私立高雄醫學大學附設中和紀念醫院開會通知單 ( 稿 )

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1 私立高雄醫學大學附設中和紀念醫院開會通知單 ( 稿 ) 受文者 發文日期及字號 開會事由 中華民國 105 年 08 月 05 日速別高醫附字第號附件 多專科消化系癌團隊聯合個案討論會 開會時間 ( 星期二 ) 中午 12:10~13:15 開會地點 18ES 討論室 主持人王照元醫師聯絡人張瑟芬個管師電話 大腸直腸外科 : 謝建勳 王照元 馬政仁 黃哲人 蔡祥麟 蘇偉智 張琮琨 黃敬文 巫承哲胃腸內科 : 蘇育正 盧建宇 郭昭宏 余方榮 吳宜珍 出 ( 列 ) 席 單位及人員 胡晃鳴 許文鴻 血液腫瘤科 : 王慧晶 放射腫瘤科 : 黃志仁 黃旼儀 黃鈞民 李欣樺 影像醫學部 : 陳巧雲 病理部 : 陳怡庭 備 註 討論個案 姓名 病歷號 診斷 主治醫師 陳天吉 朱兆康 sigmoid colon neuroendocrine carcinoma Rectosigmoid colon ca V.S 許文鴻 V.S 王照元 吳明遠 Rectal ca V.S 王照元

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6 Patient s information Cancer Meeting By PGY 廖仁孮 Name: 朱 O 康 Age: 87-year-old Gender: male Chart No.: Admission date: Discharge date: Diagnosis when admission: Gastric cancer s/p total gastrectomy in 2013/02 pt1an0m0,stage:ia Rectosigmoid colon cancer Diabetes mellitus type Brief History The 87-year-old man had history of : Gastric adenocarcinoma, pt1an0m0, stage Ia post Total gastrectomy+ Roux-en-Y jejnojejunostomy+ feeding jejunostomy on 102/2/16 Pericardial effusion, cause to be determined C3-4 retrolithesis with stenosis Hemorrhagic stroke history, Right cranial hematoa in resolution in 101/10 Diabetes mellitus, type 2 Hypertension Bilateral inguinal hernia post operation in Brief History Associated symptoms: Positive: pale conjuntiva, bloody stool Negative: fever, chills, jaundice, nausea, vomiting, hematemesis, tea-colored urine, clay-colored stool, pitting edema, palpable abdominal mass, bowel habits change, body weight loss, poor appetite, constipation, change of bowel habit, congestive sensation, caliber change of stool, body weight change CEA: ng/ml (06/06) Hgb 6.3 g/dl s/p prbc 2U /06/29 abdominal CT 2016/07/18 Sigmoidscopy Gastric cancer s/p total gastrectomy. Eccentric wall thickening at rectosigmoid colon. (Se/lm: 3/61) Suggest further survey with endoscope to rule out colon cancer. Non-enlarged lymph nodes in the paraaortic region. Small amount of ascites in the pelvic cavity. Probably a cystic lesion at pancreatic body. (Se/lm: 3/15) Suggest follow up. Suspect status post TURP. Atherosclerosis of the abdominal aorta and bilateral common iliac arteries. Spondylosis deformans of the thoracolumbar spine. Suspect osteoporosis. 5 colonoscopy was performed till 14 cm from anal verge, a circumferential tumor with lumen stenosis was noted, biopsy was done 6

7 2016/07/18 Pathologic Diagnosis: Intestine, large, colon, rectosigmoid, colonofiberoscopic biopsy, adenocarcinoma, grade /08/04 Operation Venous system with port implantation 7 8 Medication plan RT to primary tumor for 5000cGy/25fx 4500cGy/25fx, to pelvic nodal area is indicated. CT FOLFOX6 O since 2016/08/05 Case conference 朱 X 康 87M 病理部陳怡庭醫師 9 10 KMU Stomach, total gastrectomy 11 12

8 13 14 Pathologic Diagnosis Adenocarcinoma, grade II. (pt 1a N 0 ) Intestine, small, duodenum, partial resection, negative for malignancy. Esophagus, partial excision, negative for malignancy. Lymph node, regional, lymphadenectomy, y negative for malignancy. ( 0/21 ) KMU Intestine, large, colon, rectosigmoid 17 18

9 19 20 Pathologic Diagnosis Adenocarcinoma, grade II. Cancer Combined meeting Presented by R3 張建偉 Name: 陳 吉 Patient Identification Gender: male Age: 86 Chart No.: Chief Complaint Present Illness Watery diarrhea in recent 2 months 7/19 GI OPD -> Plain abdomen: ileus -> Arrange colonoscope on 7/25 Fever & dyspnea after going home 7/19 ER -> admitted to Chest ward due to COPD with AE intermittent fever up to 39'C for 1 day 23 24

