1. 경희대학교병원 간암 다학제증례집담회 Multidisciplinary case conference Liver Cancer Conference 소화기 센터 회의실 2013.9.27

2. History Case 1 12296878 조 O 배 M/39 DM (-), HTN (+) : 2 년 전부터 po medication 중 HBs Ag (-), Anti HBs Ab (+), Anti-HCV Ab (-) Op Hx (-) Alcohol Hx (+) : 주 2 회, 소주 1-2 병, Smoking Hx (+) : 10 pack years  2012 년 2 월 Abd CT ( 타병원 ) : hemangioma (S7, 9cm)  2012 년 8 월 Abd sono ( 타병원, report only) : nodule (S7, 2cm)  2012.09.03 Liver CT : Hemangioma (S6/7, S7, S2)  2013.07.31 Liver CT : Increased hemangioma (S7, 10.5cm)  토의 목적 : 향후 f/u 에 대한 논의

3. Underlying liver function and performance status CBC/DC WBC(mm 3 )5,270 Hb(g/dl)15.2 PLT(mm 3 )374,000 PT(sec)13.2 INR1.00 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.11/- AST/ALT(IU/L)19/19 ALP/rGT(IU/L)51/35 Prot/Alb(g/dL)7.2/4.4 BUN/Cr(mg/dL)13/0.7 12296878 조 O 배 M/39 Case 1 Tumor markers AFP (ng/mL)2.74 CA19-9 (U/mL) 4.09 Viral markers/ underlying liver disease HBV / HCV(-/-) Alcohol+

4. ’12.02 ’12.09 ‘13.07. 10259334 조 O 복 F/57 Hemangioma Case 1 Clinical Course 12296878 조 O 배 M/39 Liver CT (2013.7.31) Several hepatic hemangiomas at both lobes. Increased size of right hepatic hemangioma. LK cysts. 12 년 09 월 AFP 2.74 CA 19-9 4.09 3 hemangiomas Increased size 8.6 -> 10.5 Increased size 8.6 -> 10.5

5. History Case 2 12058604 고 O 숙 F/56 DM (-), HTN (-) HBs Ag (-), Anti HBs Ab (-), Anti-HCV Ab (-) Op Hx (+) : 2009 년 Cecal ca.  Rt hemicolectomy Alcohol Hx : social, Smoking Hx : ex-smoker  2009 년 Cecal cancer  Rt hemicolectomy (’09.07.21)  2012.06.08 EGD : Esophageal varix  2013.03.25 Abd US : r/o hepatic mass at left lobe of liver  2013.09.09 Liver MR : r/o focal nodular hyperplasia  토의 목적 : 영상 소견 review

6. Underlying liver function and performance status CBC/DC WBC(mm 3 )5,630 Hb(g/dl)12.6 PLT(mm 3 )123,000 PT(sec)13.7 INR1.04 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.80/- AST/ALT(IU/L)31/34 ALP/rGT(IU/L)96/135 Prot/Alb(g/dL)7.3/4.2 BUN/Cr(mg/dL)8/0.6 LC & Stage Child-Pugh MELD score Esophageal varices[Cb F1 Li RC(-)] Ascites Encephalopathy 12058604 고 O 숙 F/56 Case 2 Tumor markers AFP (ng/mL)4.35 CEA (ng/mL) 2.22 CA19-9 (U/mL) 1.68 Viral markers/ underlying liver disease HBV / HCV(-/-) Alcoholsocial

7. ’09.07 ’12.06 ’13.03 ‘13.09. 10259334 조 O 복 F/57 Cecal ca. Cecal ca. Case 2 Tumor Stage and Clinical Course 12058604 고 O 숙 F/56 Liver MR (2013.09.09) R/O focal nodular hyperplasia at caudate lobe. Splenomegaly. PET-CT (2011.08.11) No abnormal hypermetabolic lesion suggesting recurrence or metastasis 13 년 09 월 AFP4.35 CEA2.22 Esophageal varix Liver MR : r/o focal nodular hyperplasia Liver MR : r/o focal nodular hyperplasia Rt hemicolectomy Rt hemicolectomy Abd US : r/o hepatic mass Abd US : r/o hepatic mass

8. History Case 3 10738671 박 O 문 M/72 DM (+): levemir 20u + novorapid 8u x 3, HbA1c =8.0%, HTN (+) : atenolol Alcoholic LC (Child B(7) MELD 7) with ascites Op Hx (+) : 2013. 06. 04. Lap cholecystectomy (‘13.06.04) Alcohol Hx (+) : 주 7 회, 소주 2 병, Smoking Hx (+) : 20 pack years  2012 년 Alcoholic LC 진단  2013.04.15 Liver CT : GB cancer (pT2N0M0, stage II)  Laparoscopic cholecystectomy c LN dissection (‘13.06.04)  2013.09.11 Liver CT : Large amount of ascites with omental haziness  토의 목적 : 영상 소견 review

9. Underlying liver function and performance status CBC/DC WBC(mm 3 )6,790 Hb(g/dl)14.5 PLT(mm 3 )110,000 PT(sec)12.8 INR0.98 Performance status: Grade 1 Chemistry TB/DB(mg/dL)1.07/- AST/ALT(IU/L)26/5 ALP/rGT(IU/L)58/75 Prot/Alb(g/dL)7.0/4.1 BUN/Cr(mg/dL)10/0.6 LC & Stage Child-PughB (8) MELD score7 Esophageal varices- AscitesPoorly controlled Encephalopathy- 10738671 박 O 문 M/72 Case 2 Tumor markers AFP (ng/mL)13.02 CEA (ng/mL) 1.73 CA19-9 (U/mL) 4.68 Viral markers/ underlying liver disease HBV / HCV(-/-) Alcohol+

