1. 핵의학과 PK 18 조 68 번 주리히 2013.02.01 1 Case presentation 2 Disease review 3 Journal review

2.  Name : 오 ㅇ ㅇ  Age : 71  Sex : Male  Case Number : 02550352

3.  DOE

4. 2010.12 DOE (GII) develop 되었으나 work up 하지 않음 2011.02 건강검진상 LUL 에 mass 발견됨 2011.04. further w/u 위해 본원 PL dept. 내원 P/ICough (-) Sputum(-) Dyspnea(-) DOE+/- Chest pain(-) Bw loss(-) Oral intake so-so

5.  Past Medical History  pulmonary tuberculosis (-)  type 2 DM (-)  hypertension (-)  previous illness (-)  Personal History  Alcohol (+)  1 주 1 회, 소주 반 병  Smoking (ex)  6 개월 전 stop  allergy (-)  occupation (-)

6.  Family History  pulmonary tuberculosis (-)  type 2 DM (-)  hypertension (-)

7.  About 5cm sized mass like lesion at the LUL  R/O Lung cancer

8.  LUL upper division apicopost seg.br.: obstructed by mass=> Bx  Lung Cancer (SqCC)

10.  No evidence of definite brain metastasis.

12.  # NSCLC, LUL, SqCC, cT2N2M0, stage IIIA  # for curative CCRT (5wk)

14. 1. Staging 2. Treatment response

18.  Integrated PET/CT  a modality that combines PET and CT,  thus providing overlapping anatomic and metabolic information.  The technical aspects of integrated PET/CT are the same as those of CT and PET (T)  Tumor (T)  Integrated PET/CT provides the anatomic detail that is necessary to designate the primary tumor as T1a, T1b, T2a, T2b, T3, or T4.  It also distinguishes malignant lesions (increased uptake) from benign lesions (normal or decreased uptake) more accurately than either CT or PET alone.

19. (N)  Lymph nodes (N) (M)  Metastases (M) False positive results are common  Tissue sampling is required  Integrated PET/CT may be better than PET or CT alone in detecting extrathoracic metastases.  a solitary extrapulmonary : false positive results are common.

20.  치료 전 FDG PET 에서 원발종양의 SUV :  환자의 치료 후 생존을 예측하는 유의한 독립적 예후인자  즉, 원발종양의 SUV 가 높은 환자군이 유의하게 치료 후 예후가 나쁘다.  FDG PET 이 포함된 임상병기는 그렇지 않은 임상병기보다 비소세포성폐암 환자의 예후를 더 잘 반영한다.

21.  치료 후에 비소세포성폐암의 재발 또는 잔류 종양 진단에 CT 보다 정확  임상적으로 재발을 의심하는 경우에 높은 진 단 성능.  재발 진단에 FDG PET/CT 가 PET 보다 더 정 확하다고 보고

22.  비소세포성폐암의 항암약물 또는 방사선 치료효 과를 판정하는 데 CT 보다 정확, 예후를 더 잘 반 영  병리결과와 비교할 때 원발종양의 완전관해를 비 교적 정확하게 진단  임상 추적 관찰 결과와도 잘 일치  그러나 아직까지 FDG PET 의 치료효과 판정기 준에 대한 합의가 이루어져 있지 않으며, FDG PET 으로 인하여 실제로 개별 환자의 치료방침에 영향을 주었는지 알아본 연구는 아직 없다.

23. KM Kang, BK Jeong, Et al. Radiat Oncol J 2012;30(3):140-145

24.  Combined chemoradiotherapy  standard management for locally advanced non- small cell lung cancer (LA-NSCLC),  But standard treatment for elderly patients with LA-NSCLC has not been confirmed yet.  The feasibility and efficacy of concurrent chemoradiotherapy (CCRT) for elderly patients with LA-NSCLC.

25.  Among patients older than 65 years with LA- NSCLC, 36 patients, who underwent CCRT were retrospectively analyzed.  Chemotherapy was administered 3–5 times with 4 weeks interval during radiotherapy.  Thoracic radiotherapy was delivered to the primary mass and regional lymph nodes.  Total dose of 54–59.4 Gy (median, 59.4 Gy) in daily 1.8 Gy fractions and 5 fractions per week.

27. 58.2% 41.2% 31.2% 19.5% The median survival was 15 months. The median PFS was 10 months.

28.  Regarding to the toxicity developed after CCRT, pneumonitis and esophagitis with grade 3 or higher were observed in 13.9% (5 patients) and 11.1% (4 patients), respectively. Treatment-related death was not observed.

