MGR Case presentation 소화기내과 R2 이설라

periumbilical pain onset) 내원 2주전 Case 1 Case Presentation 11970021 48/M 안 O 성 Adm.2008.5.19 C.C. periumbilical pain onset) 내원 2주전 P.I. 20년전 HBV carrier 진단받고 이후 검사나 치료 받지 않음. 내원 2주전 간간히 발생한 periumbilical pain으로 타병원 에서 시행받은 복부 초음파에서 liver mass 의심되어 큰 병원 진료 권유 받고 방문.

Case 1 PMHx. DM/HTN/Tuberculosis/Hepatitis (-/-/-/+) Op Hx (-) Drug Hx (-) Alcohol (-) Smoking (+) : 10pack/year FHx : none

Review of Systems Case 1 G/A) fatigue (+) weight change (-) fever (-) chill (-) sweating (-) Skin) pigmentation (-) rash (-) itching (-) H& N) headache (-) trauma (-) stiffness (-) Eye/ ENT) diplopia (-) hearing loss(-) nasal obstruction (-) dryness(-) soreness(-) hoarseness(-) Respiratory) cough (-) sputum (-) dyspnea(-) hemoptysis(-)

Case 1 Cardiac) palpitation (-) dyspnea(-) chest pain (-) orthopnea(-) G-I) A/N/V/D/C(-/-/-/-/-) abd pain (+) : periumbilical, lower abdomen jaundice (-) melena (-) Renal & Urinary) dysuria (-) hematuria (-) polyuria (-) incontinence (-) nocturia (-) anuria(-)

Physical Examination Case 1 Alert consciousness Vital sign) 120/77mmHg – 82회/분 – 20회/분 – 36.2℃ Height : 160cm weight: 59.5Kg General appearance Alert consciousness Not acute ill-looking appearance Skin Rash (-) Pigmentation (-) Head and Neck Neck LN enlargement (-/-) Neck vein engorgement (-/-) Thyroid enlargement (-) Eyes and ENT Isocoric pupil with PLR(++/++) Whitish sclera, Pinkish conjunctiva

Case 1 Clear breathing sound without wheezing Chest Clear breathing sound without wheezing Regular heart beat without murmur Abdomen Soft and flat abdomen No abdominal tenderness No rebound tenderness No palpable abdominal mass Normoactive bowel sound No hepatosplenomegaly Back and extremities CVA tenderness(-/-) Peripheral pitting edema(-/-)

Initial lab findings Case 1 CBC/DC 3830/mm3 – 13.7 g/dL – 4.1% - 67k (seg : 68.2 %) Chemistry TB/DB 0.53/0.15mg/dL AST/ALT 28/27 IU/L ALP/GGT 61/76 IU/L Glucose 97mg/dL BUN/Cr 19/0.79 mg/dL Prot/Alb 7.3/4.3 g/dL Na/K/Cl 137/3.6/106 mmol/L Ca/Mg/P 8.5/2.9/2.1 mg/dL T-Chol 175mg/dl CRP 0.5 mg/dL Urinalysis Microscopy : WBC 0-1/HPF RBC 0-1/HPF Protein(-) Occult blood(-) Nitrate(-)

Case 1 Initial chest PA

Case 1 Initial ECG

Initial problem list Case 1 Abdomen pain due to liver mass? Known chronic hepatitis B

Initial assessment & plan Case 1 Initial assessment & plan A) Abdomen pain due to liver mass? P) abdominal CT abdominal sono tumor marker (esp. AFP, PIVKAII) EGD, colonoscopy, if needed A) known chronic hepatitis B P) viral marker HBV DNA titer 확인

Viral marker & virus titer Case 1 Viral marker & virus titer HBs Ag/Anti-HBs Ab/Anti-HBc Ab (+/-/+) Anti –HCV Ab (-) HBeAg (+) HBeAB(-) HBV PCR 정량 : 208,000 ul/mL (1,095,080 copies/mL) AFB 3.8 ng/ml 13

