1. MGR Case presentation
소화기내과
R2 이설라

2. periumbilical pain onset) 내원 2주전
Case 1
Case Presentation
48/M 안 O 성
Adm
C.C.
periumbilical pain onset) 내원 2주전
P.I.
20년전 HBV carrier 진단받고 이후 검사나 치료 받지 않음.
내원 2주전 간간히 발생한 periumbilical pain으로 타병원 에서 시행받은 복부 초음파에서 liver mass 의심되어 큰 병원 진료 권유 받고 방문.

3. Case 1 PMHx. DM/HTN/Tuberculosis/Hepatitis (-/-/-/+) Op Hx (-)
Drug Hx (-)
Alcohol (-)
Smoking (+) : 10pack/year
FHx : none

4. Review of Systems Case 1 G/A) fatigue (+) weight change (-)
fever (-) chill (-) sweating (-)
Skin) pigmentation (-) rash (-) itching (-)
H& N) headache (-) trauma (-) stiffness (-)
Eye/ ENT) diplopia (-) hearing loss(-)
nasal obstruction (-) dryness(-)
soreness(-) hoarseness(-)
Respiratory) cough (-) sputum (-) dyspnea(-) hemoptysis(-)

5. Case 1 Cardiac) palpitation (-) dyspnea(-) chest pain (-) orthopnea(-)
G-I) A/N/V/D/C(-/-/-/-/-)
abd pain (+) : periumbilical, lower abdomen
jaundice (-) melena (-)
Renal & Urinary) dysuria (-) hematuria (-) polyuria (-)
incontinence (-) nocturia (-) anuria(-)

6. Physical Examination Case 1 Alert consciousness
Vital sign) 120/77mmHg – 82회/분 – 20회/분 – 36.2℃
Height : 160cm weight: 59.5Kg
General appearance
Alert consciousness
Not acute ill-looking appearance
Skin
Rash (-) Pigmentation (-)
Head and Neck
Neck LN enlargement (-/-)
Neck vein engorgement (-/-)
Thyroid enlargement (-)
Eyes and ENT
Isocoric pupil with PLR(++/++)
Whitish sclera, Pinkish conjunctiva

7. Case 1 Clear breathing sound without wheezing
Chest
Clear breathing sound without wheezing
Regular heart beat without murmur
Abdomen
Soft and flat abdomen
No abdominal tenderness
No rebound tenderness
No palpable abdominal mass
Normoactive bowel sound
No hepatosplenomegaly
Back and extremities
CVA tenderness(-/-)
Peripheral pitting edema(-/-)

8. Initial lab findings Case 1 CBC/DC
3830/mm3 – 13.7 g/dL – 4.1% - 67k (seg : 68.2 %)
Chemistry
TB/DB /0.15mg/dL AST/ALT /27 IU/L
ALP/GGT /76 IU/L Glucose mg/dL
BUN/Cr /0.79 mg/dL Prot/Alb /4.3 g/dL
Na/K/Cl /3.6/106 mmol/L Ca/Mg/P /2.9/2.1 mg/dL
T-Chol mg/dl CRP mg/dL
Urinalysis
Microscopy : WBC /HPF RBC /HPF
Protein(-) Occult blood(-) Nitrate(-)

9. Case 1
Initial chest PA

10. Case 1
Initial ECG

11. Initial problem list Case 1 Abdomen pain due to liver mass?
Known chronic hepatitis B

12. Initial assessment & plan
Case 1
Initial assessment & plan
A) Abdomen pain due to liver mass?
P) abdominal CT
abdominal sono
tumor marker (esp. AFP, PIVKAII)
EGD, colonoscopy, if needed
A) known chronic hepatitis B
P) viral marker
HBV DNA titer 확인

13. Viral marker & virus titer
Case 1
Viral marker & virus titer
HBs Ag/Anti-HBs Ab/Anti-HBc Ab (+/-/+)
Anti –HCV Ab (-)
HBeAg (+) HBeAB(-)
HBV PCR 정량 : 208,000 ul/mL (1,095,080 copies/mL)
AFB 3.8 ng/ml 13

