1. 경희대학교병원 간암 다학제증례집담회 Multidisciplinary case conference Liver Cancer Conference 소화기 센터 회의실 2014.08.22

2. History Case 1 11118201 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 (2014.5.13) 환자로 f/u CT (2014.8.21)  토의 목적 : 영상소견 review 및 치료방침 논의

3. 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) 19.41 11118201 이 O 호 M/52 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(+/-) Virus titer<20 IU/mL Antiviral TxEntecavir Alcohol+

4. ‘12.7.23 ‘14.04.2 ’14.8.21 10259334 조 O 복 F/57 Liver MR : viable HCC Liver MR : viable HCC Case 1 Tumor Stage and Clinical Course 11118201 이 O 호 M/52 Liver MR : HCC Liver MR : HCC 2012.08.09 TACE at Lt.lateral seg. 2012.08.09 TACE at Lt.lateral seg. 2014.05.13 TACE at Lt.lateral seg. 2014.05.13 TACE at Lt.lateral seg. 12 년 8 월 12 년 12 월 13 년 8 월 14 년 4 월 AFP15.4411.8911.1514.40 Liver CT

5. 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) 0 11118201 이 O 호 M/52

6. History Case 2 12057353 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(2014.3.21), s/p tomotherapy 5000 GY (2013.8.20~2013.9.9) 받은 자로 2014.08.19 liver MRI 에서 Slightly increased size of viable HCC 소견 보임.  토의 목적 : 영상소견 review 및 치료방침 논의

7. 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) 4.36 12057353 원 O 연 M/53 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/-) Virus titer32 IU/mL Antiviral TxEntecavir Alcohol-

8. ’09 ‘12.01 ‘13.01 ’13.7 ‘14.3 2014.08.19 10259334 조 O 복 F/57 Liver MRI : HCC Liver MRI : HCC Case 2 Tumor Stage and Clinical Course Liver MRI (2014.08.19) Liver MR : HCC Liver MR : HCC 12057353 원 O 연 M/53 PET CT (2014.03.24) 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 2012.01.11 TACE #2 2012.01.11 TACE #2 Liver MRI : HCC Liver MRI : HCC 2014.03.21 TACE #5 2014.03.21 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 AFP16.0613.4417.905.8033.196.166.55 2009.07.28 TACE #1 2009.07.28 TACE #1 2013.01.15 TACE #3 2013.01.15 TACE #3 2013.07.30 TACE #4 2013.07.30 TACE #4

9. Summary – 치료 방침 결정 12057353 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) -

10. History Case 3 11568925 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 (2014.4.3)[2001.10.10] 환자로 최근 TACE 시행 후 심한 복통 장기간 지속되며 Portal vein thrombosis 로 recurrent tumor manage 논의.  토의 목적 : 영상 review 및 치료방침 논의

11. 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)13/0.5 11568925 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

12. ’01. ’02.1 ’02.6 ‘02.10 ‘03.7 ‘04.2, 05’3, ‘10.07 ‘13.4,6,10 ‘14.4.3 10259334 조 O 복 F/57 Case 1 Tumor Stage and Clinical Course Liver MRI (2014.08.18) 11568925 허 O 옥 F/59 PET CT (2014.04.01) Non-visible hypermetabolic lesion in the liver. No abnormal hypermetabolic lesion suggesting distant metastasis. AP CT : HCC AP CT : HCC 2002.1 TACE #2 2002.1 TACE #2 AP CT : HCC AP CT : HCC 2002.10 TACE #4 2002.10 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 AFP3.684.1120.461.262.741.452.19 Liver CT : HCC Liver CT : HCC 2001.1 TACE #1 2001.1 TACE #1 AP CT : HCC AP CT : HCC 2002.6 TACE #3 2002.6 TACE #3 AP CT : HCC AP CT : HCC AP CT : HCC AP CT : HCC 2003.7 TACE #5,6 2003.7 TACE #5,6 Angiography #3 2013.4 & 7 TACE #7, #8,#9 2013.4 & 7 TACE #7, #8,#9 Liver MR : HCC Liver MR : HCC 2014.4.3 TACE #10 2014.4.3 TACE #10

13. Summary – 치료 방침 결정 11568925 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) -

14. History Case 4 12119574 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 (2014.8.4) 시행.  토의 목적 : 영상 review

15. 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- 12119574 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-

16. HBV 2011.1, 2011.8, 2012.4, 2013.9 2014.07.08 2014.07.28 10259334 조 O 복 F/57 Case 4 Clinical Course 12119574 윤 O 태 M/54 Liver MR (2014.07.28) 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 (2014.07.28) 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 2014.08.04 TACE #1 2014.08.04 TACE #1

17. Summary – 치료 방침 결정 12119574 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) -