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

 98’ chronic hepatitis B  2000 Aplastic anemia  2007 BM transplantation  Abdominal sono : HCC  Liver CT : HCC (S7)  PET CT : HCC (S7), No distant metastasis  OP : Rt.hemihepatectomy ( c cholecystectomy)  토의 목적 : 치료 과정에 대한 review History Case 김 O 우 F/33 DM (-) HTN (-) Aplastic anemia s/p BMT (07’) Alcohol (-) / Smoking (-)

Underlying liver function and performance status CBC/DC WBC(mm 3 )9210 Hb(g/dl)12.2 PLT(mm 3 )166k PT(sec)15.2 INR1.22 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.06/- AST/ALT(IU/L)25/29 ALP/rGT(IU/L)97/39 Prot/Alb(g/dL)5.6/3.0 BUN/Cr(mg/dL)8/0.7 LC & Stage Child-Pugh- MELD score- Esophageal varices- Ascites- Encephalopathy 김 O 우 F/33 Case 1 Tumor markers AFP (ng/mL)2.31 CEA (ng/mL) PIVKA II (mAU/mL)- CA Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(+/-) Virus titer> IU/mL Antiviral Tx(-) Alcohol(-)

Tumor Stage and Clinical Course 98’ 00’ BMT Case 1 Aplastic anemia 김 O 우 F/33 CHB *Liver MR ( ) : Massive HCC at the posterior segment of the liver. A simple hepatic cyst at segment 5. Multiple small gallstones. PET ( ) High / Low uptakeHCC in segment 7 No abnormal hypermetabolic lesion suggesting distant metastasis OP Rt.hemihepatectomy HCC (S7) Abdominal sono Liver CT

Summary – 치료 방침 결정 김 O 우 F/33 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

2002 년 B-viral LC 진단 후 2010 년부터 entecavir 복용 중 Liver CT :HCC (S8)  TACE #1 시행 Liver MR : viable HCC (S8)  TACE # Liver CT : r/o viable HCC  Liver MR 시행 Liver MR : r/o viable HCC (S8,S5)  TACE # Liver MR : viable HCC (S8)  TACE #4 향후 치료 방향 논의 History Case 조 O 복 F/57 DM/HTN/TBc/Hepatitis(-/+/-/+) B-viral LC : 2002 년 진단. entecavir 0.5mg Op Hx (-) Alcohol Hx (-), Smoking Hx (-)

Underlying liver function and performance status CBC/DC WBC(mm 3 )4940 Hb(g/dl)13.9 PLT(mm 3 )106k PT(sec)13.5 INR1.04 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.79/0.24 AST/ALT(IU/L)32/36 ALP/rGT(IU/L)79/36 Prot/Alb(g/dL)7.8/4.2 BUN/Cr(mg/dL)9/0.7 LC & Stage Child-PughA(5) MELD score2.56 Esophageal varices(-) Ascites- Encephalopathy 조 O 복 F/57 Case 2 Tumor markers AFP (ng/mL)4.64 CEA (ng/mL) 1.98 PIVKA II (mAU/mL)- CA Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(- / +) Virus titer<20 IU/mL Antiviral TxBENVRA 0.5 mg Alcohol(-)

TACE #1 ( ) TACE #1 ( ) HCC (S8) *Liver MR ( ) : Recurred HCC at S8. Decreased size of hypovascular HCC at S5. Probably DN at the liver segment 3, 5 and 6. Lipiodolized HCC at S8, Underlying liver cirrhosis 조 O 복 F/57 B-viral LC B-viral LC TACE #2 ( ) TACE #2 ( ) Viable HCC r/o Viable HCC TACE #3 ( ) TACE #3 ( ) Case 2 Tumor Stage and Clinical Course 조 O 복 F/57 HCC (S8) TACE #4 ( ) TACE #4 ( ) 12 년 03 월 12 년 05 월 12 년 008 월 12 년 10 월 12 년 12 월 13 년 3 월 AFP PIVKA Ⅱ

Summary – 치료 방침 결정 조 O 복 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 3, N 0, M 0 Stage: III 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 -

 2008 년 B-viral LC, entecavir 복용, 부산대 병원 f/u  Abdomen CT : r/o HCC (S6)  Liver MR : r/o early HCC (S6,S7)  토의 목적 : 향후 치료 방향 논의 History Case 황 O 길 M/61 DM (-) HTN (-) B-viral LC : child A, Entecavir 0.5 mg qd Alcohol (-) / Smoking (-)

Tumor Stage and Clinical Course Case 3 Abdominal CT r/o HCC (S6) 황 O 길 M/61 B-viral LC *Liver MR ( ) : Three DNs at S7 and S6. R/O Early HCC (S7 nodule) Liver cirrhosis with esophageal varix and splenorenal shunt AP shunts Liver MR : R/O Early HCC (S6,S7) EGD Esophagus: Large esophageal varices (Cb F3 LS RC+) Stomach; No fundic varices Cardiac varices (Cb, F2, Lg-c, RC(-))

Summary – 치료 방침 결정 황 O 길 M/61 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 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

