1. Liver Transplantation Conference
Liver Transplantation Conference
경희대학교 병원 간이식팀
R3 최태웅/Prof. 김병호

2. Case 1
History
이 O 수 M/56
56/M. Alcoholic LC(Child C(11), MELD 25) c esophageal varix, c hepatic encephalopathy(grade 2)로 본원 IG(pf.김병호) f/u 중 최근 들어 flapping tremor 지속되며 hepatic encephalopathy 호전 없고 decompensated LC 상태로 LT 필요성에 대해 상의하기 위해 선정함.
DM (-), HTN (-)
Op Hx (-)
Alcohol Hx (-) Smoking Hx (-) : ex-smoker 40 PY

3. Underlying liver function and performance status
Case 1
이 O 수 M/56
Underlying liver function and performance status
Performance status: Grade 0
LC & Stage
Child-Pugh
C (11)
MELD score 25
Esophageal varices +
Ascites -
Encephalopathy
CBC/DC (‘ )
WBC
(mm3)
5,780 Hb
(g/dl)
10.2
PLT
71,000 PT
(sec)
23.5
INR
2.12
Chemistry(‘ )
TB/DB
(mg/dL)
4.37/-
AST/ALT
(IU/L)
46/25
ALP/rGT
249/16
Prot/Alb
(g/dL)
6.1/2.9
BUN/Cr
-/-
Viral markers/ underlying liver disease
HBV / HCV
(-/-)
HBeAg / HBeAb
Virus titer -
Antiviral Tx
Alcohol
Tumor markers (‘15.11)
AFP (ng/mL)
1.95
CEA (ng/mL)
5.71
PIVKA II (mAU/mL) -
CA19-9 (U/mL)
2.00

4. Kayser-Fleischer ring(-)
Case 1
조O복 F/57
Clinical Course
이 O 수 M/56
‘ ’ ’16
jaundice
→ Alcoholic- LC진단
Celuloplasmin 14
Serum Cu 66.4
Urine Cu 357.9
→ r/o Wilson
Kayser-Fleischer ring(-)
ATP7B : no mutation
Hepatic
Encephalopathy(Gr2)
Liver CT( )
Liver cirrhosis with splenomegaly.
a/w gastroesophageal varix and gastrorenal shunt.
Diverticulosis at proximal A-colon.
Non-visible small cystic lesion at pancreas tail on this exam.
No change of 2 GB stones and several both renal cyst.
Segmental atelectasis and focal emphysematous change in RML

5. Case 2
History
김 O 임 F/55
55/F. DM, HTN Hx 있으며 C-viral LC(Child B(8), MELD 12) c esophageal varix s/p EVL #2( ) c ascites, HCC (mUICC stage I, T1N0M0) s/p TACE #1 ( ) Hx 있고 2014년 03월 acute cholecystitis로 PTGBD insertion 후 op risk 높아 수술은 거부하고 항생제 치료만 시행 후 호전되어 본원 IG(Pf.김병호) 외래 f/u 중인 자로 최근 ascite 증가하고 pancytopenia 호전 없는 상태로 LT 가능성에 대해 상의하기 위해 선정함
DM (-), HTN (-)
Op Hx (-)
Alcohol Hx (-) , Smoking Hx (-)

6. Underlying liver function and performance status
Case 2
김 O 임 F/55
Underlying liver function and performance status
Performance status: Grade 0
LC & Stage
Child-Pugh
B (8)
MELD score 12
Esophageal varices +
Ascites
Encephalopathy -
CBC/DC (’ )
WBC
(mm3)
1,830 Hb
(g/dl)
8.5
PLT
47,000 PT
(sec)
48.0
INR
1.53
Chemistry(‘ )
TB/DB
(mg/dL)
1.71/0.73
AST/ALT
(IU/L)
40/14
ALP/rGT
74/50
Prot/Alb
(g/dL)
6.2/3.0
BUN/Cr
8/0.4
Viral markers/ underlying liver disease
HBV / HCV
(-/+)
HBeAg / HBeAb
(-/-)
Virus titer -
Antiviral Tx
Alcohol
Tumor markers (‘16.01)
AFP (ng/mL)
3.57
CEA (ng/mL)
1.75
PIVKA II (mAU/mL) 16
CA19-9 (U/mL)
34.43

