Case Presentation R2 이은정

CASE I 11955017 권O철 M/45 Adm> 2009.3.10 Chief Complaint for treatment of HCC Present Illness M/45, 2007년 2월 B-viral LC, HCC 진단받고 TACE #2 시행 후 f/u Liver CT에서 marginal recurrence 소견 보여 LiTx 시행함. 이후 2009.2.23 시행한 f/u Liver CT상 mass 소견 보여 TACE #3 위해 입원함.

Past medical history DM / HTN / Tbc ( - / - / - ) Hepatitis B (+) : HBs Ag (+) op Hx (-) Drug Hx (-) Family history none Personal history Smoking (-) : 2년 전부터 금연, 25 pack-yrs Alcohol (-) : 2년 전부터 금주, 4~5년간 daily 4~5병

Review of System General : fever(-) chill(-) sweat(-) weight loss(-) Skin : rash (-) itching (-) Head & Neck : headache (-) stiffness (-) Respiratory : cough (-) sputum (-) dyspnea (-) Cardiac : chest pain (-) orthopnea (-) palpitation (-) Gastrointestinal : A/N/V/D/C (-/-/-/-/-) abdominal discomfort (-) Urinary : dysuria (-) frequency (-) urgency (-) Musculoskeletal : arthralgia(-) weakness (-) numbness (-) Nervous : syncope (-) seizures (-) dizziness (-) 4 4 4

Physical Examination Vital sign 130/80 – 78회/min – 20회/min – 36.0°c weight : 99.5kg height : 178cm BMI : 31.4kg/m2 General alert consciousness Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT whitish sclerae pinkish conjunctivae Thorax clear breathing sound without crackle regular heart beat without murmur Abdomen soft and obese abdomen no tenderness / no rebound tenderness no splenomegaly no hepatomegaly

Initial Lab Findings CBC/DC 5,250/mm² - 15.0 g/dl – 43.0% - 132K (seg 51.9%) PT 14.6 INR 1.15 Chemistry TB/DB 0.79/0.31 mg/dL AST/ALT 39/26 IU/L ALP/GGT 55/69 IU/L Prot/Alb 7.6/3.5 g/dL BUN/Cr 10/0.6 mg/dL CRP <0.5 mg/dL Na/K 134/3.5 mmol/L Viral markers HBsAg(+) / anti-HBsAb(+) / anti-HBeAg(-) / anti-HBeAb(+) anti-HCV(-) / anti-HIV(-) HBV-DNA titer : positive (08.7.8)  negative (08.7.16 이후) FeUrea 18.42 prerenal type FeNa 0.07 61 IU/ml 321 copies/ml

Additional Lab Findings Tumor marker (08.3.11) Liver function Child-Pugh class : A (5점) MELD score : 8 Tumor stage LCSGJ : T1N0M0, stage I BCLC : stage 0 CLIP stage : score 0, early stage JIS score : 0 AFP 4.09 ng/mL CA 19-9 12.99 U/mL CEA 16 ng/mL FeUrea 18.42 prerenal type FeNa 0.07

Clinical course TACE #2 (08.3.10) : Rt AS Seg LiTx #1 (08.7.16) : S5 03/13 03/23 FeUrea 18.42 prerenal type FeNa 0.07 09.5.20 Liver CT상 tumor recur 소견 (seg 4,6) TACE #1 at 상계백병원 (07.2.22) : S4 09.6.12 Liver CT상 Tumor size 감소

LiTxTM light-emitting diodes (LEDs) activate LS11 (light-activated, water-soluble drug) production of singlet oxygen, kill target tissues with minimal side effects FeUrea 18.42 prerenal type FeNa 0.07

LiTxTM FeUrea 18.42 prerenal type FeNa 0.07

CASE 2 12052315 김O열 M/74 Adm> 2009.6.17 Chief Complaint for cancer evaluation Present Illness M/74, DM으로 po med, 올해 초 우연히 혈액검사에서 LFT 상승 소견 보여 전남대병원 방문, TACE 권유 받았으나 refuse 후 민간요법으로 치료하였음. 이후 전남대병원 에서 시행한 f/u liver CT상 HCC aggravation, portal thrombosis 진행소견 보여 F/E 위해 본원 전원 됨. 11

DM / HTN / Tbc ( - / - / + ) : 10년전 Tb 로 medication 후 완치됨 Past medical history DM / HTN / Tbc ( - / - / + ) : 10년전 Tb 로 medication 후 완치됨 Hepatitis (-) op Hx (-) Drug Hx (-) Family history none Personal history Smoking (-) : 50 pack - yrs Alcohol (-) : 2년 전부터 금주, daily 소주 1병 12

Review of System General : fever(-) chill(-) sweat(-) weight loss(-) Skin : rash (-) itching (-) Head & Neck : headache (-) stiffness (-) Respiratory : cough (-) sputum (-) dyspnea (-) Cardiac : chest pain (-) orthopnea (-) palpitation (-) Gastrointestinal : A/N/V/D/C (-/-/-/-/-) abdominal discomfort (-) Urinary : dysuria (-) frequency (-) urgency (-) Musculoskeletal : arthralgia(-) weakness (-) numbness (-) Nervous : syncope (-) seizures (-) dizziness (-) 13 13 13

