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

2. Case I

3. 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. 11800165 홍 O 표 (M/47) Adm date : 05.10.20 via OPD

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

5. 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

6. 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

7. Initial Lab Finding CBC/DC 8810/mm² - 16.9 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

8. Chest X-ray

9. EKG

10. Problem List #1. Malignacy of unknown origin

11. 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.

12. Neck MRI (05.2.26)

13. PET CT (05. 10. 21)

14. 조직검사결과 (05. 10. 27) Nasopharynx, left, Bx.: Undifferentiated carcinoma

15. Stage Stage III (T3,N2,M0)

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

17. Treatment Plan PRT#3 FP#3

18. Clinical course PRT#3 (05.10.27 - 05.12.12) - CISPLATIN 100mg/m 2 q3wks - RT (daily dose 180cGy, total 6600cGy) FP #3(06.1.6 – 06.2.22) - CISPLATIN 75mg/m 2 q3wks - 5FU 1000 mg/m 2

19. Neck MRI (06.5.24)

20. PET CT (06.02.22)

21. Clinical course (05.10.20) 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 (05.10.27-05.12.12) FP #3 (06.1.6 – 06.2.22) 05/10/24 CR 10/03/04

22. Case II

23. 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. 12053951 임 O 순 (F/41) Adm date : 09.7.20 via OPD

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

25. 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

26. 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

27. Initial Lab Finding CBC/DC 7680/mm² - 13.0 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 125 18.1 CA 19-9 11.45 AFP 1.02 CEA 0.806 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

28. Chest X-ray

29. EKG

30. Problem List #1. Nasopharyngeal cancer (undifferentiated carcinoma)

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

32. Neck MRI (09.7.13)

33. PET CT (09.07.16)

34. Bone Scan (09.07.20)

35. 조직검사결과 (09. 7. 8) Lymph node, neck Bx.: Metastatic undifferentiated carcinoma

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

37. 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)

38. Clinical course Before CTxAfter CTx dTxPF#1~#4(09.7.22- 09.9.24 )

39. Clinical course CCRT(concurrent chemotherapy and radiotherapy ) 시행  CTx : 09.10.20- 09.11.11 / Cisplatin #1~#2  Tomotherapy : 09.10.20-09.12.2(total 6930cGy)

40. Neck MRI (10.1.28)

41. Clinical course Before CCRTx(09.10.19) After CCRTx(10.4.29)

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

43. 조직검사결과 (10. 5. 3) Lymph node, mediastinal : Undifferentiated carcinoma, metastatic Thoracoscopic mediastinal LN Bx : Metastatic Undifferentiated carcinoma

44. Clinical course (09.07.20) 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

45. Final diagnosis #1. Recurrent Nasopharyngeal cancer s/p dTxPF#1~#4(09.7.22 - 09.9.24 ) s/p CCRT Cisplatin#1~#2(09.10.20 - 09.11.11) Tomotherapy(09.10.20 - 09.12.2) s/p mediastinal LN Bx. P) CTx. 예정