본태성고혈압 환자에서의 Doppler 심초음파 소견에 대한 연구

임석아(Seock Ah Im),정혜경(Hye Kyung Jung),정성애(Sung Ae Jung),박정은(Jung En Park),신길자(Gil Ja Shin),이우형(Woo Hyung Lee) 대한내과학회 1995 대한내과학회지 Vol.48 No.1

N/A Objectives: Systemic arterial hypertension causes structural and functional changes of myocardium and coronary circulation, increased tendency to ventricular arrhythmia, ischemic heart disease, and congestive heart failure. In recent years, the echocardiogram has been developed as noninvasive method for the evaluation of left ventricular performance. Estimation of systolic and diastolic function of left ventricle and measurement of left ventricular mass may predict outcome of hypertensive patients. Methods: We measured systolic and diastolic function of left ventricle and left ventricular mass with M-mode, two-dimensional, and Doppler echocardiography in 62 cases of hypertensives and 20 cases of healthy adults from November 1992 to August 1993. Results: 1) Hypertensive group was 62 cases (M:F=33:29), the mean age was 56±13 years. Normotensive group was 20 cases (M:F=8:12), the mean age was 53±10 years. There was no significant differences in age distribution, sex ratio, height, weight, and body mass index. 2) On M-mode echocardiographic measurements, interventricular septum thickness and LV posterior wall thickness were significantly increased in hypertensive group (14.4±2.9㎜, 13.9±2.9㎜) than normotensive group (10.7±1.1㎜, 10.3±1.6㎜) (p<0.01). 3) Ejection fraction was decreased in hypertensive group (55.8±12%) than normotensive group (63.0±6.7%) but within normal range. 4) There was no significant differences of cardiac output and cardiac index between hypertensive group (4.69±1.151/min., 3.20±2.641/min./㎡) and normotensive group (4.88±1.211/min., 3.02±0.791/min./㎡). 5) There was no significant differences of peak E velocity between hypertensive group (72.8±22.4㎝/sec) and normotensive group (77.1±16.3㎝/sec). Peak A velocity was significantly increased in hypertensive group (83.1±22.2㎝/sec) than normotensive group (62.6±15.0㎝/sec) (p<0.01). Peak E/A ratio was significantly decreased in hypertensive group (0.91±0.28) than normotensive group (1.22±0.25) (p<0.01). Mitral valve deceleration time was significantly prolonged in hypertensive group (240.0±48.4msec) than normotensive group (240.0±48.4msec) (p<0.01). Conclusion: Diastolic dysfunction and left ventricular hypertrophy were prominent in hypertensive group but systolic function was relatively saved.

위암 조직내 Thymidylate Synthase 의 발현정도가 예후에 미치는 영향

남은미(Eun Mi Nam),임석아(Seock Ah Im),이순남(Soon Nam Lee),구혜수(Hea Soo Koo) 대한내과학회 1999 대한내과학회지 Vol.56 No.3

N/A Objective : Gastric carcinoma is one of the most common cause of death in Korea with limited effectiveness of chemotherapy. Thymidylate synthase(TS) is a critical therapeutic target for the fluoropyrimidine cytotoxic drugs, that are the mainstay of the treatment for the advanced gastrointestinal malignancies. We assessed the relationship between the levels of TS expression and survival and effect of 5-fluorouracil based chemotherapy in gastric adenocarcinoma. Methods : Thirty six patients with gastric adenocarcinoma who underwent curative resection of stomach at Ewha Womans University Hospital were evaluated. TS protein expression in tumor tissues was assessed by standard immunohistochemical staining techniques with TS 106 monoclonal antibody. Results : TS expression was high(3+) in 19 patients (52.8%) and low(≤2+) in 17 patients(47.2%). Between these two groups, there was no significant difference in the histopathologic type or stage. Seventy-two point five percent of patients with low TS expression were disease free at 5 years compared with 58.2% of patients with high TS expression(p=0.31) and 73.7% of patients with low TS expression were alive at 5 years compared with 61.4% of patients with high TS expression(p=0.34). In patients with high TS expression, disease-free survival (DFS) and overall survival(OS) of patients who received adjuvant chemotherapy were longer than those of patients with surgery alone without significance(p=0.28, p=0.16). Conclusions : We could not confirm the association between the level of TS expression in tumor tissues and DFS and OS of patients with gastric adenocarcinoma who underwent curative resection. Further study with more cases as well as prospective study will be necessary for establishment of relationship between TS expression of tumor and prognosis of gastric adenocarcinoma