Physical Examination Vital sign 120/80 – 82회/min – 20회/min – 36.3°c weight : 50.5kg height : 165cm BMI : 18.5kg/m2 General alert consciousness Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT whitish sclerae pinkish conjunctivae Thorax clear breathing sound without crackle regular heart beat without murmur Abdomen soft and flat abdomen no tenderness / no rebound tenderness hepatomegaly (++) 14

Initial Lab Findings CBC/DC 6,510/mm² - 14.1 g/dl – 43.6% - 184K (seg 67.8%) PT 12.6 INR 0.94 Chemistry TB/DB 0.79/0.28 mg/dL AST/ALT 88/35 IU/L ALP/GGT 216/112 IU/L Prot/Alb 7.4/3.9 g/dL BUN/Cr 17/0.5 mg/dL CRP <0.5 mg/dL Na/K 138/4.0 mmol/L Viral markers HBsAg(-) / anti-HBsAb(-) anti-HCV(-) / anti-HIV(-) FeUrea 18.42 prerenal type FeNa 0.07 15 15

Additional Lab Findings Tumor marker (09.6.18) Liver function Child-Pugh class : A (5점) MELD score : 6 Tumor stage LCSGJ : T4N1M1, stage IV-B BCLC : stage C CLIP stage : score 4, advanced stage JIS score : 3 AFP 60500 ng/mL CA 19-9 2.0 U/mL CEA 8.04 ng/mL FeUrea 18.42 prerenal type FeNa 0.07 16 16

Clinical course Liver CT (09.6.18) Chest CT (09.6.19) TACE 시행 (09.6.22) FeUrea 18.42 prerenal type FeNa 0.07 17 17

CASE 3 12051805 송O규 M/63 Adm> 2009.6.12 Chief Complaint abdominal pain o/s> 내원 하루 전 Present Illness M/63, 특이병력 없이 지내던 자로 내원 하루 전 기침 하던중 갑자기 RUQ pain 발생하여 개인의원 방문, r/o acute cholecystitis로 큰 병원 권유 받고 본원 내원함. 18

Past medical history DM / HTN / Tbc ( - / - / - ) Hepatitis (-) op Hx (-) Drug Hx (-) Family history none Personal history Smoking (+) : 20 pack-yrs Alcohol (-) 19

Review of System General : fever(+) chill(+) sweat(-) weight loss(-) Skin : rash (-) itching (-) Head & Neck : headache (-) stiffness (-) Respiratory : cough (-) sputum (-) dyspnea (-) Cardiac : chest pain (-) orthopnea (-) palpitation (-) Gastrointestinal : A/N/V/D/C (+/-/-/-/-) abdominal pain (+) Urinary : dysuria (-) frequency (-) urgency (-) Musculoskeletal : arthralgia(-) weakness (-) numbness (-) Nervous : syncope (-) seizures (-) dizziness (-) 20 20 20

Physical Examination Vital sign 110/70 – 92회/min – 20회/min – 36.5°c weight : 63kg height : 173cm BMI : 21.04kg/m2 General alert consciousness Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT whitish sclerae pale conjunctivae Thorax clear breathing sound without crackle regular heart beat without murmur Abdomen soft and obese abdomen tenderness / rebound tenderness on RUQ no splenomegaly no hepatomegaly 21

Initial Lab Findings CBC/DC 8,170/mm² - 10.6 g/dl – 32.7% - 114K (seg 66.4%) PT 14.6 INR 1.15 Chemistry TB/DB 0.97/0.38 mg/dL AST/ALT 62/57 IU/L ALP/GGT 96/168 IU/L Prot/Alb 7.2/3.0 g/dL BUN/Cr 25/0.7 mg/dL CRP 0.5 mg/dL Na/K 136/3.6 mmol/L Viral markers HBsAg(+) / anti-HBsAb(+) / anti-HBeAg(+) / anti-HBeAb(-) anti-HCV(-) / anti-HIV(+) HBV-DNA titer : positive (08.6.19) FeUrea 18.42 prerenal type FeNa 0.07 14 x 105 IU/ml 86 x 105 copies/ml 22 22

Additional Lab Findings Tumor marker (09.6.19) Liver function Child-Pugh class : B (9점) MELD score : 8 Tumor stage LCSGJ : T3N0M0, stage III BCLC : stage C CLIP stage : score 3, intermediate stage JIS score : 3 AFP 22.8 ng/mL CA 19-9 22.96 U/mL CEA 2.52 ng/mL FeUrea 18.42 prerenal type FeNa 0.07 23 23

Clinical course Liver CT (09.6.12 / 09.6.23) Chest CT (09.6.23) TACE 시행 (09.6.12) FeUrea 18.42 prerenal type FeNa 0.07 24 24