Liver Cancer Conference 2013.04.05 Liver Cancer Conference 소화기 센터 회의실

History Case 1 2010년 Alcoholic LC 12120004 이O강 M/65 2010년 Alcoholic LC HCC at Rt segment - > 2010.6.22 RFA #1 Recurrent HCC at S7 -> 2011.8.2 TACE #1 Recurrent HCC at S7 -> 2011.10.26 TACE #2 Recurrent HCC at S7 -> 2012.11.13 TACE #3 Recurrent HCC at S7 -> 2013.1.29 TACE #4 2013.3.28 Liver MR : recurred HCC at S7, probably HCC at S4 토의 목적: 향후 치료 방향 논의 DM/HTN/TBc/Hepatitis(+/+/-/+), Parkinsonism , Alzheimer disease Op Hx (+) 2005’ C-HIVD OP Alcohol Hx (+), Smoking Hx (-) : 25갑년 .

Underlying liver function and performance status Case 1 12120004 이O강 M/65 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A (5) MELD score 0.74 Esophageal varices - Ascites Encephalopathy CBC/DC WBC (mm3) 4010 Hb (g/dl) 14.8 PLT 141k PT (sec) 12.7 INR 0.96 Chemistry TB/DB (mg/dL) 1.36/0.6 AST/ALT (IU/L) 84/20 ALP/rGT 120/- Prot/Alb (g/dL) 7.9/4.4 BUN/Cr 23/1.1 Viral markers/ underlying liver disease HBV / HCV (-/-) HBeAg / HBeAb Virus titer 0 IU/mL Antiviral Tx (-) Alcohol Tumor markers AFP (ng/mL) 15.50 CEA (ng/mL) 4.27 PIVKA II (mAU/mL) 88 CA19-9 -

Tumor Stage and Clinical Course Case 1 10259334 조O복 F/57 Tumor Stage and Clinical Course 12120004 이O강 M/65 10.06 11.08 11.10 12.11 13.01 13.03 Alcoholic LC HCC Rt seg HCC S7 HCC S7 HCC S7 HCC S7 HCC S7,S4 TACE #1 (2011.8.2) TACE #2 (2011.10.26) TACE #3 (2012.11.13) TACE #4 (2013.1.29) RFA #1 (2010.6.22) 10년06월 11년03월 11년10월 12년10월 13년01월 13년 3월 AFP 5.48 4.63 5.13 6.50 9.55 15.5 PIVKA Ⅱ 36 4 2 - 54 88 Liver MRI (2013.03.28): Increased size of maginal recurred HCC near the RFA-associated necrosis at S7. Probably HCC at S4, however less than 1cm in diameter.

Tumor Stage and Clinical Course Case 1 10259334 조O복 F/57 Tumor Stage and Clinical Course 12120004 이O강 M/65 2001 11.02 11.08 11.11 13.03 B-viral LC HCC S 6/7,8 recurrent HCC Liver abscess Rt.paraspinal mass TACE #1 (2011.3.18) RFA#1 (2011.9.8) 11년11월 12년03월 12년06월 12년09월 12년12월 13년 3월 AFP 7.73 10.02 8.28 8.18 5.84 6.63 PIVKA Ⅱ 24 20 53 - PET (2013.01.22) 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 *Liver –TACE CT (2013.3.20) : 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

Summary – 치료 방침 결정 Case 1 Tumor stage Date: BCLC Current status 12120004 이O강 M/65 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 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) Y 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

History Case 2 1997년 B-viral LC (전남대 병원) 12121743 김O곤 M/62 1997년 B-viral LC (전남대 병원) 2010.6 Esophageal varix (Cb, F3, Ls, RC(++)) EVL #1 2012.2.9 HCC at Rt post. seg- > TACE #1 (2012.2.28) 2012.11.2 HCC at S7(1.2.cm), S6/7(3.4.cm) -> TACE #2 (2012.12.4) 2013.3.8 Liver CT : vialbe HCC at S6/7 토의 목적: 향후 치료 방향 논의 DM/HTN/TBc/Hepatitis(-/-/-/+) B-viral LC : Entecavir 0.5mg 복용중 (2010.6~) Op Hx (-) : Alcohol Hx (-) :10년전 금주 , Smoking Hx (+) ex smoker : 30갑년

Underlying liver function and performance status Case 2 12121743 김O곤 M/62 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A (5) MELD score 7.20 Esophageal varices EV Cb, F2, RC (-) GV Cb, F1,RC(-) Ascites - Encephalopathy CBC/DC WBC (mm3) 2140 Hb (g/dl) 12.3 PLT 46k PT (sec) 16.1 INR 1.31 Chemistry TB/DB (mg/dL) 0.76/- AST/ALT (IU/L) 29/20 ALP/rGT 89/105 Prot/Alb (g/dL) 8.1/4.5 BUN/Cr 15/0.8 Viral markers/ underlying liver disease HBV / HCV (+/-) HBeAg / HBeAb (-/+) Virus titer <20 IU/mL Antiviral Tx Entecavir 0.5mg Alcohol (+) Tumor markers AFP (ng/mL) 2.99 CEA (ng/mL) - PIVKA II (mAU/mL) 70 CA19-9

