1. MGR 종양혈액내과 R1 김선혜 /Prof. 정재헌

2. Case 1

3.  Chief Complaint Known lung mass o/s) 내원 40 일 전  Present illness F/68, 특이병력 없는 자로 내원 40 일 전 본원 FM 에서 건 강검진 목적으로 촬영한 chest x-ray 에서 lung mass on RULZ 보여 촬영한 chest CT 에서 lung cancer 의심되어 further evaluation 위해 호흡기 내과에 입원함.

5. 1. General Fatigue(-) Fever (-) Generalized weakness(-) Chill(-) Weight change(-) Myalgia(-) 2. Skin Rash(-) Pigmentation(-)Itching(-) 3. HEENT Headache(-) Otalgia(-) Visual disturbance(-) Otorrhea(-) PND(-)Nasal obstruction(-) Rhinorrhea(-) Sore throat(-) 4. Respiratory Dyspnea(-) Cough(-) Sputum(-) Pleuritic pain(-) Hemoptysis(-) 5. Cardiac Chest pain (-) Orthopnea(-)Palpitation(-) DOE(-)

6. 6. Abdominal A/N/V/D/C(-/-/-/-/-) Abdominal pain(-) Melena(-) Hematochezia(-) Bowel habit change(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-) Hematuria(-) Nocturia(-) Flank pain (-) Oliguria(-) 8. Musculoskeletal Pain(-) Myalgia(-) Tenderness(-) Backpain(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-)

7. Height : 153cm Weight : 60kg BMI : 25.6 Vital Sign : 100/70mmHg - 64/min - 20/min - 36.4 ℃ 1. General appearance alert consciousness not-ill looking appearance 2. Head & neck normocephaly LN enlargement(-) neck vein engorgement(-) 3. E/ENT isocoric pupil c PLR(++/++) pinkish conjunctiva, whitish sclera pharyngeal injection(-), PTH(-/-)

8. 4. Chest symmetric chest expansion clear breathing sound without rale regular heart beat without murmur 5. Abdomen soft/ flat abdomen bowel sound: normo-active tenderness(-), rebound tenderness(-) palpable mass(-) 6. Back&extremities CVA Td(-/-) pretibial pitting edema(-/-) pressure sore(-) 7. Motor, sensory: intact

9. 1.CBC/DC 5,930/ ㎕ – 11.9g/ ㎗ - 34.1% - 177,000/ ㎕ (seg:63.2%) 2.Chemistry Total Bilirubin 0.89 mg/ ㎗ BUN/Cr 11/0.6 mg/ ㎗ Protein/Albumin 7.4/4.1 g/ ㎗ Na/K/Cl 140/3.9/106 mEq/L AST/ALT 18/16 IU/L Ca/P/Mg 8.5/3.8/2.0 mg/ ㎗ ALP/rGT 66/28 IU/L Uric acid 4.1 mg/ ㎗ CRP <0.3 mg/ ㎗ CK/LD 50/315 IU/L 3.UA RBC 0~1/HPF WBC 2~4/HPF Blood – Protein – Glucose – S.G 1.008 pH 6.5

10. 2011-05-312009-09-10

13. #1. Lung mass on RUL #2. Adrenal incidentaloma, Lt

14. #1. Lung mass on RULLung mass on RUL R/O malignancy (bronchogenic ca., metastatic lesions) R/O Benign disease, less likely (tuberculosis, benign neoplasm, bacterial infection) Diagnostic Plan) Histologic exam (PCNA & biopsy, Open lung biopsy) PET CT, Bone scan, Brain MRI, PFT, Mediastinoscopy Tuberculosis Test (AFB, culture, IFN-r) Sputum & blood culture  Chest CT

15. #2. Adrenal incidentaloma, Lt R/O benign disease (adrenal adenoma) R/O malignancy (adrenocortical carcinoma, metastasis) R/O functional disease ( Cushing’s disease, primary aldosteronism, pheochromocytoma or androgen & estrogen-secreting tumors) Diagnostic Plan) Fine needle aspiration biopsy, PET CT, adrenal CT 24 hour urine catecholamines and metanephrines 24 hour urine free cortisol or DMX suppression test Serum adrenal androgen & estradiol, cortisol, ACTH, aldosterone  Chest CT

16. 6월 3일6월 3일 Diagnosis: Non-small cell carcinoma Large cell carcinoma is suggested

17. 6월 5일6월 5일

18. 6월 5일6월 5일

19.  Sputum culture & cytology(-)  Blood culture(-)  Tuberculosis Test (AFP, culture, IFN-r)(-)  Procalcitonin 0.039  Mycoplasma Ig M & Ig G (-) 6월 5일6월 5일

20. 6 월 14 일

23. Diagnosis #1. Non-small cell carcinoma Large cell carcinoma is suggested (T1N2M0, stage IIIA) #2. Left adrenal adenoma Therapeutic plan #1. Surgery ± adjuvant chemotherapy Induction chemotherapy ± RTx (± Surgery ± CTx ± RTx) Concurrent chemoradiation therapy #2. Observation

25.  ** **

26. Surgery 2011.06.22 Right Upper Lobe Lobectomy and Mediastinal Lymph Node Dissection

27. Diagnosis: Non-small cell carcinoma Adenocarcinoma, poorly differentiated 1) Size: 3.2 x 3.1 x 3 cm 2) No tumor identified at visceral pleura 3) No tumor identified at bronchial resection margin (safety margin: 3.2 cm) 4) Metastasis to 14 out of 36 regional lymph nodes (14/36) ("LN2": 5/5, "LN4": 5/14, "interlobar": 1/3, "hilar": 2/5, "LN10": 0/2, "peri-esophageal": 1/4, "subcarinal": 0/3) 5) Lymphatic invasion: not identified 6) Vascular invasion: not identified 7) Pathologic staging: pT2aN2

