경희대학교병원 간암 다학제증례집담회 Multidisciplinary case conference Liver Cancer Conference 소화기 센터 회의실

History Case 이 O 호 M/52 DM (-), HTN (+) Esophageal varix(-) Op Hx (-) Alcohol Hx (+), Smoking Hx (-)  C.C) HCC  52/M B-viral & alcoholic LC, multiple HCC s/p TACE #2 ( ) 환자로 f/u CT ( )  토의 목적 : 영상소견 review 및 치료방침 논의

Underlying liver function and performance status CBC/DC WBC(mm 3 )6,260 Hb(g/dl)15.2 PLT(mm 3 )214,000 PT(sec)13.3 INR1.01 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.39 AST/ALT(IU/L)45/31 ALP/rGT(IU/L)67/223 Prot/Alb(g/dL)7.8/4.2 BUN/Cr(mg/dL)10/0.7 LC & Stage Child-PughA (5) MELD score6 Esophageal varices- Ascites- Encephalopathy- Case 1 Tumor markers AFP (ng/mL)14.40 CEA (ng/mL) - PIVKA II (mAU/mL)28 CA19-9 (U/mL) 이 O 호 M/52 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(+/-) Virus titer<20 IU/mL Antiviral TxEntecavir Alcohol+

‘ ‘ ’ 조 O 복 F/57 Liver MR : viable HCC Liver MR : viable HCC Case 1 Tumor Stage and Clinical Course 이 O 호 M/52 Liver MR : HCC Liver MR : HCC TACE at Lt.lateral seg TACE at Lt.lateral seg TACE at Lt.lateral seg TACE at Lt.lateral seg. 12 년 8 월 12 년 12 월 13 년 8 월 14 년 4 월 AFP Liver CT

Summary – 치료 방침 결정 Case 1 Current liver function Normal Well preserved (no risk of decompensation) Compensated (risk of decompensation) Decompensated Terminal state Extent of current tumor Localized (curative) Locally advanced (resectable) Locally advanced (unresectable) No < 4 Diffuse or multiple (> 3) Initial Tumor stage Date: 2012 년 7 월 Modified UICC ( 대한간암연구학회 ) T 1 N 0 M 0 Stage I JIS score 2 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status locally advanced HCC with compensated liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation N Tumor number 1 Repeated TACE ( 1 회 / 기간 ) 2 Vascular or bile duct invasion N High uptake of PET N High AFP or PIVKA II Y Not normalized AFP after curative Tx N Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease N ART score (Good Px 2.5) 이 O 호 M/52

History Case 원 O 연 M/53 DM (-), HTN (-) Esophageal varix(+) Op Hx (-) Alcohol Hx (-), 09 년부터 금주, Smoking Hx (-)  53/M B-viral LC, HCC s/p TACE #5( ), s/p tomotherapy 5000 GY ( ~ ) 받은 자로 liver MRI 에서 Slightly increased size of viable HCC 소견 보임.  토의 목적 : 영상소견 review 및 치료방침 논의

Underlying liver function and performance status CBC/DC WBC(mm 3 )2,880 Hb(g/dl)14.1 PLT(mm 3 )79,000 PT(sec)32.5 INR1.11 Performance status: Grade 0 Chemistry TB/DB(mg/dL)2.20 AST/ALT(IU/L)37/30 ALP/rGT(IU/L)70 Prot/Alb(g/dL)7.8/4.3 BUN/Cr(mg/dL)14/0.7 LC & Stage Child-PughA (5) MELD score5 Esophageal varices+ Ascites- Encephalopathy- Case 2 Tumor markers AFP (ng/mL)6.55 CEA (ng/mL) 1.48 PIVKA II (mAU/mL)15 CA19-9 (U/mL) 원 O 연 M/53 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/-) Virus titer32 IU/mL Antiviral TxEntecavir Alcohol-

’09 ‘12.01 ‘13.01 ’13.7 ‘ 조 O 복 F/57 Liver MRI : HCC Liver MRI : HCC Case 2 Tumor Stage and Clinical Course Liver MRI ( ) Liver MR : HCC Liver MR : HCC 원 O 연 M/53 PET CT ( ) Non-visible hypermetabolic lesion in the liver. Disappeared hypermetabolic activity of seeding lesion at anterior pararenal space and retrocaval LN metastasis Liver CT : HCC c PVT Liver CT : HCC c PVT Liver CT : HCC Liver CT : HCC TACE # TACE #2 Liver MRI : HCC Liver MRI : HCC TACE # TACE #5 Liver MRI : HCC Liver MRI : HCC 09 년 7 월 09 년 10 월 12 년 1 월 12 년 5 월 13 년 7 월 13 년 10 월 14 년 8 월 AFP TACE # TACE # TACE # TACE # TACE # TACE #4

Summary – 치료 방침 결정 원 O 연 M/53 Case 2 Current liver function Normal Well preserved (no risk of decompensation) Compensated (risk of decompensation) Decompensated Terminal state Extent of current tumor Localized (curative) Locally advanced (resectable) Locally advanced (unresectable) No < 4 Diffuse or multiple (> 3) Initial Tumor stage Date: 2013 년 8 월 Modified UICC ( 대한간암연구학회 ) T 2 N 0 M 0 Stage II JIS score 1 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Locally advanced HCC with decompensated liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis Y Tumor size > 5 cm, capsulation N Tumor number 1 Repeated TACE ( 1 회 / 기간 ) 1 Vascular or bile duct invasion Y High uptake of PET - High AFP or PIVKA II Y Not normalized AFP after curative Tx N Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease - ART score (Good Px 2.5) -