10. ’12.06 ’13.04 ~ ’13.06 ‘13.09. 10259334 조 O 복 F/57 Alcoholic LC Alcoholic LC Case 3 Clinical Course 10738671 박 O 문 M/72 Liver CT (2013.9.11) S/P cholcystectomy. Large amount of ascites with omental haziness. --> Suggestive of LC-related reactive change. R/O peritoneal carcinomatosis. Liver cirrhosis with atrophy. PET-CT (2013.05.15) No abnormal hypermetabolic lesion suggesting metastasis. 13 년 04 월 13 년 05 월 13 년 09 월 AFP13.02-- CA 19-9-2.004.68 GB cancer Lap. cholecystectomy Lap. cholecystectomy Liver CT : ascites Liver CT : ascites

11. History Case 4 12334933 한 O 덕 70/M DM (-), HTN (+) : amlodipine C-viral LC (Child A(5) MELD 7) Op Hx (-) Alcohol Hx (-), Smoking Hx : ex-smoker  2006 년경 C-viral LC, HCC 진단  Peg-interferon, RFA ( 타병원 )  2013.03.25 Liver CT : Low attenuated mass at S6, R/O RFA area  2013.09.06 Liver CT : Increased size of hepatic mass (Lt hepatic lobe)  2013.09.24 Liver MR : HCC (left lobe)  토의 목적 : 영상 소견 review 및 향후 치료 방침 결정

12. Underlying liver function and performance status CBC/DC WBC(mm 3 )2,810 Hb(g/dl)13.2 PLT(mm 3 )122,000 PT(sec)14.5 INR1.14 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.78/- AST/ALT(IU/L)118/94 ALP/rGT(IU/L)83/334 Prot/Alb(g/dL)7.8/4.0 BUN/Cr(mg/dL)18/0.9 LC & Stage Child-PughA (5) MELD score7 Esophageal varices- Ascites- Encephalopathy- 12334933 한 O 덕 70/M Case 4 Tumor markers AFP (ng/mL)12.14 CEA (ng/mL) - PIVKA II (mAU/mL)19 CA19-9 (U/mL) - Viral markers/ underlying liver disease HBV / HCV(-/+) Genotype2 Virus titerNot detected Antiviral TxPeg-interferon, ribavirin Alcohol-

13. 2006? ’13.03 ‘13.08. 10259334 조 O 복 F/57 C-viral LC, HCC C-viral LC, HCC Case 4 Tumor Stage and Clinical Course 12334933 한 O 덕 70/M Liver CT (2013.9.6) Increased size of hepatic mass in the left hepatic lobe. No change of low attenuated lesion at segment 6. Multiple both renal cysts. Underlying liver cirrhosis. 13 년 03 월 13 년 08 월 AFP18.9112.14 PIVKA II19- Transfer to KMC Liver CT : S6, r/o RFA area Liver CT : S6, r/o RFA area Liver CT : Increased hepatic mass Liver CT : Increased hepatic mass RFA

14. Summary – 치료 방침 결정 12334933 한 O 덕 70/M 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: 2013 년 03 월 Modified UICC ( 대한간암연구학회 ) T 1 N 0 M 0 Stage I JIS score 0 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Locally advanced HCC with compensated 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 ) 0 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 - ART score (Good Px 2.5) 0

15. History Case 5 11922160 박 O 환 M/53 DM (-), HTN (+) : olmesartan + amlodipine, propranolol, h/o stable angina B-viral LC (Child A(5) MELD 9) with esophageal varix Op Hx (-) Alcohol Hx (+) : 주 3 회, 소주 1.5 병, Smoking Hx (-)  2010 년 B-viral LC 진단  Entecavir 복용 중  2010.12.27 Abd CT : Dysplastic nodule (S4)  2013.08.26 Liver CT : New HCC (S5)  토의 목적 : 기간에 따른 영상 소견의 변화 review

16. Underlying liver function and performance status CBC/DC WBC(mm 3 )6,650 Hb(g/dl)16.8 PLT(mm 3 )101,000 PT(sec)13.0 INR1.00 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.77/- AST/ALT(IU/L)46/42 ALP/rGT(IU/L)105/507 Prot/Alb(g/dL)7.6/4.2 BUN/Cr(mg/dL)14/1.0 LC & Stage Child-PughA (5) MELD score9 Esophageal varices[Cb F2 Li RC(++)] Ascites- Encephalopathy- 11922160 박 O 환 M/53 Case 5 Tumor markers AFP (ng/mL)9.84 CEA (ng/mL) 2.82 PIVKA II (mAU/mL)- CA19-9 (U/mL) 3.74 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/-) Virus titer<20 IU/mL Antiviral TxEntecavir Alcohol+

17. ’10.12 ‘13.08. 10259334 조 O 복 F/57 B-viral LC B-viral LC Case 5 Clinical Course 11922160 박 O 환 M/53 Liver CT (2013.8.26) New HCC at S5. Equivocal change of dysplastic nodule at left medial segment of liver. Underlying liver cirrhosis with splenomegaly, mild coronary collateral with esophageal and paraesophageal varices. 10 년 12 월 11 년 05 월 12 년 01 월 12 년 07 월 13 년 08 월 AFP15.229.437.67.329.84 PIVKA II----- Liver CT : New HCC (S5) Liver CT : New HCC (S5) Abd CT : Dysplastic nodule (S4) Abd CT : Dysplastic nodule (S4)

18. Summary – 치료 방침 결정 11922160 박 O 환 M/53 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) Initial Tumor stage Date: 2013 년 08 월 Modified UICC ( 대한간암연구학회 ) T 1 N 0 M 0 Stage II JIS score 2 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Localized HCC with compensated 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 ) 0 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 - ART score (Good Px 2.5) 0