1. History Case 1 12422837 양 O 환 M/62 DM (+), HTN (+) Alcohol Hx (+) 소주 1 병 x 2 회 / 주 Smoking Hx (+) 0.5 x 30 p-y  62/M DM, HTN, Chronic hepatitis B 로 local f/u 중 2015 년 9 월 시행한 Abd.US 에서 Liver mass 2 개 발견되어 본원 IG opd 방문한 자로 liver CT, MRI 상 three hepatic mass 와 함께 pancreatic tail mass 소견 보여 liver Bx 예정임. 영상 review 및 향후 치료방침 결정 위해 선정함  토의 목적 : 영상소견 review 및 추후 치료방침 논의

2. 12422837 양 O 환 M/62 Underlying liver function and performance status CBC/DC (2015.10.05) WBC(mm 3 )5,700 Hb(g/dl)15.0 PLT(mm 3 )155,000 PT(sec)12.0 INR0.88 Performance status: Grade 0 Chemistry (2015.10.05) TB/DB(mg/dL)0.73/- AST/ALT(IU/L)16/13 ALP/rGT(IU/L)47/27 Prot/Alb(g/dL)7.5/4.4 BUN/Cr(mg/dL)13/0.9 LC & Stage Child-Pugh- MELD score- Esophageal varices- Ascites- Encephalopathy- Case 1 Tumor markers (2015.08.05) AFP (ng/mL)1.36 CEA (ng/mL) - PIVKA II (mAU/mL)- CA19-9 (U/mL) 2.00 Viral markers/ underlying liver disease HBV / HCV+/- HBeAg / HBeAb-/+ Virus titer- Antiviral TxEntecavir Alcohol+

3. 12422837 양 O 환 M/62 15.09 15.10 Case 1 Clinical Course Liver MR(2015.10.21) Three hepatic masses. --> R/O peliosis hepatica, R/O HCC. Pancreatic mass at tail. --> DDx: acinar cell carcinoma, SPT, neuroendocrine tumor rather than adenocarcinoma. 2 liver mass 2 liver mass Hepatic masses at S7/8 and Lt. lateral segment Hepatic masses at S7/8 and Lt. lateral segment

4. History Case 2 11568925 허 O 옥 60/F DM (-), HTN (-) Alcohol Hx (-) Smoking Hx (-)  60/F B-viral LC(Child A_, HCC(T2N0M0, stage II) s/p TACE #15, s/p RFA #1(2014.9) 으로 본원 IG f/u 중이며 Lt Femur bone metastasis 로 인한 recurrent Fx. 및 infection 으로 OR/IF, I&D 시행한 과거력 있는 자로 S7,S4 HCC 악화로 Sonafenib 복용하였으나 rash 로 중단하였고 2015 년 9 월 3 일부터 palliative EBRT #10 시행함. 퇴원 후 2015 년 10 월 14 일 Rt. Flank pain 으로 재입원하였고 Abd. CT 상 HCC 가 Rt. Pleura 와 colon 으로 fistula 형성하여 hydropenumothorax 생겨 chest tube drainage 중인 환자임. 영상 review 및 향후 치료방침 논의 위해 선정함  토의 목적 : 영상소견 review 및 추후 치료방침 논의

5. Underlying liver function and performance status CBC/DC (‘15.10.02) WBC(mm 3 )5490 Hb(g/dl)12.2 PLT(mm 3 )261000 PT(sec)- INR- Performance status: Grade 1 Chemistry TB/DB(mg/dL)1.13/0.58 AST/ALT(IU/L)43/18 ALP/rGT(IU/L)137/63 Prot/Alb(g/dL)7.6/3.1 BUN/Cr(mg/dL)9/0.4 LC & Stage Child-Pugh- MELD score- Esophageal varices- Ascites- Encephalopathy- 11568925 허 O 옥 60/F Case 2 Tumor markers AFP (ng/mL)949.6 CEA (ng/mL) 1.80 PIVKA II (mAU/mL)2242 CA19-9 (U/mL) 20.40 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb-/+ Virus titer<20 Antiviral TxEntecaivr Alcohol-

6. ’01.10 ’02.1 ’03.8~‘06.5 ‘14.9 ’15.3 ‘15.8 ’15.10 Case 2 Clinical Course 11568925 허 O 옥 60/F LIVER CT (2015.10.24) Decreased amount of infected hydropneumothorax, right. Equivocal change of lipiodolized HCC at S5/8 with fistula formation between HCC-colonic hepatic flexure and HCC-right pleura. Post-radiation necrosis and decreased size of HCC at S7. Equivocal change of HCCs at S4 and S7. No change of biloma at S3. Underlying liver cirrhosis and splenomegaly. Increased amount of ascites. ‘04.2‘06.5‘14.9‘15.3‘15.8‘15.10 AFP6.8320.468.3131.392940949 PIVKA II - -508026092242 Abd CT: HCC Abd CT: HCC TACE #2 TACE #1 Pathologic Fx Femur Lt s/p OR/IF Pathologic Fx Femur Lt s/p OR/IF TACE #15 Palliative EBRT #10 Palliative EBRT #10 Chest/Abd. CT Post-radiation Necrosis HCC-pleural fistula HCC-colon fistula Chest/Abd. CT Post-radiation Necrosis HCC-pleural fistula HCC-colon fistula RFA #1