10 Past History Chronic obstructive pulmonary disease, grade B Hoarseness, r/o vocal cord tumor Parkinson s disease Sleep disorder Hypertension 25 Personal history Cigarette Smoking : quitted for 30 years, 1 PPD for 20 years Alcohol : 600ml of beer QD, and 一小杯烈酒 per day in winter Occupation history : retired, 目前為廟會負責人 Contact history : denied Travel history : went to Japan 1.5 months ago 26 Physical Examination Consciuos:clear E4V5M6 HEENT: conjunctiva:pale(-), sclera:icteric(-), LAP(-), JVE(-) Chest: symmetric expansion, no accessory msucle usage heart sound: RHB, murmur(-) breath sound: bil coarse(+) Abdomen: soft & not distend, bowel sound: normo-active tympanic(-), shifting dullness(-) tenderness(-)rebound pain(-)percussion pain(-)muscle guarding(-) Extremities: bilateral lower limbs pitting edema(-), free movable no erythema or heat Skin: warm, purpura/petechiae(-/-), rash(-) 7/20 Abdomen CT Impression: 1) Wall thickening with enhancement at the sigmoid colon (Se/Im:400/10-14) with suspicious peritoneal soft tissue extending. Malignancy should be suspected. Recommend clinical correlation and tissue proof. The primitive tumor staging depicts later. 2) Consider metastatic lymphadenopathy at the adjacency, aortocaval area, paraaortic space, pericaval region and right external iliac chain. 3) Subpleural consolidation at the left lower lobe of lungs. Superimposed soft tissue metastasis can't be excluded. 4) A hypodense nodule in the S8 of liver (Se/Im:3/18). DDx: metastasis. Suggest follow-up. ===== 大腸直腸癌癌症分期統一報告格式(Based on RSROC ) ===== Cancer staging by CT on 2016/07/20: TNMStage: T4aN2bM1b (according to AJCC cancer staging 7th ed., 2010) Stage group: IVB 29 7/28 Colonoscopy Colonoscopic finding : Up to S-colon, 35cm from anus, circumferential ulcerated lesion with necrosis was noted and colonosscopy can't pass through. S-colon tumor was impressed. Bx1-9. Another colon polyp was noted over 15cm from anus and mixed hemorrhoid was also noted. Endoscopic diagnosis: Advanced colorectal cancer,sigmoid colon,s/p biopsy 30 Tubular adenoma Isp 位置不明與肛門口距離

11 7/28 Colonoscopy Coo oscopy 7/28 pathology Intestine, large, colon, sigmoid, colonofiberoscopic biopsy, large cell neuroendocrine carcinoma, grade Impression Pre-OP survey 7/30 Sigmoid colon cancer, Lung liver metastasis, T4aN2bM1b, stage IVB Sepsis, focus on suspect aspiration pneumonia Chronic obstructive pulmonary disease, grade D /8/1 OP Transverse colostomy + Venous port implantation Case conference 陳 X 吉 86M 病理部陳怡庭醫師 35 36

12 KMU Intestine, large, colon, sigmoid Synaptophysin Chromogranin-A 41 42

13 Ki-67 Pathologic Diagnosis Large cell neuroendocrine carcinoma, grade Thanks for your listening! Cancer Meeting (105/08/09) R2 劉宗憲 吳 o 遠 Age: 64 Gender: male Chart number: Date of admission: 105/07/22 Date of operation: 105/08/01 Diagnosis: Rectal adenocarcinoma, ct3n1m0, stage IIIB Brief History 64 y/o male underlying hypertension Presented with bloody stool for 1 month - no poor appetite, no body weight loss, no bowel habit change - OPD: circumferential tumor at 3 cm AAV - Colonscopy: at 2-7 cm from anal verge, biopsy: adenocarcinoma, grade

14 Abd CT on 2016/03/25 Consider lower rectal cancer with pericolic fat infiltration and visible small size lymph nodes in the presacral region Maximal depth of the tumor: 1.23cm 5 o'clock Maximal length of the tumor: 3cm 2-7 o'clock oclock CT staging: ct3n1mb, stage IIIB T3: Tumor invades into pericolorectal l tissues N: presacral LN M: Can't be assessed MRI on 2016/03/28 The maximal depth : 1.25cm The maximal length : 3.6cm Impression: - Consider lower rectal cancer with minimal pericolic fat infiltration and visible small size lymph nodes in the presacral regions. - The upper margin of the tumor to the anal verge is around cm Previous Tx Join PEP503 RC 1001 clinical trial - PEP503 injected via colonscopy on 105/03/29 (tumor volume: 21.1ml, injected 1.06ml) - venous port implantation on 105/03/30 - neoadjuvant CCRT (5-FU 5cycle(5*5) and RTO 5000cGY/25fx) MRI on 2016/05/06 (D57) The maximal depth : > 1.0cm The maximal length : 3.6 -> 2.45cm Interval decrease size with residual lower rectal cancer. Visible tiny lymph nodes in the presacral regions. The upper margin of the tumor to the anal verge is around cm MRI on 2016/07/01 (D93) The maximal depth : > 1.0 -> 0.94cm The maximal length : 3.6 -> > 1.94cm Persistent shrinkage and residual lower rectal cancer Suspicious post irradiation fibrosis in the perirectal region Abscent of tiny LNin the presacral regions. The upper margin of the tumor to the anal verge is around cm Ad on 105/07/22 for OP 53 54

15 CEA trend Proctosigmoidectomy with Pull through coloanal anastomosis+ T- colostomy 105/07/ Pathology report on 105/07/26 Intestine, large, rectum, adenocarcinoma, grade 2 (ypt3n0). Lymph node, regional, lymphadenectomy, negative for malignancy ( 0/6 ). Lymph node, apical, lymphadenectomy, negative for malignancy ( 0/1 ). Lymph-vascular invasion: not identified. Perineural invasion: not identified. Tumor deposits (discontinuous extramural extension): not identified. IHC testing for Mismatch Repair(MMR) proteins: MLH1: intact of nuclear expression. MSH2: intact of nuclear expression. MSH6: intact of nuclear expression. PMS2: intact of nuclear expression. Interprepation and Note: 58 - No loss of nuclear expression of MMR proteins: low probability of Case conference 吳 X 遠 64M 病理部陳怡庭醫師 KMU Intestine, large, rectum, radical proctectomy 59 60

16 61 62 Pathologic Diagnosis Adenocarcinoma, grade 2 (ypt 3 N 0 ). Lymph node, regional, lymphadenectomy, y, negative for malignancy ( 0/6 ). Lymph node, apical, lymphadenectomy, ecto y, negative e for malignancy ( 0/1 ). LVI (-), PNI (-), TRG 2, MMR (intact) 63 64