Case 1 Liver CT

Case 1

Case 1 Liver MRI

Initial diagnosis Case 1 HCC B-viral LC (Child A score 5, MELD score 7) 17

Case 1 Chest CT

Case 1 Bone scan

Case 1 Gastroscopy

Korean Liver Cancer Study Group

TNM - AJCC Stage I T1 N0 M0 55% 5 yr survival Stage II T2 Stage IIIA T3 16% 5 yr survival IIIB T4 IIIC Any T N1 Stage IV Any N M1 T definitions T1 – solitary nodule without vascular invasion T2 – solitary tumor with vascular invasion or multiple nodules all <5cm T3 – multinodular >5cm, or tumor with major vasculature invasion T4 – Tumor with invasion of adjacent organs N1 Regional lymph node metastasis / M1 Distant metastasis The American Joint Committee on Cancer (AJCC) TNM staging system (identical to that of the Union Internationale Contre le Cancer [UICC]), was revised and simplified in 2002 (show table 1) [10]. This system recognizes the most important predictors of prognosis: presence of vascular invasion within the tumor [11,12], and firosis in the underlying liver [13-16]. Compared to the 1997 staging system, it recognizes that although tumor size and number may predict the presence of vascular invasion, solitary tumors as large as 5 cm without vascular invasion have the same prognosis as small (<2 cm) solitary tumors AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, Inc 22

Fig. 1. Barcelona Clinic Liver Cancer (BCLC) staging classification and treatment schedule. Stage 0, Patients with very early hepatocellular carcinoma (HCC) are optimal candidates for resection. Stage A, Patients with early HCC are candidates for radical therapies (resection, liver transplantation, or percutaneous treatments). Stage B, Patients with intermediate HCC may benefit from chemoembolization. Stage C, Patients with advanced HCC may receive new agents in the setting of randomized controlled trials (RCTs). Stage D, Patients with endstage disease will receive symptomatic treatment. PST, performance status test; CLT/LDLT, cadaveric liver transplantation/living-donor liver transplantation; PEI/RF, percutaneous ethanol injection/ radiofrequency thermal ablation; ttc, treatment; yr, year. Modified from Llovet et al.,4 with permission N1 Regional lymph node metastasis / M1 Distant metastasis 23

Case 1 TACE 시행

Case 1 6월 9일 op 전 liver CT

Case 1 6월 10일 Lt. segmentectomy

Final diagnosis Case 1 HCC stage I s/p TACE #1 s/p Lt. segmentectomy B-viral LC child A MELD score 7

Case Presentation Case 2 11952299 39/M 유 O 복 Adm.2008.2.27 C.C. RUQ pain onset) 내원 한달 전 P.I. 과거 medical history 없는 환자로 한달 전 RUQ pain있었으나 특별한 치료없이 저절로 호전됨. 최근 4일 전 트럭에서 낙상 후 상기 증세 재발되어 외부병원 방문. 시행한 복부 CT 에서 liver mass 발견되어 본원 방문 30

PMHx. Case 2 DM/HTN/Tuberculosis/Hepatitis (-/-/-/-) Op Hx (-) Drug Hx : (-) Alcohol (+) : 소주 ½병 /d X 10년 smoking (+) : 7pack/year X 14년 FHx : 어머니, 여동생이 HCC로 사망 31

Review of Systems Case 2 G/A) fatigue (-) weight change (-) fever (-) chill (-) sweating (-) Skin) pigmentation (-) rash (-) itching (-) H& N) headache (-) trauma (-) stiffness (-) Eye/ ENT) diplopia (-) hearing loss(-) nasal obstruction (-) dryness(-) soreness(-) hoarseness(-) Respiratory) cough (-) sputum (-) dyspnea(-) hemoptysis(-) 32

Case 2 Cardiac) palpitation (-) dyspnea(-) chest pain (-) orthopnea(-) G-I) A/N/V/D/C(-/-/-/-/-) abd pain (+) : RUQ jaundice (-) melena (-) Renal & Urinary) dysuria (-) hematuria (-) polyuria (-) incontinence (-) nocturia (-) anuria(-) 33

Physical Examination Case 2 Alert consciousness Vital sign) 130/80mmHg – 64회/분 – 20회/분 – 36.5℃ Height : 178.7cm weight: 72.3Kg General appearance Alert consciousness Acute ill-looking appearance Skin Rash (-) Pigmentation (-) Head and Neck Neck LN enlargement (-/-) Neck vein engorgement (-/-) Thyroid enlargement (-) Eyes and ENT Isocoric pupil with PLR(++/++) Whitish sclera, Pinkish conjunctiva 34

Case 2 Clear breathing sound without wheezing Chest Clear breathing sound without wheezing Regular heart beat without murmur Abdomen Soft and flat abdomen Abdominal tenderness No rebound tenderness No palpable abdominal mass Normoactive bowel sound No hepatosplenomegaly Back and extremities CVA tenderness(-/-) Peripheral pitting edema(-/-) 35

