MGR - case R2. 유정선 / Prof. 정재헌

Case 1

송 O 섭 M/67 Adm date: Chief complaint Left neck mass o/s) 15 일전 Present illness 67/M, 2009 년 12 월 EGC (T1bN0M0) 로 Distal gastrectomy with B-I anastomosis 과거력 있는 자로 내원 15 일전 생긴 Left neck mass 커지는 양상이어서 본원 이비인후과 방문하여 시행한 nasal mass biopsy 상 Nasopharyngeal cancer (Undifferentiated carcinoma) 진단되어 stage work up 및 치료 위해서 내원 함.

Past medical history DM / HTN / Tb / Hepatitis (-/-/-/-) Medication Hx : None OP Hx (+) : 2009 년 12 월 Distal gastrectomy with B-I anastomosis Personal History Smoking (+) : 과거흡연 1 pack/day x 30 years Alcohol (-) Occupation: 회사원 Family History Unremarkable

Review of system General generalized weakness (-) fever (-) fatigue(-) wt change (-) Skin rash (-) itching (-) pigmentation (-) Head / Neck headache (-) hoarseness (-) sore throat (-) hearing disturbance (-) nasal obstruction (-) Left palpable neck mass (+) Respiratory cough (-) sputum (-) dyspnea (-) hemoptysis (-) Cardiac chest pain (-) DOE(-) palpitation (-) GI A/N/V/D/C (-/-/-/-) hematochezia(-) hematemesis(-) bowel habit change(-) abdominal pain (-) Urinary dysuria(-) hematuria(-) nocturia(-) Musculoskeletal pain(-) swelling(-) tenderness(-)

Physical examination Vital sign 110/70 mmHg – 80 회 /min - 20 회 /min °C cm – 46kg – 15.4 kg/m 2 General alert mentality acutely ill looking appearance Head & Neck isocoric pupil c PLR (++/++) cervical LN enlargement (-) no neck vein engorgement PI (-) PTH (+/+) Left neck region palpable mass : Size : 3cm, Level II Td (-), Swelling (-), Redness(-), heating sensation(-) Thorax symmetrical chest expansion clear breathing sounds s rale or wheezing regular heart beat without murmur

Abdomen soft & flat abdomen normoactive bowel sound tenderness (-) rebound tenderness (-) no palpable mass no hepatomegaly Back & Extremity CVA Td (-/-) no pretibial pitting edema Neurology Motor V V Sensory V V ECOG : 1

Initial lab finding CBC/DC 8420/mm² g/dl – 39.2 %- 230K (seg : 50.5%) aPTT 42.3sec PT(INR) 12.0 (0.92) Chemistry AST / ALT 20 / 8 U/L BUN / Cr 9 / 0.7 mg/dL TB 0.89 mg/dL Na / K / Cl 138 / 3.4 / 98 mmol/L ALP / GGT 62 / 22 U/L Ca / P / Mg 8.3 / 2.8 / 1.9 mg/dL Protein / Alb 8.0 / 4.0 g/dL Uric acid 4.8 mg/dL CRP <0.3 mg/dL LD 319 IU/L UA RBC (-) WBC 0~1/HPF Protein (-) Nitrite (-) Glucose (-)

Chest X-ray

EKG

Initial problem list #1. Nasopharyngeal cancer

Initial assessment & plan #1. Nasopharyngeal cancer diagnostic plan) 1. Biopsy 2. Chest-CT 3. Neck-CT 4. Neck-MRI 5. PET-CT 6. Dental evaluation 7. Abdome-CT 8. Bone scan NCCN Guidelines 2011

NECK CT (6/13)

Chest CT (6/22)

Abdomen CT (6/22)

PET CT (6/21)

Staging

Stage IVB

Final diagnosis #1. Nasopharyngeal cancer (cT2N3bM0, stage Ivb)

Treatment NCCN Guidelines 2011

Treatment: 1. Induction chemotherapy, 2. CCRT 1. Induction chemotherapy : dTxPF - Docetaxel (60 mg/m²) - Cisplatin (60 mg/m²) - 5-FU (600 mg/m²) 2. CCRT - Cisplatin (100 mg/m²) - 5-FU (1000 mg/m²) - RT

Clinical course - dTxPF #1(7/1~7/5) Docetaxel 60 mg/m² 5-FU 600 mg/m² CDDP 60 mg/m² LD 외래에서 시행한 CBC/DC 에서 Neutropenia (ANC= 160) 소견 보임  G-CSF 2 일간 투약 ( ~07.13 ) 후 ANC = 1300 으로 회복 되어서 퇴원 함.

Docetaxel 60 mg/m² 5-FU 600 mg/m² CDDP 60 mg/m² LD Clinical course - dTxPF #2(7/23~7/27) 외래에서 시행한 CBC/DC 에서 Neutropenia (ANC= 390) 소견 보임  G-CSF 2 일간 투약 ( ~08.03 ) 후 ANC = 3100 으로 회복 되어서 퇴원 함.

