1. 경희대학교병원 간암 다학제증례집담회 Multidisciplinary case conference Liver Cancer Conference 소화기 센터 회의실 2013.5.31

2.  ’99 HBV carrier 진단  ’09.1. B-viral LC(Child A), HCC 진단 → TACE #1(’09.1.29)  ‘09.4.24. Wedge resection of S8 d/t HCC remained viable tumor  ‘11.1.4. CT : nodular HCC at S8 → TACE #2(’11.1.21)  ‘13.1.28. MR : marginal recurrence of HCC at S8, suggested a small HCC at S2 → TACE #3(’13.2.19)  ‘13.5.22. MR : no recurrence of HCC  토의 목적 : 향후 치료 방향 논의 History Case 1 12023308 박 O 호 M/63 DM/HTN/TBc/Hepatitis(-/-/-/+) : HBV carrier - Clevudine 30mg qd 복용 중 B-viral LC (Child A(5), MELD -1.64) Op Hx (+) : ‘09.4.24 Wedge resection of S8 Alcohol Hx (-), Smoking Hx (+) : ex-smoker 15py

3. Underlying liver function and performance status CBC/DC WBC(mm 3 )4210 Hb(g/dl)15.0 PLT(mm 3 )216,000 PT(sec)12.4 INR0.94 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.35/- AST/ALT(IU/L)30/46 ALP/rGT(IU/L)73/- Prot/Alb(g/dL)8.1/4.5 BUN/Cr(mg/dL)11/0.7 LC & Stage Child-PughA (5) MELD score-1.64 Esophageal varices- Ascites- Encephalopathy- 12023308 박 O 호 M/63 Case 1 Tumor markers AFP (ng/mL)3.62 CEA (ng/mL) 1.04 PIVKA II (mAU/mL)18 CA19-9 6.91 Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/-) Virus titer0 IU/mL Antiviral TxClevudine 30mg Alcohol-

4. ’99. ’09.1. ’09.4. ’11.1. ‘13.1. TACE #1 (’09.1.29) TACE #1 (’09.1.29) B-viral LC HCC at S8 B-viral LC HCC at S8 10259334 조 O 복 F/57 CHB CHB Wedge resection of S8 (’09.4.24) Wedge resection of S8 (’09.4.24) Recurred HCC at S8 Case 1 Tumor Stage and Clinical Course 12023308 박 O 호 M/63 Marginal recurred HCC at S8 Small HCC at S2 Marginal recurred HCC at S8 Small HCC at S2 09 년 1 월 09 년 3 월 10 년 1 월 11 년 4 월 12 년 1 월 12 년 5 월 13 년 2 월 13 년 5 월 AFP 7.536.142.652.502.332.193.083.62 PIVKA Ⅱ 9413141622-- PET-CT (2009.2.6) No specific abnormal FDG uptake to suggest malignancy (including liver area) Nodular HCC at S8 TACE #2 (’11.1.21) TACE #2 (’11.1.21) TACE #3 (’13.2.19) TACE #3 (’13.2.19) *Liver-TACE CT(2013.5.22) : Additional lipiodol uptake in the recurred HCC at S4/8 without viable tumor. Suggested hepatic ischemia rather than infarction at S7. Previously noted HCC at S2 at MR cannot be defined. No change of a hepatic cyst at S8 and mild both IHD dilatation. No change of surgical clips on left medial segment and multiple calcification at S4/8. Underlying liver cirrhosis.

5. Summary – 치료 방침 결정 12023308 박 O 호 M/63 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: 2009 년 1 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 2 Repeated TACE ( 1 회 / 기간 ) 2 Vascular or bile duct invasion N High uptake of PET N High AFP or PIVKA II N Not normalized AFP after curative Tx Y Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease N

6.  ‘12.6. HCV 진단  ‘12.7. C-viral LC(Child A(5), MELD 4.31) with EV 진단 → EVL #1(‘12.11.6)  ‘13.5.9. MR : r/o Early HCC vs DN at S4 → 3 개월 후 f/u 예정  토의 목적 : 향후 치료 방향 논의 History Case 2 12282619 김 O 임 F/53 DM/HTN/TBc/Hepatitis(+/+/-/+) : CHC C-viral LC(Child A(5), MELD 4.31) with EV s/p EVL #1(‘12.11.6) Op Hx (+) : Hysterectomy (‘04) Alcohol Hx (+) : social drinking, Smoking Hx (-)