14. Case 1
Liver CT

15. Case 1

16. Case 1
Liver MRI

17. Initial diagnosis Case 1 HCC
B-viral LC (Child A score 5, MELD score 7) 17

18. Case 1
Chest CT

19. Case 1
Bone scan

20. Case 1
Gastroscopy

21. Korean Liver Cancer Study Group

22. TNM - AJCC Stage I T1 N0 M0 55% 5 yr survival Stage II T2
Stage IIIA T3
16% 5 yr survival
IIIB T4
IIIC
Any T N1
Stage IV
Any N M1
T definitions
T1 – solitary nodule without vascular invasion
T2 – solitary tumor with vascular invasion or multiple nodules all <5cm
T3 – multinodular >5cm, or tumor with major vasculature invasion
T4 – Tumor with invasion of adjacent organs
N1 Regional lymph node metastasis / M1 Distant metastasis
The American Joint Committee on Cancer (AJCC) TNM staging system (identical to that of the Union Internationale Contre le Cancer [UICC]), was revised and simplified in 2002 (show table 1) [10]. This system recognizes the most important predictors of prognosis: presence of vascular invasion within the tumor [11,12], and firosis in the underlying liver [13-16]. Compared to the 1997 staging system, it recognizes that although tumor size and number may predict the presence of vascular invasion, solitary tumors as large as 5 cm without vascular invasion have the same prognosis as small (<2 cm) solitary tumors
AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, Inc 22

23. Fig. 1. Barcelona Clinic Liver Cancer (BCLC) staging classification and treatment schedule. Stage 0, Patients with very early
hepatocellular carcinoma (HCC) are optimal candidates for resection. Stage A, Patients with early HCC are candidates for
radical therapies (resection, liver transplantation, or percutaneous treatments). Stage B, Patients with intermediate HCC may
benefit from chemoembolization. Stage C, Patients with advanced HCC may receive new agents in the setting of randomized
controlled trials (RCTs). Stage D, Patients with endstage disease will receive symptomatic treatment. PST, performance status
test; CLT/LDLT, cadaveric liver transplantation/living-donor liver transplantation; PEI/RF, percutaneous ethanol injection/
radiofrequency thermal ablation; ttc, treatment; yr, year. Modified from Llovet et al.,4 with permission
N1 Regional lymph node metastasis / M1 Distant metastasis 23

24. Case 1
TACE 시행

25. Case 1
6월 9일 op 전 liver CT

26. Case 1
6월 10일 Lt. segmentectomy

29. Final diagnosis Case 1 HCC stage I s/p TACE #1 s/p Lt. segmentectomy
B-viral LC child A
MELD score 7

30. Case Presentation Case 2 11952299 39/M 유 O 복 Adm.2008.2.27 C.C.
RUQ pain onset) 내원 한달 전
P.I.
과거 medical history 없는 환자로 한달 전 RUQ pain있었으나 특별한 치료없이 저절로 호전됨.
최근 4일 전 트럭에서 낙상 후 상기 증세 재발되어 외부병원 방문. 시행한 복부 CT 에서 liver mass 발견되어 본원 방문 30

31. PMHx. Case 2 DM/HTN/Tuberculosis/Hepatitis (-/-/-/-) Op Hx (-)
Drug Hx : (-)
Alcohol (+) : 소주 ½병 /d X 10년
smoking (+) : 7pack/year X 14년
FHx : 어머니, 여동생이 HCC로 사망 31

32. Review of Systems Case 2 G/A) fatigue (-) weight change (-)
fever (-) chill (-) sweating (-)
Skin) pigmentation (-) rash (-) itching (-)
H& N) headache (-) trauma (-) stiffness (-)
Eye/ ENT) diplopia (-) hearing loss(-)
nasal obstruction (-) dryness(-)
soreness(-) hoarseness(-)
Respiratory) cough (-) sputum (-) dyspnea(-) hemoptysis(-) 32

33. Case 2 Cardiac) palpitation (-) dyspnea(-) chest pain (-) orthopnea(-)
G-I) A/N/V/D/C(-/-/-/-/-)
abd pain (+) : RUQ jaundice (-) melena (-)
Renal & Urinary) dysuria (-) hematuria (-) polyuria (-)
incontinence (-) nocturia (-) anuria(-) 33

