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

 2001 년 chronic hepatitis B, 09 년 부터 B-viral LC 로 본원 f/u  HCC at S 6/7,8 -> TACE #1  recurrent HCC at S5 -> RFA #  liver abscess 로 입원 후 퇴원.  Liver CT 상 right pleural mass or right paraspinal mass.  PET CT Suggestive of neurogenic tumor, R/O Metastasis  토의 목적 : 향후 치료 방향 논의 History Case 윤 O 식 M/53 DM/HTN/TBc/Hepatitis(-/-/-/+) B-viral LC : 2001 년 진단 부터 entecavir 0.5mg 복용중 Op Hx (-) Alcohol Hx (-), Smoking Hx (-)

Underlying liver function and performance status CBC/DC WBC(mm 3 )6470 Hb(g/dl)14.8 PLT(mm 3 )164k PT(sec)13.4 INR1.00 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.57/- AST/ALT(IU/L)27/35 ALP/rGT(IU/L)67/48 Prot/Alb(g/dL)7.5/4.5 BUN/Cr(mg/dL)-/- LC & Stage Child-PughA (5) MELD score0.74 Esophageal varices- Ascites- Encephalopathy 윤 O 식 M/53 Case 1 Tumor markers AFP (ng/mL)6.63 CEA (ng/mL) - PIVKA II (mAU/mL)53 CA Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer0 IU/mL Antiviral Txentecavir 0.5mg Alcohol(-)

TACE #1 ( ) TACE #1 ( ) HCC S 6/7,8 *Liver –TACE CT ( ) : Increased size of right pleural mass or right paraspinal mass. 1. metastasis, 2. neurogenic tumor with rapid growing --> malignant lesion is more likely. No change of fibrotic scarring after RFA at segment 8/5. No change of FNH like nodules at segment 7 and segment 4. Liver cirrhosis with multiple regenerating nodules and dysplastic nodules 조 O 복 F/57 B-viral LC B-viral LC RFA#1 ( ) RFA#1 ( ) recurrent HCC Liver abscess Case 1 Tumor Stage and Clinical Course 윤 O 식 M/53 Rt.paraspinal mass 11 년 11 월 12 년 03 월 12 년 06 월 12 년 09 월 12 년 12 월 13 년 3 월 AFP PIVKA Ⅱ PET ( ) No abnormal hypermetabolic lesion suggesting recurrence in liver Hypermetabolic lesion in right paravertebral space and adjacent T12 body : Suggestive of neurogenic tumor R/O Metastasis

Summary – 치료 방침 결정 윤 O 식 M/53 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: Modified UICC ( 대한간암연구학회 ) T 2, N 0, M 0 Stage: II BCLC Very early/Early/ Intermediate / Advanced Current status Locally advanced with Well preserved 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 ) Y 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 N

 2008 년 Alcoholic LC c ehophageal varix, 본원 IG f/u  Abdominal distention 및 diarrhea 증세로 소화기 내과 입원  Liver CT : - HCCs at S5, S7 and left lateral segment - Portal vein, splenic vein, and superior mesenteric vein thrombosis.  TACE indication 되지 않아 Tomo Tx 시행 예정. 향후 치료 방향 논의 History Case 유 O 조 F/57 DM/HTN/TBc/Hepatitis(-/-/-/-) Op Hx (+) : 01’ appendectomy, 09’ kyphosis OP Alcohol Hx (+), Smoking Hx (+) ex smoker : 10 갑년

Underlying liver function and performance status CBC/DC WBC(mm 3 )2440 Hb(g/dl)11.8 PLT(mm 3 )57k PT(sec)19.9 INR1.72 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.65/0.97 AST/ALT(IU/L)86/40 ALP/rGT(IU/L)145/219 Prot/Alb(g/dL)6.5/3.1 BUN/Cr(mg/dL)12/0.8 LC & Stage Child-PughB (8) MELD score12.26 Esophageal varicesCb F2 Li-m RC++ Ascites2 Encephalopathy 유 O 조 F/57 Case 2 Tumor markers AFP (ng/mL)232 CEA (ng/mL) - PIVKA II (mAU/mL)- CA Viral markers/ underlying liver disease HBV / HCV(-/-) HBeAg / HBeAb(-/-) Virus titer0 IU/mL Antiviral Tx- Alcohol(+)

Tumor Stage and Clinical Course Case 2 Esophageal varix EVL x 유 O 조 F/57 Alcoholic LC *Liver MR ( ) : Variable sized, multiple HCC at the liver both lobes. with tumor thrombosis at right, left portal vein. with thrombosis in main portal vein, splenic vein, SMV. Liver CT : HCCs at S5, S7 and left lateral segment. Portal vein, splenic vein, superior mesenteric vein thrombosis. PET ( ) HCCs in segment 5 and left lateral segment No abnormal hypermetabolic lesion suggesting distant metastasis Underlying liver cirrhosis with ascites

Summary – 치료 방침 결정 유 O 조 F/57 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: Modified UICC ( 대한간암연구학회 ) T 4, N 0, M 0 Stage: VI BCLC Very early/Early/ Intermediate / Advanced Current status Locally advanced HCC with Compensated (risk of decompensation) Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation Y Tumor number 2 Repeated TACE ( 2 회 / 기간 ) N Vascular or bile duct invasion Y High uptake of PET Y 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 -