History Case 허 O 옥 F/59 DM (-), HTN (-) Op Hx (+) : Lt.subtrochanteric Fx. of femer (a/w pathologic Fx. d/t HCC) Alcohol Hx (-)  52/M B-viral LC, HCC s/p TACE #13 ( )[ ] 환자로 최근 TACE 시행 후 심한 복통 장기간 지속되며 Portal vein thrombosis 로 recurrent tumor manage 논의.  토의 목적 : 영상 review 및 치료방침 논의

Underlying liver function and performance status CBC/DC WBC(mm 3 )3,830 Hb(g/dl)12.0 PLT(mm 3 )213,000 PT(sec)13.6 INR1.04 Performance status: Grade 0 Chemistry TB(mg/dL)0.48 AST/ALT(IU/L)36/17 ALP/GGT(IU/L)129 Prot/Alb(g/dL)7.4/4.0 BUN/Cr(mg/dL)13/ 허 O 옥 F/59 Case 3 LC & Stage Child-PughA (5) MELD score6 Esophageal varices- Ascites- Encephalopathy- Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer<20 IU/mL Antiviral TxEntecavir Alcohol- Tumor markers AFP (ng/mL)2.19 CEA (ng/mL) 1.80 PIVKA II (mAU/mL)13 CA19-9 (U/mL) 20.40

’01. ’02.1 ’02.6 ‘02.10 ‘03.7 ‘04.2, 05’3, ‘10.07 ‘13.4,6,10 ‘ 조 O 복 F/57 Case 1 Tumor Stage and Clinical Course Liver MRI ( ) 허 O 옥 F/59 PET CT ( ) Non-visible hypermetabolic lesion in the liver. No abnormal hypermetabolic lesion suggesting distant metastasis. AP CT : HCC AP CT : HCC TACE # TACE #2 AP CT : HCC AP CT : HCC TACE # TACE #4 03 년 12 월 05 년 1 월 07 년 2 월 10 년 1 월 12 년 3 월 14 년 4 월 14 년 7 월 AFP Liver CT : HCC Liver CT : HCC TACE # TACE #1 AP CT : HCC AP CT : HCC TACE # TACE #3 AP CT : HCC AP CT : HCC AP CT : HCC AP CT : HCC TACE #5, TACE #5,6 Angiography # & 7 TACE #7, #8,# & 7 TACE #7, #8,#9 Liver MR : HCC Liver MR : HCC TACE # TACE #10

Summary – 치료 방침 결정 허 O 옥 F/59 Case 3 Current liver function Normal Well preserved (no risk of decompensation) Compensated (risk of decompensation) Decompensated Terminal state Extent of current tumor Localized (curative) Locally advanced (resectable) Locally advanced (unresectable) No < 4 Diffuse or multiple (> 3) Initial Tumor stage Date: 2001 년 Modified UICC ( 대한간암연구학회 ) T 3 N 0 M 0 Stage III JIS score 2 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Locally advanced HCC with compensated liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation N Tumor number 3 Repeated TACE ( 1 회 / 기간 ) 10 Vascular or bile duct invasion N High uptake of PET - High AFP or PIVKA II N Not normalized AFP after curative Tx N Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease - ART score (Good Px 2.5) -

History Case 윤 O 태 M/54 DM (-), HTN (-) B-viral LC (Child A(5) MELD 5) Op Hx (-) Alcohol Hx (+) 한번에 1 잔 /1 회 /1 주, Smoking Hx (+) : 17.5PY  B-viral LC, diffuse infiltrative HCC c PTV 로 chest CT 에서 r/o metastatic nodule 보여 TACE ( ) 시행.  토의 목적 : 영상 review

Underlying liver function and performance status CBC/DC WBC(mm 3 )5,690 Hb(g/dl)15.2 PLT(mm 3 )193,000 PT(sec)15.1 INR1.19 Performance status: Grade 0 Chemistry TB/DB(mg/dL)3.21 AST/ALT(IU/L)177/58 ALP/rGT(IU/L)414/242 Prot/Alb(g/dL)6.4/3.4 BUN/Cr(mg/dL)18/0.6 LC & Stage Child-PughA (5) MELD score7 Esophageal varices+ Ascites- Encephalopathy 윤 O 태 M/54 Case 4 Tumor markers AFP (ng/mL)12.37 PIVKA II (mAU/mL)13 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer0 Antiviral Txentecavir Alcohol-

HBV , , , 조 O 복 F/57 Case 4 Clinical Course 윤 O 태 M/54 Liver MR ( ) LIVER CT : LC LIVER CT : LC Liver sono : LC c Rt.PVT Liver sono : LC c Rt.PVT Liver MR : Diffuse infiltrating HCC C Rt.PVT Liver MR : Diffuse infiltrating HCC C Rt.PVT PET CT ( ) C/W diffuse hepatocelluar carcinoma in the liver right lobe Underlying liver cirrhosis with splenomegaly No abnormal hypermetabolic lesion suggesting distant metastasis Liver sono : LC c mild splenomegaly Liver sono : LC c mild splenomegaly TACE # TACE #1

Summary – 치료 방침 결정 윤 O 태 M/54 Case 4 Current liver function Normal Well preserved (no risk of decompensation) Compensated (risk of decompensation) Decompensated Terminal state Extent of current tumor Localized (curative) Locally advanced (resectable) Locally advanced (unresectable) No < 4 Diffuse or multiple (> 3) Initial Tumor stage Date: 2014 년 7 월 Modified UICC ( 대한간암연구학회 ) T 3b N 0 M 0 Stage III JIS score 2 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Diffuse and multiple HCC with compensated liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis Y Tumor size > 5 cm, capsulation Y Tumor number - Repeated TACE ( 1 회 / 기간 ) 1 Vascular or bile duct invasion Y High uptake of PET - High AFP or PIVKA II Y Not normalized AFP after curative Tx N Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease - ART score (Good Px 2.5) -