via PD. These specimens included those with venous resection (n = 36) and those without (n = 75). These patients underwent PD between March 2014 and December 2018 at the Seoul National University Bundang Hospital. All circumferential margin/surface of the pancreas (anterior, posterior, SMV/PV groove, and SMA), pancreatic neck margin, bile duct margin, and intestinal margins were painted using standardized ink color codes and were sectioned via the axial slicing method. The entire pancreatic head was submitted for histopathological mapping, and the safety margins for all margin/surface were recorded in millimeters. The patients were followed up for up to 69 months (median: 23 months), and the margin status was correlated with the patient outcome, including overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and post-operative complications. Moreover, surfaces were classified into either anterior or posterior, whereas resection margins were classified into pancreatic neck, SMV/PV groove, or SMA margins. Results: Of the 111 specimens, 26 (23.4%) and 91 (82.0%) were regarded as R1 by the 0 mm rule and the 1 mm rule, respectively. Female sex (p = 0.035, hazard ratio [HR] = 1.853, 95% confidence interval [CI] = 1.043-3.291), histologic differentiation (moderate and poorly differentiated) (p = 0.004, HR 3.061, 95% CI = 1.427-6.570), and 0 mm R1 in resection margin (p = 0.001, HR = 3.178, 95% CI = 1.628-6.203) were identified as independent risk factors for OS. For DFS, only 0 mm R1 in resection margin [p = 0.013, HR = 3.595, 95% CI = 1.308-9.885) was an independent prognostic factor. When each circumferential margin/surface was analyzed using the recurrence rate by the 0 mm and 1 mm rules, the pancreas neck margin was involved in 5 (4.5%) and 12 (10.8%) cases; the anterior surface was involved in 3 (2.7%) and 35 (31.5%) cases; the posterior surface was involved in 8 (7.2%) and 43 (38.7%) cases; the SMV/PV groove was involved in 15 (13.5%) and 74 (66.7%) cases; and the SMA margin was positive in 8 (7.2%) and 38 (34.2%) cases; and any margin was positive in 26 (23.4) and 91 (82.0) cases, respectively. The presence of SMA margin involvement was significantly associated with local recurrence after surgery, if the 0 mm (p = 0.036) rule was applied. Conclusion: A positive margin defined by the 0 mm rule