29. #1. Non-small cell lung cancer (adenocarcinoma, pT2aN2M0, stage IIIA) s/p RUL lobectomy c Mediastinal LN dissection (2011-06-22) Therapeutic plan ) adjuvant chemotherapy #2. Adrenal adenoma, Lt

31. CHEMOTHERAPY 2011.07.20 ~ 08.17 PVnb #1 (cisplatin 50/m²+ vinorelbine25/m²)

32. Case 2

33.  Chief Complaint Known lung mass o/s) 내원 20 일 전  Present illness M/66, 내원 20 일 전부터 시작된 sputum, hoarseness 로 본원 호흡기 내과 외래 방문하여 시행한 chest x-ray 에서 lung mass on RML 발견되어 시행한 chest CT 에 서 lung cancer 의심되어 further evaluation 위해 호흡기 내과에 입원함.

35. 1. General Fatigue(-) Fever (-) Generalized weakness(-) Chill(-) Weight change(-) Myalgia(-) 2. Skin Rash(-) Pigmentation(-)Itching(-) 3. HEENT Headache(-) Otalgia(-) Visual disturbance(-) Otorrhea(-) PND(-)Hoarseness(+) Rhinorrhea(-) Sore throat(-) 4. Respiratory Dyspnea(-) Cough(+) Sputum(+) : blood tingled Pleuritic pain(-) Hemoptysis(-) 5. Cardiac Chest pain (-) Orthopnea(-)Palpitation(-) DOE(-)

36. 6. Abdominal A/N/V/D/C(-/-/-/-/-) Abdominal pain(-) Melena(-) Hematochezia(-) Bowel habit change(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-) Hematuria(-) Nocturia(-) Flank pain (-) Oliguria(-) 8. Musculoskeletal Pain(-) Myalgia(-) Tenderness(-) Backpain(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-)

37. Height : 153cm Weight : 60kg BMI : 25.6 Vital Sign : 100/70mmHg - 64/min - 20/min - 36.4 ℃ 1. General appearance alert consciousness not-ill looking appearance 2. Head & neck normocephaly LN enlargement(-) neck vein engorgement(-) 3. E/ENT isocoric pupil c PLR(++/++) pinkish conjunctiva, whitish sclera pharyngeal injection(-), PTH(-/-)

38. 4. Chest symmetric chest expansion clear breathing sound without rale regular heart beat without murmur 5. Abdomen soft/ flat abdomen bowel sound: normo-active tenderness(-), rebound tenderness(-) palpable mass(-) 6. Back&extremities CVA Td(-/-) pretibial pitting edema(-/-) pressure sore(-) 7. Motor, sensory: intact

39. 1.CBC/DC 7,390/ ㎕ – 13.9g/ ㎗ – 42.4% - 349,000/ ㎕ (seg:69.3%) 2.Chemistry Total Bilirubin 0.39 mg/ ㎗ BUN/Cr 18/1.0 mg/ ㎗ Protein/Albumin 7.5/4.4 g/ ㎗ Na/K/Cl 141/4.1/104 mEq/L AST/ALT 18/16 IU/L Ca/P/Mg 8.6/3.5/2.2 mg/ ㎗ ALP/rGT 66/28 IU/L Uric acid 6.9 mg/dL CRP <0.3 mg/ ㎗ CK/LD 41/1362 IU/L 3.UA RBC 0~1/HPF WBC 0~1/HPF Blood – Protein – Glucose –S.G 1.009 pH 6.5

40. 2011-05-122009-09-17

42. 2011-05-02

43. #1. Known lung mass on RUL & RML #2. History of traumatic SAH c SDH

44. #1. Known lung mass on RUL & RML R/O malignancy (Bronchogenic ca., metastatic lesions) R/O Benign disease (tuberculosis, benign neoplasm, bacterial infection) Diagnostic Plan) Histologic exam (Bronchoscopy c washing, brushing, and biopsy, percutaneous fine needle aspiration & biopsy, Open lung biopsy, mediastinoscopy) PET CT, Bone scan, Brain MRI, PFT Blood culture, Tuberculosis Test (AFP, culture, IFN-r)  Chest CT

45. #2. History of traumatic SAH c SDH Plan)  Chest CT Close observation brain CT or MRI if needs

46. 5 월 13 일 Bronchial brushing & washing Diagnosis: Non-small cell carcinoma Adenocarcinoma

47. 5 월 17 일 Diagnosis: Non-small cell carcinoma Large cell neuroendocrine carcinoma

48. 5 월 19 일

49. 5 월 20 일

51. Diagnosis #1. Non-small cell carcinoma Large cell neuroendocrine carcinoma (T3N3M0, stage IIIB) #2. History of traumatic SAH c SDH Therapeutic plan #1. Concurrent Chemo-radiation therapy #2. Observation

53. Concurrent ChemoRadiation Therapy #1 2011.05.26~2011.06.06 Tomotherapy (210 cGy/d, freq 30) Chemotherapy(Cisplatin 50/m²+Etoposide 50/m² )

54. Concurrent ChemoRadiation Therapy #2 2011.06.27~2011.07.04 Tomotherapy (210 cGy/d, freq 30) Chemotherapy(Cisplatin 50/m²+Etoposide 50/m² )

55. 2011-05-022011-07-18

56. #1. Non-small cell lung cancer (Large cell neuroendocrine carcinoma, T3N3M0, stage IIIB) s/p CCRT #1 (CDDP + ETOPO,2011-05-26~06-06) s/p CCRT #2 (CDDP + ETOPO,2011-06-27~07-04) #2. History of traumatic SAH c SDH