1. Seoul National University Hospital 우상복부 종괴을 주소로 내원 한 65 세 남자환자 서울대학교병원 소화기내과 이상협, 박주경, 윤원재, 이준규 류지곤, 김용태, 윤용범

2. Seoul National University Hospital Brief Case Summary : Present illness 65 세 남자환자 내원 5-6 년 전부터 1 년에 2-3 차례의 간헐적인 우 상복부 통증 발생 증상 발생시 인근병원에서 수 차례 복부 초음 파 검사를 시행하였으나 이상 소견은 없었음 입원 2 개월 전부터 우상복부에 종괴 촉지 되어 F/E 위해 본원 내원 과거력에서 당뇨병 이외에 특이소견 없음 계통적 문진에서 특이소견 없음

3. Seoul National University Hospital Brief Case Summary: Physical examination General appearance – Not so ill-looking, oriented, alert mental status V/S 130/70 mmHg-78/min-20/min-36.5°C HEENT – Not anemic conjunctivae, anicteric sclerae Chest – RHB without murmur, VBS without rale Abdomen – Normoactive bowel sound – No tenderness – No rebound tenderness – Palpable mass on RUQ Back & Extrimity – No costovertebral angle tenderness – No pittig, clubbing and cyanosis

4. Seoul National University Hospital Brief Case Summary : Laboratory values CBC –WBC: 5,800/mm 3 Hb:13.9 g/dL Plt:324,000 /mm 3 Chemistry –Cholesterol: 168mg/dL Protein: 7.1g/dL Albumin 4.2 g/dL –Total bilirubin: 1.0 mg/dL Glucose:132 mg/dL –Alkaline phosphatase: 89 IU AST/ALT: 22/22 IU/L Coagulation –PT/aPTT: 0.96( INR: 0.8-1.2 ) / 31.6( 29 ~45sec) Tumor marker –CEA 1.3 (0~5 ng/ml) –CA 19-9 9 (0~37 U/ml)

5. Seoul National University Hospital Initial W/U

6. Seoul National University Hospital USG 2005 년 4 월 26 일 :1 차 입원 38 일전

7. Seoul National University Hospital Abdomen CT 2005 년 5 월 13 일 :1 차 입원 20 일 전

8. Seoul National University Hospital Abdomen CT 2005 년 5 월 13 일 :1 차 입원 20 일 전

9. Seoul National University Hospital EUS 2005 년 6 월 3 일 :1 차 입원

10. Seoul National University Hospital ERCP 2005 년 6 월 3 일 :1 차 입원

11. Seoul National University Hospital Initial W/U 후 경과 R/O Acute cholecystitis d/t cystic duct tumor, Cystic duct stone, GB sludge 로 진단 후 initial W/U 당시 증상 없어서, elective cholecystectomy 예정으 로 퇴원 퇴원 후 15 일 뒤 Acute cholecystitis 발생하여 본원 응급실 내원하여 수술 전 MRCP, cholecystostomy, USG 시행

12. Seoul National University Hospital 2nd W/U

13. Seoul National University Hospital MRI/MRCP 2005 년 6 월 20 일 :2 차 입원

14. Seoul National University Hospital MRI/MRCP 2005 년 6 월 20 일 :2 차 입원

15. Seoul National University Hospital MRI/MRCP 2005 년 6 월 20 일 :2 차 입원

16. Seoul National University Hospital Cholecystostomy/USG 2005 년 6 월 23 일 :2 차 입원 2005 년 6 월 24 일 :2 차 입원

17. Seoul National University Hospital Preoperative Diagnosis R/O Acute cholecystitis d/t cystic duct tumor

18. Seoul National University Hospital Operation 1st: Open cholecystectomy2nd:Excision of other bile duct

19. Seoul National University Hospital Pathology Gross finding after 1 st Operation

20. Seoul National University Hospital Pathology Microscopic finding after 1 st Operation

21. Seoul National University Hospital Pathology Microscopic finding after 1 st Operation

22. Seoul National University Hospital Pathology Microscopic finding after 1 st Operation Ki-67p53

23. Seoul National University Hospital Pathology Microscopic finding after 2 nd Operation

24. Seoul National University Hospital Pathology Microscopic finding after 2 nd Operation

25. Seoul National University Hospital Postoperative Diagnosis CBD invasion of Cystic duct cancer

26. Seoul National University Hospital Cystic Duct Carcinoma Farrar’s criteria –Tumor growth restricted to the cystic duct –No neoplastic process in the gallbladder, hepatic ducts, or common bile duct –Histological confirmation the presence of carcinoma cells Extremely rare cancer by Farrar’s criteria –2.6 ∼ 3.3% of extrahepatic bile duct cancer –1.5% of gall bladder carcinoma

27. Seoul National University Hospital Cystic Duct Carcinoma Clinical presentation –Mean age: 63.2 yrs (38-80yrs) –M:F=2.5:1 in western countries (1:1 in Japan) –Gallstone: 25-37% in patients ( less than other extrahepatic carcinoma) –Usually nonspecific and varied presentation Abdominal pain:68.5% Abdominal mass:60% Obstructive jaundice:34.3%

28. Seoul National University Hospital Cystic Duct Carcinoma Diagnosis –Should be suspected in patients presenting with cystic duct obstruction accompanied by distended nonfunctioning GB without stone impaction Distended GB without associated gallstones in USG Non-opacified cystic duct or gallbladder in cholangiography –Difficult to differentiate from tumors that have invaded from nearby structures such as GB or extrahepatic biliary tree in advanced stage Farrar’s criteria are not always helpful in diagnosis –Difficult to diagnose preoperatively Generally discovered during laparotomy or pathologic examination

29. Seoul National University Hospital Cystic Duct Carcinoma Treatment –GB resection with bile duct and lymph node dissection –2 nd laparotomy for curative resection when confirmed as positive resection margin in postoperative examination after cholecystectomy –Liver resection or pancreaticoduodenectomy in advanced stage Prognosis –Remains dismal –Mean survival: 20.2 month (3.2-11.4 months in extrahepatic bile duct carcinoma or 5.8 months in GB carcinoma) –Quite good when limited to the cystic duct