was an independent risk factor for OS and DFS. An R1 SMA margin was associated with an increased risk of local recurrence rather than systemic recurrence. In comparison, a positive margin by the 1 mm rule was not associated with OS and DFS. These findings suggest that the 0 mm rule is more appropriate in predicting recurrence and survival than 1 mm rule. To confirm our findings, a well-designed large-scale study is needed.배경: 현미경적 잔존암 (R1 절제)은 췌관선암 (PDAC)의 독립적인 예후 인자로 보고되었지만 췌관선암에 대한 R1 절제의 의미는 다음과 같은 이유로 다양하다. 1) R1 절제의 정의에 대한 합의 부족(1 mm 규칙 대 0 mm 규칙), 2) 다양한 절제 변연 및 표면(예: 전방, 후방, 상부 장간막 정맥/간문맥 (SMV/PV) 및 상부 장간막 동맥(SMA)), 및 3) 췌장 십이지장 절제술 표본에 대한 병리학 실험실의 다양한 육안적 병리 소견. 대상 및 방법: 2014년 3월부터 2018년 12월까지 분당서울대학교 병원에서 췌십이지장절제술과 혈관절제를 같이 시행한 경우(n=36) 또는 시행하지 않은 경우(n=75)의 췌관선암 111예를 대상으로 전향적 임상병리학적 분석을 시행하였다. 췌장의 모든 절제 변연 및 표면 (전방, 후방, SMV/PV, SMA, 췌장 경부), 담관 가장자리 및 십이지장 경계는 표준화된 잉크로 도색되었으며, 축 절단 방법으로 절단되었다. 전체 췌장 두부는 조직병리학적 매핑을 위해 수집 및 구분되었으며 모든 경계/표면에 대한 안전연은 밀리미터로 기록되었다. 환자들은 최대 69개월(중앙값: 23개월) 동안 추적 관찰되었으며, 절제 변연 및 표면 상태는 전체 생존(OS), 무병 생존(DFS), 무국소재발 생존(LRFS), 무원발전이 생존(DMFS) 및 수술 후 합병증을 포함한 환자 결과와 상관관계를 분석하였다. 절제 표면은 전방 표면, 후방 표면으로 정의하였고, 절제 변연은 췌장 경부 변연, SMV/PV 변연, SMA 변연으로 정의하였다. 결 과: 111개의 증례 중 26명/111명 (23.4%)의 경우가 0 mm 규칙에 의한 R1이었고 R1 비율은 1 mm 규칙에 의해 91명/111명 (82.0%)으로 증가하였다. 여성 [P=0.035, HR 1.853 (95% CI 1.043-3.291)], 세포 분화도 (중등도분화도, 저분화도) [P=0.004, HR 3.061 (95% CI 1.427-6.570)], and 0 mm 규칙에 의한 절제 변연 양성인 경우가 [P=0.001, HR 3.178 (95% CI 1.628-6.203)] OS의 독립 예후 인자였다. DFS의 경우, 0 mm 규칙에 의한 절제 변연이 포함된 경우 [P=0.013, HR 3.595 (95% CI 1.308-9.885)] 만이 독립 예후 인자였다. 0 mm, 1 mm 규칙으로 각 주변 절제 변연 및 표면별 재발율을 분석한 결과, 췌장 경부 변연 5명 (4.5%), 12명 (10.8%), 전방 표면 3명 (2.7%), 35명 (31.5%), 후방 표면 8명 (7.2%), 43명 (38.7%)였으며 SMV/PV 변연은 각각 15명 (13.5%)와 74명 (66.7%), SMA 변연은 각각 8명 (7.2%) 및 38명 (34.2%)에서 재발 소견을 보였다. SMA 변연 침범은 0 mm (P=0.036) 규칙에서 적용했을 때 수술 후 국소 재발과 유의한 관련이 있었다. 결 론: 절제연의 0 mm 규칙에 의한 ‘절제연 양성’은 OS와 DFS의 독립적인 위험 인자이며, SMA 변연 양성은 전신 재발이 아닌 국소 재발의 위험 증가와 관련이 있었다. 비교하면 1 mm 규칙에 의한 절제연 양성은 OS 및 DFS와 연관되지 않았다. 이러한 결과는 1 mm 규칙보다 0 mm 규칙이 재발과 생존 예측에 더 적합하다는 것을 시사한다. 위의 연구 결과를 검증하려면 적절하게 설계된 대규모 연구가 필요하다.Table of Contents Chapter 1. Introduction 1 1. Study Background 1 2. Purpose of Research 3 Chapter 2. Body 4 1. Methods 4 2. Results 9 3. Discussion 23 Chapter 3. Conclusion 27 Bibliography 28 Abstract in Korean 30석

