2. Chief Complaint RUQ pain onset > 10days ago Present Illness F/49, 특이병력 없는 자로 내원 열흘 전부터 RUQ area 콕콕 쑤시는 통증 및 불편감 주소로 외부병원에서 시행한 복부초음파에서 liver mass 발견되어 이에 대한 정밀검사 위하여 입원함. Case 1 조 O 진 (F/49) 12243237 Admission date : 2011.12.22

3. Past-medical history DM / HTN / Tbc / Hepatitis (-/-/-/-) Operation Hx (+): 2006 년 Hysterectomy d/t uterine myoma 1977 년 Appendectomy Medication Hx : none Family history None Personal history S S moking : (-) Alcohol : (-)

4. Review of system Weight loss (-) A/N/V/D/C(-/-/-/-/-) Abdominal pain(+): RUQ pain (sharp pain, NRS 3~6 점 ) Melena(-) Hematochezia(-) Hematemesis(-) Physical examination No palpable LN Soft and flat abdomen Normoactive bowel sound Td/RTd(-/-)

5. Initial Lab Findings CBC/DC 6950/mm 3 (52.8%) – 12.2 g/dL - 36.8 % - 282,000/mm 3 PT(INR) 12.6 sec (0.92) aPTT 35.3 sec Chemistry TB/DB 0.50/0.15 mg/dL Prot/Alb 6.7/4.0g/dL AST/ALT 12/15 U/LBUN/Cr 19/0.7 mg/dL ALP/GGT 68/17 U/LNa/K/Cl 139/4.1/106 mmol/L LD/CK 321/72 U/LCa/P/Mg 8.4/3.3/2.0 mg/dL CRP < 0.3 CA 19-9/CEA 6.01/0.804

6. Work Up 2011.12.16 Liver CT 2011.12.23 Liver MRI 2011.12.26 Liver needle biopsy 2012.01.02 EGD 2012.02.16 Liver MRI

7. Liver needle biospy (S-2011-20278) Diagnosis : Inflammatory myofibroblastic tumor

8. Final Diagnosis Inflammatory myofibroblastic tumor of the liver

9. Review Inflammatory myofibroblastic tumor (IMT) of the liver

10. Mean age : 37 years M/F : 1.5/1 Most common lesion : lung (liver ; rare) Clinical findings : fever, abdominal discomfort, weight loss, weakness, anorexia Physical findings : RUQ td, hepatomegaly, jaundice Laboratory investigations Leukocytosis ( neutrophilia ), anemia, thrombocytosis Elevated ESR and CRP, slightly elevated LFT AFP and CEA : normal

11. The etiology of IMT : unclear unusual infections & unusual reaction to an infection ; 1/3 infection pts Baced on histopathological studies ; plasma cell granuloma Initial infection Cytokines IL-1 ↑, IL-6 ↑ Dysregulation of cytokines Chrosomal rearrangement Anaplastic lymphoma kinase (ALK) gene Low grade mesenchymal neoplasm

12. The differential diagnosis liver abscesses, metastases and primary tumors (such as cholangiocarcinoma and hepatocellular carcinoma)

14. Chief Complaint Recurred stomach cancer Present Illness 2009 년 1 월 EGC 로 subtotal gastrectomy B-I 시행 후 본원 외과 ( 김용호 교 수님 ) opd f/u 해오던 중 위내시경 추적검사에서 recurred stomach cancer 소견 보여 정밀 검사 위하여 입원함. Case 2 박 O 웅 (M/62) 12021108 Admission date : 2012.02.01

15. Past-medical history DM / HTN / Tbc / Hepatitis (-/+/-/-) Operation Hx (+): 2009 년 laparoscopy assisted distal gastrectomy, B-I Medication Hx :(-) Family history None Personal history S S moking : (-) Alcohol : (+)

16. Review of system Weight loss (-) A/N/V/D/C(-/-/-/-/-) Abdominal pain(-) Melena(-) Hematochezia(-) Hematemesis(-) Physical examination No palpable LN Soft and flat abdomen Normoactive bowel sound Td/RTd(-/-)

17. Initial Lab Findings CBC/DC 9100/mm 3 (72.8%) – 14.4 g/dL - 43.2 % - 397,000/mm 3 PT(INR) 12.7 sec (0.95) aPTT 36.9 sec Chemistry TB/DB 0.63/0.15 mg/dL Prot/Alb 7.9/4.4g/dL AST/ALT 23/13 U/LBUN/Cr 16/0.6mg/dL ALP/GGT 71/23 U/LNa/K/Cl 141/4.3/103mmol/L LD/CK 392/64 U/LCa/P/Mg 7.4/2.8/2.2 mg/dL CRP < 0.3 CA 19-9/CEA 15.72/3.17

18. Work Up (2009.01.07 laparoscopy assisted distal gastrectomy ) 2012.01.10 Abdomen CT 2012.01.10 EGD 2012.01.12 PET CT 2012.02.01 EGD & EUS // Chest CT 2012.02.06 Total gastrectomy

19. 2008.12

20. 2012.01

21. Final Diagnosis Advanced gastric cancer (stage IIIB)