Liver Transplantation Conference 2016.03.08 Liver Transplantation Conference 경희대학교 병원 간이식팀 R3 최태웅/Prof. 김병호

Case 1 History 12371927 이 O 수 M/56 56/M. Alcoholic LC(Child C(11), MELD 25) c esophageal varix, c hepatic encephalopathy(grade 2)로 본원 IG(pf.김병호) f/u 중 최근 들어 flapping tremor 지속되며 hepatic encephalopathy 호전 없고 decompensated LC 상태로 LT 필요성에 대해 상의하기 위해 선정함. DM (-), HTN (-) Op Hx (-) Alcohol Hx (-) Smoking Hx (-) : ex-smoker 40 PY

Underlying liver function and performance status Case 1 12371927 이 O 수 M/56 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh C (11) MELD score 25 Esophageal varices + Ascites - Encephalopathy CBC/DC (‘15.11.23) WBC (mm3) 5,780 Hb (g/dl) 10.2 PLT 71,000 PT (sec) 23.5 INR 2.12 Chemistry(‘15.11.23) TB/DB (mg/dL) 4.37/- AST/ALT (IU/L) 46/25 ALP/rGT 249/16 Prot/Alb (g/dL) 6.1/2.9 BUN/Cr -/- Viral markers/ underlying liver disease HBV / HCV (-/-) HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol Tumor markers (‘15.11) AFP (ng/mL) 1.95 CEA (ng/mL) 5.71 PIVKA II (mAU/mL) - CA19-9 (U/mL) 2.00

Kayser-Fleischer ring(-) Case 1 10259334 조O복 F/57 Clinical Course 12371927 이 O 수 M/56 ‘13 ’14 ’16 jaundice → Alcoholic- LC진단 Celuloplasmin 14 Serum Cu 66.4 Urine Cu 357.9 → r/o Wilson Kayser-Fleischer ring(-) ATP7B : no mutation Hepatic Encephalopathy(Gr2) Liver CT(2016.02.04) Liver cirrhosis with splenomegaly. a/w gastroesophageal varix and gastrorenal shunt. Diverticulosis at proximal A-colon. Non-visible small cystic lesion at pancreas tail on this exam. No change of 2 GB stones and several both renal cyst. Segmental atelectasis and focal emphysematous change in RML

Case 2 History 12282619 김 O 임 F/55 55/F. DM, HTN Hx 있으며 C-viral LC(Child B(8), MELD 12) c esophageal varix s/p EVL #2(2014.07) c ascites, HCC (mUICC stage I, T1N0M0) s/p TACE #1 (2014.01) Hx 있고 2014년 03월 acute cholecystitis로 PTGBD insertion 후 op risk 높아 수술은 거부하고 항생제 치료만 시행 후 호전되어 본원 IG(Pf.김병호) 외래 f/u 중인 자로 최근 ascite 증가하고 pancytopenia 호전 없는 상태로 LT 가능성에 대해 상의하기 위해 선정함 DM (-), HTN (-) Op Hx (-) Alcohol Hx (-) , Smoking Hx (-)

Underlying liver function and performance status Case 2 12282619 김 O 임 F/55 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh B (8) MELD score 12 Esophageal varices + Ascites Encephalopathy - CBC/DC (’16.02.25) WBC (mm3) 1,830 Hb (g/dl) 8.5 PLT 47,000 PT (sec) 48.0 INR 1.53 Chemistry(‘16.02.25) TB/DB (mg/dL) 1.71/0.73 AST/ALT (IU/L) 40/14 ALP/rGT 74/50 Prot/Alb (g/dL) 6.2/3.0 BUN/Cr 8/0.4 Viral markers/ underlying liver disease HBV / HCV (-/+) HBeAg / HBeAb (-/-) Virus titer - Antiviral Tx Alcohol Tumor markers (‘16.01) AFP (ng/mL) 3.57 CEA (ng/mL) 1.75 PIVKA II (mAU/mL) 16 CA19-9 (U/mL) 34.43