증례 : 혈액종양 ; 젊은 여성의 유방에 발생한 원발성 활막 육종 1예

김지원 ( Ji Won Kim ),권지현 ( Ji Hyun Kwon ),오도연 ( Do Youn Oh ),조나리야 ( Nariya Cho ),임석아 ( Seock Ah Im ),김영태 ( Young Tae Kim ),박인애 ( In Ae Park ) 대한내과학회 2010 대한내과학회지 Vol.78 No.5

활막 육종은 주로 관절 주위 조직에 호발하는 악성 종양이다. 종종 관절 이외의 다른 부위에 발생하는 경우도 보고되어있는데, 원발성 유방 활막 육종은 세계적으로도 보고된 예가 드물다. 본 증례는 원발성 유방 활막 육종으로 진단된 15세 여자 환자의 1예이다. 진단 후 유방 종괴에 대한 광범위 절제술을 시행하였으나 9개월 후 국소 재발하였고, 이에재발 부위에 대한 광범위 절제술을 다시 시행하였다. 그러나, 27개월 후 폐의 우상엽에 고립성 폐 전이가 발견되었다. 이에 폐 병변에 대한 절제술 및 고식적 화학요법으로 doxorubicin 및 ifosfamide의 병합 화학요법을 시행하였다. 현재 항암화학요법 종료 후 28개월째 재발의 증거 없이 경과관찰중이다. 이에 저자들은 본 증례를 문헌고찰과 함께 보고하는 바이다. Synovial sarcoma is a malignant soft tissue neoplasm that develops mainly in para-articular locations in the extremities, but can arise in a wide variety of other sites. Primary breast synovial sarcoma has been reported infrequently worldwide. We report the case of 15-year-old female who was diagnosed with primary breast synovial sarcoma. We performed wide excision for the breast mass. However, local recurrence was detected 9 months later. We performed wide excision for the recurrent breast tumor. After 27 months, a solitary metastasis was found in the right upper lobe of the lung. We performed wedge resection for the lung mass and treated her with palliative chemotherapy using doxorubicin and ifosfamide. Twenty-eight months after chemotherapy, she is alive without evidence of recurrence. We report the details of this case along with a review of the literature. (Korean J Med 78:640-644, 2010)

38세 여자의 공장에서 발생한 원시신경외배엽종양 1예

김기환 ( Ki Hwan Kim ),이지영 ( Ji Young Rhee ),이재경 ( Jae Kyung Lee ),조화영 ( Hwa Young Cho ),임석아 ( Seock Ah Im ),박규주 ( Kyu Joo Park ),김종재 ( Chong Jai Kim ) 대한내과학회 2008 대한내과학회지 Vol.75 No.2

저자들은 복부 통증과 복부의 종괴를 주소로 내원한 38세 성인 여자 환자에서 복부컴퓨터단층촬영과 3차원재구성 가상내시경으로 공장의 종괴를 진단하여 근치적인 절제술을 시행하였으며, 병리조직검사를 통해 공장에서 발생한 원시신경외배엽종양을 진단하여 수술 후 보조항암화학요법으로 VAC/IE 복합항암화학요법을 적극적으로 시행하여 30개월 무병생존한 공장의 원시신경외배엽종양 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Primitive neuroectodermal tumor (PNET) is frequent in children and adolescents, but rare in adults. Most of the extraosseous Ewing`s sarcoma or PNET occur in the soft tissues of the extremities, the paravertebral region, and the pelvic cavity. PNET in the gastrointestinal tract is uncommon. We report herein a case of PNET arising from the jejunum in a 38-year-old woman. She presented with anorexia, nausea, vomiting, and weight loss. Abdominal computed tomography revealed a mass in the small bowel with obstruction. She had a small bowel segmental resection, from which PNET was diagnosed. Multi-agent chemotherapy comprised of vincristine, adriamycin, cyclophophamide, ifosfamide, and etoposide (VAC/IE) was administered for 1 year. The treatment was well-tolerated. She remains alive and continues to be disease free 30 months postoperatively. (Korean J Med 75:237-241, 2008)

