1. 경희대학교병원 간암 다학제증례집담회 Multidisciplinary case conference Liver Cancer Conference 소화기 센터 회의실 2014.09.26

2. History Case 1 11583248 박 O 자 F/44 DM (+), HTN (-) Op Hx (-) Alcohol Hx (-), Smoking Hx (-)  B-viral LC, HCC 환자로, TACE #2, RFA #1. 시행력 있는며, 2014 년 6 월 Liver MRI 검사상 새로운 nodule 과 thrombosis 관찰되었으나 AFP 감소 보여 inflammatory nodule 로 의심되어 경과관찰 한자. 2014 년 9 월 Liver MRI 시행하 였으며, AFP 상승한 상태로 영상 소견과 앞으로의 치료방향에 대해 논의  토의 목적 : 영상 review 및 치료방침 논의

3. Underlying liver function and performance status CBC/DC WBC(mm 3 )4,040 Hb(g/dl)13.3 PLT(mm 3 )147,000 PT(sec)11.7 INR0.87 Performance status: Grade 0 Chemistry TB(mg/dL)1.04 AST/ALT(IU/L)32/26 ALP/GGT(IU/L)137/ - Prot/Alb(g/dL)7.9/4.2 BUN/Cr(mg/dL)19/0.7 Case 1 LC & Stage Child-PughA (5) MELD score7 Esophageal varices- Ascites- Encephalopathy- Tumor markers AFP (ng/mL)8.68 CEA (ng/mL) 2.16 PIVKA II (mAU/mL)9 CA19-9 (U/mL) 10.99 Viral markers/ underlying liver disease HBV / HCV(+/-) Alcohol- 11583248 박 O 자 F/44

4. ’13.5 13.9 14.3 ’14.9 10259334 조 O 복 F/57 Case 1 Tumor Stage and Clinical Course Liver TACE CT : viable HCC S8 Liver TACE CT : viable HCC S8 11583248 박 O 자 F/44 Liver MRI : HCC S4/8, S4 Liver MRI : HCC S4/8, S4 13 년 8 월 13 년 12 월 14 년 3 월 14 년 4 월 14 년 9 월 AFP25.5381.682881.088.68 2013.6.11 TACE #1 2013.6.11 TACE #1 2013.9.9 RFA #1 2013.9.9 RFA #1 Liver MRI : viable HCC S4 Liver MRI : viable HCC S4 2014.03.25 TACE #2 2014.03.25 TACE #2 Liver MRI (2014.09.19) Liver MRI

5. Summary – 치료 방침 결정 11583248 박 O 자 F/44 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: 2014 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 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 ) 2 Vascular or bile duct invasion N High uptake of PET N High AFP or PIVKA II Y Not normalized AFP after curative Tx - Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease - ART score (Good Px 2.5) -

6. History Case 2 11530530 이 O 원 M/59 DM (-), HTN (-) op Hx (-) Alcohol Hx (+) : 소주 0.5 병 주 1 회 (2013 년 12 월 금주 ),Smoking Hx (+) : ex smoker 10PY  B-viral LC, HCC rupture 로 고대병원에서 embolization 시행 받았던 자. Marginal recur & new HCC 로 2014/7/24 TACE #1 시행한 자로 Chest CT 상 r/o Lung meta 소견 보임. 2014/9/12 Chest 및 Liver CT F/U 시행하였으며, 이에 대 한 영상 리뷰 논의  토의 목적 : 영상소견 review

7. Underlying liver function and performance status CBC/DC WBC(mm 3 )6,410 Hb(g/dl)14.0 PLT(mm 3 )235,000 PT(sec)13.5 INR1.03 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.52/0.10 AST/ALT(IU/L)43/73 ALP/rGT(IU/L)109/90 Prot/Alb(g/dL)7.6/4.4 BUN/Cr(mg/dL)18/0.9 LC & Stage Child-PughA (5) MELD score7 Esophageal varices- Ascites- Encephalopathy- Case 2 Tumor markers AFP (ng/mL)6.60 CEA (ng/mL) - PIVKA II (mAU/mL)31 CA19-9 (U/mL) 3.02 11530530 이 O 원 M/59 Viral markers/ underlying liver disease HBV / HCV(+/-) Alcohol+

8. ’13.12 ’14.7 ’14.9 10259334 조 O 복 F/57 Liver MRI : marginal recurr Liver MRI : marginal recurr Case 2 Tumor Stage and Clinical Course 11530530 이 O 원 M/59 Liver CT : ruptured HCC, Lt lobe Liver CT : ruptured HCC, Lt lobe 2013.12 TACE#1 2013.12 TACE#1 2014.7.24 TACE #2 2014.7.24 TACE #2 13 년 12 월 14 년 3 월 14 년 6 월 14 년 7 월 AFP6.609.067.296.62 Chest CT Liver TACE CT Chest CT (2014.07.23) Newly visible well-defined round shaped nodules, both lungs. -> Suggestive of multiple metastasis in both lungs.