7. Clinical Course Case 2 ’12 ‘14.01 ’14.03 ’14.07 ‘16.02
조O복 F/57
Clinical Course
김 O 임 F/55
’ ‘ ’ ’ ‘16.02
LFT abnormality,
Esophageal varix
→ C-viral LC 진단,
EVL #1 시행
Liver MR 상
HCC at S4
→ TACE #1 시행
Acute cholecystits
→ PTGBD 삽입,
수술 거부함
Esophageal varix
→ prophylactic EVL #2
Chronic
cholecystitis
→ 항생제 치료
GB & billiary CT( )
No demonstrable HCC on CT. However, possibility of HCC cannot be excluded.
Equivocal changes, as follows;
Liver cirrhosis with splenomegaly.
GB stone.
Subserosal edema of the gallbladder and portal hypertensive colonopathy involving right side colon.
Large amount of ascites.
S/P hysterectomy.

8. Summary Case 2 Initial Tumor stage Date: 2014년 1월 BCLC Current status
김 O 임 F/55
Initial Tumor stage Date: 2014년 1월
Modified UICC (대한간암연구학회)
T 1 N 0 M Stage I JIS score 1
BCLC
Very early / Early / Intermediate / Advanced / Terminal
Current status
HCC with decopmpensated liver function
Extent of current tumor
Localized (curative)
Locally advanced (resectable)
Locally advanced (unresectable) No < 4
Diffuse or multiple (> 3)
Risk factors of recurrence / Tumor biology
Extrahepatic metastasis N
Tumor size > 5 cm, capsulation
Tumor number
2(S4,S6)
Repeated TACE ( 1회/기간) 1
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 Y
Current liver function
Normal
Well preserved (no risk of decompensation)
Compensated (risk of decompensation)
Decompensated
Terminal state

9. Case 3
History
송 O 기 M/58
58/M. 최근 fatigue, abd distension 있어 local 의원에서 DM, Alcoholic & C-viral LC(Child A(6), MELD 9) c ascites 진단받고 further evaluation 위해 본원 IG(Pf.심재준) 입원 중인 자로 Liver MR 상 multiple scirrhous type HCC or combined HCC/CC in S7/6소견 보여 LT 가능성에 대해 상의하기 위해 선정함
DM (+), HTN (-)
Op Hx (-)
Alcohol Hx (-) : 3개원 전 금주(매일 소주1병, 맥주2병) Smoking Hx (-) : 20PY

10. Underlying liver function and performance status
Case 3
송 O 기 M/58
Underlying liver function and performance status
Performance status: Grade 0
LC & Stage
Child-Pugh
A (6)
MELD score 9
Esophageal varices +
Ascites
Encephalopathy -
CBC/DC (’ )
WBC
(mm3)
7,520 Hb
(g/dl)
11.6
PLT
184,000 PT
(sec)
14.9
INR
1.20
Chemistry(‘ )
TB/DB
(mg/dL)
0.79/0.40
AST/ALT
(IU/L)
46/31
ALP/rGT
86/80
Prot/Alb
(g/dL)
6.1/2.8
BUN/Cr
22/1.0
Viral markers/ underlying liver disease
HBV / HCV
(-/+)
HBeAg / HBeAb
(-/-)
Virus titer
402,000 IU/mL
Antiviral Tx -
Alcohol
Tumor markers (‘16.03)
AFP (ng/mL)
4.90
CEA (ng/mL)
4.92
PIVKA II (mAU/mL) 16
CA19-9 (U/mL)
2.00

11. Fatigue, abd distension → Alcoholic & C-viral LC 진단
Case 3
조O복 F/57
Clinical Course
송 O 기 M/58
‘16.2
Fatigue, abd distension
→ Alcoholic & C-viral LC 진단
Liver MR( )
Suggestive of multiple scirrhous type HCC or combined HCC/CC in S7/6.
- a/w small daugther nodule and multiple retroperitoneal metastatic LAP.
- R/O cholangiocarcinoma.
- less possibility of multiple hepatic metastases from other primary organs.
Underlying liver cirrhosis with portal hypertension and considerable amount of ascites.
Probably small RN or DN in S8.

