1. 경희대학교병원 간암 다학제증례집담회 Multidisciplinary case conference Liver Cancer Conference 소화기 센터 회의실 2014.09.05

2. History Case 1 10592087 김 O 선 F/74 DM (+), HTN (-) Op Hx (-) Alcohol Hx (-), Smoking Hx (-)  C-viral LC, HCC s/p TACE #8 및 2013 년 6 월 RT 시행한자. RT 시행 부분에 새로 발생한 Small HCC, r/o surrounding infiltration 으로 F/U MRI 시행하였으며 향 후 치료 방향에 대해 논의  토의 목적 : 영상소견 review 및 치료방침 논의

3. Underlying liver function and performance status CBC/DC WBC(mm 3 )5,420 Hb(g/dl)10.6 PLT(mm 3 )96,000 PT(sec)16.3 INR1.31 Performance status: Grade 0 Chemistry TB(mg/dL)1.96 AST/ALT(IU/L)93/31 ALP(IU/L)199 Prot/Alb(g/dL)6.1/2.8 BUN/Cr(mg/dL)17/0.7 LC & Stage Child-PughA (6) MELD score12 Esophageal varices- Ascites- Encephalopathy- Case 1 Tumor markers AFP (ng/mL)27.94 CEA (ng/mL) 4.61 PIVKA II (mAU/mL)17 CA19-9 (U/mL) 38.61 10592087 김 O 선 F/74 Viral markers/ underlying liver disease HBV / HCV(-/+) Alcohol-

4. ’09.7 ‘09.12 ‘10.4 ’11.7 ‘12.3 ’12.5 ’12.12 10259334 조 O 복 F/57 Liver MRI : recur HCC S7 Liver MRI : recur HCC S7 Case 1 Tumor Stage and Clinical Course Liver MRI : recur HCC S4 Liver MRI : recur HCC S4 10592087 김 O 선 F/74 Liver CT : HCC S4 Liver CT : HCC S4 Liver CT : recur HCC Liver CT : recur HCC 2010.01.05 TACE #2 2010.01.05 TACE #2 Liver CT : HCC S7 Liver CT : HCC S7 2012.04.16 TACE #5 2012.04.16 TACE #5 09 년 7 월 10 년 1 월 10 년 4 월 11 년 9 월 12 년 9 월 12 년 12 월 AFP65.7229.4640.4743.5753.62212.3 2009.7.27 TACE #1 2009.7.27 TACE #1 2010.04.20 TACE #3 2010.04.20 TACE #3 2011.7.27 TACE #4 2011.7.27 TACE #4 Liver CT : recurr HCC S4 Liver CT : recurr HCC S4 2012.07.23 TACE #6 2012.07.23 TACE #6 Liver MRI :recur HCC Liver MRI :recur HCC 2012.12.20 TACE #7 2012.12.20 TACE #7 Liver MRI (2014.09.03) PET CT (2014.09.03) S/P TACE No abnormal hypermetabolic lesion suggesting malignancy. Decreased amount of ascites.

5. ‘13.3 ’13.6 ’14.7 10259334 조 O 복 F/57 Case 1 Tumor Stage and Clinical Course Liver MRI (2014.09.03) Liver CT : viable HCC S4/8 Liver CT : viable HCC S4/8 10592087 김 O 선 F/74 PET CT (2014.09.03) S/P TACE No abnormal hypermetabolic lesion suggesting malignancy. Decreased amount of ascites. Liver CT : viable HCC S4/8 Liver CT : viable HCC S4/8 2013.03.26 TACE #8 2013.03.26 TACE #8 13 년 6 월 13 년 10 월 13 년 12 월 14 년 3 월 14 년 6 월 AFP29616.1217.5015.8627.94 2013.6.20 ~ 7.24 TOMOTHERAPY 2013.6.20 ~ 7.24 TOMOTHERAPY Liver CT : New HCC S7 Liver CT : New HCC S7

6. Summary – 치료 방침 결정 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 7 월 Modified UICC ( 대한간암연구학회 ) T 2 N 0 M 0 Stage II JIS score 1 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status locally advanced HCC with preserved liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation N Tumor number 3 Repeated TACE ( 1 회 / 기간 ) 8 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 N ART score (Good Px 2.5) 0 10592087 김 O 선 F/74

