제1회 다학제 종양 컨퍼런스 소화기 소화기내과 2010-04-19.

Presentation on theme: "제1회 다학제 종양 컨퍼런스 소화기 소화기내과 2010-04-19."— Presentation transcript:

1 제1회 다학제 종양 컨퍼런스 소화기 소화기내과

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

3 Case 1 C.C.) Known gastric cancer
윤O숙 (F/55) Adm 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

4 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

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

6 2009년 11월, 내시경

7 EUS,M2, 좋은 예 나쁜 예

8 영상의학과 CT, abdomen CT, chest

9 ESD,

10

11 F/U EGD,

12 Subtotal gastrectomy, 2010-03-19

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

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

15 Gastric Cancer 2007;10:1-11

16 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

17 Case 2 C.C.) Evaluation for GB malignancy
최O자 (F/73) Adm 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

18 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

19 Initial lab findings CBC/DC 7,910/mm3 – 13.3 g/dL – 40.6% - 374k(55.8%) PT/INR (0.99) aPTT 33.9 Chesmistry TB/DB /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

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

21 외부 내시경,

22 외부 ESD,

23 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

24 EGD,

25 영상의학과 외부 CT, abdomen MRI, liver MRCP

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

27 Case 3 강O식 (M/58) Adm 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

28 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)

29 Initial lab findings CBC/DC ,670/mm3 – 9.2 g/dL – 31.9% – 752k(82.4%) PT/INR (1.06) aPTT 29.3 Chesmistry TB/DB /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

30 Evaluation Gastroscopy (2010.04.05) Abdomen CT (2010.04.05)
Chest CT ( ) PET-CT ( )

31 EGD,

32 EGD,

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