 2009 년 C-viral LC 진단  HCC at S4 - > TACE #1  Marginal reccurred HCC, S4 -> TACE #2  Marginal recurrence, small nodular HCC (S7) -> TACE #3  Recurrent (S4) & new (S7/8) HCC -> TACE #4  Marginal recurrence, S7/8 -> TACE #5  Viable tumor(S4/8), marginal recurrence(S7),HCC(S8) -> TACE #6  Suggestive of recurrent HCC in junction of S4/8-> TACE #7  recurred HCC S4/8 -> TACE #8 향후 치료 방향 논의 History Case 김 O F/73 DM/HTN/TBc/Hepatitis(-/-/-/+) C-viral LC : 2009 년 진단.., Hypothyroidism 으로 Synthyroxine 0.1mg 복용중. Op Hx (-) Alcohol Hx (-), Smoking Hx (-)

Underlying liver function and performance status CBC/DC WBC(mm 3 )3690 Hb(g/dl)11.2 PLT(mm 3 )78k PT(sec)14.4 INR1.13 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.85/0.5 AST/ALT(IU/L)74/31 ALP/rGT(IU/L)133/91 Prot/Alb(g/dL)5.9/2.9 BUN/Cr(mg/dL)12/0.5 LC & Stage Child-PughA(6) MELD score4.2 Esophageal varices(-) Ascites- Encephalopathy 김 O F/73 Case 3 Tumor markers AFP (ng/mL)213 CEA (ng/mL) 4.61 PIVKA II (mAU/mL)- CA Viral markers/ underlying liver disease HBV / HCV(-/+) HBeAg / HBeAb(- / -) Virus titer- Antiviral Tx- Alcohol(-)

TACE #1 ( ) TACE #1 ( ) HCC (S4) 조 O 복 F/57 C-viral LC C-viral LC TACE #2 ( ) TACE #2 ( ) TACE #3 ( ) TACE #3 ( ) Case 3 Tumor Stage and Clinical Course 김 O F/73 10 년 01 월 11 년 06 월 12 년 03 월 12 년 09 월 12 년 12 월 13 년 3 월 AFP PIVKA Ⅱ HCC (S4) HCC (S7) HCC (S4.7) TACE #4 ( ) TACE #4 ( ) TACE #5 ( ) TACE #5 ( ) TACE #6 ( ) TACE #6 ( ) HCC (S7/8) HCC (S4/8) TACE #7 ( ) TACE #7 ( ) TACE #8 ( ) TACE #8 ( ) PET ( ) No abnormal hypermetabolic lesion in lipiodolized HCC of segment 4/8 Post-TACE state in segment 4

Summary – 치료 방침 결정 김 O F/73 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: Modified UICC ( 대한간암연구학회 ) T 2, N 0, M 0 Stage: II BCLC Very early/Early/ Intermediate / Advanced Current status Locally advanced HCC with well preserved liver function and low-risk for recurrence Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation N Tumor number 2 Repeated TACE ( 2 회 / 기간 ) Y 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 -

 epigastric pain 으로 대구 파티마 병원 내원, - B-viral LC, r/o HCC (segment 5~8 8x6 cm) 진단  HCC at Rt lobe -> TACE#1 ( )  HCC at S8,S5 -> TACE #2 ( )  HCC at S8,S5 -> TACE #3 ( )  HCC at S8,S5 ->TACE #4 ( )  S4,5,8 sectionectomy  chemo Tx (5-FU, 1-VL) 1 차  토의 목적 : 향후 치료 방향 논의 History Case 홍 O 선 M/44 DM/HTN/TBc/Hepatitis(-/-/-/+) B-viral LC : 진단 Entecavir 0.5mg 복용중 Op Hx (+) S4,5,8 sectionectomy Alcohol Hx (+), Smoking Hx (+) ex somker 20 갑년

Underlying liver function and performance status CBC/DC WBC(mm 3 )7870 Hb(g/dl)15.6 PLT(mm 3 )309k PT(sec)12 INR0.88 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.75/0.57 AST/ALT(IU/L)41/26 ALP/rGT(IU/L)136/169 Prot/Alb(g/dL)7.7/4.4 BUN/Cr(mg/dL)9/0.7 LC & Stage Child-PughA (5) MELD score0.83 Esophageal varices- Ascites- Encephalopathy 홍 O 선 M/44 Case 4 Tumor markers AFP (ng/mL)119 CEA (ng/mL) - PIVKA II (mAU/mL)>2000 CA Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer34 IU/mL Antiviral Txentecavir 0.5mg Alcohol(+)

TACE #1 ( ) TACE #1 ( ) HCC S 5, 조 O 복 F/57 B-viral LC HCC S5,S8 B-viral LC HCC S5,S8 Case 4 Tumor Stage and Clinical Course 홍 O 선 M/44 12 년 07 월 12 년 08 월 12 년 12 월 13 년 2 월 AFP PIVKA Ⅱ > PET ( ) Known HCC : No abnormal hypermetabolic lesion in the liver. No abnormal activity suggesting metastasis. No abnormal hypermetabolic lesion suggesting malignancy.. HCC S 5,8 TACE #2 ( ) TACE #2 ( ) HCC S 5,8 TACE #3 ( ) TACE #3 ( ) HCC S 5,8 TACE #4 ( ) TACE #4 ( ) OP S4,5,8 sectionectomy S4,5,8 sectionectomy Chemo Tx

Summary – 치료 방침 결정 홍 O 선 M/44 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: Modified UICC ( 대한간암연구학회 ) T 3, N 0, M 0 Stage: III BCLC Very early/Early/ Intermediate / Advanced Current status Locally advanced with Well preserved 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 ) Y 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 N