7. History Case 2 11606403 김 O 남 M/44 DM (-), HTN (+) op Hx (+) : Lt. AVF (2004) Alcohol Hx (+) : 소주 1 병 / 주 2 회,Smoking Hx (+) : Current smoker 10PY  B-viral LC, HCC s/p TACE #6 및 RF #1 시행한 환자로 2014.5.29 TACE #6 시행 후에도 S7 에 viable tumor size 커지고 있어 RF 시행 가능 여부에 대해 논의  토의 목적 : 영상소견 review 및 치료방침 논의

8. Underlying liver function and performance status CBC/DC WBC(mm 3 )3,650 Hb(g/dl)11.9 PLT(mm 3 )224,000 PT(sec)13.0 INR0.98 Performance status: Grade 0 Chemistry TB/DB(mg/dL)0.46/0.18 AST/ALT(IU/L)24/20 ALP/rGT(IU/L)161/81 Prot/Alb(g/dL)7.0/4.2 BUN/Cr(mg/dL)18/4.4 LC & Stage Child-PughA (5) MELD score20 Esophageal varices- Ascites- Encephalopathy- Case 2 Tumor markers AFP (ng/mL)418.1 CEA (ng/mL) 2.10 PIVKA II (mAU/mL)14 CA19-9 (U/mL) - 11606403 김 O 남 M/44 Viral markers/ underlying liver disease HBV / HCV(+/-) Alcohol+

9. ’09.3 ‘11.6 ’12.11 ‘13.7 ’13.10 ’14.1 10259334 조 O 복 F/57 Liver MRI : recur HCC S7 Liver MRI : recur HCC S7 Case 2 Tumor Stage and Clinical Course Liver MRI : recur HCC S7 Liver MRI : recur HCC S7 10592087 김 O 선 F/74 Liver CT : HCC S7 Liver CT : HCC S7 Liver MRI : New HCC S5, S7 Liver MRI : New HCC S5, S7 2011.07.06 RFA 2011.07.06 RFA 2013.07.25 TACE #3 2013.07.25 TACE #3 09 년 3 월 09 년 6 월 11 년 9 월 12 년 9 월 13 년 6 월 13 년 10 월 14 년 1 월 AFP59925.773.11334.5895.31196464.5 2009.4.09 TACE #1 2009.4.09 TACE #1 2012.12.18 TACE #2 2012.12.18 TACE #2 Liver MRI : recurr HCC S7 Liver MRI : recurr HCC S7 2013.11.05 TACE #4 2013.11.05 TACE #4 Liver MRI :recur HCC S7 Liver MRI :recur HCC S7 2014.02.07 TACE #5 2014.02.07 TACE #5 Liver MRI (2014.08.27) PET CT (2014.08.25) FDG uptake at medial aspect of lipiodol uptake in the liver S7: R/O viable tumor

10. ‘14.5 ‘14.8 10259334 조 O 복 F/57 Liver MRI : increased HCC S7 Liver MRI : increased HCC S7 Case 2 Tumor Stage and Clinical Course 10592087 김 O 선 F/74 Liver MRI : New HCC S5, S5/6 Liver MRI : New HCC S5, S5/6 2014.05.29 TACE #6 2014.05.29 TACE #6 14 년월 14 년 8 월 AFP355418 Liver MRI (2014.08.27) PET CT (2014.08.25) FDG uptake at medial aspect of lipiodol uptak in the liver S7: R/O viable tumor

11. Summary – 치료 방침 결정 11606403 김 O 남 M/44 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: 2009 년 3 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 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 ) 6 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 - ART score (Good Px 2.5) -

12. History Case 3 12381907 조 O 학 M/47 DM (-), HTN (-) Op Hx (-) Alcohol Hx (+), daily 3 병, 5yrs, Smoking Hx (-)  Alocoholic LC c ascites 환자로 타병원에서 liver mass 있어 biopsy 시행하여 r/o angiolipoma 소견 들었던 자. 최근 CT f/u 에서 mass 의 equivocal change 및 외부 병리 슬라이드 판독상 chronic hepatitis, cirrhosis 소견 외 이상소견 없어 case 리뷰  토의 목적 : 영상 & 병리 review

13. Underlying liver function and performance status CBC/DC WBC(mm 3 )4,470 Hb(g/dl)13.6 PLT(mm 3 )53,000 PT(sec)18.3 INR1.52 Performance status: Grade 0 Chemistry TB(mg/dL)2.69 AST/ALT(IU/L)53/29 ALP/GGT(IU/L)174/30 Prot/Alb(g/dL)6.8/3.2 BUN/Cr(mg/dL)13/0.7 Case 3 LC & Stage Child-PughB (8) MELD score15 Esophageal varices+ (Low risk of bleeding) Ascites+ Encephalopathy- Tumor markers AFP (ng/mL)6.82 CEA (ng/mL) - PIVKA II (mAU/mL)- CA19-9 (U/mL) - Viral markers/ underlying liver disease HBV / HCV(+/-) Alcohol+ 12381907 조 O 학 M/47

