1. 종양표지자 상승으로 의뢰된 51 세 자궁평활근육종 환자 2009. 12. 1 국립암센터 위암센터 이종열 제 86 회 대한소화기내시경학회 월례집담회

2. Present illness Female 51 –20MA Uterine leiomyosarcoma Dx –TAH & BSO –CCRT (carboplatin+docetaxol) –NED 로 FU 중 – 종양표지자 지속 상승으로 work-up 위해 입원

3. Past Medical History – –DM/HTN/Tbc./Hepatitis (-/-/-/-) Social History – –alcohol (-) – –smoking (-) Family History – –Lung cancer: pt’s father

4. Review of systems General: weight loss (+) 4kg/6months febrile sense(-) fatigue (-) Skin: pruritus (-) rash (-) petechia(-) Head & neck: headache (-) otalgia (-) blurred vision (-) Respiratory: dyspnea (-) cough/sputum (-/-) Cardiovascular: chest pain(-) orthopnea (-) palpitation (-) Gastrointestinal: abdominal discomfort (+), Indigestion(-) A/N/V/D/C (-/-/-/-/-) melena / hematochezia (-/-) Genitourinary: urgency (-) frequency (-) flank pain (-) Musculoskeletal: myalgia (-) arthralgia (-)

5. Physical examination V/S: 128/66 mmHg - 96/min - 18/min - 36.6°C General: not so ill looking appearance, alert HEENT: not so anemic, anicteric, cervical L/N(-) Pulmonary: clear breathing sound, crackle(-) CV: regular heart beat without murmur Abdomen: soft and flat, op. scar(+) normoactive bowel sound tenderness (-), rebound tenderness(-) palpable mass(-), hepatomegaly (-), splenomegaly (-) Back & Extremities: pretibial pitting edema(-/-) CVA tenderness (-/-)

6. Laboratory data CBC: WBC 11,120/mm 3, Hb 9.1 g/dL, PLT 368 K/mm 3 (seg 75.7% lymph 18.1%, mono 4.7%) LFT : AST/ALT 77/116 IU/L, ALP 218 IU/L, T-Bil 0.5 mg/dL Protein/Albumin 6.0/3.8 mg/dL, Ca/P 8.0/3.2 mg/dL CRP 2.7 mg/dL, BUN/Cr 10/0.7 mg/dL, HBsAg/Ab (-/+) CA 125 54.7 U/ml, CA 19-9 27.9 U/ml, CEA 0.9 ng/ml Occult blood, human (+) (850ng/mL)

7. CT

8. PET

9. CPA Lung PCNBx

10. EGD

11. Colonoscopy

12. Pathology Uterus, myometrium, hysterectomy: Leiomyosarcoma with 1) Involvement of myometrium and 1) Involvement of myometrium and endometrium endometrium 2) Mitosis: 22/10HPFs 2) Mitosis: 22/10HPFs 3) Mild to moderate cytologic atypia 3) Mild to moderate cytologic atypia 4) Coagulation necrosis: present 4) Coagulation necrosis: present 5) Infiltrative border 5) Infiltrative border

13. Pathology

14. Final Diagnosis Metastatic leiomyosarcoma of the uterus to the stomach to the stomach lung lung colon colon lymph node lymph node

15. Metastatic cancer to stomach Incidence (necropsy) – –0.2~0.8%: benign & mal. diseases – –1.7~5.4%: mal. neoplasm Common primary sites – –Lung, breast, melanoma, esophagus Common clinical symptoms – –Upper GI bleeding Macroscopic features on EGD – –Solitary > multiple – –Located in middle or upper third of stomach – –Appearance: SMT (52%), primary gastric cancer (39%) Campoli et al. Gastric Cancer 2006 Oda et al. Endoscopy 2001

16. Uterine leiomyosarcoma Incidence – –1/3 in uterine sarcomas ( < 2/100,000 females) Histologic criteria for diagnosis – –Cytologic atypia, mitotic index, coagulative necrosis – –Mitoses > 20/HPF: aggressive behavior Therapy – –Surgery: treatment of choice for initial therapy – –Adjuvant RT & Chemo: did not show benefit Common metastatic sites – –Lung or liver (hematogenous) Gadducci et al. Crit Rev Oncol Hematol 2008 Reed Clin Oncol 2008

17. 경청해주셔서 감사합니다.