1. 경희대학교병원 간암 다학제증례집담회 Multidisciplinary case conference Liver Cancer Conference 소화기 센터 회의실 2013.6.21

2.  B-viral LC 와 DM 으로 한양대 병원 f/u 해옴  ‘12.10.10 Angina 로 심장내과 입원해 시행한 Abd US 상 suggestive of HCC at S5/7, Liver MR 상 HCC at S7 → TACE #1 (’12.10.23)  ‘12.12.13 CT : no recurrence of HCC  ’13.3.7 CT : no recurrence of HCC  ’13.6.4 MR : Viable tumor at the posterior aspect to the lipiodolized HCC at S7  토의 목적 : 향후 치료 방향 논의 (op or intraop RF?) History Case 1 12235403 김 O 열 M/49 DM/HTN/TBc/Hepatitis(+/-/-/+) : HBV carrier – Baraclude 0.5mg qd 복용 중 B-viral LC (Child A(5), MELD 5.68) with esophageal varix Op Hx (-) Alcohol Hx (-), Smoking Hx (+) : 20py

3. Underlying liver function and performance status CBC/DC WBC(mm 3 )4,100 Hb(g/dl)14.7 PLT(mm 3 )107,000 PT(sec)14.7 INR1.17 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.07/- AST/ALT(IU/L)27/25 ALP/rGT(IU/L)54/- Prot/Alb(g/dL)8.0/4.4 BUN/Cr(mg/dL)-/- LC & Stage Child-PughA (5) MELD score5.68 Esophageal varices+ Ascites- Encephalopathy- 12235403 김 O 열 M/49 Case 1 Tumor markers AFP (ng/mL)60.54 CEA (ng/mL) - PIVKA II (mAU/mL)15 CA19-9 20.44 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer<20 IU/mL Antiviral TxBaraclude 0.5mg Alcohol-

4. ’12.10. ‘12.12. ’13.3. ‘13.6. TACE #1 (’12.10.23) TACE #1 (’12.10.23) Angina s/p PCI HCC at S7 Angina s/p PCI HCC at S7 10259334 조 O 복 F/57 B-viral LC DM B-viral LC DM CT : no recurrence Case 1 Tumor Stage and Clinical Course 12235403 김 O 열 M/49 MR : viable tumor at S7 12 년 10 월 12 년 12 월 13 년 3 월 13 년 6 월 AFP 162935.574160.54 PIVKA Ⅱ 52202315 PET-CT (2012.10.23) 1. C/W HCC at segment VII of liver 2. No abnormal hypermetabolic lesion suggesting metastasis *Liver-MRI (2013.6.4) Viable tumor at the posterior aspect to the lipiodolized HCC at S7. CT : no recurrence

5. ART score system

6. ART score 12235403 김 O 열 M/49 Case 1 indexfindingsscoreNET score Child-Pugh score increase Absent0 1 + 1 point1.5 + ≥2 points3 AST increase (≥ 25%) Absent0 Present4 Radiologic tumor response Present (CR, PR)0 Absent (SD, PD)1

7. Summary – 치료 방침 결정 12235403 김 O 열 M/49 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: 2012 년 10 월 Modified UICC ( 대한간암연구학회 ) T 2 N 0 M 0 Stage II JIS score 1 BCLC stage Very early / Early / Intermediate / Advanced / Terminal 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 ) 0 Vascular or bile duct invasion N High uptake of PET Y High AFP or PIVKA II Y Not normalized AFP after curative Tx Y Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease N ART score 1

8.  ’11.5. Chronic hepatitis C : ‘11.7~11. interferon 투약 중 부작용으로 중단  ‘12.2. CT : HCC at S8 → TACE #1 (‘12.2.10)  ‘13.2. MR : Recurrence of lipiodolized HCC at S4/8 → TACE #2 (‘13.2.27)  ‘13.5. MR : Suggested viable HCC at S4/8  토의 목적 : 영상 소견에 대한 논의 History Case 2 12197278 이 O 복 M/62 DM/HTN/TBc/Hepatitis(-/-/-/+) : CHC C-viral LC (Child A(5), MELD 5.61) Op Hx (-) Alcohol Hx (-), Smoking Hx (+) : 30py