12. Case 4
History
김 O 도 M/65
65/M. DM, HTN 있으며 B-viral LC(Child B(9), MELD 12) c esophageal varix s/p EVL #3(2013), HCC(mUICC stage 3, T3N0M0, JIS score 2) s/p TACE #3(2014)로 본원 IG(Pf.심재준) 외래 f/u 중인 자로 복수 조절 안되며 Liver MR 상 newly HCC lesion 있어 LT 가능성에 대해 상의하기 위해 선정함
DM (+), HTN (+)
Op Hx (-)
Alcohol Hx (-) Smoking Hx (-)

13. Underlying liver function and performance status
Case 4
김 O 도 M/65
Underlying liver function and performance status
Performance status: Grade 0
LC & Stage
Child-Pugh
B (9)
MELD score 12
Esophageal varices +
Ascites
Encephalopathy -
CBC/DC (’ )
WBC
(mm3)
4,020 Hb
(g/dl)
15.4
PLT
73,000 PT
(sec)
14.9
INR
1.17
Chemistry(‘ )
TB/DB
(mg/dL)
3.07/-
AST/ALT
(IU/L)
67/44
ALP/rGT
244/167
Prot/Alb
(g/dL)
8.7/3.7
BUN/Cr
10/0.8
Viral markers/ underlying liver disease
HBV / HCV
(+/-)
HBeAg / HBeAb
(-/+)
Virus titer
402,000 IU/mL
Antiviral Tx -
Alcohol
Tumor markers (‘16.02)
AFP (ng/mL)
8.80
CEA (ng/mL) -
PIVKA II (mAU/mL) 33
CA19-9 (U/mL)

14. Clinical Course Case 4 ’05 ’12 ’13.01 ’14 ‘16 Liver MRI(2016.02.22)
조O복 F/57
Clinical Course
김 O 도 M/65
’ ’ ’ ’ ‘16
B-viral LC 진단
EVL #2(‘12.07~’12.10)
Liver MRI 상
HCC at S7,8
→ TACE #1,
EVL #3
Liver MRI 상
S7 lesion
→ TACE #3
Liver MRI
→ new HCC
at Lt lat seg
Liver MRI( )
Suggested a new HCC at left lateral segment.
No evidence of viable tumor at partial lipiodolized mass at S7.
Equivocal change of multiple FNH like nodules.
Equivocal change of bland thrombosis at the umbilical segment of left PV, main PV and SMV.
Underlying liver cirrhosis with splenomegaly and ascites.

15. Summary Case 4 Initial Tumor stage Date: 2016년 2월 BCLC Current status
김 O 도 M/65
Initial Tumor stage Date: 2016년 2월
Modified UICC (대한간암연구학회)
T 3 N 0 M Stage III JIS score 3
BCLC
Very early / Early / Intermediate / Advanced / Terminal
Current status
HCC with decopmpensated liver function
Extent of current tumor
Localized (curative)
Locally advanced (resectable)
Locally advanced (unresectable) No < 4
Diffuse or multiple (> 3)
Risk factors of recurrence / Tumor biology
Extrahepatic metastasis N
Tumor size > 5 cm, capsulation
Tumor number 2
Repeated TACE ( 1회/기간) 3
Vascular or bile duct invasion
High uptake of PET
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
Current liver function
Normal
Well preserved (no risk of decompensation)
Compensated (risk of decompensation)
Decompensated
Terminal state

16. Case 5
History
김 O 현 M/74
74/M. C-viral LC(Child C(11), MELD 23) c esophageal varix s/p EVL #4(2016), HCC(mUICC stage 3, T3N0M0) s/p TACE #5로 본원 IG(Pf.심재준) 외래 f/u 중인 자로 최근 ascites 조절 안되고 tumor marker 상승하며 Liver MR 상 기존 병변 크기 증가 있어 LT 가능성에 대해 상의하기 위해 선정함
DM (-), HTN (-)
Op Hx (-)
Alcohol Hx (-) Smoking Hx (-)

17. Underlying liver function and performance status
Case 5
김 O 현 M/74
Underlying liver function and performance status
Performance status: Grade 0
LC & Stage
Child-Pugh
C (11)
MELD score 23
Esophageal varices +
Ascites
Encephalopathy -
CBC/DC (’ )
WBC
(mm3)
3,520 Hb
(g/dl)
8.3
PLT
64,000 PT
(sec)
19.6
INR
1.70
Chemistry(‘ )
TB/DB
(mg/dL)
3.49/2.63
AST/ALT
(IU/L)
48/23
ALP/rGT
89/33
Prot/Alb
(g/dL)
6.2/3.0
BUN/Cr
48/1.4
Viral markers/ underlying liver disease
HBV / HCV
(-/+)
HBeAg / HBeAb
(-/-)
Virus titer -
Antiviral Tx
Alcohol
Tumor markers (‘16.03)
AFP (ng/mL)
25983
CEA (ng/mL)
3.82
PIVKA II (mAU/mL) 86
CA19-9 (U/mL)
30.62