Clinical Course Case 2 ’12 ‘14.01 ’14.03 ’14.07 ‘16.02 10259334 조O복 F/57 Clinical Course 12282619 김 O 임 F/55 ’12 ‘14.01 ’14.03 ’14.07 ‘16.02 LFT abnormality, Esophageal varix → C-viral LC 진단, EVL #1 시행 Liver MR 상 HCC at S4 → TACE #1 시행 Acute cholecystits → PTGBD 삽입, 수술 거부함 Esophageal varix → prophylactic EVL #2 Chronic cholecystitis → 항생제 치료 GB & billiary CT(2016.02.19) No demonstrable HCC on CT. However, possibility of HCC cannot be excluded. Equivocal changes, as follows; Liver cirrhosis with splenomegaly. GB stone. Subserosal edema of the gallbladder and portal hypertensive colonopathy involving right side colon. Large amount of ascites. S/P hysterectomy.

Summary Case 2 Initial Tumor stage Date: 2014년 1월 BCLC Current status 12282619 김 O 임 F/55 Initial Tumor stage Date: 2014년 1월 Modified UICC (대한간암연구학회) T 1 N 0 M 0 Stage I JIS score 1 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status HCC with decopmpensated 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(S4,S6) Repeated TACE ( 1회/기간) 1 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 Y Current liver function Normal Well preserved (no risk of decompensation) Compensated (risk of decompensation) Decompensated Terminal state

Case 3 History 12559450 송 O 기 M/58 58/M. 최근 fatigue, abd distension 있어 local 의원에서 DM, Alcoholic & C-viral LC(Child A(6), MELD 9) c ascites 진단받고 further evaluation 위해 본원 IG(Pf.심재준) 입원 중인 자로 Liver MR 상 multiple scirrhous type HCC or combined HCC/CC in S7/6소견 보여 LT 가능성에 대해 상의하기 위해 선정함 DM (+), HTN (-) Op Hx (-) Alcohol Hx (-) : 3개원 전 금주(매일 소주1병, 맥주2병) Smoking Hx (-) : 20PY

Underlying liver function and performance status Case 3 12559450 송 O 기 M/58 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A (6) MELD score 9 Esophageal varices + Ascites Encephalopathy - CBC/DC (’16.03.07) WBC (mm3) 7,520 Hb (g/dl) 11.6 PLT 184,000 PT (sec) 14.9 INR 1.20 Chemistry(‘16.03.07) TB/DB (mg/dL) 0.79/0.40 AST/ALT (IU/L) 46/31 ALP/rGT 86/80 Prot/Alb (g/dL) 6.1/2.8 BUN/Cr 22/1.0 Viral markers/ underlying liver disease HBV / HCV (-/+) HBeAg / HBeAb (-/-) Virus titer 402,000 IU/mL Antiviral Tx - Alcohol Tumor markers (‘16.03) AFP (ng/mL) 4.90 CEA (ng/mL) 4.92 PIVKA II (mAU/mL) 16 CA19-9 (U/mL) 2.00

Fatigue, abd distension → Alcoholic & C-viral LC 진단 Case 3 10259334 조O복 F/57 Clinical Course 12559450 송 O 기 M/58 ‘16.2 Fatigue, abd distension → Alcoholic & C-viral LC 진단 Liver MR(2016.03.02) Suggestive of multiple scirrhous type HCC or combined HCC/CC in S7/6. - a/w small daugther nodule and multiple retroperitoneal metastatic LAP. - R/O cholangiocarcinoma. - less possibility of multiple hepatic metastases from other primary organs. Underlying liver cirrhosis with portal hypertension and considerable amount of ascites. Probably small RN or DN in S8.