9. Underlying liver function and performance status CBC/DC WBC(mm 3 )5,910 Hb(g/dl)13.0 PLT(mm 3 )350,000 PT(sec)14.7 INR1.17 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.54/- AST/ALT(IU/L)23/15 ALP/rGT(IU/L)179/- Prot/Alb(g/dL)8.5/4.6 BUN/Cr(mg/dL)-/- LC & Stage Child-PughA (5) MELD score5.61 Esophageal varices- Ascites- Encephalopathy- 12197278 이 O 복 M/62 Case 2 Tumor markers AFP (ng/mL)5.34 CEA (ng/mL) 2.18 PIVKA II (mAU/mL)30 CA19-9 13.15 Viral markers/ underlying liver disease HBV / HCV(-/+) HBeAg / HBeAb(-/-) Virus titer0 IU/mL Antiviral Tx- Alcohol-

10. ’11.5. ‘12.2. ‘13.2. ‘13.5. CT : HCC at S8 10259334 조 O 복 F/57 CHC CHC Case 2 Tumor Stage and Clinical Course 12197278 이 O 복 M/62 TACE #2 (‘13.2.27) Liver MRI (2013.5.23) Suggested viable HCC between the right hepatic lobe and the right diaphragm. Additional lipiodol uptake within the previously noted viable portion of HCC at S4/8 with disappearance of hepatic cysts. Multiple AP shunts and hepatic cysts at both lobes. Hepatic necrosis at S8 and ischemia at S7. Liver cirrhosis. PET-CT (2013.2.28) Post-TACE state, unremarkable No abnormal hypermetabolic lesion suggesting distant metastasis MR : Recur of HCC at S4/8 TACE #1 (‘12.2.10) MR : Suggested viable HCC at S4/8 12 년 1 월 12 년 3 월 12 년 7 월 12 년 10 월 13 년 1 월 13 년 5 월 AFP111.56.574.264.45.155.34 PIVKA II15342530

11. ART score 12197278 이 O 복 M/62 Case 2 indexfindingsscoreNET score Child-Pugh score increase Absent0 1 + 1 point1.5 + ≥2 points3 AST increase (≥ 25%) Absent0 Present4 Radiologic tumor response Present (CR, PR)0 Absent (SD, PD)1

12. Summary – 치료 방침 결정 12197278 이 O 복 M/62 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: 2012 년 2 월 Modified UICC ( 대한간암연구학회 ) T 2 N 0 M 0 Stage II JIS score 1 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Localized advanced with well preserved 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 ) 1 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 N ART score 0

13. History Case 3 12008627 조 O 웅 M/68 DM/HTN/Tb/Hepatitis(+/+/-/-) Cryptogenic LC c esophageal varix Op Hx (-) Family Hx (-) Alcohol Hx (+) : social drinking, Smoking Hx (-)  ’12.12. Cryptogenic LC with esophageal varix 로 본원 소화기내과 외래 내원  ‘13.5.27 CT : HCC(2.4cm) at S6 → TACE #1 (’13.6.5)  ‘13.5.27 CT : TCC → MR : small TCC at LK upper pole → URO f/u  토의 목적 : 향후 치료 방향 논의

14. Underlying liver function and performance status CBC/DC WBC(mm 3 )4,450 Hb(g/dl)12.9 PLT(mm 3 )129,000 PT(sec)13.7 INR1.08 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.60/0.19 AST/ALT(IU/L)54/27 ALP/rGT(IU/L)176/328 Prot/Alb(g/dL)8.0/4.2 BUN/Cr(mg/dL)16/0.9 LC & Stage Child-PughA (5) MELD score4.25 Esophageal varices Fundic varices +-+- Ascites- Encephalopathy- 12008627 조 O 웅 M/68 Case 3 Tumor markers AFP (ng/mL)27.35 CEA (ng/mL) 4.16 PIVKA II (mAU/mL)16 CA19-9 (U/mL) 2.00 Viral markers/ underlying liver disease HBV / HCV(-/-) HBeAg / HBeAb(-/-) Virus titer0 IU/mL Antiviral Txnone Alcohol(+) : social drinking

15. Tumor Stage and Clinical Course ’12.12. ‘13.5. Case 3 12008627 조 O 웅 M/68 *Kidney & adrenal MR (2013.5.31) Possible small TCC at upper pole calyx and renal pelvis of left kidney. - no evidence of renal parenchymal invasion. Early HCC at liver S6. A left renal cyst. PET (2013.5.30) No visible hypermetabolic activity of known HCC on S6 C/W malignant mass at upper pole calyx of left kidney Cryptogenic LC c EV Cryptogenic LC c EV HCC at S6 HCC at S6 TACE #1 (‘13.6.5) 13 년 2 월 AFP 27.35 PIVKA Ⅱ 16