Initial lab findings Case 2 PT CBC/DC 5280/mm3 – 14.3 g/dL – 43.1% - 178k (seg : 51.4 %) INR:1.01 PT Chemistry TB/DB 0.8/0.2mg/dL AST/ALT 62/50 IU/L ALP/GGT 87/88 IU/L Glucose 94mg/dL BUN/Cr 8/0.8 mg/dL Prot/Alb 7.1/3.8 g/dL Na/K/Cl 134/3.4/102 mmol/L Ca/Mg/P 8.1/2.9/4.5 mg/dL T-Chol 135mg/dl CRP 1.8 mg/dL Urinalysis Microscopy : WBC 0-1/HPF RBC 0-1/HPF Protein(-) Occult blood(-) Nitrate(-) 36

Case 2 Initial chest PA 37 37

Case 2 Initial ECG 38 38

Case 2 Initial problem list RUQ pain due to liver mass? 39

Initial assessment & plan Case 2 Initial assessment & plan A) RUQ pain due to liver mass P) abdominal CT abdominal sono tumor marker (esp. AFP, PIVKAII) 40 40

Case 2 HBs Ag(+) Anti-HBc Ab (+) anti-HBs Ab (-) HBe Ag(+-) HBeAb (-) Anti –HCV Ab (-) anti-HIV (-) AFB 20894 ng/ml CEA 1.04 ng/ml ICGR 15 : 19% 41

Case 2 2월 27일 Liver CT

Case 2 Initial diagnosis HCC with portal vein thrombus 44

Korean Liver Cancer Study Group

TNM - AJCC Stage I T1 N0 M0 55% 5 yr survival Stage II T2 Stage IIIA T3 16% 5 yr survival IIIB T4 IIIC Any T N1 Stage IV Any N M1 T definitions T1 – solitary nodule without vascular invasion T2 – solitary tumor with vascular invasion or multiple nodules all <5cm T3 – multinodular >5cm, or tumor with major vasculature invasion T4 – Tumor with invasion of adjacent organs N1 Regional lymph node metastasis / M1 Distant metastasis The American Joint Committee on Cancer (AJCC) TNM staging system (identical to that of the Union Internationale Contre le Cancer [UICC]), was revised and simplified in 2002 (show table 1) [10]. This system recognizes the most important predictors of prognosis: presence of vascular invasion within the tumor [11,12], and firosis in the underlying liver [13-16]. Compared to the 1997 staging system, it recognizes that although tumor size and number may predict the presence of vascular invasion, solitary tumors as large as 5 cm without vascular invasion have the same prognosis as small (<2 cm) solitary tumors AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, Inc 46

Fig. 1. Barcelona Clinic Liver Cancer (BCLC) staging classification and treatment schedule. Stage 0, Patients with very early hepatocellular carcinoma (HCC) are optimal candidates for resection. Stage A, Patients with early HCC are candidates for radical therapies (resection, liver transplantation, or percutaneous treatments). Stage B, Patients with intermediate HCC may benefit from chemoembolization. Stage C, Patients with advanced HCC may receive new agents in the setting of randomized controlled trials (RCTs). Stage D, Patients with endstage disease will receive symptomatic treatment. PST, performance status test; CLT/LDLT, cadaveric liver transplantation/living-donor liver transplantation; PEI/RF, percutaneous ethanol injection/ radiofrequency thermal ablation; ttc, treatment; yr, year. Modified from Llovet et al.,4 with permission N1 Regional lymph node metastasis / M1 Distant metastasis 47

Case 2 2월 29일 TACE 시행

Case 2 3월 3일 PET-CT 시행

Case 2

Case 2 3월 15일 입원 : Rt. portal vein embolization 위해 입원 portal vein thrombosis 심해 시행하지 못함

Case 2

Case 2 2008년 3월 25일 : Rt. lobectomy & caudate lobectomy

Case 2 55

Case 2 56

Case 2 57

Post op. Case 2 GS에서 복용 5-FU(Cotacil 100mg, Uracil 224mg) 2T tid 상황균사체(mezai 500mg) 2T tid

Case 2 4월 30일 GI 외래 방문 HBV PCR : positive 115,000ul/ml 604,900 copies/ml Entecavir 0.5mg qd 복용중 5월 28일 부터 5-FU, 상황균사체 복용 중지

Case 2 Follow up liver CT (6/5)

Case 2

Final diagnosis Case 2 HCC stage IV s/p TACE#1 s/p Rt. lobectomy & caudate lobectomy 2. B-viral LC child A 62