대장의 점막하 침윤암의 심달도와 림프절 전이에 따른 기질단백분해효소와 억제인자의 발현 및 신생혈관 형성

정성애 ( Sung Ae Jung ),양석균 ( Suk Kyun Yang ),김정선 ( Jeong Sun Kim ),심기남 ( Ki Nam Shim ),임석아 ( Seock Ah Im ),명승재 ( Seung Jae Myung ),정훈용 ( Hwoon Yong Jung ),유창식 ( Chang Sik Yu ),김진천 ( Jin Cheon Kim ),홍원선 대한소화기학회 2005 대한소화기학회지 Vol.45 No.6

Background/Aims: Lymph node (LN) metastasis occurs in approximately 10% of patients with submucosally invasive colorectal carcinoma. This study was performed to determine the role of matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinase

직장암 환자의 수술 전 항암화학방사선치료에서 비적정 항암화학요법의 영향

이지혜(Jihye Lee),강현철(Hyun-Cheol Kang),지의규(Eui Kyu Chie),강경훈(Gyeong Hoon Kang),박재갑(Jae-Gahb Park),오도연(Do-Youn Oh),임석아(Seock-Ah Im),김태유(Tae-You Kim),방영주(Yung-Jue Bang),하성환(Sung Whan Ha) 대한방사선종양학회 2009 Radiation Oncology Journal Vol.27 No.2

목 적: 직장암에서 수술 전 항암화학방사선치료는 수술 후 항암화학방사선치료에 비하여 치료 성적은 비슷하며 독 성은 낮아 최근에 많이 시행되고 있다. 본 연구에서는 수술 전 항암화학방사선치료 시 병행한 항암화학요법 중 적 정 요법과 적정 이하의 비적정 요법에 따른 치료 결과를 알아보고자 하였다. 대상 및 방법: 2003년 4월부터 2006년 4월까지 수술 전 항암화학방사선치료와 수술을 시행한 환자 중 수술 병리결과 확보가 가능하고 단일 제제 화학요법을 시행한 환자 43명을 대상으로 하였다. 방사선치료는 전 골반에 41.4∼50.4 Gy (중앙값, 45 Gy), 종양에 추가조사 0∼5.4 Gy (중앙값, 5.4 Gy), 총 41.4∼50.4 Gy (중앙값, 50.4 Gy)를 시행하였다. 적정군은 5-fluorouracil (5-FU) 500 mg/m2/day를 방사선치료 첫 3일 동안과 5주 후 3일 동안에 반복 급속 정주 한 6명과 경구 capecitabine을 방사선 치료일에 사용한 6명으로 총 12명이었다. 비적정군은 동일량의 5-FU를 방사선치료 첫 3일에만 급속 정주한 31명이었다. 수술은 방사선치료가 끝난 뒤 40∼71일(중앙값, 58일)에시행하였고 36명은 하전방절제술을, 7명은 복회음절제술을 시행하였다.결 과: 적정군과 비적정군 사이에, 치료반응 등급 3 이상의 치료반응(83.3% vs. 67.7%, p=0.456), 수술 전과 비교한 수술 후의 병기하강(75.0% vs. 67.7%, p=0.727), 주변절제연 2 mm 초과의 획득(66.7% vs. 83.9%, p=0.237)등에서 통계적으로 유의하게 차이를 보이지는 않았으나, 병변의 위치가 항문에서 5 cm 이내에 위치한 경우 비적정군에서 괄약근 보존 수술을 시행한 비율이 적정군에 비하여 더 낮은 경향을 보였다(75% vs. 100%, p=0.068). 모든환자에서 3도 이상의 독성은 관찰되지 않았다. 결 론: 비적정군에서 치료에 수반되는 독성은 낮았으나 모두 2도 이하였고, 항문에서 5 cm 이내에 위치한 직장암의 수술 시 괄약근 보존 수술률이 더 낮은 경향을 보여 적정 화학요법의 병행을 시행하는 것이 바람직하겠다. Purpose: To examine the effect of suboptimal chemotherapy in patients undergoing preoperative chemoradiotherapy for the treatment of rectal cancer. Materials and Methods: The medical records of 43 patients who received preoperative concurrent chemoradiotherapy, followed by radical surgery for the treatment of pathologically proven adenocarcinoma of the rectum from April 2003 to April 2006 were retrospectively reviewed. The delivered radiation dose ranged from 41.4 to 50.4 Gy. The standard group consisted of patients receiving two cycles of a 5-FU bolus injection for three days on the first and fifth week of radiotherapy or twice daily with apecitabine. The standard group included six patients for each regimen. The non-standard group consisted of patients receiving one cycle of 5-FU bolus injection for three days on the first week of radiotherapy. The non-standard group included 31 patients. Radical surgery was performed at a median of 58 days after the end of radiotherapy. A low anterior resection was performed in 36 patients, whereas an abdominoperineal resection was performed in 7 patients. Results: No significant difference was observed between the groups with respect to pathologic responses ranging from grades 3 to 5 (83.3% vs. 67.7%, p=0.456), downstaging (75.0% vs. 67.7%, p=0.727), and a radial resection margin greater than 2 mm (66.7% vs. 83.9%, p=0.237). The sphincter-saving surgery rate in low-lying rectal cancers was lower in the non-standard group (100% vs. 75%, p=0.068). There was no grade 3 or higher toxicity observed in all patients. Conclusion: Considering that the sphincter-saving surgery rate in low-lying rectal cancer was marginally lower for patients treated with non-standard, suboptimal chemotherapy, and that toxicity higher than grade 2 was not observed in the both groups, suboptimal chemotherapy should be avoided in this setting.

