Case Presentation 1 R2 이은정

Chief Complaint for cancer evaluation Present Illness F/58, 특이병력 없던 자로 내원 6 개월 전 Rt flank pain 으로 개인의원 방문, chest CT 상 우연히 liver mass 발견 하였으며 이후 pain 지속되어 3 개월 전 타 병원 내원하여 위내시경 시행, 특이 소견 없어 liver mass 에 대하여 F/E 위해 외래 경유 입원함 이 O 희 F/58 Adm> CASE I 2

Past medical historyPast medical history DM / HTN / Tbc ( - / - / - ) Hepatitis (-) op Hx (+) : 2001 년 uterine myoma 로 hysterectomy Drug Hx (-) Family history none Personal history Smoking (-) Alcohol (-) 3

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 (+) - RUQ Urinary : dysuria (-) frequency (-) urgency (-) Musculoskeletal : arthralgia(-) weakness (-) numbness (-) Nervous : syncope (-) seizures (-) dizziness (-) 4 Review of System

Physical Examination Vital sign 140/90 – 66 회 /min – 20 회 /min – 36.2°c weight : 46kg height : 145cm BMI : 21.8 kg/m 2 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 tenderness (+) : RUQ / no rebound tenderness no rigidity / no guarding 5

Initial Lab Findings CBC/DC 8,390/mm² g/dl – 40.2% - 372k (seg 70.5%) PT 12.8 INR 0.96 Chemistry TB/DB 0.43/0.13 mg/dL AST/ALT 39/26 IU/L ALP/GGT 284/167 IU/L Prot/Alb 7.4/4.2 g/dL BUN/Cr 12/0.5 mg/dL CRP 1.1 mg/dL Na/K 141/3.9 mmol/L Viral markers HBsAg(-) anti-HCV(-) / anti-HIV(-) 6

Additional Lab Findings Tumor marker ( ) Liver function Child-Pugh class : A (5 점 ) MELD score : 6 Tumor stage LCSGJ : stage III (T3N0M0) BCLC : stage C CLIP stage : score 2, intermediate stage JIS score : 2 7 AFP3.13 ng/mL CA U/mL CEA510.1 ng/mL

Clinical course Liver CT 시행 Chest CT Liver MRI, PET CT

Clinical course GS admission OP : Lt lobectomy & cholecystectomy CBD stone removal ~14 ICU care 퇴원함

Pathology Frozen section Permanent section

Chief Complaint for cancer evaluation Present Illness M/40, 2 년전부터 B-viral LC 로 외래 f/u 하던 자로 liver CT 에서 liver mass 발견되어 liver MRI 시행, r/o sclerosing HCC, r/o cholangiocellular carcinoma 결과 나와 liver biopsy 위해 입원함 윤 O 일 M/40 Adm> CASE 2 11

Past medical historyPast medical history DM / HTN / Tbc ( - / - / - ) Hepatitis B (+) : HBs Ag (+) op Hx (-) Drug Hx (-) Family history none Personal history Smoking (+) : 20 pack - yrs Alcohol (-) : 2 년 전부터 금주 12

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 Review of System

Physical Examination Vital sign 110/70 – 70 회 /min – 20 회 /min – 36.5°c weight : 86.7kg height : 177.9cm BMI : 27.6 kg/m 2 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 (-) splenomegaly (-) 14

Initial Lab Findings CBC/DC 7,380/mm² g/dl – 44.8% - 201K (seg 53.4%) PT 14 INR 1.07 Chemistry TB/DB 0.92/0.27 mg/dL AST/ALT 42/74 IU/L ALP/GGT 83/74 IU/L Prot/Alb 7.1/4.1 g/dL BUN/Cr 9/0.7 mg/dL CRP <0.5 mg/dL Na/K 140/3.9 mmol/L Viral markers HBsAg(+) / anti-HBsAb(-) / HBeAg (-) / anti-Hbe Ab (-) anti-HCV(-) / anti-HIV(-) HBV-DNA titer : positive ( )  negative ( 이후 ) IU/ml 3287 copies/ml

Additional Lab Findings Tumor marker ( ) Liver function Child-Pugh class : A (5 점 ) MELD score : 6 Tumor stage LCSGJ : stage III (T3N0M0) BCLC : stage B CLIP stage : score 1, intermediate stage JIS score : 2 16 AFP3.31 ng/mL CA U/mL CEA1.48 ng/mL