7. History Case 3 11628652 이 O 석 77 /M DM (+), HTN (-) Op Hx (-) Alcohol Hx (-) Smoking (-)  77/M DM 으로 local 에서 po med 하던 자로 2015 년 8 월 삼육서울병원에서 시행한 Abd.CT 상 huge hepatic mass c GB invasion, T-colon metastasis 소견 보여 colonoscopic Bx 상 suggestive HCC 로 Sorafenib 400mg BID 복용 시작하였던 자로 F/E 위해 본원으로 전원됨 환자 2015.10.20 입원하여 liver Bx 시행하였고 HCC 소견 보임. 영상 리뷰 및 치료방침 결정 위해 선정함.  토의 목적 : 영상 review 및 향후 치료 방침 논의 위해 선정함

8. 11628652 이 O 석 77 /M Underlying liver function and performance status CBC/DC (’15.10.14) WBC(mm 3 )5,710 Hb(g/dl)8.9 PLT(mm 3 )224,000 PT(sec)13.1 INR0.99 Performance status: Grade 1 Chemistry (’15.10.14) TB/DB(mg/dL)1.22/0.74 AST/ALT(IU/L)19/79 ALP/rGT(IU/L)94/49 Prot/Alb(g/dL)6.6/3.8 BUN/Cr(mg/dL)13/0.7 LC & Stage Child-Pugh- MELD score- Esophageal varices - Ascites- Encephalopathy- Case 3 Tumor markers AFP (ng/mL)6917 CEA (ng/mL) 13.12 PIVKA II (mAU/mL)>75,000 CA19-9 (U/mL) 996.02 Viral markers/ underlying liver disease HBV / HCV(-/-) Virus titerTarget Not Detected Antiviral Tx- Alcohol-

9. 12422837 양 O 환 M/62 15.08 15.10 Case 3 Clinical Course Liver CT(2015.10.26) Huge HCC at left lobe. Colonic metastasis at hepatic flexure with GB invasion. Several hepatic cysts at right lobe. Multiple both renal cysts. Huge HCC c GB invasion c colon meta Bx : HCC Huge HCC c GB invasion c colon meta Bx : HCC Huge HCC c GB invasion c colon meta Huge HCC c GB invasion c colon meta

10. 12422837 양 O 환 M/62 Summary – 치료 방침 결정 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: 2015 년 10 월 Modified UICC ( 대한간암연구학회 ) T 2 N 0 M 1 Stage IVb JIS score 3 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Huge HCC with decompensated liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis Y Tumor size > 5 cm, capsulation Y Tumor number 2 Repeated TACE (1 회 / 기간 ) N Vascular or bile duct invasion Y 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 -

11. History Case 4 11298433 박 O 수 66/M DM (-), HTN (-) alcoholic LC (Child-Pugh A) Op Hx (-) Alcohol (+) 1.5 병 / daily smoking (-)  66/M. Chronic alcoholics 로 2015.3 stage IV HCC c lung metastasis, alcoholic LC (Child A) 진단 후 sorafenib 복용 중인 자로 2015.10 liver MR f/u 하였으며 영상 리뷰 위해 선정함.   토의 목적 : 영상 review

12. Underlying liver function and performance status CBC/DC (2015.07.02) WBC(mm 3 )7710 Hb(g/dl)14.2 PLT(mm 3 )154,000 PT(sec)13.2 INR1.00 Performance status: Grade 0 Chemistry (2015.10.13) TB/DB(mg/dL)1.38 AST/ALT(IU/L)124/92 ALP/rGT(IU/L)173/- Prot/Alb(g/dL)8.4/3.7 BUN/Cr(mg/dL) 11/0.5 LC & Stage Child-PughA MELD score0 Esophageal varices - Ascites+ Encephalopathy- 11298433 박 O 수 66/M Case 4 Tumor markers (2015.10) AFP (ng/mL) 13396 CEA (ng/mL) - PIVKA II (mAU/mL) 74967 CA19-9 (U/mL) 3.84 Viral markers/ underlying liver disease HBV / HCV(-/-) Virus titer- Antiviral Tx- Alcohol+

13. 15’-03 ‘15-07 ‘15-10 Case 4 Clinical Course 11298433 박 O 수 66/M Liver MR (2015.10.13) Aggravation of tumor thrombosis within IVC, middle HV and PV (right, left and main PV). Slightly decreased size of massive HCC at right lobe and S4. Equivocal change or slightly increased size of scattered nodular HCCs at right and left lateral segment. Increased extent of hepatic infarction at right posterior segment. Scanty ascites. Massive HCC at Rt. lobe & S4. a/w HCCs at Rt & Lt lateral seg. a/w tumor thrombosis ; multiple/ largest (13.1cm) Massive HCC at Rt. lobe & S4. a/w HCCs at Rt & Lt lateral seg. a/w tumor thrombosis ; multiple/ largest (13.1cm) HCC at Rt. lobe, S4 a/w tumor thrombosis HCC at Rt. lobe, S4 a/w tumor thrombosis Agg. of tumor thrombosis Slightly decreased of HCC at Rt lobe and S4. Agg. of tumor thrombosis Slightly decreased of HCC at Rt lobe and S4. ’15.03’15.07’15.10 AFP17732346313396 PIVKA II342211070174967

14. Summary – 치료 방침 결정 11298433 박 O 수 66/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) Risk factors of recurrence / Tumor biology Extrahepatic metastasis Y Tumor size > 5 cm, capsulation Y Tumor number 5 Repeated TACE (1 회 / 기간 ) - Vascular or bile duct invasion Y High uptake of PET - 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 - Initial Tumor stage Date: 2015 년 07 월 Modified UICC ( 대한간암연구학회 ) T 4 N 1 M 1 Stage IVb JIS score 3 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Multiple with compensated liver function