99’ 위용종 (uncertain) 으로 subtotal gastrectomy 시행.(at 원자력병원 ). 내원 1 주일전부터 jaundice 증세 있어 본원 소화기 내과 외래 진료후 시행한 Abdominal US 에서 klatskin tumor 의심소견있어 F/E 위해 입원함 GB & Billiary CT : Klatskin tumor bismuth type IV ERCP : EST, Both IHD stent insertion Sono guided bx : Adenocarcinoma, metastatic PET CT : Suggestive of ascending colon cancer Multiple liver metastases Colonoscopy : Distal A-colon cancer - Bx Adenocarcinoma, moderately differentiated  토의 목적 : 향후 치료 방향 논의 History Case 김 O 준 M/52 DM/HTN/TBc/Hepatitis(-/-/-/-) OP Hx (-) Alcohol Hx (-), Smoking Hx (-)

Underlying liver function and performance status CBC/DC WBC(mm 3 )8020 Hb(g/dl)9.5 PLT(mm 3 )426k PT(sec)13.7 INR1.06 Performance status: Grade 0 Chemistry TB/DB(mg/dL)3.09/2.62 AST/ALT(IU/L)31/34 ALP/rGT(IU/L)94/98 Prot/Alb(g/dL)6.3/3.2 BUN/Cr(mg/dL)12/0.7 LC & Stage Child-Pugh- MELD score- Esophageal varices- Ascites- Encephalopathy 김 O 준 M/52 Case 4 Tumor markers AFP (ng/mL)2.21 CEA (ng/mL) 5.94 PIVKA II (mAU/mL) - CA Viral markers/ underlying liver disease HBV / HCV(-/-) HBeAg / HBeAb(-/-) Virus titer - Antiviral Tx- Alcohol(-)

Tumor Stage and Clinical Course 천 O 현 M/46 GB & Billiary CT Sono guided Bx : Adenocarcinoma, metastatic Sono guided Bx : Adenocarcinoma, metastatic PET CT ERCP : ENBD ERCP : ENBD Colonoscopy Bx : Adenocarcinoma, moderately differentiated Bx : Adenocarcinoma, moderately differentiated Cholangitis Chemo Tx : FOLFOX Case 김 O 준 M/52 PET ( ) Suggestive of ascending colon cancer Multiple liver metastases Metastatic lymphadenopathy in left paraaortic and aortocaval nodes MRCP ( ): Peribiliary metastasis at the confluence vs. Klatskin tumor (Bismuth type IV rather than IIIa). Multiple liver metastasis. Extensive porta hepatis and retroperitoneal LNs metastasis. ERCP : Both IHD Stent insertion ERCP : Both IHD Stent insertion MRCP

Summary – 치료 방침 결정 김 O 준 M/52 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) DX Klatskin tumor (Bismuth type IV ) c Colon cancer Colon cancer c biliary invasion, multiple liver meta Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation Y Tumor number >5 Repeated TACE (10 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

 B-viral LC (at local)  Liver CT : HCC (both lobe)  Liver MR : HCC (both lobe)  TACE #1  Liver CT : aggravation of infiltrating HCC  토의 목적 : 향후 치료 방향 논의 History Case 안 O 진 M/36 DM (-) HTN (-) B-viral LC : Tenofovir Alcohol (+) : 1 년전 금주 / Smoking (+) 1 갑 x 20 년 Family Hx : 누나 - HBV carrier, 모 - 간경화로 사망, 부 - 폐암, COPD 로 사망

Underlying liver function and performance status CBC/DC WBC(mm 3 )7180 Hb(g/dl)16.1 PLT(mm 3 )172k PT(sec)16.4 INR1.34 Performance status: Grade 0 Chemistry TB/DB(mg/dL)3.2/1.9 AST/ALT(IU/L)178/23 ALP/rGT(IU/L)346/445 Prot/Alb(g/dL)7.3/3.5 BUN/Cr(mg/dL)9/0.7 LC & Stage Child-PughB(7) MELD score10.74 Esophageal varicesCb, F2-3, Lm, RC (+) AscitesGrade 2 Encephalopathy 안 O 진 M/36 Case 5 Tumor markers AFP (ng/mL)303.2 CEA (ng/mL) 3.29 PIVKA II (mAU/mL)>75000 CA Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer 1960 IU/mL Antiviral TxTenofovir Alcohol(+)

Tumor Stage and Clinical Course TACE #1 ( ) Case 5 HCC (Both lobe) 안 O 진 M/36 B-viral LC 13 년 01 월 13 년 03 월 AFP PIVKA Ⅱ >75000 *Liver MR ( ) : Massive and diffuse infiltrating HCC involving both hepatic lobes. Tumor thrombosis in the right portal vein. PET ( ) High / Low uptakeDiffuse involvement of HCC, particularly right lobe. Liver MR : Aggravation of infiltrating HCC Sorafenib

Summary – 치료 방침 결정 안 O 진 M/36 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) Tumor stage Date: Modified UICC ( 대한간암연구학회 ) T 4, N 0, M 1 Stage: IV BCLC Very early/Early/ Intermediate / Advanced 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 >3 Repeated TACE ( 1 회 / 기간 ) Y Vascular or bile duct invasion N 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 N