7. Underlying liver function and performance status CBC/DC WBC(mm 3 )5090 Hb(g/dl)13.9 PLT(mm 3 )55,000 PT(sec)15.8 INR1.28 Performance status: Grade 0 Chemistry TB/DB(mg/dL)1.50/- AST/ALT(IU/L)45/22 ALP/rGT(IU/L)73/194 Prot/Alb(g/dL)7.3/3.9 BUN/Cr(mg/dL)-/- LC & Stage Child-PughA (5) MELD score4.31 Esophageal varices+ Ascites- Encephalopathy- 12282619 김 O 임 F/53 Case 2 Tumor markers AFP (ng/mL)7.12 CEA (ng/mL) - PIVKA II (mAU/mL)- CA19-9 - Viral markers/ underlying liver disease HBV / HCV(-/+) HBeAg / HBeAb(-/-) Virus titer0 IU/mL Antiviral Tx- Alcohol+

8. ’12.6. ‘12.7. ‘13.5. C-viral LC 10259334 조 O 복 F/57 HCV HCV Case 2 Tumor Stage and Clinical Course 12282619 김 O 임 F/53 F/U after 3 months Liver MRI (2013.5.9): Early HCC vs. DN at S4 DNs at 1, 3 are more likely Underlying liver cirrhosis with splenomegaly Rec) Close Follow up or RFA with contrast enhanced US, if applicable.. 12 년 10 월 AFP 7.12 EGD (2013.1.9) 1. Esophageal varices - High risk of bleeding 2. Mild congestive gastropathy 3. Marked erythematous gastritis r/o Early HCC vs DN at S4 EVL #1(‘12.11.6)

9. Summary – 치료 방침 결정 12282619 김 O 임 F/53 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: 2013 년 5 월 Modified UICC ( 대한간암연구학회 ) T 1 N 0 M 0 Stage I JIS score 0 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 ) N 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

10. History Case 3 11359301 오 O 순 F/76 DM/HTN/TBc/Hepatitis(+/+/-/+) : CHB B-viral LC c EV & ascites, CHF c severe AS Op Hx (-) Family Hx (-) Alcohol Hx (-), Smoking Hx (-)  ’78. HBV carrier 진단  ‘13.2. HCC & B-viral LC with EV and ascites 진단  ‘13.2.4. MR : HCC at S5/6 with tumor thrombosis, exophytic growing HCC at S6 → Tomotherapy (‘13.2.14 ~ ‘13.3.14)  ‘13.5.9. CT : Decreased size of HCC with internal necrosis  ‘13.5.29. MR : Decrease size of an exophytic growing HCC at S5/6, Newly visible fat containing HCCs at S3,4, and 4/8  토의 목적 : 향후 치료 방향 논의

11. Underlying liver function and performance status CBC/DC WBC(mm 3 )5090 Hb(g/dl)11.1 PLT(mm 3 )132,000 PT(sec)- INR- Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.65/0.27 AST/ALT(IU/L)60/29 ALP/rGT(IU/L)124/284 Prot/Alb(g/dL)8.1/4.2 BUN/Cr(mg/dL)-/- LC & Stage Child-PughA (6) MELD score3.03 Esophageal varices Fundic varices +-+- Ascites+ Encephalopathy- 11359301 오 O 순 F/76 Case 3 Tumor markers AFP (ng/mL)3353 CEA (ng/mL) 1.93 PIVKA II (mAU/mL)177 CA19-9 (U/mL) - Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer74 IU/mL Antiviral Txnone Alcohol(-)

12. Tumor Stage and Clinical Course ‘78. ‘13.2. ‘13.2.14~’13.3.14 ‘13.5. Case 3 11359301 오 O 순 F/76 *Liver MR (2013.5.29) (pre-check) No change of a Fat-containing HCC at S5/6. a/w tumor thrombus at right portal vein and S5,6 portal vein branches. Decrease size of an exophytic growing HCC at S5 and 6. Newly visible fat containing HCCs at S3,4, and 4/8. Liver cirrhosis and ascites. Hepatic ischemia at both hepatic lobes. PET (2013.2.6) Two HCCs in segment VI and V/VI LC with ascites Benign lung nodules in RUL and RML R/O Thyroid adenoma or malignancy in the right lobe --> REC) US HBV carrier HBV carrier HCC, B-viral LC HCC, B-viral LC HCC at S5/6 with tumor thrombosis exophytic growing HCC at S6 HCC at S5/6 with tumor thrombosis exophytic growing HCC at S6 Tomotherapy Tomotherapy decreased mass 13 년 2 월 13 년 3 월 13 년 5 월 AFP 300618043353 PIVKA Ⅱ 2101-177

13. Summary – 치료 방침 결정 11359301 오 O 순 F/76 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 2 월 Modified UICC ( 대한간암연구학회 ) T 4 N 0 M 0 Stage IV JIS score 3 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Multiple with well preserved liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation Y Tumor number 6 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