29.  Patients who undergo thoracic or neck irradiation for the treatment of malignancy are at risk for radiation pneumonitis and radiation fibrosis. method of irradiation the volume of irradiated lung the total dosage and frequency of irradiation associated chemotherapy genetic background  Typical symptoms  dyspnea, cough, chest pain, fever, and malaise. “subacute radiation pneumonitis ““late or fibrotic radiation pneumonitis”

30.  Subacute radiation pneumonitis  chest radiograph may show perivascular haziness  chest computed tomography may show patchy alveolar ground glass or consolidative opacities.  Chronic phase of radiation pneumonitis  volume loss with coarse reticular or dense opacities.  A straight line effect, which does not conform to anatomical units but rather to the confines of the radiation port, is virtually diagnostic of radiation- induced lung injury.

31.  The correlation between the onset of symptoms and signs with the timing of irradiation and between the pattern of radiographic changes and the radiation therapy portal.  Careful exclusion of other possible diagnoses,  such as infection, thromboembolic disease, drug- induced pneumonitis, pericarditis, esophagitis, or tracheoesophageal fistula, is key.  The optimal treatment for radiation-induced lung injury is not known.

32.  This clinical results strongly suggested that the aggressive CCRT could be also effective and safe in elderly patient group in considering of both respects of survival gain as well as complication risk  1) Response rate  2) Survival rate  3) Treatment induced complication

33.  1) Response rate  The overall response rate was substantially higher than any of the previously reported results  29% in Southwest Oncology Group  51.3% in Kang et al. 83.3%

34.  2) Survival rate  The median survival (15.0 months) was also better than previous results  13.0 months in Southwest Oncology Group  10.4 months in Davidoff et al.  The 2-year OS rates of 19.5% was comparable, than the previous results  21.0% in Southwest Oncology Group  23.0% in Davidoff et al.

35.  3) Treatment induced complication  The treatment-induced complication, which might be the most critical point when considering the CCRT to elderly patients, was sharply lower than the previous results.  grade 4 or higher hematologic toxicity  56% in younger than 70 years  78% in older than 70 years,  grade 4 or higher pneumonitis  1% in younger than 70 years  6% in older than 70 years  Higher than grade 3 ; 2.8–13.9%  in 15–78% of patients. Kang et al. Schild et al.

36.  The treatment-related toxicity as esophagitis and pneumonitis were noticeably lower when was compared with the previously reported results, and the survival rate was higher than radiotherapy alone.  The results indicate that CCRT is an effective in terms of survival and treatment related toxicity for elderly patients over 65 years old with LA- NSCLC.

37.  고창순, 핵의학 제 3 판, 고려의학, 2008; 260-270  Radiat Oncol J 2012;30(3):140-145

38.  71 세 남자가 건강검진 상 폐에 종괴가 발견되어 내원했다. 기관지 내시경 검사에서 좌상엽 일부 segment 를 완전히 막 고 있는 종괴가 관찰되었고 병리 소견에서 비소세포성암종 으로 진단되었다. PET CT 에서 종괴의 크기는 5cm 였고, 좌 측 대동맥하 림프절, 좌측 하부 기관 옆 림프절, 좌측 폐문 림프절에 전이 소견이 있었고 원격전이는 없었다. 흉벽이 나 횡격막, 심막 또는 carina 로부터 2cm 내에는 병변이 없 었다. 적합한 TNM 병기는 ?  1. T1N1M0 (Stage 1B)  2. T1N2M0 (Stage 3A)  3. T2N2M0 (Stage 3A)  4. T3N1M0 (Stage 3A)  5. T3N2M0 (Stage 3A)

39.  71 세 남자가 건강검진 상 폐에 종괴가 발견되어 내원했다. 기관지 내시경 검사에서 좌상엽 일부 segment 를 완전히 막 고 있는 종괴가 관찰되었고 병리 소견에서 비소세포성암종 으로 진단되었다. PET CT 에서 종괴의 크기는 5cm 였고, 좌 측 대동맥하 림프절, 좌측 하부 기관 옆 림프절, 좌측 폐문 림프절에 전이 소견이 있었고 원격전이는 없었다. 흉벽이 나 횡격막, 심막 또는 carina 로부터 2cm 내에는 병변이 없 었다. 적합한 TNM 병기는 ?  1. T1N1M0 (Stage 1B)  2. T1N2M0 (Stage 3A)  3. T2N2M0 (Stage 3A)  4. T3N1M0 (Stage 3A)  5. T3N2M0 (Stage 3A)