16. Summary – 치료 방침 결정 12008627 조 O 웅 M/68 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: 2013 년 5 월 Modified UICC ( 대한간암연구학회 ) T 2 N 0 M 0 Stage II JIS score 1 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Localized 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 ) - Vascular or bile duct invasion N High uptake of PET Y 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 N ART score -

17.  HTN, DM, B-viral LC 로 local clinc f/u 중 HCC 의심 소견 (mass at S5, AFP 상승 ) 으 로 소화기내과 외래 내원  ’13.1. CT : HCC at right AI segment, Malignant portal vein thrombosis  ‘13.1. MR : Huge HCC in Rt hepatic lobe with multi-nodular HCCs → TACE #1 at Rt AI segment & TAE #1 at lateral segment (‘13.1.28) → Tomotherapy to Rt lobe (‘13.2.4~’13.3.5)  ‘13.4. CT : Increased size and extent of multifocal arterial enhancing lesions in Rt lobe of liver, HCCs and Malignant thrombus with AP shunt in right portal vein  ‘13.6. MR f/u 예정  토의 목적 : Tomotherapy 후 치료 반응 평가 및 향후 치료 방침 논의 History Case 4 12321251 안 O 석 M/61 DM/HTN/TBc/Hepatitis(+/+/-/+) : CHB B-viral LC(Child A(5), MELD 3.60), GU Op Hx (+) : HIVD op Alcohol Hx (+) : 소주 1~1.5 병 / 회, 3 회 / 주, Smoking Hx (+) : 2p x 20y

18. Underlying liver function and performance status CBC/DC WBC(mm 3 )3,190 Hb(g/dl)15.1 PLT(mm 3 )71,000 PT(sec)12.6 INR0.95 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.59/- AST/ALT(IU/L)36/49 ALP/rGT(IU/L)88/62 Prot/Alb(g/dL)6.6/3.9 BUN/Cr(mg/dL)-/- LC & Stage Child-PughA(5) MELD score3.60 Esophageal varices- Ascites- Encephalopathy- 12321251 안 O 석 M/61 Case 4 Tumor markers AFP (ng/mL)3,068 CEA (ng/mL) 1.75 PIVKA II (mAU/mL)92 CA19-9 12.43 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer<20 Antiviral Tx- Alcohol-

19. ‘13.1. ‘13.4. ‘13.6. CT : HCC with malig PVT MR : Huge HCC with multi-nodular HCCS CT : HCC with malig PVT MR : Huge HCC with multi-nodular HCCS 10259334 조 O 복 F/57 B-viral LC Case 4 Tumor Stage and Clinical Course 12321251 안 O 석 M/61 Liver-TACE CT (2013.4.11) Three lipiodolized recurrent HCC in S5/8, S7 and dome area of right AS, and left lateral segment Increased size and extent of multifocal arterial enhancing lesions in right lobe of liver, HCCs. Malignant thrombus with Ap shunt in right portal vein. A lipiodolized mass without viable tumor in S3. Rec;liver MR PET-CT (2013.1.25) Known HCC in the right lobe with right portal vein thrombosis No abnormal hypermetabolic lesion suggesting distant metastasis CT : increasing size & extent of HCC Malignant PVT CT : increasing size & extent of HCC Malignant PVT MR f/u TACE & TAE #1(‘13.1.28) Tomotherapy (‘13.2.4~’13.3.5) 13 년 1 월 13 년 2 월 13 년 4 월 13 년 5 월 13 년 6 월 AFP3413230507692535423068 PIVKA II523--92-

20. ART score 12321251 안 O 석 M/61 Case 4 indexfindingsscoreNET score Child-Pugh score increase Absent0 1 + 1 point1.5 + ≥2 points3 AST increase (≥ 25%) Absent0 Present4 Radiologic tumor response Present (CR, PR)0 Absent (SD, PD)1

21. Summary – 치료 방침 결정 12321251 안 O 석 M/61 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 1 월 Modified UICC ( 대한간암연구학회 ) T 3 N 0 M 0 Stage III JIS score 2 BCLC Very early / Early / Intermediate / Advanced / Termin Current status Diffuse or multiple with well preserved liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation Y Tumor number multiple Repeated TACE ( 1 회 / 기간 ) N Vascular or bile duct invasion N High uptake of PET Y High AFP or PIVKA II Y Not normalized AFP after curative Tx Y Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease N ART score 1