1. 경희대학교병원 간암 다학제증례집담회 Multidisciplinary case conference Liver Cancer Conference 소화기 센터 회의실 2013.9.6.

2. History Case 1 12106363 전 O 수 F/71 DM (+): glimepride 1mg qd, HbA1c =6.1%, CKD B-viral LC (Child B(7) MELD 12) with gastro-esophageal varix s/p EVL #4(2013.07.02) Op Hx (-) Alcohol Hx (-), Smoking Hx (-)  2009 년 LC, HCC 진단  TACE #1 (‘09.03.05)  2010.03.08 Liver CT : viable HCC (S4)  TACE #2 (‘10.03.19)  2010.04.28 Liver CT : viable HCC (S4)  TACE #3 (‘10.04.29)  2010.07.27 Liver CT : new HCC (S6)  TACE #4 (‘10.07.29)  2011.01.18 Liver CT : viable HCC (S4)  TACE #5 (‘11.01.19)  2011.04.26 Liver CT : viable HCC (S4,S2)  TACE #6 (‘11.05.17)  2011.08.04 Liver CT : viable HCC (S4,S2)  TACE #7 (‘11.08.22)  2011.11.29 Liver CT : viable HCC (S4)  TACE #8 (‘11.11.30)  2012.01.30 Liver CT : viable HCC (S4)  RFA #1 (’12.02.02)  2012.05.08 Liver CT : viable HCC (S2,S7,S8)  TACE #9 (‘12.05.11)  2012.08.21 Liver MR : viable HCC (S4,S6)  TACE #10 (‘12.08.22)  2013.05.08 Liver CT : viable HCC (S3,S4,S7/8)  TACE #11 (‘13.05.13)  2013.08.27 Liver CT : viable HCC (S3,S4,S7/8)  TACE #12 (’13.08.28)  토의 목적 : 향후 치료 방향 논의

3. Underlying liver function and performance status CBC/DC WBC(mm 3 )2,610 Hb(g/dl)9.0 PLT(mm 3 )46,000 PT(sec)17.6 INR1.50 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.72/0.29 AST/ALT(IU/L)31/7 ALP/rGT(IU/L)118/86 Prot/Alb(g/dL)7.7/3.8 BUN/Cr(mg/dL)25/1.5 LC & Stage Child-PughB (7) MELD score12.8 Esophageal varices[Cb F3 Ls RC(+++)] Ascites+ Encephalopathy- 12106363 전 O 수 F/71 Case 1 Tumor markers AFP (ng/mL)2439 CEA (ng/mL) 1.94 PIVKA II (mAU/mL)16 CA19-9 (U/mL) 3.95 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer<20 IU/mL Antiviral Tx- Alcohol-

4. ’09.03 ’10.03 ~’11.11 ‘12.02. ’12.08~’13.05. ‘13.08. 10259334 조 O 복 F/57 cryptogenic LC HCC cryptogenic LC HCC Case 1 Tumor Stage and Clinical Course 12106363 전 O 수 F/71 Liver CT (2013.8.27) Increased size of recurred HCC at the anterior margin of RFA site at segment 4. Increased size of HCC at segment 3. Increased size of HCC at the liver dome. PET-CT (2013.02.19) No evidence of distant metastasis 10 년 03 월 10 년 10 월 11 년 01 월 11 년 08 월 11 년 11 월 12 년 05 월 12 년 11 월 13 년 05 월 13 년 08 월 AFP128.435.11219.6250.3358.1212.3161.110842439 PIVKA II-1621182215-16 B-viral LC Recurred HCC B-viral LC Recurred HCC Recurred HCC TACE #2~#8 (’10.03.19~’11.11.30) TACE #2~#8 (’10.03.19~’11.11.30) TACE #9~#11 (‘12.05.11~’13.05.13) TACE #9~#11 (‘12.05.11~’13.05.13) TACE #1 (‘09.03.05) TACE #1 (‘09.03.05) Recurred HCC Recurred HCC TACE #12 (‘13.08.28) TACE #12 (‘13.08.28) RFA #1 (‘12.02.02) RFA #1 (‘12.02.02) Viable HCC Viable HCC