내분비 ; 한국인에서 sunitinib 치료 후 발생한 갑상선기능저하의 특성

안화영 ( Hwa Young Ahn ),이은경 ( Eun Kyung Lee ),최훈성 ( Hoon Sung Choi ),이은정 ( Eun Jung Lee ),이유진 ( You Jin Lee ),김경원 ( Kyung Won Kim ),이세훈 ( Se Hoon Lee ),임석아 ( Seock Ah Im ),박영주 ( Young Joo Park ),박도준 ( D 대한내과학회 2009 대한내과학회지 Vol.76 No.1

목적: Sunitinib 치료 후 발생하는 갑상선기능저하증은 흔한 부작용이다. 발병 기전으로 sunitinib에 의한 파괴성 갑상선염, 갑상선으로의 요오드 운반 억제, 갑상선호르몬 합성과정의 억제 등이 제시되었다. 이는 요오드 섭취 정도에 따라서도 sunitinib에 의한 갑상선기능이상의 발생률이나 임상적 특성이 다를 수 있음을 시사한다. 이에 본 연구에서는 요오드 풍부 지역의 하나인 한국인에서 sunitinib 투여로 인한 갑상선기능저하증의 발생률 및 특성에 대해 조사해 보고자 하였다. 방법: 2005년 11월부터 2007년 7월까지 서울대학교병원에서 sunitinib을 투약했던 환자 중 sunitinib 치료 기간 혹은 후에 갑상선호르몬을 측정한 환자 25명을 대상으로 하였다. 13명은 sunitinib 투여 기간 혹은 후에 갑상선기능저하증을 의심할 수 있는 임상상을 보여 갑상선호르몬을 측정하였고, 12명은 임상상에 관계없이 추적관찰 위해 sunitinib 치료 기간 동안 갑상선호르몬을 측정하였다. 결과: 갑상선기능저하증을 의심할 수 있는 임상상을 보여 갑상선호르몬을 측정한 13명에서는 모두 갑상선기능저하증 소견을 보였으며(현성 9명, 무증상 4명), 임상상에 관계없이 sunitinib 투여 기간 중 갑상선호르몬을 측정한 12명에서는 6명이 갑상선기능저하증 소견을 보였고(현성 2명, 무증상 4명), 2명이 갑상선중독증 소견을 보였다. 19명의 갑상선기능저하증 환자들을 현성과 무증상 갑상선기능저하증으로 나누어 비교해 본 결과 갑상선자극호르몬 상승이 발견된 시기가 현성 갑상선기능저하증 환자들에서 유의하게 늦게 나타났고(44.5 대. 14.8주, p<0.05), sunitinib 누적 투여량은 유의하게 높게 나타났다(8050±3211 대. 3718±1961 mg, p<0.05). 19명의 환자에서 갑상선자극호르몬 수치와 갑상선자극호르몬 상승시까지의 sunitinib 투여 기간 및 투여 누적량 사이에는 상관성이 있는 것으로 나타났다. 결론: Sunitinib 투여 후 갑상선기능저하증의 발생률은 50% 이상일 것으로 예상되었으며, 다른 지역에서 시행된 연구와 비교해 볼 때 요오드 섭취 정도가 sunitinib에 의한 갑상선기능저하증 발병에 영향을 준다고 말하기는 어려운 결과를 보였다. 갑상선 기능저하증 정도는 sunitinib 투여기간 및 용량에 비례하였다. 향후 전향적 연구를 통해 정확한 발생률 및 요오드 섭취에 의한 영향을 평가해 보는 것이 필요하겠다. Background/Aims: Hypothyroidism is a common side effect induced by sunitinib. Studies have suggested that sunitinib induces destructive thyroiditis or inhibits iodine uptake by the thyroid or anti-thyroid peroxidase activity. Therefore, the