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

History Case 조 O 배 M/39 DM (-), HTN (+) : 2 년 전부터 po medication 중 HBs Ag (-), Anti HBs Ab (+), Anti-HCV Ab (-) Op Hx (-) Alcohol Hx (+) : 주 2 회, 소주 1-2 병, Smoking Hx (+) : 10 pack years  2012 년 2 월 Abd CT ( 타병원 ) : hemangioma (S7, 9cm)  2012 년 8 월 Abd sono ( 타병원, report only) : nodule (S7, 2cm)  Liver CT : Hemangioma (S6/7, S7, S2)  Liver CT : Increased hemangioma (S7, 10.5cm)  토의 목적 : 향후 f/u 에 대한 논의

Underlying liver function and performance status CBC/DC WBC(mm 3 )5,270 Hb(g/dl)15.2 PLT(mm 3 )374,000 PT(sec)13.2 INR1.00 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.11/- AST/ALT(IU/L)19/19 ALP/rGT(IU/L)51/35 Prot/Alb(g/dL)7.2/4.4 BUN/Cr(mg/dL)13/ 조 O 배 M/39 Case 1 Tumor markers AFP (ng/mL)2.74 CA19-9 (U/mL) 4.09 Viral markers/ underlying liver disease HBV / HCV(-/-) Alcohol+

’12.02 ’12.09 ‘ 조 O 복 F/57 Hemangioma Case 1 Clinical Course 조 O 배 M/39 Liver CT ( ) Several hepatic hemangiomas at both lobes. Increased size of right hepatic hemangioma. LK cysts. 12 년 09 월 AFP 2.74 CA hemangiomas Increased size 8.6 -> 10.5 Increased size 8.6 -> 10.5

History Case 고 O 숙 F/56 DM (-), HTN (-) HBs Ag (-), Anti HBs Ab (-), Anti-HCV Ab (-) Op Hx (+) : 2009 년 Cecal ca.  Rt hemicolectomy Alcohol Hx : social, Smoking Hx : ex-smoker  2009 년 Cecal cancer  Rt hemicolectomy (’ )  EGD : Esophageal varix  Abd US : r/o hepatic mass at left lobe of liver  Liver MR : r/o focal nodular hyperplasia  토의 목적 : 영상 소견 review

Underlying liver function and performance status CBC/DC WBC(mm 3 )5,630 Hb(g/dl)12.6 PLT(mm 3 )123,000 PT(sec)13.7 INR1.04 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.80/- AST/ALT(IU/L)31/34 ALP/rGT(IU/L)96/135 Prot/Alb(g/dL)7.3/4.2 BUN/Cr(mg/dL)8/0.6 LC & Stage Child-Pugh MELD score Esophageal varices[Cb F1 Li RC(-)] Ascites Encephalopathy 고 O 숙 F/56 Case 2 Tumor markers AFP (ng/mL)4.35 CEA (ng/mL) 2.22 CA19-9 (U/mL) 1.68 Viral markers/ underlying liver disease HBV / HCV(-/-) Alcoholsocial

’09.07 ’12.06 ’13.03 ‘ 조 O 복 F/57 Cecal ca. Cecal ca. Case 2 Tumor Stage and Clinical Course 고 O 숙 F/56 Liver MR ( ) R/O focal nodular hyperplasia at caudate lobe. Splenomegaly. PET-CT ( ) No abnormal hypermetabolic lesion suggesting recurrence or metastasis 13 년 09 월 AFP4.35 CEA2.22 Esophageal varix Liver MR : r/o focal nodular hyperplasia Liver MR : r/o focal nodular hyperplasia Rt hemicolectomy Rt hemicolectomy Abd US : r/o hepatic mass Abd US : r/o hepatic mass

History Case 박 O 문 M/72 DM (+): levemir 20u + novorapid 8u x 3, HbA1c =8.0%, HTN (+) : atenolol Alcoholic LC (Child B(7) MELD 7) with ascites Op Hx (+) : Lap cholecystectomy (‘ ) Alcohol Hx (+) : 주 7 회, 소주 2 병, Smoking Hx (+) : 20 pack years  2012 년 Alcoholic LC 진단  Liver CT : GB cancer (pT2N0M0, stage II)  Laparoscopic cholecystectomy c LN dissection (‘ )  Liver CT : Large amount of ascites with omental haziness  토의 목적 : 영상 소견 review

Underlying liver function and performance status CBC/DC WBC(mm 3 )6,790 Hb(g/dl)14.5 PLT(mm 3 )110,000 PT(sec)12.8 INR0.98 Performance status: Grade 1 Chemistry TB/DB(mg/dL)1.07/- AST/ALT(IU/L)26/5 ALP/rGT(IU/L)58/75 Prot/Alb(g/dL)7.0/4.1 BUN/Cr(mg/dL)10/0.6 LC & Stage Child-PughB (8) MELD score7 Esophageal varices- AscitesPoorly controlled Encephalopathy 박 O 문 M/72 Case 2 Tumor markers AFP (ng/mL)13.02 CEA (ng/mL) 1.73 CA19-9 (U/mL) 4.68 Viral markers/ underlying liver disease HBV / HCV(-/-) Alcohol+

