M.G.R 혈액종양내과 R2 윤현아 /prof. 백선경 Neck mass 를 주소로 온 환자

Case I

C.C) Rt. Neck mass o/s) 20 days ago P. I ) M/47, 특이병력 없는 환자로 내원 20 일전 Rt. Neck mass 발견해 제주 한마음 병원에서 FNA, chest/ neck CT 시행 후 r/o metastatic squamous cell carcinoma 진단 후 1’ origin 찾기 위해 본원 IH 입원 홍 O 표 (M/47) Adm date : via OPD

PMHx) DM/HTN/ hepatitis/ Tbc (-/-/-/-) Op Hx (-) PHx) Smoking (+) : 25 pack years Alcohol (+) : 소주 1 병 x 2 회 /wk FHx) none

Review of system fever (-) chills (-) fatigue (-) wt loss (-) rash (-) itching (-) pigmentation (-) headache (-) otorrhea (-) visual disturbance (-) rhinorrhea (-) nasal obx (-) sore throat (-) hoarseness (-) cough (-) sputum (-) dyspnea (-) hemoptysis (-) chest pain (-) palpitation (-) DOE (-) orthpnea (-) abdominal pain (-) A/N/V/D/C (-/-/-/-/-) hematochezia (-) melena (-) frank pain (-) dysuria (-) urgency (-) frequency (-) back pain (-) myalgia (-) dizziness (-) syncope (-) General Skin HEENT Respiratory Cardiac G-I Genitourinary Musculo skeletal Neurology

Physical examination Vital sign 100/70mmHg – 72/min- 20/min – 36.5°C General app. alert mentality not so - ill looking appearance HEENT isocoric pupil c PLR (++/++) whitish sclera / pinkish conjunctiva Rt. Neck palpable 3 mass (3.5x4.5, 3x3, 0.5x0.5) Thorax clear breathing sound w/o rale & wheezing regular heart beat w/o murmur Abdomen soft & flat abdomen, Td/rTd (-/-) normoactive bowel sound Back & Ext. CVA Td (-/-) pretibial pitting edema (-/-) Neurology sensory & motor : intact

Initial Lab Finding CBC/DC 8810/mm² g/dl – 49.5% - 418K (seg. 73.9%) PT (INR) 12.5 (1.00) aPTT 33 Chemistry TB /DB 0.73/0.19 mg/dL Prot/alb 8/4.7 g/dL AST/ALT 26/16 IU/L ALP/GGT 72/41 IU/L U/A RBC 0-1/HPF WBC 0-1/HPF Tumor marker SCC 0.7 BUN/Cr 12/0.8 mg/dl Na/K/Cl 141/4.3/101 mg/dl Ca/P/Mg 9.8/3.1/2.3 mg/dl LD/CK 538/78 U/L

Chest X-ray

EKG

Problem List #1. Malignacy of unknown origin

Initial assessment & plan #1. r/o Head & neck cancer NSCLC Esophageal cancer plan) Laryngoscopy Bronchoscopy Esophagoscopy Neck CT Neck MRI Chest CT Bone Scan PET CT Bx.

Neck MRI ( )

PET CT ( )

조직검사결과 ( ) Nasopharynx, left, Bx.: Undifferentiated carcinoma

Stage Stage III (T3,N2,M0)

Final diagnosis #1. Nasopharyngeal cancer & LN meta. Stage III (T3,N2,M0)

Treatment Plan PRT#3 FP#3

Clinical course PRT#3 ( ) - CISPLATIN 100mg/m 2 q3wks - RT (daily dose 180cGy, total 6600cGy) FP #3( – ) - CISPLATIN 75mg/m 2 q3wks - 5FU 1000 mg/m 2

Neck MRI ( )

PET CT ( )

Clinical course ( ) Nasopharyngeal ca. Dx 05/10/20 Bx.PRT #3 05/10/2705/12/1206/01/0606/02/28 FP #3 A) Nasopharyngeal ca. & LN meta P) CCRT(RT 6660cGy) : PRT #3 ( ) FP #3 ( – ) 05/10/24 CR 10/03/04

Case II

C.C) known nasopharyngeal ca. & LN meta o/s) 1 month ago P. I ) F/41, 특이병력 없는 환자로, 내원 한달 전 both Neck mass 발견해 본원 ENT 에서 Bx. 후에 undifferentiated carcinoma 진단 후 F/E 및 Tx. 위해 입원 임 O 순 (F/41) Adm date : via OPD

