M G R Two Cases of Superficial esophageal neoplasm CASE 1 R1 이은정 / R3 조창현 / prof 장재영

History 심○정 (M/58) Adm> Chief Complaint 식도 병변의 평가 식도 병변의 평가 Present illness 58 세 남환, 건강검진으로 시행한 위내시경에서 우연히 식도 병변이 발견되어 평가 위해 입원함 우연히 식도 병변이 발견되어 평가 위해 입원함

Past Medical History DM (-) HTN (-) Hepatitis (-) Pulmonary 쓔 (-) DM (-) HTN (-) Hepatitis (-) Pulmonary 쓔 (-) Operation Hx (-) Operation Hx (-) Personal History Alcohol (+) : 주 1 회, 소주 한 병 Alcohol (+) : 주 1 회, 소주 한 병 Smoking (+) : 30 갑년 Smoking (+) : 30 갑년 Family History Unremarkable Unremarkable History

Review of System General Fatigue (-) Febrile sensation (-) Chill (-) Wt Loss (-) Performance status : ECOG grade 0 Skin Rash (-) Pigmentation (-) Itching (-) H&N Headache (-) Sore throat (-) Respiratory Cough (-) Sputum (-) Dyspnea (-) Cardiac Chest pain (-) Orthopnea (-) Palpitation (-) G-I Anorexia (-) Nausea (-) Vomiting (-) Dysphagia (-) Abdominal pain (-) Diarrhea (-) Constipation (-) Abdominal pain (-) Diarrhea (-) Constipation (-) Renal Dysuria (-) Urgency (-) Frequency (-) Hematuria (-) B/Ext. Upper back pain (-) Lower back pain (-)

Physical Examination V/S 110/70mmHg – 60/min – 20/min – 36.2°C V/S 110/70mmHg – 60/min – 20/min – 36.2°C General Appearance General Appearance Alert mentality Not so ill looking appearance Alert mentality Not so ill looking appearance Head & Neck Head & Neck No cervical LN enlargement No neck vein engorgement No cervical LN enlargement No neck vein engorgement Eye & ENT Eye & ENT Isocoric pupil with PLR (++/++) Pinkish conjunctiva Clear sclera Isocoric pupil with PLR (++/++) Pinkish conjunctiva Clear sclera Chest Chest Clear breathing sound without crackle Clear breathing sound without crackle Regular heart beat without murmur Regular heart beat without murmur Abdomen Abdomen Soft & flat abdomen Normoactive bowel sound Soft & flat abdomen Normoactive bowel sound Tenderness (-) Rebound tenderness (-) Hepatosplenomegaly (-) Tenderness (-) Rebound tenderness (-) Hepatosplenomegaly (-) Back & Ext. Back & Ext. CVA tenderness (-/-) Pretibial pitting edema (-/-) CVA tenderness (-/-) Pretibial pitting edema (-/-) Body weight :46 Kg Height : 164 cm BMI : 17.1

Initial Laboratory Findings CBC/DC CBC/DC 4660/mm 3 – 15.8 g/dL – 46.3% -202,000 /mm /mm 3 – 15.8 g/dL – 46.3% -202,000 /mm 3 (Seg. 42.2%) PT INR 1.0 (Seg. 42.2%) PT INR 1.0 Chemistry Total Bilirubin 0.98 mg/dL CRP <0.5 mg/dL Total Bilirubin 0.98 mg/dL CRP <0.5 mg/dL Prot/ Alb 7.1 / 4.4 g/dL Glucose 83 mg/dL Prot/ Alb 7.1 / 4.4 g/dL Glucose 83 mg/dL AST/ ALT 21/ 12 U/L LD/ CK 374 / 92 U/L AST/ ALT 21/ 12 U/L LD/ CK 374 / 92 U/L ALP/ GTT 63/ 14 U/L Cholesterol 196 mg/dL ALP/ GTT 63/ 14 U/L Cholesterol 196 mg/dL BUN/ Cr 7/ 0.9 mg/dL BUN/ Cr 7/ 0.9 mg/dL Na/ K/ Cl 143 / 4.0 / 101 mmol/L Na/ K/ Cl 143 / 4.0 / 101 mmol/L Ca/ P 8.6/ 3.2 mg/dL Ca/ P 8.6/ 3.2 mg/dL