9. Summary – 치료 방침 결정 11530530 이 O 원 M/59 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: 2014 년 8 월 Modified UICC ( 대한간암연구학회 ) T 2 N 1 M 1 Stage IV JIS score 3 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Diffuse HCC with compensated liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation N Tumor number 4 Repeated TACE ( 1 회 / 기간 ) 1 Vascular or bile duct invasion N High uptake of PET N High AFP or PIVKA II Y Not normalized AFP after curative Tx - Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease - ART score (Good Px 2.5) -

10. History Case 3 11718380 임 O 순 F/63 DM (-), HTN (-) Op Hx (+) : (1992) Lap. Cholecystectomy, (2011) Lt. lobectomy Alcohol Hx (-), Smoking Hx (-)  1992 년 Cholecystectomy d/t acute cholecystitis, 2011 년 Lt. lobectomcy d/t Lt. IHD stones 병력있는자. 2014 년 1 월 Liver abscess 및 Rt. IHD stone 진단하 에 PCD & PTBD insertion 시행하여 치료 받았으며, 2014 년 5 월 16 일 Liver MRI 에서 Nearly resolved abscess 소견 보였으나 9 월 타 병원에서 terminal cancer 얘기 들음. 영상 review.  토의 목적 : 영상 review

11. Underlying liver function and performance status CBC/DC WBC(mm 3 )3,680 Hb(g/dl)12.6 PLT(mm 3 )187,000 PT(sec)12.0 INR0.88 Performance status: Grade 4 Chemistry TB(mg/dL)1.00 AST/ALT(IU/L)43/43 ALP/GGT(IU/L)156/405 Prot/Alb(g/dL)8.4/4.6 BUN/Cr(mg/dL)6/0.2 Case 3 LC & Stage Child-PughA (5) MELD score6 Esophageal varices- Ascites- Encephalopathy- Tumor markers AFP (ng/mL)1.99 CEA (ng/mL) 2.02 PIVKA II (mAU/mL)- CA19-9 (U/mL) >12,000 Viral markers/ underlying liver disease HBV / HCV(-/-) Alcohol- 11718380 임 O 순 F/63

12. ’14.1 ’14.2 ’14.5 10259334 조 O 복 F/57 GB & Biliary CT : decreased abscess GB & Biliary CT : decreased abscess Case 3 Tumor Stage and Clinical Course 11718380 임 O 순 F/63 GB & Biliary CT : Liver abscess Rt. IHD stone GB & Biliary CT : Liver abscess Rt. IHD stone PTBD & PCD ERCP, PTCS 14 년 1 월 14 년 3 월 14 년 4 월 14 년 5 월 AFP3110.6911523.2610974.48>12000 Liver MRI Liver MRI (2014.05.16) 1. Nearly resolved abscess with fibrotic scars at S8 of the liver. 2. Right IHD - underyling recurrent pyogenic cholangitis. 3. New AP shunt at right anterior inferior segment (S5). 4. Possibly, focal fibrosis at anterior section of the liver (HBP, img : 49, 65). 5. Possibly, portal vein thrombosis with secondary change, S5 portal vein branches 6. S/P Left hepatectomy and cholecystectomy. 7. No evidence of cholangiocarcinoma.

13. Summary – 치료 방침 결정 11718380 임 O 순 F/63 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: 2014 년 6 월 Modified UICC ( 대한간암연구학회 ) T - N - M - Stage - JIS score - BCLC Very early / Early / Intermediate / Advanced / Terminal Current status - Risk factors of recurrence / Tumor biology Extrahepatic metastasis - Tumor size > 5 cm, capsulation - Tumor number - Repeated TACE ( 1 회 / 기간 ) - Vascular or bile duct invasion - High uptake of PET - High AFP or PIVKA II - Not normalized AFP after curative Tx - Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease - ART score (Good Px 2.5) -

14. History Case 4 12093564 정 O 남 F/73 DM (-), HTN (+) Op Hx (+) : (2014) Laparoscopic cholecystectomy Alcohol Hx (-), Smoking Hx (-)  Acute cholecystitis 로 2014 년 2 월 Cholecystectomy 시행후 dyspnea, abd. Distension 심화되어 소화기내과 치료 중인 자. Postoperative ascites development 로 현재 치료 중으로 복수 원인에 대한 토의 및 영상 review  토의 목적 : 영상 및 병리 review

15. Underlying liver function and performance status CBC/DC WBC(mm 3 )6,420 Hb(g/dl)11.8 PLT(mm 3 )122,000 PT(sec)14.4 INR1.12 Performance status: Grade 4 Chemistry TB(mg/dL)1.33 AST/ALT(IU/L)23/15 ALP/GGT(IU/L)222/52 Prot/Alb(g/dL)7.1/4.0 BUN/Cr(mg/dL)6/0.2 Case 4 LC & Stage Child-PughA (6) MELD score9 Esophageal varices- Ascites+ Encephalopathy- Tumor markers AFP (ng/mL)2.03 CEA (ng/mL) 15.6 PIVKA II (mAU/mL)- CA19-9 (U/mL) 2.00 Viral markers/ underlying liver disease HBV / HCV(-/-) Alcohol- 12093564 정 O 남 F/73

16. 2014.2 2014.5 10259334 조 O 복 F/57 Case 4 Tumor Stage and Clinical Course Abdomen CT (2014.05.27) 12093564 정 O 남 F/73 Cholecystectomy Liver CT

17. Summary – 치료 방침 결정 12093564 정 O 남 F/73 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 6 월 Modified UICC ( 대한간암연구학회 ) T - N - M - Stage - JIS score - BCLC Very early / Early / Intermediate / Advanced / Terminal Current status - Risk factors of recurrence / Tumor biology Extrahepatic metastasis - Tumor size > 5 cm, capsulation - Tumor number - Repeated TACE ( 1 회 / 기간 ) - Vascular or bile duct invasion - High uptake of PET - High AFP or PIVKA II - Not normalized AFP after curative Tx - Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease - ART score (Good Px 2.5) -