14.  ’96. Chronic hepatitis B 진단  ’07. B-viral LC 진단  ‘11.4. MR : HCC at S6, suggestive hypovascular HCC at S8 → TACE #1(‘11.4.21)  ‘11.6. MR : Increased size of hypovascular HCC at S8  ‘13.5. TACE #1 이후 f/u loss 되었다가 외래 내원  토의 목적 : 향후 치료 방향 논의 History Case 4 11924990 홍 O 표 M/73 DM/HTN/TBc/Hepatitis(-/-/-/+) : CHB B-viral LC : 2007 년 진단 Op Hx (-) Alcohol Hx (-), Smoking Hx (-)

15. Underlying liver function and performance status CBC/DC WBC(mm 3 )6690 Hb(g/dl)14.6 PLT(mm 3 )157,000 PT(sec)13.7 INR1.06 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.94/- AST/ALT(IU/L)26/22 ALP/rGT(IU/L)88/62 Prot/Alb(g/dL)7.1/4.3 BUN/Cr(mg/dL)19/0.8 LC & Stage Child-PughA(5) MELD score4.71 Esophageal varices- Ascites- Encephalopathy- 11924990 홍 O 표 M/73 Case 4 Tumor markers AFP (ng/mL)12.97 CEA (ng/mL) - PIVKA II (mAU/mL)- CA19-9 - Viral markers/ underlying liver disease HBV / HCV(+/-) HBeAg / HBeAb(-/+) Virus titer<20 Antiviral Tx- Alcohol-

16. ‘96. ‘07. ‘11.4. ‘11.6. ‘13.5. B-viral LC 10259334 조 O 복 F/57 CHB Case 2 Tumor Stage and Clinical Course 11924990 홍 O 표 M/73 TACE #1(‘11.4.21) Liver MRI (2011.6.20) Increased size of hypovascular HCC on segment 8. a/w tumor thrombi at anterosuperior branch of portal vein. Lipiodolized mass on segment 6 without viable tumor. A small hepatic cyst in segment 6. Underlying liver cirrhosis. Slightly decreased size of cystic lesion at pancreatic body, suggesting serous cystadenoma, R/O IPMN(branch duct type). No interval change of both renal cysts. PET-CT (2011.4.22) 1. C/W HCC in right posterosuperior segment of liver : Rec) Liver MRI correlation 2. Lipiodolization state in posteroinferior segment of liver without hypermetabolic lesion HCC at S6 suggestive hypovascular HCC at S8 HCC at S6 suggestive hypovascular HCC at S8 Increased size of hypovascular HCC at S8 Increased size of hypovascular HCC at S8 Opd visit 11 년 4 월 11 년 6 월 12 년 11 월 13 년 5 월 AFP 32.05705.72.7112.97 PIVKA Ⅱ ----

17. Summary – 치료 방침 결정 11924990 홍 O 표 M/73 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 : 2011 년 4 월 Modified UICC ( 대한간암연구학회 ) T 3 N 0 M 0 Stage III JIS score 2 BCLC Very early / Early / Intermediate / Advanced / Termin 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 2 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 N Histology (microvascular invasion) - Histology (satellite lesion, differentiation) - Poor control of underlying liver disease N

18.  ‘11.11. AGC(stage IIa) → LADG  ‘13.5.13 Fatigue 주소로 간기능 검사 원하여 IG opd 내원  토의 목적 : 영상 소견에 대한 상의 History Case 5 12232529 고 O 순 M/81 DM/HTN/TBc/Hepatitis(+/-/-/-) Op Hx (+) : ’11.11.11 Laparoscopy-assisted distal gastrectomy Alcohol Hx (-), Smoking Hx (-)

19. Underlying liver function and performance status CBC/DC WBC(mm 3 )6320 Hb(g/dl)16.3 PLT(mm 3 )140,000 PT(sec)- INR- Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.64/- AST/ALT(IU/L)25/23 ALP/rGT(IU/L)76/41 Prot/Alb(g/dL)6.8/4.4 BUN/Cr(mg/dL)13/0.6 LC & Stage Child-Pugh- MELD score- Esophageal varices- Ascites- Encephalopathy- 12232529 고 O 순 M/81 Case 5 Tumor markers AFP (ng/mL)- CEA (ng/mL) 1.78 PIVKA II (mAU/mL)- CA19-9 7.45 Viral markers/ underlying liver disease HBV / HCV(-/-) HBeAg / HBeAb(-/-) Virus titer- Antiviral Tx- Alcohol-