14. 2013.12 2014.4 2014.06 10259334 조 O 복 F/57 Case 3 Tumor Stage and Clinical Course S6 core biopsy : Cirrhosis, no evidence of HCC (2014.07.30) 12381907 조 O 학 M/47 Liver sono : LC, HCC S5/6 Liver sono : LC, HCC S5/6 Liver CT : r/o AML, r/o HCC Liver CT : r/o AML, r/o HCC 14 년 6 월 AFP6.82 2014.07.30 외부슬라이드판독 2014.07.30 외부슬라이드판독 Liver Biopsy : Angiomyolipoma Liver Biopsy : Angiomyolipoma Liver CT : no HCC Liver CT : no HCC

15. Summary – 치료 방침 결정 12381907 조 O 학 M/47 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: 2014 년 6 월 Modified UICC ( 대한간암연구학회 ) T 1 N 0 M 0 Stage I JIS score 1 BCLC Very early / Early / Intermediate / Advanced / Terminal Current status Localized HCC with decompensated 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 - 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) -

16. History Case 4 11393606 구 O 화 M/53 DM (+), HTN (-) Op Hx (+) : LLL lobectomy d/t NSCLC (2011), Subtotal gastrectomy c R-Y anastomosis c gastrojejunostomy d/t AGC (2012) Alcohol Hx (+), daily 1 병, 50yrs, current smoker 50PY  B-viral LC, HCC s/p TACE #2 시행받은 자로 TACE #2 시행 후 bile duct injury 로 secondary liver abscess, bronchobiliary fistula 발생하였던 자로 영상 review 및 향후 치료방침 논의  토의 목적 : 영상 review 및 치료방침 논의

17. Underlying liver function and performance status CBC/DC WBC(mm 3 )8,360 Hb(g/dl)8.3 PLT(mm 3 )237,000 PT(sec)15.7 INR1.24 Performance status: Grade 0 Chemistry TB(mg/dL)0.77/0.44 AST/ALT(IU/L)40/22 ALP/GGT(IU/L)404/182 Prot/Alb(g/dL)7.9/3.2 BUN/Cr(mg/dL)12/0.7 Case 4 LC & Stage Child-PughA (6) MELD score9 Esophageal varices- Ascites- Encephalopathy- Tumor markers AFP (ng/mL)177.5 CEA (ng/mL) 0.885 PIVKA II (mAU/mL)510 CA19-9 (U/mL) 25.33 Viral markers/ underlying liver disease HBV / HCV(+/-) Alcohol+ 11393606 구 O 화 M/53

18. ’13.1 14.1 ’14.3 ’14.5 10259334 조 O 복 F/57 Case 4 Tumor Stage and Clinical Course Liver MRI : viable HCC S1, New HCC S2, S7 Liver MRI : viable HCC S1, New HCC S2, S7 11393606 구 O 화 M/53 Liver CT, MRI : HCC S1 Liver CT, MRI : HCC S1 13 년 1 월 13 년 4 월 14 년 1 월 14 년 4 월 14 년 8 월 AFP46516.2119418.09177 2013.3.04 TACE #1 2013.3.04 TACE #1 2013.2.10 TACE #2 2013.2.10 TACE #2 Abdomen CT : Liver Abscess & Bilomas Abdomen CT : Liver Abscess & Bilomas PCD, PTBD Tubogram :Bronchobiliary fistula Tubogram :Bronchobiliary fistula 2014.07.22 Glue embolization 2014.07.22 Glue embolization Tubogram (2014.05.12) Right hepatic abscess/biloma in S6, communicating with right hepatic duct (through B6 superior IHD). - Probably blood clots or debris in right IHD.

19. Summary – 치료 방침 결정 11393606 구 O 화 M/53 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: 2014 년 8 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 HCC with compensated liver function Risk factors of recurrence / Tumor biology Extrahepatic metastasis N Tumor size > 5 cm, capsulation N Tumor number 3 Repeated TACE ( 1 회 / 기간 ) 2 Vascular or bile duct invasion N High uptake of PET N 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 - ART score (Good Px 2.5) -