The Effect of a Military Backpack-Supporting Device on Activity the Cervical Erector Spinae, Upper Trapezius, and Rectus Abdominis Muscles

인간공학치료학전공/석사[한글]본 연구는 군장 착용 시 요대에 부착한 군장지지대가 경부척추기립근, 상부승모근, 복직근의 근활성도에 미치는 영향을 알아보는 것이었다. 연구 대상자는 건강한 성인 남자 17명이었으며, 대상자들에게 24 kg의 군장을 메고 기립자세로 서 있도록 한 후, 요대에 부착하는 군장지지대를 착용하였을 때와 제거하였을 때의 경부척추기립근과 상부승모근, 복직근의 근활성도를 측정하였다. 각 근육의 근활성도는 표면 근전도 시스템을 이용하여 측정하였으며, 수집된 근전도 신호들은 각 근육마다 측정된 최대등척성 수축을 할 때의 근전도 신호량을 이용하여 % MVIC로 정량화하였다. 경부척추기립근과 상부승모근 그리고 복직근으로부터 측정된 군장지지대의 사용유무에 따른 근활성도의 차이는 짝비교 t-검정(paired t-test)을 이용하여 비교하였다. 군장지지대를 착용하였을 때나 제거했을 때 모두에 있어서 좌우측 간의 경부척추기립근과 상부승모근 그리고 복직근의 근활성도에는 유의한 차이가 없었다(p>0.05). 그러나 군장지지대를 착용하였을 때의 경부척추기립근과 상부승모근의 근전도 신호량은 군장지지대를 제거했을 때에 비해 유의하게 감소하였고(p0.05). 따라서 군장지지대를 사용하는 것이 경부척추기립근과 상부승모근의 근활성도가 유의하게 감소되었으므로 군장지지대가 군장의 무게로 인해 어깨에 부과되는 부하를 감소시켜 주었음을 의미한다. 앞으로는 군장지지대를 실제의 군 훈련이나 행군 시에 군장에 착용시켜 세 가지 근육의 근활성도의 변화나 경부 및 어깨의 근골격계 통증에 어떠한 효과가 있는지 알아보는 연구가 필요할 것이다. [영문]This study examined the effect of a military backpack-supporting device that is attached to a belt on the activities of the cervical erector spinae, upper trapezius, and rectus abdominis muscles while wearing a military backpack. Seventeen healthy males were recruited for this study. The activity of the cervical erector spinae, upper trapezius, and rectus abdominis muscles was measured using surface electromyography during normal alignment standing with and without the military backpack- supporting device. The muscle activity was normalized using the maximum voluntary isometric contraction(MVIC). The paired t-test was used to compare muscle activity between the conditions of with and without the military backpack-supporting device, and on both sides. The activity of the cervical erector spinae and upper trapezius muscle on both sides was significantly decreased with the military backpack-supporting device, compared to without the device(p<0.05). However, there was no significant difference in the activity of the rectus abdominis muscle between the two conditions. In addition, there was no significant difference in the activity of the cervical erector spinae, upper trapezius, and rectus abdominis muscles between the right and left sides in both conditions. This study showed that the military backpack-supporting device significantly decreased the activity of the cervical erector spinae and upper trapezius muscles. Further studies are needed to determine whether the device can prevent musculoskeletal pain related to wearing a military backpack, and to determine the effect of the military backpack- supporting device on military performance and energy consumption in a real situation.ope

일본의 아트매니지먼트 교육에 관한 연구

This study is prepared to survey the present situation of Arts Management Education in Japan. In Japan arts management was understood as the operation of cultural halls and other facilities in a narrow sense, but nowadays there is a new trend to define it as non-profit management aimed at arranging for opportunities where arts and the public meet. That is, it is very closely related to the cultural policies as a whole to improve the community"s potential ability and scientific approach to be applied to administration of cultural facilities. In this study the present situation of Arts Management Education in Japan is surveyed on three levels : 1) on the university level, 2) on the public administration level, and 3) on the private corporate level. Finally it introduce the concrete proposals which may contribute to enhancing arts management : 1) Establishment of training networks and training facilities, 2) Establishment of core locations for education and research, 3) Exploration of arts management theories, and 4) Improved understanding concerning cultural activities. Especially the third point seems to be more important than others. It is discussed to develop the possibility enhancing the contents of Arts Management Education through connecting it to the management theory for Non-profit Organization by P. F. Drucker

Situation of East-European Art: concerning on the Post socialist

In this article we will concentrate our view on the situation of the European art scene, especially the situation of East Europe around the year 1990. The reason for concentrating on this era is to explore the relationship between the development of art and the dismantling of real existing socialist countries, especially regarding the dissolution of the USSR. This task requires inevitably the approach of comparison with the concurring western system, as well as a sight on the endogenous development of the socialist system itself. The changes within the system did not suddenly occur in the 1990s but were derived from former revisions in the 1950s, following the death of Josef Stalin. Nonetheless, the radical changes of the Perestroika since 1985 finally put an end to the political system of socialism. This article, in its main part, deals with the phenomena of socialism, post-socialism, nationalism and post-modernism which evolved in the arts of East-Europe around the year 1990. These changes however are not limited to the actual art scene but can also be observed in the theoretical engagement of Aesthetics. Unfortunately the great classics of Marx, Engels and Lenin have left a lack in this particular field of interest. The late publication of The Basics of Marx-Leninist Aesthetics in 1960, which followed a vast repression from the political side, is an indication how difficult it was to develop a theory of arts in this setting. The politically distorted arts of the late socialist era can easily be regarded as a temporary phenomenon based on its particular historical and political conditions, which are now to be seen as part of the past. Even so, in the current Korean situation, where we eventually have to deal with the North-Korean version of a similar political setting, the occupation with the subject will hopefully shed some light on the future