1. Anaplastic thyroid cancer R1 박민아 / 이상열교수님

2.  Chief Complain neck mass o/s) 1 주일 전  Present Illness 62 세 여자환자 dyslipidemia 로 본원 IN(pf. 이태원 ) 외래 방문하며 po medication 하던 자로 내원 일주일 전 목에 mass 가 만져져 local ENT 방 문하였으나 갑상선 문제인 것 같다는 이야기 듣고 큰병원 권유받아 본원 내분비내과 외래 방문하였음 11977342 양 O 순 (F/62) 외래방문일 : 2013.09.04

3.  Past Medical History DM/ HTN/ hepatitis/ Tbc (-/-/-/-) Dyslipidemia : 2010.1 월 진단 후 약제복용시작 (atorvastatin 10mg 1T qd) Op Hx(-)  Personal History Smoking (-) Alcohol (-)  Family History (-)

4. Review of System GeneralFever (-) Chills (-) Weakness (-) Weight change(-) SkinRash (-) Itching (-) Pigmentation (-) sweating(-) HEENT Headache (-) Visual disturbance (-) Rhinorrhea (-) Sore throat (-) Hoarseness (-) RespiratoryCough (-) Sputum (-) Dyspnea (-) Hemoptysis (-) Cardiac Chest pain (-) Palpitation (-) Syncope (-) GI A/N/V/D/C (-/-/-/-) Abdominal pain (-) Hematochezia (-) Melena (-) Hematemesis(-) GU Oliguria (-) Hematuria (-) Discharge(-)

5. Physical examination Vital sign120/70mmHg - 72/min - 18/min - 36.0°C General Alert mentality Not so - ill looking appearance HEENTCervical LN enlargement (-) Thyroid nodule / goiter (+/+) ThoraxSymmetrical chest expansion Clear breathing sound s rale Regular heart beat s murmur AbdomenSoft & flat abdomen Normoactive bowel sound Rt.thyroid enlargement - Size : 1-2cm - Margin : regular - Consistancy : soft - Movable : movable - Tenderness/pain (-/-)

6. Initial lab finding CBC/DC 8,400/mm² - 13.9 g/dl – 41.2% - 297K (Seg. 72.9%) Chemistry Prot/Alb8.1/4.7 g/dLBUN/Cr 14/0.6 mg/dL TB/DB 0.75/0.22 mg/dLNa/K/Cl 137/4.1/99mEq/L AST/ALT22/16 IU/LCa/P/Mg 9.4/3.4/2.2 ALP/γGT102/18 IU/Lhs-CRP 3.38 mg/L Glucose98 mg/dL Total –chol 166 mg/dL TG 115 mg/dL HDL-chol 56 mg/dL LDL-chol 88 mg/dL U/A Occult blood - Protein –Glucose -Keton - RBC 0-4/HFPWBC 0-1/HPF

7. Chest x-ray 7

8. EKG

9. Problem list #1. Neck mass #2. Lung mass RLLF #3. Dyslipidemia

10. Assessment and plan #1. Thyroid nodule (benign/malignancy)  TFT, thyroid US & FNA, 필요시 Neck CT #2. Lung mass RLLF  Chest CT, 필요시 mass 에 대해서 PCNA 고려 #3. Dyslipidemia  self medication 유지 및 lipid profile f/u

11. Clinical coarse ( 외래 ) Thyroid FNA : anaplastic ca. 9.5 Neck CT 9.9 PET-CT regional LN, both iliac bone meta known malignant mass at Rt.thyroid 9.4 Chest CT necrotizing pneumonia r/o lung metastasis

12. Thyroid sono Rt. thyroid 2.82 x 1.93 x 3.88 cm sized ill defined hypoechoic nodule  FNA 시행

13. Thyroid sono Lt. thyroid 0.996 x 0.912 x 1.40 cm sized well defined cystic nodule 0.452 x 0.488 x 0.837 cm sized spongyform nodule

14. Thyroid FNA (2013-09-04)

16. Present case Benign follicular nodule

20. Pathologic Finding  Increased cellularity, necrotic and scanty colloid background  Irregular sheets of hyperchromatic and pleomorphic cells showing multiple prominent nucleoli  Increased mitotic figures  anaplastic malignant tumor 의 소견  Differential diagnosis 1) anaplastic (undifferentiated) carcinoma 2) medullary carcinoma 3) poorly differentiated(insular) thyroid carcinoma (less likely) 4) metastasis from other site

