림프절 종대를 주소로 내원한 70세 위암 과거력 환자

Presentation on theme: "림프절 종대를 주소로 내원한 70세 위암 과거력 환자"— Presentation transcript:

1 림프절 종대를 주소로 내원한 70세 위암 과거력 환자
MGR 림프절 종대를 주소로 내원한 70세 위암 과거력 환자 R2 진상욱

2 권O락 M/70 Admission on Chief Complaint onset : 2006년 1월경 abdominal pain Present Illness 2000년 9월 삼성의료원에서 위암 진단 받고 위절제술 및 항암화학요법 (UFT) 1년간 시행 받았으며 이후 완전 관해 상태로 외래에서 경과 관찰해오던 환자로 2006년 1월경부터 발생한 식사시의 간헐적인 복통으로 시행한 PET-CT에서 multiple bone metastasis, neck / mediastinal / intraabdominal LN enlargement 소견 보여 위암재발판정 받고 항암화학요법 권유 받았으나 거부하고 본원에서의 추가적인 검사 및 치료 위해 내원함.

3 Past medical history DM/HTN/Tb/HB (-/-/-/-) 2000년 9월 위암진단(adenocarcinoma, T2N0M0, stage Ib) : → s/p RSTG with B-I (2000/10) and chemoTx (UFT for 1 year) → 2005년 검사 : CR BPH, PNS → 약물 복용 중 Personal history Smoking : 하루 1갑 x 40년 (내원 2년 전부터 금연 중) Alcohol : 주3회 소주 2병 Family history none

4 Review of System General
fatigue (+) febrile sense (-) edema(-) sweating (-) weight loss (+) : 6kg for 2 months Skin rash (-) itching (-) pigmentation (-) bruise (-) Head & Neck headache (-) Eye & ENT visual disturbance (-) nasal obstruction(+) Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-) Cardiac chest pain (-) palpitation (-) orthopnea (-)

5 Review of System Gastrointestinal Urinary Musculoskeletal Neurologic
A/N/V/D/C (-/-/-/-/-) hematemesis (-) melena (-) hematochezia (-) Urinary dysuria (-) frequency (+) urgency (-) RU sense (-) flank pain (+) : Lt. side Musculoskeletal none Neurologic syncope (-) seizure (-) dizziness (-)

6 Physical Examination Vital sign 95/60mmHg – 75회/min – 20회/min – 36.6°c
General alert mentality chronically ill looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement palpable LN at both supraclavicular region Eye & ENT isocoric pupil with PLR (++/++) whitish sclera pinkish conjunctiva PI (-) PTH (-/-)

7 Physical Examination Thorax clear breathing sound without crackle or wheezing regular heart beat without murmur Abdomen soft and flat abdomen normoactive bowel sound tenderness (-) rebound tenderness (-) no palpable mass no abdominal bruit splenomegaly(+) no hepatomegaly Back & Extremities CVA tenderness (-/-) pretibial pitting edema (-/-) palpable LN at both axillary and inguinal area

8 Initial Lab Findings CBC/DC 29,000/mm² -11.3 g/dl – 33.4%- 92K
neutrophil segment : 24.0% immature cell : 67% reticulocyte count (%) : 2.5% corrected reticulocyte count : 1.86 reticulocyte production index : 1.24 PB smear RBC anisocytosis polychromasia poikilocytosis

9 Initial Lab Findings Chemistry TB 0.7 mg/dL AST/ALT 37/32 IU/L
ALP/GGT /191 IU/L Prot/Alb /3.9 g/dL BUN/Cr /0.8 mg/dL Ca/P/uric acid /3.6/7.8 mg/dL Na/K/Cl /4.7/93 mmol/L LD IU/L β2-microglobulin 5.7 mg/L CRP U/A RBC 2-4/HPF WBC 0-1/HPF Blood (-) Protein (1+) Glucose (1+) SG 1.018

10 EKG

11 Chest PA

12 Problem List Leukocytosis with immature cells Anemia Thrombocytopenia
Multiple LN enlargement Known gastric cancer

13 Initial Assessment #1. Leukocytosis with immature cells #2. Anemia
#3. Thrombocytopenia #4. Multiple LN enlargement r/o myelodysplasitc syndrome r/o leukemia r/o lymphoma r/o myelophthisic anemia #5. known gastric cancer possible relapse

14 Plans 1. Bone marrow aspiration and biopsy
2. Chest CT, neck CT, abdominal CT 3. LN biopsy 4. Follow up gastroscopy

15 Bone Marrow Biopsy

16 Chest CT

17 Abdominal CT

18 Neck CT

19 Gastroscopy

20 Pathology

21 Pathology

22 Special and Immunohistochemical Staining CD 5

23 Special and Immunohistochemical Staining CD 10

24 Special and Immunohistochemical Staining CD 20

25 Special and Immunohistochemical Staining CD 23

26 Special and Immunohistochemical Staining CYCLIN D1

27 Special and Immunohistochemical Staining KI-67

28 Special and Immunohistochemical Staining
CD 5 positive CD 10 negative CD 20 CD 23 Cyclin D1 KI-67 positive (about 35%)

29 Mantle cell lymphoma, blastoid variant
Final Diagnosis Mantle cell lymphoma, blastoid variant (Stage IV, IPI score 2)

30 Clinical Progression Initial WBC 29,000 on 7/7 → 66,700 on 8/9
Chemotherapy as a palliative purpose → CVP #1 on 8/10 → no improvement on splenomegaly and multiple LN enlargement on F/U abdominal CT on 8/29 → No more chemotherapy due to poor performance status Discharged on 9/9 Readmitted on 9/16 due to general weakness and poor oral intake WBC 79,500 → 131,900 → 162,200 (blast 95%) Expired on 9/29