18. Clinical Course Case 5 ’99 ’02 ’16.01 ’16.03 Liver MRI(2016.03.04)
조O복 F/57
Clinical Course
김 O 현 M/74
’ ’ ’ ’16.03
C-viral LC,
HCC 진단
TACE #5
EVL #4
Uncontrolled ascites,
Liver MRI 상 size 증가
’13
’15.10
’16.03
AFP
4.17
916.7
25983
PIVKA II 21 86
5369
Liver MRI( )
Increased size of viable HCC at anterior aspect to lipiodolized HCC (2.8cm)--> 6.4cm.
Slightly increased size of suggested viable HCC at posteroinferior aspect to lipiodolized HCC.
Increased at size of cyst in right lobe.
No change of liver cirrhosis with large amount of ascites.
Aggravation of bland thrombosis in main portal vein and SMV.

19. Summary Case 5 Initial Tumor stage Date: 2016년 2월 BCLC Current status
김 O 현 M/74
Initial Tumor stage Date: 2016년 2월
Modified UICC (대한간암연구학회)
T 3 N 0 M Stage III JIS score 4
BCLC
Very early / Early / Intermediate / Advanced / Terminal
Current status
HCC with decopmpensated liver function
Extent of current tumor
Localized (curative)
Locally advanced (resectable)
Locally advanced (unresectable) No < 4
Diffuse or multiple (> 3)
Risk factors of recurrence / Tumor biology
Extrahepatic metastasis N
Tumor size > 5 cm, capsulation Y
Tumor number 2
Repeated TACE ( 1회/기간) 5
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
Current liver function
Normal
Well preserved (no risk of decompensation)
Compensated (risk of decompensation)
Decompensated
Terminal state

20. Case 6
History
강 O 자 F/74
74/M. Old CVA, HTN Hx 있는 자로 2012년 한약 복용 후 toxic hepatitis imp으로 입원력(Pf.동석호) 있는 자로 2015년 12월 부터 LFT 상승 보여 autoimmune hepatitis(score 10)에 의한 LC(Child B(8), MELD 19) 진행 소견으로 외래 통해 입원하여 steroid therapy (16/2/11~2/13)도중 fever 발생하며 r/o SBP, r/o urosepsis imp 하에 항생제 치료 후 호전되어 3/4 부터 다시 steroid 시작하였으며 증상 호전되어 금일 퇴원한 자로 LT 가능성에 대해 상의하기 위해 선정함
DM (-), HTN (+)
Op Hx (-)
Alcohol Hx (-) Smoking Hx (-)

21. Underlying liver function and performance status
Case 6
강 O 자 F/74
Underlying liver function and performance status
Performance status: Grade 0
LC & Stage
Child-Pugh
B (8)
MELD score 19
Esophageal varices -
Ascites
Encephalopathy
CBC/DC (’ )
WBC
(mm3)
4,300 Hb
(g/dl)
10.6
PLT
83,000 PT
(sec)
15.8
INR
1.29
Chemistry(‘ )
TB/DB
(mg/dL)
3.92/3.34
AST/ALT
(IU/L)
75/61
ALP/rGT
140/102
Prot/Alb
(g/dL)
6.8/2.9
BUN/Cr
33/0.8
Viral markers/ underlying liver disease
HBV / HCV
(-/-)
HBeAg / HBeAb
Virus titer -
Antiviral Tx
Alcohol
Tumor markers (‘16.02)
AFP (ng/mL)
694.0
CEA (ng/mL)
2.42
PIVKA II (mAU/mL) -
CA19-9 (U/mL)
15.06

22. Clinical Course Case 6 ’12 ’15.12 ’16.02 ’16.02 ’16.03
조O복 F/57
Clinical Course
강 O 자 F/74
’ ’ ’ ’ ’16.03
Toxic hepatitis
LFT 상승
LC c autoimmune
hepatitis
Steroid therapy
2/11~2/13
r/o SBP, r/o urosepsis
→ antibiotics(2/13~2/27)
Steroid therapy
재시작 : 3/4~
GB & billiary CT( )
No evidence of abnormal focal lesion in liver.
Suggestive of liver cirrhosis.
Hepatic cysts.
Contracted GB.
BK cysts.

23. Thank you for listening