5. Summary – 치료 방침 결정 12106363 전 O 수 F/71 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: 2009 년 3 월 Modified UICC ( 대한간암연구학회 ) T 3 N 0 M 0 Stage III JIS score 2 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Multiple HCC with decompensated 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 ) 12 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 - ART score (Good Px 2.5) 0

6. History Case 2 11713807 김 O 웅 74/M DM (+): no medication, HbA1c =4.3%, HTN (+) Chronic hepatitis B Op. Hx : bladder cancer c lung meta 로 partial cystectomy c RLL lobectomy (2004) Alcohol Hx (-), Smoking Hx (-)  2004 년 Chronic hepatitis B 진단 후 Lamivudine 복용.  2006.06.30 Liver MR : HCC (S4)  TACE #1 (‘06.07.04)  2006.07.18 Liver CT : viable HCC c middle hepatic vein invasion (S4)  central bisegmentectomy c cholecystectomy (‘06. 08. 03)  2009.02.19 Liver CT : viable HCC (Lt lat segment)  TACE #2 (‘09.04.01)  2009.10.21 Liver CT : viable HCC (S8)  TACE #3 (’09.10.29)  2010.02.10 Liver CT : viable HCC (Rt ant segment)  TACE #4 (’10.02.23)  2011.03.07 Liver CT : viable HCC (Rt ant segment)  TACE #5 (’11.04.07)  2011.07.07 Liver CT : viable HCC (S2)  TACE #6 (’11.07.14)  2011.11.21 Liver MR : viable HCC (S5,S8)  TACE #7 (’11.11.28)  2012.02.21 Liver CT : viable HCC (S5)  RFA #1 (’12.03.06)  2012.12.10 Liver MR : viable HCC (S2,S3)  TACE #8 (’12.12.27)  2013.06.12 Liver MR : viable HCC (S2,S6,S8)  TACE #9 (’13.06.25)  토의 목적 : 향후 치료 방향 논의

7. Underlying liver function and performance status CBC/DC WBC(mm 3 )4,500 Hb(g/dl)9.7 PLT(mm 3 )124,000 PT(sec)14.7 INR1.18 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.69/0.87 AST/ALT(IU/L)31/25 ALP/rGT(IU/L)123/65 Prot/Alb(g/dL)7.4/3.4 BUN/Cr(mg/dL)15/1.2 LC & Stage Child-PughA (5) MELD score12 Esophageal varices- Ascites- Encephalopathy- 11713807 김 O 웅 74/M Case 2 Tumor markers AFP (ng/mL)8.00 CEA (ng/mL) 1.94 PIVKA II (mAU/mL)22 CA19-9 (U/mL) 7.54 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(+/-) Virus titer<20 IU/mL Antiviral Tx+ (lamivudine+adefovir) Alcohol-

8. ’04.06 ’06.06 ‘06.07 ’09.02~’11.11. ‘12.02. ‘12.12~’13.06 10259334 조 O 복 F/57 CHB CHB Case 2 Tumor Stage and Clinical Course 11713807 김 O 웅 74/M Liver MR (2013.8.26) Four viable tumors within partial lipiodolized HCCs at S3, S6 and S8. Lipiodolized HCC without vaible tumor at S2 of the liver. Several DNs and cysts at both lobes of the liver. Underlying liver cirrhosis with splenomegaly. PET-CT (2012.12.31) Post-TACE state, both hepatic lobes Suggestive of benign fractures in the right 5th and 8th ribs No change of benign tumor in the left parotid gland 04 년 12 월 06 년 07 월 06 년 10 월 09 년 3 월 09 년 10 월 11 년 03 월 12 년 02 월 13 년 06 월 13 년 08 월 AFP19.944.546.527.686.285.277.186.568.00 PIVKA II-1123371825791322 HCC TACE #1 (’06.07.04) TACE #1 (’06.07.04) Viable HCC Viable HCC RFA#1 (’12.03.06) RFA#1 (’12.03.06) TACE#2~#7 (’09.04.01~’11.11.28) TACE#2~#7 (’09.04.01~’11.11.28) Viable HCC Viable HCC Viable HCC Hepatic v. invasion Viable HCC Hepatic v. invasion central bisegmentectomy Cholecystectomy (’06.08.03) central bisegmentectomy Cholecystectomy (’06.08.03) TACE#8~#9 (’12.12.27~’13.06.25) TACE#8~#9 (’12.12.27~’13.06.25) Viable HCC Viable HCC