Initial Chest X-ray

Esophagogastroduodenoscopy (EGD, ) Biopsy 결과 : squamous cell carcinoma Biopsy 결과 : squamous cell carcinoma

#1. Esophageal squamous cell carcinoma Initial Problem Lists

Diagnostic & Therapeutic Plans Diagnostic plan Endoscopic ultrasound Chest CT Abdominal CT If needed, Positron Emission Tomography scan If needed, Positron Emission Tomography scan Therapeutic Plan Operation Operation Chemotherapy Chemotherapy Radiation therapy Radiation therapy

Endoscopic ultrasonography ( )

Lugol solution spray ( )

Abdominal CT ( )

Chest CT ( )

PET CT ( )

Preoperative Stage T1b N0 M0 Stage I Stage I  Treatment Plan Esophagectomy Esophagectomy

Operation ( ) ► Ivor Lewis operation (1) Transthoracic esophagectomy (2) Esophagogastrostomy (3) Resection of thoracic duct (4) Mediastinal & celiac LN dissection (5) Pyloroplasty (6) Feeding jejunostomy 1. Incision upper midline laparotomy incision & Rt posterolateral incision via 5 th ICS 2. Abdomen a. peritoneal cavity : acites (-) adhesion (-) hematoma on lesser omentum b. stomach : fundus mucosa - inflammation, black colorization c. LNs : common hepatic LNE (-), celiac LNE (-) d. hypertrophied pyloric muscle (+) 3. Thracic cavity a. pleural cavity : adhesion (+) – RUI and parietal pleura, loose b. esophageal tumor : definite esophageal wall thickening or mass (-) adjacent organ invasion (-) c. LNE : paraesophageal (-) bronchiotracheal (-) subcarinal (+) paratracheal (-) L20 (-) R20 (-) Rt lower paratracheal (+) Lt hilar (-)

Pathologic Findings

Postoperative Stage Esophageal squamous cell carcinoma, well differentiated (T1aN0M0, Stage I)

operation Pneumonia sepsis, intubation intubation extubation Brief clinical course ( ~ 10.9)

Dysphagia 발생, 1 차 balloon dilatation ( )

2 차 balloon dilatation ( )

3 차 balloon dilatation ( )

No cancer recurrence Clinical course after discharge

CASE 2 CASE 2

History 이○길 (M/67) Adm> Chief Complaint 위암의 평가 위암의 평가 Present illness 67 세 남환, 2008 년 6 월 건강검진 내시경에서 67 세 남환, 2008 년 6 월 건강검진 내시경에서 우연히 위 병변 발견되어 평가 및 치료 위해 입원함 우연히 위 병변 발견되어 평가 및 치료 위해 입원함

Past Medical History HTN (+) DM (-) Hepatitis (-) Pulmonary Tb (-) HTN (+) DM (-) Hepatitis (-) Pulmonary Tb (-) Personal History Alcohol (+) : 소주 1 병, 매일 Alcohol (+) : 소주 1 병, 매일 Smoking (+) : 20 갑년 Smoking (+) : 20 갑년 Family History Unremarkable Unremarkable History

Review of System General Fatigue (-) Febrile sensation (-) Chill (-) Wt Loss (-) Performance status : ECOG grade 0 Skin Rash (-) Pigmentation (-) Itching (-) H&N Headache (-) Sore throat (-) Respiratory Cough (-) Sputum (-) Dyspnea (-) Cardiac Chest pain (-) Orthopnea (-) Palpitation (-) G-I Anorexia (-) Nausea (-) Vomiting (-) Dyspepsia (-) Abdominal pain (-) Diarrhea (-) Constipation (-) Abdominal pain (-) Diarrhea (-) Constipation (-) Renal Dysuria (-) Frequency (-) Hematuria (-) Back & Ext. Upper back pain (-) Lower back pain (-)