’12.06 ’13.04 ~ ’13.06 ‘ 조 O 복 F/57 Alcoholic LC Alcoholic LC Case 3 Clinical Course 박 O 문 M/72 Liver CT ( ) S/P cholcystectomy. Large amount of ascites with omental haziness. --> Suggestive of LC-related reactive change. R/O peritoneal carcinomatosis. Liver cirrhosis with atrophy. PET-CT ( ) No abnormal hypermetabolic lesion suggesting metastasis. 13 년 04 월 13 년 05 월 13 년 09 월 AFP CA GB cancer Lap. cholecystectomy Lap. cholecystectomy Liver CT : ascites Liver CT : ascites

History Case 한 O 덕 70/M DM (-), HTN (+) : amlodipine C-viral LC (Child A(5) MELD 7) Op Hx (-) Alcohol Hx (-), Smoking Hx : ex-smoker  2006 년경 C-viral LC, HCC 진단  Peg-interferon, RFA ( 타병원 )  Liver CT : Low attenuated mass at S6, R/O RFA area  Liver CT : Increased size of hepatic mass (Lt hepatic lobe)  Liver MR : HCC (left lobe)  토의 목적 : 영상 소견 review 및 향후 치료 방침 결정

Underlying liver function and performance status CBC/DC WBC(mm 3 )2,810 Hb(g/dl)13.2 PLT(mm 3 )122,000 PT(sec)14.5 INR1.14 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.78/- AST/ALT(IU/L)118/94 ALP/rGT(IU/L)83/334 Prot/Alb(g/dL)7.8/4.0 BUN/Cr(mg/dL)18/0.9 LC & Stage Child-PughA (5) MELD score7 Esophageal varices- Ascites- Encephalopathy 한 O 덕 70/M Case 4 Tumor markers AFP (ng/mL)12.14 CEA (ng/mL) - PIVKA II (mAU/mL)19 CA19-9 (U/mL) - Viral markers/ underlying liver disease HBV / HCV(-/+) Genotype2 Virus titerNot detected Antiviral TxPeg-interferon, ribavirin Alcohol-

2006? ’13.03 ‘ 조 O 복 F/57 C-viral LC, HCC C-viral LC, HCC Case 4 Tumor Stage and Clinical Course 한 O 덕 70/M Liver CT ( ) Increased size of hepatic mass in the left hepatic lobe. No change of low attenuated lesion at segment 6. Multiple both renal cysts. Underlying liver cirrhosis. 13 년 03 월 13 년 08 월 AFP PIVKA II19- Transfer to KMC Liver CT : S6, r/o RFA area Liver CT : S6, r/o RFA area Liver CT : Increased hepatic mass Liver CT : Increased hepatic mass RFA

Summary – 치료 방침 결정 한 O 덕 70/M 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: 2013 년 03 월 Modified UICC ( 대한간암연구학회 ) T 1 N 0 M 0 Stage I JIS score 0 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 2 Repeated TACE ( 1 회 / 기간 ) 0 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

History Case 박 O 환 M/53 DM (-), HTN (+) : olmesartan + amlodipine, propranolol, h/o stable angina B-viral LC (Child A(5) MELD 9) with esophageal varix Op Hx (-) Alcohol Hx (+) : 주 3 회, 소주 1.5 병, Smoking Hx (-)  2010 년 B-viral LC 진단  Entecavir 복용 중  Abd CT : Dysplastic nodule (S4)  Liver CT : New HCC (S5)  토의 목적 : 기간에 따른 영상 소견의 변화 review

Underlying liver function and performance status CBC/DC WBC(mm 3 )6,650 Hb(g/dl)16.8 PLT(mm 3 )101,000 PT(sec)13.0 INR1.00 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.77/- AST/ALT(IU/L)46/42 ALP/rGT(IU/L)105/507 Prot/Alb(g/dL)7.6/4.2 BUN/Cr(mg/dL)14/1.0 LC & Stage Child-PughA (5) MELD score9 Esophageal varices[Cb F2 Li RC(++)] Ascites- Encephalopathy 박 O 환 M/53 Case 5 Tumor markers AFP (ng/mL)9.84 CEA (ng/mL) 2.82 PIVKA II (mAU/mL)- CA19-9 (U/mL) 3.74 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/-) Virus titer<20 IU/mL Antiviral TxEntecavir Alcohol+

’10.12 ‘ 조 O 복 F/57 B-viral LC B-viral LC Case 5 Clinical Course 박 O 환 M/53 Liver CT ( ) New HCC at S5. Equivocal change of dysplastic nodule at left medial segment of liver. Underlying liver cirrhosis with splenomegaly, mild coronary collateral with esophageal and paraesophageal varices. 10 년 12 월 11 년 05 월 12 년 01 월 12 년 07 월 13 년 08 월 AFP PIVKA II----- Liver CT : New HCC (S5) Liver CT : New HCC (S5) Abd CT : Dysplastic nodule (S4) Abd CT : Dysplastic nodule (S4)

Summary – 치료 방침 결정 박 O 환 M/53 Case 5 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 08 월 Modified UICC ( 대한간암연구학회 ) T 1 N 0 M 0 Stage II JIS score 2 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 1 Repeated TACE ( 1 회 / 기간 ) 0 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