건국대학교병원 소화기내과 이선영, 김정환, 성인경, 박형석, 진춘조, 최규완 호흡곤란을 주소로 내원한 74세 남자 건국대학교병원 소화기내과 이선영, 김정환, 성인경, 박형석, 진춘조, 최규완

Case presentation 이 O 근 (M/74) 주호소 숨이 차다 (내원 15일 전) 현병력 내원 15일 전부터 호흡곤란이 발생하여 의원을 방문한 결과, 왼쪽 늑막이 두꺼워졌다는 이야기를 듣고 본원 호흡기내과로 내원함. 촬영한 chest X-ray상 이상소견이 있어서 chest CT를 검사한 결과, 우연히 위내 점막하 종양이 발견되어 전과됨. 01254974 이승근

History Past history DM(-), HTN(-), Tbc(-) Family history 특이소견 없음 Social history 술 – 소주 1-2병, 주 4회 담배 – 1 갑/일 x 50년

Review of system General weight loss 6 kg/ 6 months, fatigue (+) HEENT headache (-), dizziness (-) Chest cough (+), sputum (+), dyspnea (+), chest pain (-), palpitation (-) Abdomen anorexia (+), nausea (-), vomiting (-), diarrhea (-), constipation (-), intermittent left flank pain (+)

Physical examination Vital sign BP 116/74 mmHg, HR 98/min, RR 26/min, BT 37.6 C General alert mentality, chronic ill looking HEENT not anemic conjunctivae, anicteric sclerae Chest coarse breathing sound with crackle regular heart beat without murmur Abdomen no tenderness, no palpable mass normal bowel sound

Laboratory finding WBC – Hb – PLT 25940 - 10.5 – 336K ESR 76 mm/hr T-prot / Alb 6.3 / 2.6 g/dl T-bil / OT / PT 0.4 / 25 / 18 U/L BUN / Cr 28.8 / 3.0 mg/dl Na / K / Cl 131 / 4.0 / 96 mEq/L U/A – RBC ++, WBC +++

Chest X-ray

Chest CT

Abdomen CT

Impression #1. Gastric submucosal tumor → GIST #2. Emphysema → Interstitial pulmonary fibrosis #3. Left hydronephrosis due to stag-horn stone → Pyelonephritis

Biopsy

Surgical finding Gastric submucosal tumor가 left diaphragm와 접해 있었음. Mass와 diaphragm을 en-bloc으로 한꺼번에 제거함. Gore-tex patch를 이용해서 defect를 closure함.

Pathologic finding

Postoperative course POD 0 - extubation시행 POD 1 - 일반병동으로 전원 POD 2 - 지속적인 dyspnea로 다시 ICU care시작 POD 12 - Cr및 K상승으로 CCRT시행 POD 15 - tracheostomy시행 POD 33 - Expire due to multiorgan failure

Squamous Cell Carcinoma of the Stomach Sun-Young Lee M.D., Ph.D. Department of Internal Medicine Konkuk University College of Medicine

Squamous cell carcinoma of the stomach Only 80 cases reported up to date Male : female = 5 : 1 Peak on sixth decade 0.04 - 0.7% of gastric cancer Often associated with direct invasion of other organs High serum level of SCC-related antigen Radical surgical resection is only therapeutic option Koide N et al. J Gastroenterol 2001;36:259-263.

Primary SCC of the stomach Diagnostic criteria (Park RE. AJR 1967;101:447-449) Tumor must not be located in the cardia Tumor must not extend into the esophagus There must be no evidence of SCC in any other organ Pathogenesis - still unknown Heterotrophic squamous epithelium Squamous metaplasia of gastric vessels Multipotential stem cell Overgrowth of squamous component in primary adenocarcinoma Schmidt Ch et al. Hepato-Gastroenterology 2001;48:1033-1036.