제1회 다학제 종양 컨퍼런스 소화기 소화기내과 2010-04-19

다학제 종양 컨퍼런스의 의의 진행성암 전이와 관련되어 환자 상태에 가장 적합한 치료 결정 조기암 내시경 절제? 수술?

Case 1 C.C.) Known gastric cancer 11749094 윤O숙 (F/55) Adm. 2009.11.26 via OPD C.C.) Known gastric cancer P.I.) 55세 여자환자 내원 1달전 외부 병원에서 건강 검진상 시행한 위내시경 검사에서 조기위암 진단받고 검사와 치료위해 외래 경유 내원. PMHx.) DM/HTN/TB/Hepatitis(-/-/-/-) CVA history(+) Op. history(-) Personal history) Smoking(-) , Alcohol(-) Family history ) None O/S) 1 months ago

Case 1 Review of systems Physical examination Weight loss (-) Epigastric pain (-) A/N/V/D/C (-/-/-/-/-) Hematemesis (-), Hematochezia (-), Melena (-) Physical examination V/S) 110/80 mmHg – 78/min – 20/min – 36.8℃ Abdomen tenderness (-) Soft and flat abdomen Lab findings : unremarkable Hb 11.9 mg/dL CEA/CA19-9 : 0.54/2.15

Case 1 Gastroscopy and EUS(2009.11.26) Chest CT (2009.11.27) Abdomen CT (2009.11.23) - 외부 PET-CT (2009.11.27) ESD 시행 (2009.11.27) F/U Gastroscopy (2010.02.18) : EGC, signet ring cell STG c B-I (2010.03.19)

2009년 11월, 내시경

EUS,M2, 2009-11-26 좋은 예 나쁜 예

영상의학과 CT, abdomen CT, chest

ESD, 2009-11-27

F/U EGD, 2010-02-18

Subtotal gastrectomy, 2010-03-19

병리결과 ESD, specimen F/U EGD, Bx Op. specimen

논 의 Undifferentiated adenocarcinoma Treatment guideline Signet ring cell Poorly differentiated Treatment guideline ESD Op

Gastric Cancer 2007;10:1-11

Proposed Extended Criteria for Endoscopic Submucosal Dissection Mucosal cancer Submucosal cancer UL (-) UL (+) SM1 SM2 20 20< 30 30< Any size Differentiated Undifferentiated Depth Histology Guideline criteria for EMR Surgery Extended criteria for ESD Consider surgery Gastric Cancer 2007;10:1-11

Case 2 C.C.) Evaluation for GB malignancy 12111484 최O자 (F/73) Adm.2010.04.13 C.C.) Evaluation for GB malignancy P.I.) 73세 여자, 고혈압 외 특이병력 없던 자로 2009년 11월 조기위암 진단 후 2010년 3월 중순경 울산대 병원에서 ESD 시행, 이 당시 촬영한 복부 CT에서 R/O GB cancer 소견 보여 이에 검사와 치료 위해 내원함. PMHx.) DM/HTN/TB/Hepatitis (-/+/-/-) Op. history (-) Personal history) Smoking (-), Alcohol (-) Family history ) None

Case 2 Review of systems Physical examination Weight loss (-) Epigastric discomfort (+) Nausea (-), Vomiting (-), Diarrhea (-) Hematemesis (-), Hematochezia (-), Melena (-) Physical examination Height/Weight : 149 cm/47 kg BMI : 21.2 kg/m2 V/S) 130/80 mmHg – 66/min – 20/min – 36.3℃ Abdomen tenderness(-) Soft and flat abdomen Normoactive bowel sound

Initial lab findings CBC/DC 7,910/mm3 – 13.3 g/dL – 40.6% - 374k(55.8%) PT/INR 13.3 (0.99) aPTT 33.9 Chesmistry TB/DB 0.50/0.04 mg/dL BUN/Cr 14/0.7 mg/dL ALP/γGT 92/22 U/L AST/ALT 18/11 IU/L Na/K/Cl 142/3.9/104 mEq/L Tumor marker CEA/CA19-9 : 1.00/2.53

Evaluation 외부 Gastroscopy (2010.03.22) 외부 ESD 시행(2010.03.31) 외부 F/U gastroscopy (2010.04.01) Gastroscopy (2010.04.14) 외부 Abdomen CT(2010.03.30) Liver MRI and MRCP(2010.04.15) PET-CT(2010.04.14)

외부 내시경, 2010-03-22

외부 ESD, 2010-03-31

이전 병원 생검 병리 결과 Gross : Received in formalin is a specimen of gastric mucosectomy(2.3 x 2.0 x 0.3 cm). There is a depressed lesion(1.0 x 0.8 cm). Multisected and ESS in three blocks. Section code 1 : anterior wall and posterior wall resection margin 2-3 : serial section(anterior wall to posterior wall) Ink code : Red – proximal, anterior wall. Green – Distal Diagnosis Stomach (mid body, lesser curvature), endoscopic mucosal resection : Signet ring cell carcinoma, 1.2cm in greatest dimension with 1) confined to mucosa(involvement of muscularis mucosae) 2) No lymphovascular invasion 3) clear resection margin

EGD, 2010-04-14

영상의학과 외부 CT, abdomen MRI, liver MRCP

논 의 Synchronous double primary cancer Metastasis Early gastric cancer GB cancer Metastasis

Case 3 11629457 강O식 (M/58) Adm.2010.04.04 C.C.) 구토 P.I.) 58세 남자, 02년 교통사고로 하반신 마비상태로 지내던 자로 내원 3주전 하루 3-4회 물같은 양상의 설사와 10회 이상의 구토가 2주 이상 지속되어 이에 대해 검사와 치료 위해 응급실 경유 입원. PMHx.) DM/HTN/TB/Hepatitis(-/-/-/-) Op. history(-) Personal history) Smoking(+): 30 PYs, Alcohol(-) Family history ) None O/S) 내원 3주전

Case 3 Review of systems Physical examination Weight loss (-) Epigastric discomfort (+) Nausea (+), Vomiting (+) : 하루 10회 이상, Diarrhea(-) Hematemesis (-), Hematochezia (-), Melena (-) Physical examination Height/Weight : 165 cm/65 kg BMI : 23.8 kg/m2 V/S) 100/60 mmHg – 64/min – 20/min - 36℃ Abdomen tenderness(-) Soft and flat abdomen Both leg motor disturbance(0/0), sensory disturbance(0/0)

Initial lab findings CBC/DC 15,670/mm3 – 9.2 g/dL – 31.9% – 752k(82.4%) PT/INR 14.1(1.06) aPTT 29.3 Chesmistry TB/DB 0.71/0.22 mg/dL BUN/Cr 46/2.0 mg/dL ALP/γGT 101/13 U/L AST/ALT 19/15 IU/L Na/K/Cl 134/2.5/64 mEq/L Uric acid 14.6mg/dL Tumor marker CEA/CA19-9 : 0.77/46.38

Evaluation Gastroscopy (2010.04.05) Abdomen CT (2010.04.05) Chest CT (2010.04.06) PET-CT (2010.04.07)

EGD, 2002-12-11

EGD, 2010-04-05

영상의학과 Abdomen CT (2010.04.05) Chest CT (2010.04.06) PET-CT (2010.04.07)