PMHx) DM/HTN/ hepatitis/ Tbc (-/-/-/-) Op Hx (-) PHx) Smoking (-) Alcohol (-) FHx) none

Review of system fever (-) chills (-) fatigue (-) wt loss (-) rash (-) itching (-) pigmentation (-) headache (-) otorrhea (-) visual disturbance (-) rhinorrhea (-) nasal obx (-) sore throat (-) hoarseness (-) cough (-) sputum (-) dyspnea (-) hemoptysis (-) chest pain (-) palpitation (-) DOE (-) orthpnea (-) abdominal pain (-) A/N/V/D/C (-/-/-/-/-) hematochezia (-) melena (-) frank pain (-) dysuria (-) urgency (-) frequency (-) back pain (-) myalgia (-) dizziness (-) syncope (-) General Skin HEENT Respiratory Cardiac G-I Genitourinary Musculo skeletal Neurology

Physical examination Vital sign 120/80mmHg – 84/min- 20/min – 36.7°C General app. alert mentality not so - ill looking appearance HEENT isocoric pupil c PLR (++/++) whitish sclera / pinkish conjunctiva both. Neck palpable mass (Rt : 3X3, Lt: 4X4) Thorax clear breathing sound w/o rale & wheezing regular heart beat w/o murmur Abdomen soft & flat abdomen, Td/RTd (-/-) normoactive bowel sound Back & Ext. CVA Td (-/-) pretibial pitting edema (-/-) Neurology sensory & motor : intact

Initial Lab Finding CBC/DC 7680/mm² g/dl – 69.3% - 289K (seg. 69.3%) PT (INR) 13.3 (1.00) aPTT 38.7 Chemistry TB /DB 0.64/0.15 mg/dL Prot/alb 8/4.4 g/dL AST/ALT 24/23 IU/L ALP/GGT 36/18 IU/L Uric acid 4.3mg/dL U/A RBC 5-9/HPF WBC 0-1/HPF Tumor marker CA CA AFP 1.02 CEA BUN/Cr 10/0.6 mg/dl Na/K/Cl 137/4.2/102 mg/dl Ca/P/Mg 8.8/3.8/2.3 mg/dl LD/CK 999/208 U/L

Chest X-ray

EKG

Problem List #1. Nasopharyngeal cancer (undifferentiated carcinoma)

Initial assessment & plan #1. Nasopharyngeal cancer plan) Neck CT Neck MRI Chest CT Bone Scan PET CT

Neck MRI ( )

PET CT ( )

Bone Scan ( )

조직검사결과 ( ) Lymph node, neck Bx.: Metastatic undifferentiated carcinoma

Final diagnosis #1. Nasopharyngeal cancer & LN meta. Stage III (T2, N2, M0)

Treatment Plan dTxPF #1~#4 docetaxel (70mg/m 2 ), Cisplatin(75mg/m 2 ), 5-FU(750mg/m 2 ) CCRT Cisplatin(100mg/m 2 ) #1~#2 Tomotherapy(daily dose 210cGy. Total 7350cGy)

Clinical course Before CTxAfter CTx dTxPF#1~#4( )

Clinical course CCRT(concurrent chemotherapy and radiotherapy ) 시행  CTx : / Cisplatin #1~#2  Tomotherapy : (total 6930cGy)

Neck MRI ( )

Clinical course Before CCRTx( ) After CCRTx( )

Clinical course A) Mediastinal LN meta P) Chest CT Thoracoscopic mediastinal LN Bx. - 5/3 TS Thoracoscopic mediastinal LN Bx.

조직검사결과 ( ) Lymph node, mediastinal : Undifferentiated carcinoma, metastatic Thoracoscopic mediastinal LN Bx : Metastatic Undifferentiated carcinoma

Clinical course ( ) Nasopharyngeal ca. Dx 09/7/20 Bx.dTxPF #1 ~ #4 09/7/2209/9/2409/10/2009/12/2 CCRT : cisplatin #1~#2 Tomotherapy 09/7/8 Bx. 10/5/3 RecurPR

Final diagnosis #1. Recurrent Nasopharyngeal cancer s/p dTxPF#1~#4( ) s/p CCRT Cisplatin#1~#2( ) Tomotherapy( ) s/p mediastinal LN Bx. P) CTx. 예정