Case 4 History 12234781 김 O 도 M/65 65/M. DM, HTN 있으며 B-viral LC(Child B(9), MELD 12) c esophageal varix s/p EVL #3(2013), HCC(mUICC stage 3, T3N0M0, JIS score 2) s/p TACE #3(2014)로 본원 IG(Pf.심재준) 외래 f/u 중인 자로 복수 조절 안되며 Liver MR 상 newly HCC lesion 있어 LT 가능성에 대해 상의하기 위해 선정함 DM (+), HTN (+) Op Hx (-) Alcohol Hx (-) Smoking Hx (-)

Underlying liver function and performance status Case 4 12234781 김 O 도 M/65 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh B (9) MELD score 12 Esophageal varices + Ascites Encephalopathy - CBC/DC (’16.01.18) WBC (mm3) 4,020 Hb (g/dl) 15.4 PLT 73,000 PT (sec) 14.9 INR 1.17 Chemistry(‘16.02.22) TB/DB (mg/dL) 3.07/- AST/ALT (IU/L) 67/44 ALP/rGT 244/167 Prot/Alb (g/dL) 8.7/3.7 BUN/Cr 10/0.8 Viral markers/ underlying liver disease HBV / HCV (+/-) HBeAg / HBeAb (-/+) Virus titer 402,000 IU/mL Antiviral Tx - Alcohol Tumor markers (‘16.02) AFP (ng/mL) 8.80 CEA (ng/mL) - PIVKA II (mAU/mL) 33 CA19-9 (U/mL)

Clinical Course Case 4 ’05 ’12 ’13.01 ’14 ‘16 Liver MRI(2016.02.22) 10259334 조O복 F/57 Clinical Course 12234781 김 O 도 M/65 ’05 ’12 ’13.01 ’14 ‘16 B-viral LC 진단 EVL #2(‘12.07~’12.10) Liver MRI 상 HCC at S7,8 → TACE #1, EVL #3 Liver MRI 상 S7 lesion → TACE #3 Liver MRI → new HCC at Lt lat seg Liver MRI(2016.02.22) Suggested a new HCC at left lateral segment. No evidence of viable tumor at partial lipiodolized mass at S7. Equivocal change of multiple FNH like nodules. Equivocal change of bland thrombosis at the umbilical segment of left PV, main PV and SMV. Underlying liver cirrhosis with splenomegaly and ascites.

Summary Case 4 Initial Tumor stage Date: 2016년 2월 BCLC Current status 12234781 김 O 도 M/65 Initial Tumor stage Date: 2016년 2월 Modified UICC (대한간암연구학회) T 3 N 0 M 0 Stage III JIS score 3 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status HCC with decopmpensated 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) 3 Vascular or bile duct invasion High uptake of PET High AFP or PIVKA II Y 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

Case 5 History 10961140 김 O 현 M/74 74/M. C-viral LC(Child C(11), MELD 23) c esophageal varix s/p EVL #4(2016), HCC(mUICC stage 3, T3N0M0) s/p TACE #5로 본원 IG(Pf.심재준) 외래 f/u 중인 자로 최근 ascites 조절 안되고 tumor marker 상승하며 Liver MR 상 기존 병변 크기 증가 있어 LT 가능성에 대해 상의하기 위해 선정함 DM (-), HTN (-) Op Hx (-) Alcohol Hx (-) Smoking Hx (-)

Underlying liver function and performance status Case 5 10961140 김 O 현 M/74 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh C (11) MELD score 23 Esophageal varices + Ascites Encephalopathy - CBC/DC (’16.03.06) WBC (mm3) 3,520 Hb (g/dl) 8.3 PLT 64,000 PT (sec) 19.6 INR 1.70 Chemistry(‘16.03.06) TB/DB (mg/dL) 3.49/2.63 AST/ALT (IU/L) 48/23 ALP/rGT 89/33 Prot/Alb (g/dL) 6.2/3.0 BUN/Cr 48/1.4 Viral markers/ underlying liver disease HBV / HCV (-/+) HBeAg / HBeAb (-/-) Virus titer - Antiviral Tx Alcohol Tumor markers (‘16.03) AFP (ng/mL) 25983 CEA (ng/mL) 3.82 PIVKA II (mAU/mL) 86 CA19-9 (U/mL) 30.62

