1. M.G.R 혈액종양내과 R2 신아리 /prof. 백선경 혈변을 주소로 온 50 세 여자 환자

2. C.C) Hematochezia o/s– 내원 1yr ago P. I ) 특이병력 없는 환자로, 10 여년전부터 constipation 있었고, 내원 1 년전부터 간간히 hematochezia 있었으나 치료 없이 지냈음. 내원 6 개월전부터 hematochezia 양 및 빈도 증가하고 내원 1 주전부터 hematochezia 및 watery diarrhea 동반하여 local clinic 경유 큰병원 진료 권유받아 ED 경유 adm. ( ED 시행 : L-tube (-) / DRE (+) - blood tinged stool ) 11759691 이 O 일 (F/50) Adm date : 05.02.16 via ED

3. PMHx) DM/HTN/ hepatitis/ Tbc (-/-/-/-) Op Hx (+) : salphingectomy d/t ectopic preg (20yrs ago) PHx) Smoking (+) : 3-4.5 pack year Alcohol (+) : 소주 1/2 병 x 1~2 회 /wk FHx) none

4. Review of system fever (-) chills (-) fatigue (-) wt loss (+) : 6-7kg/6mon rash (-) itching (-) pigmentation (-) headache (-) otorrhea (-) visual disturbance (-) rhinorrhea (-) nasal obx (-) sore throat (-) hoarseness (-) cough (-) sputum (-) dyspnea (-) hemoptysis (-) chest pain (-) palpitation (-) DOE (-) orthpnea (-) abdominal pain (+) : low abd 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 Neurology 1 년전부터 stool caliber change 동반한 constipation 1 주전부터 15-20 회 / 일 빈도로 지리는 양상의 watery diarrhea

5. Physical examination Vital sign 140/80mmHg – 72/min- 20/min – 36.5°C General app. alert mentality acute-ill looking appearance HEENT isocoric pupil c PLR (++/++) whitish sclera / pale conjunctiva LNE (-) NVE (-) Thorax clear breathing sound s rale regular heart beat s murmur Abdomen soft & flat abdomen, Td/RTd (+/-) hyperactive bowel sound rectal exam : AV 6cm 상방, lumen 을 거의 막는 hard mass 촉지 Back & Ext. CVA Td (-/-) pretibial pitting edema (-/-) Neurology sensory & motor : intact

6. Initial Lab Finding CBC/DC 5900/mm² - 9.0 g/dl – 27.1% - 301K (seg. 53.7%) PT (INR) 12.8 (1.00) aPTT 32.3 Chemistry TB 0.6 mg/dL Prot/alb 6.3/3.9 g/dL AST/ALT 16/9 IU/L ALP/GGT 81/8 IU/L U/A RBC 0-1/HPF WBC 0-1/HPF Tumor marker CA125 2.6 CA 19-9 23.7 AFP 1.01 CEA 2.54 BUN/Cr 11/0.6 mg/dl Na/K/Cl 142/3.9/107 mg/dl Ca/P/Mg 8.3/3.8/1.9 mg/dl LD/CK 366/173 U/L

7. Chest X-ray

8. Simple abdomen

9. EKG

10. Problem List #1. Hematochezia #2. Rectal mass above 6cm of AV #3. Anemia

11. Initial assessment & plan #1.#2. d/t rectal cancer r/o d/t rectal polyp r/o d/t hemorrhoid #3. Anemia d/t Lower GI bleeding

12. Initial assessment & plan #1. Rectal cancer r/o rectal polyp r/o hemorroid plan) Colonoscopy TRUS, Abdomen CT if needed Chest CT, pelvis MRI, PET CT or bone scan #2. Anemia plan) Anemia study (iron/TIBC, ferritin/folate/VitB12,PBS,reticulocyte) If needed pack RBC transfusion