9. Summary – 치료 방침 결정 11713807 김 O 웅 74/M 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: 2006 년 06 월 Modified UICC ( 대한간암연구학회 ) T 2 N 0 M 0 Stage II JIS score 1 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Multiple 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 ) 9 Vascular or bile duct invasion Y High uptake of PET N 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) 0

10. History Case 3 11891168 한 O 덕 54/M DM / HTN (-/-) B-viral LC (Child A(5) MELD 2.8) Op. Hx : (-) Alcohol Hx (-), Smoking Hx (+) : 30 pack years  2010. 11. B-viral LC, HCC 진단  TACE #1 (’10.11.18)  2011.02.15 Liver MR : viable HCC (S7)  TACE #2 (’11.02.15)  2012.01.03 Liver MR : viable HCC (S6)  TACE #3 (’12.02.03)  2013.04.24 Liver CT : Newly arterial enhancement at the upper margin of previous dysplastic nodule at S7  2013.08.22 Liver MR : Slightly increased arterial enhancing portion within small viable HCC at S7.  토의 목적 : 검사결과 review 및 향후 치료방향 논의

11. Underlying liver function and performance status CBC/DC WBC(mm 3 )4,990 Hb(g/dl)16.3 PLT(mm 3 )218,000 PT(sec)12.8 INR0.97 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.62/- AST/ALT(IU/L)29/29 ALP/rGT(IU/L)83/82 Prot/Alb(g/dL)7.0/4.4 BUN/Cr(mg/dL)13/0.9 LC & Stage Child-PughA (5) MELD score2.8 Esophageal varices- Ascites- Encephalopathy- 11891168 한 O 덕 54/M Case 3 Tumor markers AFP (ng/mL)3.72 CEA (ng/mL) 2.15 PIVKA II (mAU/mL)22 CA19-9 (U/mL) 9.29 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer<20 IU/mL Antiviral Tx+ (Entecavir) Alcohol-

12. ’10.11 ‘11.02 ‘12.02. ’13.08 10259334 조 O 복 F/57 B-viral LC HCC B-viral LC HCC Case 3 Tumor Stage and Clinical Course 11891168 한 O 덕 54/M Liver MR (2013.8.22) Slightly increased arterial enhancing portion within small viable HCC at S7. No change of AP shunt in both lobes. Liver cirrhosis. PET-CT (2010.11.19) Diffuse hypermetabolic activity in right lobe of the liver: post-TACE change No visible uptake of known hepatoma in segment 7 No abnormal hypermetabolic lesion suggesting distant metastasis 10 년 07 월 11 년 02 월 11 년 06 월 11 년 10 월 12 년 01 월 12 년 04 월 12 년 07 월 13 년 01 월 13 년 04 월 AFP5.6815.524.042.963.23.032.662.813.72 PIVKA II703724102151649 TACE#3 (’12.02.03) TACE#3 (’12.02.03) Viable HCC Viable HCC Viable HCC TACE#2 ( ’11.02.15) TACE#2 ( ’11.02.15) Liver MR : Increased size of arterial enhancing nodule Liver MR : Increased size of arterial enhancing nodule TACE #1 (‘10.11.18) TACE #1 (‘10.11.18)

13. Summary – 치료 방침 결정 11891168 한 O 덕 54/M 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: 2010 년 11 월 Modified UICC ( 대한간암연구학회 ) T 1 N 0 M 0 Stage I JIS score 0 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Localized 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 ) 3 Vascular or bile duct invasion N High uptake of PET N 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) 0