Clinical Course Case 5 ’99 ’02 ’16.01 ’16.03 Liver MRI(2016.03.04) 10259334 조O복 F/57 Clinical Course 10961140 김 O 현 M/74 ’99 ’02 ’16.01 ’16.03 C-viral LC, HCC 진단 TACE #5 EVL #4 Uncontrolled ascites, Liver MRI 상 size 증가 ’13 ’15.10 ’16.03 AFP 4.17 916.7 25983 PIVKA II 21 86 5369 Liver MRI(2016.03.04) Increased size of viable HCC at anterior aspect to lipiodolized HCC (2.8cm)--> 6.4cm. Slightly increased size of suggested viable HCC at posteroinferior aspect to lipiodolized HCC. Increased at size of cyst in right lobe. No change of liver cirrhosis with large amount of ascites. Aggravation of bland thrombosis in main portal vein and SMV.

Summary Case 5 Initial Tumor stage Date: 2016년 2월 BCLC Current status 10961140 김 O 현 M/74 Initial Tumor stage Date: 2016년 2월 Modified UICC (대한간암연구학회) T 3 N 0 M 0 Stage III JIS score 4 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status HCC with decopmpensated 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 Y Tumor number 2 Repeated TACE ( 1회/기간) 5 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

Case 6 History 11276242 강 O 자 F/74 74/M. Old CVA, HTN Hx 있는 자로 2012년 한약 복용 후 toxic hepatitis imp으로 입원력(Pf.동석호) 있는 자로 2015년 12월 부터 LFT 상승 보여 autoimmune hepatitis(score 10)에 의한 LC(Child B(8), MELD 19) 진행 소견으로 외래 통해 입원하여 steroid therapy (16/2/11~2/13)도중 fever 발생하며 r/o SBP, r/o urosepsis imp 하에 항생제 치료 후 호전되어 3/4 부터 다시 steroid 시작하였으며 증상 호전되어 금일 퇴원한 자로 LT 가능성에 대해 상의하기 위해 선정함 DM (-), HTN (+) Op Hx (-) Alcohol Hx (-) Smoking Hx (-)

Underlying liver function and performance status Case 6 11276242 강 O 자 F/74 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh B (8) MELD score 19 Esophageal varices - Ascites Encephalopathy CBC/DC (’16.03.07) WBC (mm3) 4,300 Hb (g/dl) 10.6 PLT 83,000 PT (sec) 15.8 INR 1.29 Chemistry(‘16.03.07) TB/DB (mg/dL) 3.92/3.34 AST/ALT (IU/L) 75/61 ALP/rGT 140/102 Prot/Alb (g/dL) 6.8/2.9 BUN/Cr 33/0.8 Viral markers/ underlying liver disease HBV / HCV (-/-) HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol Tumor markers (‘16.02) AFP (ng/mL) 694.0 CEA (ng/mL) 2.42 PIVKA II (mAU/mL) - CA19-9 (U/mL) 15.06

Clinical Course Case 6 ’12 ’15.12 ’16.02 ’16.02 ’16.03 10259334 조O복 F/57 Clinical Course 11276242 강 O 자 F/74 ’12 ’15.12 ’16.02 ’16.02 ’16.03 Toxic hepatitis LFT 상승 LC c autoimmune hepatitis Steroid therapy 2/11~2/13 r/o SBP, r/o urosepsis → antibiotics(2/13~2/27) Steroid therapy 재시작 : 3/4~ GB & billiary CT(2016.02.01) No evidence of abnormal focal lesion in liver. Suggestive of liver cirrhosis. Hepatic cysts. Contracted GB. BK cysts.

Thank you for listening