13. Colonoscopy (05.2.18) Rectum, colonoscopic bx : adenocarcinoma

14. TRUS (05.2.17)

15. Abdomen CT (05.2.19)

16. Pelvis MRI (05.2.28)

17. Bone Scan (05.3.7)

18. Stage Rectal ca, adenocarcinoma, stage Ⅲ C (T3N2M0)

19. Treatment Plan Neoadjuvant CTx+RTx Op Adjuvant CTx

20. Clinical course Neoadjuvant CTx+RTx 시행 CTx : 05.3.7-05.5.2 / LV5FU2#1~#5 RTx : 05.3.8-05.4.20 / total 5400cGY Before neoadjuvant TxAfter neoadjuvant Tx

21. Clinical course Op 위해 GS adm (2005.6.12) Operation (2005.6.15) Preop Dx : Rectal cancer Op name : Laparoscopic LAR c loop ileostomy Gross & Pathologic finding - location : rectum, AV 상방 4cm - character : 4x3cm, ulcerating, encirculating mass - histology : adenocarcinoma, moderate differentiated - depth : invades perirectal soft tissues (pT3) - regional LN : meta to 2/9 regional LN (pN1) - margin (-), lymphatic/vascular invasion (-/-)

22. Clinical course Postop f/u abdomen CT (2005.7.5)

23. Clinical course Adjuvant CTx 시행 CTx : 05.7.5-05.9.30 / LV5FU2#6~#12 F/U After Adjuvant CTx (05.12) Abdomen CT Tumor marker CA19-9 15 CEA 1.23 Complete remission of rectal cancer !!

24. Clinical course 08.7 IH OPD visit O) tumor marker CEA 3.12 / CA19-9 157.44 F/U Abdomen CT, Chest CT, Bone scan 시행 Wedge resection & lung Bx : Metastatic adenocarcinoma

25. Clinical course A) Rectal cancer c lung metastasis P) Chemotherapy : 08.8.4-09.1.30 / mFOLFOX6 #1~#11

26. Clinical course F/U After CTx ; mFOLFOX6 #1~#11 (09.4) Chest CT Abdomen CT Tumor marker CA 19-9 9.16 CEA 1.71 Complete remission of rectal cancer !!

27. Clinical course 09.7 IH adm S) Rt. Leg pain, LBP (o/s : 1month ago) O) P/Ex sensory motor Tumor marker PET CT CA19-9 116.24 CEA 4.8 100 ⅤⅤ ⅤⅤ

28. Clinical course O) Spine MRI A) Rectal cancer c lung meta c spine meta P) Dexamethasone 및 spine radiotherapy

29. Clinical course 09.9 IH adm O) tumor marker : CA19-9 / CEA 166.24 / 8.67 spine MRI A) Rectal cancer c lung meta c spine meta P) CTx ; Xeloda 1800mg bid (09.9.9~) 09.7 spine MRI09.9 spine MRI

30. Clinical course 09.11 IH adm O) tumor marker : CA19-9 / CEA 205.17 / 14.87 spine MRI A) Rectal cancer c lung meta c aggravated spine meta P) CTx regimen change ; FOLFIRI (09.11.17~ 현재 ) 09.9 spine MRI 09.11 spine MRI

31. Clinical course (05.2-) 05/5 Neoadjuvant CTx+RTx (LV5FU2#5) CTx (Xeloda#3) (FOLFIRI#4) CTx (mFOLFOX6#11) 10/305/608/705/309/9 Rectal Ca Dx Adjuvant CTx+RTx (LV5FU2#12) 05/7 05/9 09/109/7 Rectal ca c lung meta Dx Rectal ca c lung meta c spine meta Dx Op RTx

32. Final diagnosis #1. Rectal cancer c lung meta c spine meta s/p neoadjuvant LV5FU#5+RTx s/p laparoscopic LAR s/p adjuvant LV5FU2#7 s/p mFOLFOX6 #11 s/p spine RTx s/p Xeloda #3 s/p FOLFIRI #4