Docetaxel 60 mg/m² 5-FU 600 mg/m² CDDP 60 mg/m² LD Clinical course - dTxPF #3(8/19~8/23)

F/U NECK CT (9/8) Partial remission

Clinical course - FP #1 CCRT (9/28~10/1) 5-FU 1000 mg/m² CDDP 100 mg/m²

5-FU 1000 mg/m² CDDP 100 mg/m² Clinical course - FP #2 CCRT(10/27~10/30)

Bx: Nasopharynx (Undifferentiated carcinoma) ~ ~07.27 dTxPF # ~08.23 FP #1 CCRT daily dose 200cGy ~ ~10.30 FP #2 CCRT daily dose 200cGy dTxPF #1dTxPF #3

Case 2

Chief complaint Sore throat o/s) 내원 1 주전 Present illness 51/M, 특이 병력 없는 자로 내원 1 주일전에 입안의 Ulcerative swelling lesion 보여 서 본원 치과대학 병원에서 시행한 biopsy 에서 Squamous cell carcinoma 발견 되어 본원 이비인후과 내원하여 시행 한 검사 결과 상 Oropharyngeal cancer 진단 받고 Induction chemotherapy 위해서 혈액 종양 내과로 전과 됨 박 O 규 M/51 Adm date:

Past medical history DM / HTN / Tb / Hepatitis (-/-/-/-) Medication Hx (-) OP Hx (-) Personal History Smoking (+) : 과거흡연 1 pack/day x 30 years Alcohol (+) : 과거 음주 ( 소주 1 병, 주 2 회 ) Occupation: 자영업 Family History Unremarkable

Review of system General generalized weakness (-) fever (-) fatigue(-) wt change (-) Skin rash (-) Itching (-) pigmentation (-) Head / Neck headache (-) hoarseness (+) sore throat (+) hearing disturbance (-) Respiratory cough (-) sputum (-) dyspnea (-) hemoptysis (-) Cardiac chest pain (-) DOE(-) palpitation (-) GI A/N/V/D/C (-/-/-/-) hematochezia(-) hematemesis(-) bowel habit change(-) abdominal pain (-) Urinary dysuria(-) hematuria(-) nocturia(-) Musculoskeletal pain(-) swelling(-) tenderness(-)

Physical examination Vital sign 130/80 mmHg – 64 회 /min - 20 회 /min °C 169.5cm – 67.4 kg – 23.5 kg/m 2 General alert mentality acutely ill looking appearance Head & Neck isocoric pupil c PLR (++/++) cervical LN enlargement (-) no neck vein engorgement PI (-) PTH (-/-) Pharynx & Oral cavity : soft tissue ulceration Thorax symmetrical chest expansion clear breathing sounds s rale or wheezing regular heart beat without murmur

Abdomen soft & flat abdomen normoactive bowel sound tenderness (-) rebound tenderness (-) no palpable mass no hepatomegaly Back & Extremity CVA Td (-/-) no pretibial pitting edema Neurology Motor V V Sensory V V ECOG : 1

Initial lab finding CBC/DC 7610/mm² g/dl – 37.9 %- 278K (seg : 72.9%) aPTT 39.2 sec PT(INR) 13.5 (1.07) Chemistry AST / ALT 12 / 9 U/L BUN / Cr 10 / 0.6 mg/dL TB / DB 0.39/ 0.15 mg/dL Na / K / Cl 140 / 3.7/ 99 mmol/L ALP / GGT 68 / 16 U/L Ca / P / Mg 9.1 / 3.4 / 2.0 mg/dL Protein / Alb 6.6/ 3.8 g/dL Uric acid 3.8 mg/dL CRP 1.62 mg/dL LD 469 IU/L UA RBC 0~1 WBC 0~1/HPF Protein (-) Nitrite (-) Glucose (-)

Chest X-ray

EKG

Initial problem list #1. Oropharyngeal cancer

Initial assessment & plan #1. Oropharyngeal cancer diagnostic plan) 1. Biopsy 2. Tumor HPV testing 3. Chest-CT 4. Neck-CT 5. Neck-MRI 5. PET-CT 6. Dental evaluation NCCN Guidelines 2011

Neck CT (7/30)

Chest CT (8/4)

PET CT (8/1)

Staging

Stage IVB

Final diagnosis #1. Oropharyngeal cancer (cT4bN2bM0 stage IVB)

Treatment NCCN Guidelines 2011

Treatment: 1. Induction Chemotherapy 2. ENT 에서 Op 예정 1. Induction chemotherapy : dTxPF - Docetaxel (70 mg/m²) - Cisplatin (75 mg/m²) - 5-FU (750 mg/m²)

Bx: Oropharyngeal cancer (Squamous cell carcinoma) ~ ~09.03 dTxPF # ~10.2 dTxPF #1dTxPF #3