Physical Examination V/S 130/70 mmHg – 76 /min – 20 /min – 36.3 O C V/S 130/70 mmHg – 76 /min – 20 /min – 36.3 O C General Appearance General Appearance Alert mental status Not so ill-looking appearance Alert mental status Not so ill-looking appearance Head & Neck Head & Neck No cervical LN enlargement No neck vein engorgement No cervical LN enlargement No neck vein engorgement Eye & ENT Eye & ENT Isocoric pupil with PLR (++/++) Pinkish conjunctiva Clear sclera Isocoric pupil with PLR (++/++) Pinkish conjunctiva Clear sclera Chest Chest Clear breathing sound without crackle Clear breathing sound without crackle Regular heart beat without murmur Regular heart beat without murmur Abdomen Abdomen Soft & flat abdomen Normoactive bowel sound Soft & flat abdomen Normoactive bowel sound Tenderness (-) Rebound tenderness (-) Hepatosplenomegaly (-) Tenderness (-) Rebound tenderness (-) Hepatosplenomegaly (-) Back & Ext. Back & Ext. CVA tenderness (-/-) Pretibial pitting edema (-/-) CVA tenderness (-/-) Pretibial pitting edema (-/-) Body weight: 67.7 Kg Height : cm BMI: 24.5

Initial Laboratory Findings CBC/DC CBC/DC 8,480 /mm 3 – 11.5 g/dL – 34.9% – 382,000 /mm 3 8,480 /mm 3 – 11.5 g/dL – 34.9% – 382,000 /mm 3 (Seg. 55.9%) (Seg. 55.9%) Chemistry Total Bilirubin 0.25 mg/dL Glucose 111 mg/dL Total Bilirubin 0.25 mg/dL Glucose 111 mg/dL Prot / Alb 6.4 / 4.0 g/dL Uric acid 6.6 mg/dL Prot / Alb 6.4 / 4.0 g/dL Uric acid 6.6 mg/dL AST / ALT 21 / 12 U/L Cholesterol 187 mg/dL AST / ALT 21 / 12 U/L Cholesterol 187 mg/dL ALP / GTT 70 / 49 U/L ALP / GTT 70 / 49 U/L BUN / Cr 16 / 0.8 mg/dL BUN / Cr 16 / 0.8 mg/dL Na/ K / Cl 144 / 4.0 / 105 mmol/L Na/ K / Cl 144 / 4.0 / 105 mmol/L Ca / P 8.3 / 2.9 mg/dL Ca / P 8.3 / 2.9 mg/dL Tumor marker CEA : 1.13 ng/mL CA 19-9 : U/mL AFP : 2.36 ng/mL

Initial Chest X-ray

EGD ( ) Biopsy 결과 : adenocarcinoma Biopsy 결과 : adenocarcinoma

Biopsy 결과 : squamous cell carcinoma Biopsy 결과 : squamous cell carcinoma

Initial Problem Lists #1. Triple primary cancer Double primary stomach cancer Cervical esophageal cancer

Diagnostic plan EUS Abdominal CT Chest CT Positron Emission Tomography scan, Positron Emission Tomography scan, if needed Therapeutic Plan Operation Operation Endoscopic treatment Endoscopic treatment Diagnostic & Therapeutic Plans

Abdominal CT ( )

Chest CT ( )

Preoperative Stage Esophageal cancer T1b N0 M0 Stage I Stage I Gastric cancer T1 T1 N0 N0 M0 M0 Stage IA Stage IA

Therapeutic Plans Laparoscopy assisted subtotal gastrectomy Intraoperative endoscopic submucosal dissection Transabdominal total gastrectomy Duodenocolonostomy Transthoracic esophagectomy Cervical esophago-colono-duodenostomy

Operation ( ) ► Laparoscopy - assisted distal gastrectomy Endoscopic submucosal dissection 1. Lesion Low body, posterior wall EGC IIc, 5 x 2 cm 2. Resection margin : frozen (-) proximal 4cm, distal 3 cm 3. Lymph node enlargement : 3,4,7,8 4. Lymph node dissection : D1 + 7,8,9 5. Reconstruction : B-I, stapled 6. Distant metastasis (-)

ESD at operating room ( )

Endoscopic submucosal resection ( )

Pathologic Findings

Postoperative Stage Esophageal cancer T1b N0 M0 Stage I Stage I Gastric cancer T1 T1 N0 N0 M0 M0 Stage IA Stage IA

Follow up EGD ( )

Clinical course after discharge - F/U EGD (11.07) 1.No local recurrence 2.Post ESD chemoRT