amount of iodine intake will also influence the incidence and clinical characteristics of hypothyroidism after sunitinib treatment. We evaluated the incidence and clinical characteristics of hypothyroidism after sunitinib treatment in Korea, an area where iodine is abundant. Methods: Between November 2005 and July 2007, 25 patients who had thyroid hormone levels measured during or after sunitinib treatment were included. Of the 25 patients, 13 had thyroid function tests (TFT) because they had symptoms suggesting hypothyroidism and 12 underwent TFT independent of symptoms for screening. Results: All 13 patients who had symptoms suggesting hypothyroidism were hypothyroid (9 overt, 4 subclinical), 6 of 12 patients who had TFT independent of symptoms were hypothyroid (2 overt, 4 subclinical), and two had thyrotoxicosis. Of the 19 hypothyroid patients, the 11 overt hypothyroid patients took longer for a diagnosis of TSH elevation (44.5 vs. 14.8 weeks, p<0.05) and had a greater cumulative sunitinib dose (8050±3211 vs. 3718±1961 mg, p<0.05) compared with the subclinically hypothyroid patients. At the point of detecting TSH elevation, the TSH level correlated with the period and cumulative dose of sunitinib. Conclusions: The anticipated incidence of sunitinib-induced hypothyroidism is more than 50%. Compared with previous studies performed in other areas, the iodine intake did not affect the incidence of sunitinib-induced hypothyroidism. (Korean J Med 76:37-43, 2009)

유방암에서 유방보존수술 및 수술 후 방사선치료의 결과

지의규(Eui Kyu Chie),김규보(Kyubo Kim),최진화(Jin-Hwa Choi),장나영(Na-Young Jang),한원식(Wonshik Han),노동영(Dong-Young Noh),임석아(Seock-Ah Im),김태유(Tae-You Kim),방영주(Yung-Jue Bang),하성환(Sung Whan Ha) 대한방사선종양학회 2008 Radiation Oncology Journal Vol.26 No.3