Clinical course Liver biopsy ( ) 17

Clinical course Bone scan ( ) Chest CT ( ) TACE 시행 (09.7.1) 18

Chief Complaint jaundice o/s> 내원 3 일전 Present Illness M/67, HTN 으로 po med, 내원 2 주전부터 itching sensation 발생하였으며 내원 3 일전부터 jaundice, dark color urine 발생하여 개인의원 경유, 큰 병원 권유 받고 응 급실 경유 입원함 석 O 학 M/67 Adm> CASE 3 19

Past medical historyPast medical history DM / HTN / Tbc ( - / + / - ) Hepatitis (-) op Hx (-) Drug Hx (-) Family history none Personal history Smoking (-) : 5 년 전부터 금연, 30 pack-yrs Alcohol (+) : 주 1 회, 소주 1 병 20

21 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 (+) : epigastrium Urinary : dysuria (-) frequency (-) urgency (-) Musculoskeletal : arthralgia(-) weakness (-) numbness (-) Nervous : syncope (-) seizures (-) dizziness (-)

Physical Examination Vital sign 120/80 – 72 회 /min – 20 회 /min – 36.6°c weight : 58kg height : 168cm BMI : kg/m 2 General alert consciousness Head & Neck no neck vein engorgement no neck LN enlargement Eye & ENT icteric 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 (-) splenomegaly (-) 22

Initial Lab Findings CBC/DC 6,670/mm² g/dl – 41.3% - 129K (seg 63.5%) PT 14.7 INR 1.14 Chemistry TB/DB 6.29/4.63 mg/dL AST/ALT 46/85 IU/L ALP/GGT 138/789 IU/L Prot/Alb 6.9/3.9 g/dL BUN/Cr 12/0.8 mg/dL CRP 2.9 mg/dL Na/K 139/4.1 mmol/L Viral markers HBsAg(-) anti-HCV(-) / anti-HIV(-) 23

Additional Lab Findings Tumor marker ( ) Liver function Child-Pugh class : B (7 점 ) MELD score : AFP5.73 ng/mL CEA2.61 ng/mL

Clinical course

Liver CT ( ) MRCP ( ) PET CT ( ) PTBD, tube change ( / 6.23, ) 26

Chief Complaint for TACE Present Illness M/62, DM, HTN 으로 po med, daily 소주 한 병씩 마시 던 heavy alcoholics 로 2009 년 1 월 녹색병원에서 시행한 복부초음파상 liver mass 발견되어 본원 전원, HCC 진단 되어 2009 년 2 월 TACE 시행하였으며 이후 f/u liver CT 상 incomplete lipiodolized HCC 발견되어 TACE 재 시행 위 해 입원함 전 O 규 M/62 Adm> CASE 3 27

Past medical historyPast medical history DM / HTN / Tbc ( + / + / - ) Hepatitis (-) op Hx (-) Drug Hx (-) Family history none Personal history Smoking (+) : 40 pack-yrs Alcohol (+) : 6 개월 전부터 금주, daily 소주 한병 x 40yrs 28

29 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 (-)

Physical Examination Vital sign 100/80 – 72 회 /min – 20 회 /min – 36.4°c weight : 63.4kg height : 168cm BMI : 22.4 kg/m 2 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 (-) splenomegaly (-) 30

Initial Lab Findings CBC/DC 8,130/mm² g/dl – 52.6% - 156K (seg 52.6%) PT 13.3 INR 1 Chemistry TB/DB 0.61/0.23 mg/dL AST/ALT 27/30 IU/L ALP/GGT 110/34 IU/L Prot/Alb 7.4/4.3 g/dL BUN/Cr 12/0.7 mg/dL CRP <0.5 mg/dL Na/K 136/4.2 mmol/L Viral markers HBsAg(-) anti-HCV(-) / anti-HIV(-) 31

Additional Lab Findings Tumor marker ( ) Liver function Child-Pugh class : A (5 점 ) MELD score : 6 Tumor stage LCSGJ : BCLC : CLIP stage : JIS score : 32 AFP5883 ng/mL CA U/mL CEA3.98 ng/mL

Clinical course Liver CT (09.5.7) TACE 시행 ( ) 33