21. Additional lab Thyroid function test T3 163 ng/dL FT4 2.33 ng/dL TSH 0.03 μU/mL TG 193.1 ng/mL TG-Ab 49.1 U/ml PTH 20.9 pg/ml Calcitonin <2.0 pg/ml

22. Neck CT (2013-09-05)

23. PET-CT (2013-09-09)

25. Chest CT (2013-09-09)

26. Clinical coarse ( 입원 ) 9.13 s/p total thyroidectomy Pathologic staging : pT3N1

27. Total thyroidectomy

28. Total thyroidectomy (2013-09-13)  조직  Gross 사진

29. Clinical coarse ( 입원 ) 9.13 s/p total thyroidectomy Pathologic staging : pT3N1 9.17 PCNA 시행 Anaplastic ca., metastatic

30. PCNA (2013-09-17)  조직

31. Clinical coarse ( 입원 ) 9.13 s/p total thyroidectomy Pathologic staging : pT3N1 9.17 PCNA 시행 Anaplastic ca., metastatic 9.23 craniectomy and hematoma Evacuation d/t Br-hrr Anaplastic ca., metastatic mental drowsy  Br-CT 촬영 후 응급수술진행

32. 수술 전 Brain CT 1. Subcortical hrr at frontal lobe Lt., SDH, IVH (at all ventricle) 2. Midline shifting 1cm to contralateral side (subfalcian herniation) 3. Irregular hematoma shape and perilesional edema  suspicious secondary hemorrhage (especially tumor)  Enhanced CT 시행함.

33. 수술 전 3D-angio-enhanced-CT 1. Abnormal vascular markings around hematoma, cortical area (arrows) 2. Imp) Subcortical hrr w/ IVH, SDH

34. Intraoperative finding 1. Craniectomy 후 dura 를 curvilinear incision 을 하여 retraction 을 함. 2. Scanty 한 SDH 가 있었으나 irrigation 으로 쉽게 제거할 수 있었음. 3. SDH 는 subcortical hrr 에서 origin 한 것으로 보였음. ( 사진에 검은 부분 ) 4. Frontal base (Forceps 방향 ) 쪽에 yellowish mass 가 cortex 밖으로 노출된 것이 관찰되었음. ( 사진 ) 5. Mass 는 비교적 쉽게 박리가 되었음.  metastatic brain tumor 를 시사하였음. 6. Hematoma 와 mass 를 제거한 뒤에 lesion 주위로 gliotic tissue 가 싸고 있는 것을 관찰할 수 있었음. 7. Frontal horn of lateral ventricle 까지 hematoma 와 mass 를 제거한 뒤 EVD catheter 를 삽입함. 8. 수술 필드 상에서 brain 이 충분히 sunken 되어 decompression 이 된 것으로 판단하고 bone flap 을 덮고 수술을 마침. ( 수술명 : craniotomy and hematoma & mass removal)

35. Op field 의 위치 관계  aaa

36. 수술 후 f/u CT 1. 수술 후 hematoma 와 mass 는 잘 제거된 상태임. 2. mass effect 감소로 인하여 herniation 은 풀린 상태임. 3. EVD 는 Foramen of Monro-3rd ventricle 에 위치하고 있음.

37. 수술 2 일 뒤 MR 1. Hematoma 와 동반되었던 mass 는 남김없이 제거되었음. 2. 다른 부위에 추가적인 mass 는 관찰되지 않았음.

38. Pathology (2013-09-23)

39. Clinical coarse ( 입원 ) 9.17 PCNA 시행 Anaplastic ca., metastatic 9.23 craniectomy and hematoma Evacuation d/t Br-hrr Anaplastic ca., metastatic mental drowsy  Br-CT 촬영 후 응급수술진행 10.8 LFT 상승 Hb 감소 Abd pain 호소 Abdomen CT

40. Abdomen CT (2013-10-08) 9.1210.8

41. Final Diagnosis Anaplastic thyroid cancer, Rt with lung, brain, liver, both kidney, both iliac bone metastasis (stage IVc)