목 적: 조기유방암의 치료에 있어 과거에는 유방 전적출술이 주된 치료였으나 현재는 유방보존술이 표준 치료방법 으로 정립되었다. 저자들은 서울대학교병원에서 유방보존수술 및 방사선치료를 받은 환자의 임상적 특성을 조사 하고 치료결과 및 예후인자를 분석하고자 하였다. 대상 및 방법: 1992년 2월부터 2002년 1월까지 침윤성 유방암으로 유방보존수술 및 수술 후 방사선치료를 받은 424명을 대상으로 후향적으로 분석하였다. 대부분의 환자는 사분절제술 및 액와림프절 청소술을 시행 받았다(396명, 93.4%). 302명이 T1이었고 122명은 T2 병기였으며, 림프절 전이는 107명에서 확인되었다. 방사선치료는 전체 유방에 28회에 걸쳐 50.4 Gy를 조사한 후 종양이 있었던 부위에 10 Gy의 추가조사를 실시하였다. 영역림프절 조사는 57명에서 시행되었다. 항암화학요법은 231명에서 시행되었으며, 그 중 170명이 cyclophosphamide, methotrexate 및 5-fluorouracil을 투여 받았다. 중앙추적기간은 64개월이었다. 결 과: 전체 환자의 5년 국소제어율은 95.6%이었다. 추적관찰 중 15명의 환자에서 국소재발이 확인되었다. 5년 생존율은 93.1%이었고, 병기에 따른 5년 생존율은 I기 94.8%, IIA기 95.0%, IIB기 91.1%, IIIA기 75.9%, IIIC기 57.1% 이었다. 5년 무병생존율은 88.7%이었고, 병기별로는 I기 93.1%, IIA기 89.4%, IIB기 82.8%, IIIA기 62.0%, IIIC기 28.6%이었다. 예후인자 분석에서는 N 병기(p=0.0483)가 생존율에, 연령(p=0.0284)과 N 병기(p=0.0001)가 무병생존율에 각각 유의한 영향을 보였다. 결 론: 조기유방암에서 유방보존수술 및 수술 후 방사선치료는 우수한 국소제어율 및 생존율을 기대할 수 있는 치료법임을 확인할 수 있었다. Purpose: We analyzed the treatment outcomes and prognostic factors of breast conserving surgery, followed by postoperative radiotherapy. Materials and Methods: A total of 424 breast cancer patients treated with breast conserving surgery and postoperative radiotherapy between February 1992 and January 2001 were retrospectively analyzed. A quadrantectomy and axillary lymph node dissection was performed in 396 patients. A total of 302 patients had T1 disease, and 122 patients had T2 disease. Lymph node involvement was confirmed in 107 patients. Whole breast irradiation was administered at up to 50.4 Gy in 28 fractions, followed by a 10 Gy boost in 5 fractions to the tumor bed. In addition, 57 patients underwent regional lymph node irradiation. Moreover, chemotherapy was administered in 231 patients. A regimen consisting of cyclophosphamide, methotrexate, and 5-fluorouracil was most frequently used with 170 patients. The median follow-up time was 64 months. Results: The 5-year local control rate was 95.6%. During the follow-up period, local tumor recurrence was observed in 15 patients. The 5-year overall and disease-free survival rates were 93.1% and 88.7%, respectively. The 5-year overall survival rates, by stage, were 94.8% for stage I, 95.0% for stage IIA, 91.1% for stage IIB, 75.9% for stage IIIA, and 57.1% for stage IIIC. As for disease-free survival, the corresponding figures, by stage (in the same order), were 93.1%, 89.4%, 82.8%, 62.0%, and 28.6%, respectively. The advanced N stage (p=0.0483) was found to be a significant prognostic factor in predicting poor overall survival, while the N stage (p=0.0284) and age at diagnosis (p=0.0001) were associated with disease-free survival. Conclusion: This study has shown that breast conserving surgery and postoperative radiotherapy for early breast cancer results was excellent for local control and survival.

유방암조직의 Tissue Microarrays에서의 면역화학염색법을 이용한 Apoptosis 관련단백질의 발현

김정수(Jeong Soo Kim),김기환(Kee Hwan Kim),안창혁(Chang Hyeok Ahn),전해명(Hae Myung Jeon),정상설(Sang Seol Jung),임석아(Seock Ah Im) 대한외과학회 2001 Annals of Surgical Treatment and Research(ASRT) Vol.60 No.6

염색체 이상과 동반된 원발성 알도스테론증 환자의 8년 후 추적 관찰 1예 보고

임석아,남은미,박시훈,신길자,이우형,심봉석 梨花女子大學校 醫科大學 醫科學硏究所 1996 EMJ (Ewha medical journal) Vol.19 No.1

8년전 양측성 부신증식에 의한 원발성 알토스테론증으로 진단받고 spironolactone 및 칼슘차단제를 투여하여 혈압이 조절되던 환제에서 최근 혈압이 조절되지 않아 전산화 단층 촬영을 제디행한 결과 부신선종이 동반된 것을 발견하고 부신 적출술 후 소량의 항고혈압제로 혈압이 조절되었던 1예를 보고하는 바이다. We describe an unusual 30-year-old female patient with a history of refractory hypertension and hypokalemia. She was diagnosed as primary aldosteronoism with bilateral adrenal hyperplasia 8 years age and blood pressure has been controlled with spironolactone 200mg/day, nifedipine 40mg/day, Cardura 4mg/day and oral potassium supplement till these days. Recently refractory high blood pressure was developed and about 5*4*4.5cm sized left a-drenal mass was observed by abdominal CT. The hypertension and hypokalemia was controlled by left adrenalectomy.