Tumor Stage and Clinical Course Case 2 Tumor Stage and Clinical Course 12121743 김O곤 M/62 97 10.06 12.02 12.12 13.3. B-viral LC Esophageal varix EVL#1 x12 HCC At Rt,post HCC At S7, S6/7 Liver CT vialbe HCC at S6/7 TACE #1 (2012.2.28) TACE #2 (2012.12.4) 10년06월 11년08월 12년02월 12년09월 12년12월 13년 3월 AFP 443 10.84 4.48 3.51 8.18 2.78 2.99 PIVKA Ⅱ 20 - 38 70 *Liver CT (2013.03.08) : Lipiodol uptaken HCC at S7. Increased size and remaining viable portion within HCC at S6/7. Underlying liver cirrhosis with splenomegaly. A GB stone, and both renal cysts..

Summary – 치료 방침 결정 Case 2 Tumor stage Date: BCLC Current status 12121743 김O곤 M/62 Tumor stage Date: Modified UICC (대한간암연구학회) T 3, N 0, M 0 Stage: III JIS score 2 BCLC Very early/Early/ Intermediate / Advanced Current status Locally advanced with Well preserved 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) Y 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

History Case 3 10년 전 hepatitis B virus carrier 진단 12321302 천O현 M/46 10년 전 hepatitis B virus carrier 진단 2013.01.20 Liver CT malignant mass of S4 liver with both IHD dilatation. 2013.01.22 PET CT : Malignant tumor in liver, S4. No distant metastatic lesion 2013.01.23 Liver MR : Malignant hepatic mass in segment 4 with tumor thrombosis. tumor growing within the both IHD and CHD. 2013.01.24 Sono guided bx : Hepatocellular carcinoma 2013.01.25 ERCP : EST, Stent insertion, both IHD 2013.02.04 TACE #1 at Lt lobe 2013.02.18, 20 PDT 시행 2013.3.29 GB & biliary CT, 2013.04.02 Liver MR :Aggravation of bile duct invasion of malignant hepatic tumor. 토의 목적: 향후 치료 방향 토의 DM/HTN/TBc/Hepatitis(-/-/-/+) HBV carrier Op Hx (-) Alcohol Hx (+) 소주 1~2병 /주 2회 Smoking Hx (+) 10년전 금연. 20갑년

Underlying liver function and performance status Case 3 12321302 천O현 M/46 12321302 천O현 M/46 Underlying liver function and performance status Performance status: Grade 0 Viral markers Anti-HCV Ab (-) HBsAg/HBeAg /anti –HBe Ab +/-/+ Anti-HBs Ab/Anti-HBcAb HBV Rt-PCR titer (-)/(+) 149 IU/mL 867copies/mL Anti-HIV Ab CBC/DC WBC (mm3) 4100 Hb (g/dl) 10.3 PLT 377k PT (sec) 13.6 INR 1.05 Chemistry TB/DB (mg/dL) 0.98/0.77 AST/ALT (IU/L) 73/58 ALP/rGT 568/481 Amylase 77 Lipase 48 CRP 12.04 Prot/Alb (g/dL) 6.3/3.1 BUN/Cr 5/0.6 Tumor markers CEA (ng/mL) 2.19 AFP (U/mL) 54.55 <- 24.89 CA 19-9 (U/mL) 268.7 <- 1750 Biopsy (Sono guided . 1/24) Hepatocellular carcinoma Hep-par1 (+), CK7 (-), CK20 (-) Masson's Trichrome (+), Reticulum (+)

Hep-par1 (+) Immunohistochemical finding: Hep-par1 (+), CK7 (-), CK20 (-)

CK7 (-) CK 7

CK20 (-) CK 20

Tumor Stage and Clinical Course Case 3 12321302 천O현 M/46 12321302 천O현 M/46 Tumor Stage and Clinical Course 2013.01.20 2013.01.21 2013.01.22 2013.01.23 2013.01.24 Liver CT GB & Bile duct sono PET CT Liver MR Sono guided Bx : HCC 2013.01.25 2013.02 2013.3.29 2013.04.02 ERCP : Both IHD Stent insertion TACE #1 Cholangitis PTBD (13.4.1) Liver MR PDT PET (2013.01.22) c/w Malignant tumor in liver, S4. (max SUV : 6.9) No abnormal hypermetabolic lesion suggesting distant metastasis. Liver MRI (2013.04.02): Aggravation of bile duct invasion of malignant hepatic tumor. - biliary stent insertion in both IHD and CHD with nearly total obstruction of left IHD stent due to tumor ingrowth. Mild aggravation of LNs metastases.

Summary – 치료 방침 결정 Case 3 Tumor stage Date: BCLC Current status 12321302 천O현 M/46 Tumor stage Date: Modified UICC (대한간암연구학회) T 4, N 1, M 0 Stage: IVA BCLC Very early/Early/ Intermediate / Advanced Current status advanced with high-risk for recurrence 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 >3 Repeated TACE ( 회/기간) 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