34. Physical Examination Case 2 Alert consciousness
Vital sign) 130/80mmHg – 64회/분 – 20회/분 – 36.5℃
Height : 178.7cm weight: 72.3Kg
General appearance
Alert consciousness
Acute ill-looking appearance
Skin
Rash (-) Pigmentation (-)
Head and Neck
Neck LN enlargement (-/-)
Neck vein engorgement (-/-)
Thyroid enlargement (-)
Eyes and ENT
Isocoric pupil with PLR(++/++)
Whitish sclera, Pinkish conjunctiva 34

35. Case 2 Clear breathing sound without wheezing
Chest
Clear breathing sound without wheezing
Regular heart beat without murmur
Abdomen
Soft and flat abdomen
Abdominal tenderness
No rebound tenderness
No palpable abdominal mass
Normoactive bowel sound
No hepatosplenomegaly
Back and extremities
CVA tenderness(-/-)
Peripheral pitting edema(-/-) 35

36. Initial lab findings Case 2 PT CBC/DC
5280/mm3 – 14.3 g/dL – 43.1% - 178k (seg : 51.4 %) INR:1.01 PT
Chemistry
TB/DB /0.2mg/dL AST/ALT 62/50 IU/L
ALP/GGT /88 IU/L Glucose mg/dL
BUN/Cr /0.8 mg/dL Prot/Alb /3.8 g/dL
Na/K/Cl /3.4/102 mmol/L Ca/Mg/P /2.9/4.5 mg/dL
T-Chol mg/dl CRP mg/dL
Urinalysis
Microscopy : WBC /HPF RBC /HPF
Protein(-) Occult blood(-) Nitrate(-) 36

37. Case 2
Initial chest PA 37 37

38. Case 2
Initial ECG 38 38

39. Case 2
Initial problem list
RUQ pain
due to liver mass? 39

40. Initial assessment & plan
Case 2
Initial assessment & plan
A) RUQ pain due to liver mass
P) abdominal CT
abdominal sono
tumor marker (esp. AFP, PIVKAII) 40 40

41. Case 2 HBs Ag(+) Anti-HBc Ab (+) anti-HBs Ab (-) HBe Ag(+-) HBeAb (-)
Anti –HCV Ab (-) anti-HIV (-)
AFB ng/ml
CEA 1.04 ng/ml
ICGR 15 : 19% 41

42. Case 2
2월 27일 Liver CT

44. Case 2
Initial diagnosis
HCC with portal vein thrombus 44

45. Korean Liver Cancer Study Group

46. TNM - AJCC Stage I T1 N0 M0 55% 5 yr survival Stage II T2
Stage IIIA T3
16% 5 yr survival
IIIB T4
IIIC
Any T N1
Stage IV
Any N M1
T definitions
T1 – solitary nodule without vascular invasion
T2 – solitary tumor with vascular invasion or multiple nodules all <5cm
T3 – multinodular >5cm, or tumor with major vasculature invasion
T4 – Tumor with invasion of adjacent organs
N1 Regional lymph node metastasis / M1 Distant metastasis
The American Joint Committee on Cancer (AJCC) TNM staging system (identical to that of the Union Internationale Contre le Cancer [UICC]), was revised and simplified in 2002 (show table 1) [10]. This system recognizes the most important predictors of prognosis: presence of vascular invasion within the tumor [11,12], and firosis in the underlying liver [13-16]. Compared to the 1997 staging system, it recognizes that although tumor size and number may predict the presence of vascular invasion, solitary tumors as large as 5 cm without vascular invasion have the same prognosis as small (<2 cm) solitary tumors
AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, Inc 46

47. Fig. 1. Barcelona Clinic Liver Cancer (BCLC) staging classification and treatment schedule. Stage 0, Patients with very early
hepatocellular carcinoma (HCC) are optimal candidates for resection. Stage A, Patients with early HCC are candidates for
radical therapies (resection, liver transplantation, or percutaneous treatments). Stage B, Patients with intermediate HCC may
benefit from chemoembolization. Stage C, Patients with advanced HCC may receive new agents in the setting of randomized
controlled trials (RCTs). Stage D, Patients with endstage disease will receive symptomatic treatment. PST, performance status
test; CLT/LDLT, cadaveric liver transplantation/living-donor liver transplantation; PEI/RF, percutaneous ethanol injection/
radiofrequency thermal ablation; ttc, treatment; yr, year. Modified from Llovet et al.,4 with permission
N1 Regional lymph node metastasis / M1 Distant metastasis 47

49. Case 2
2월 29일 TACE 시행

50. Case 2
3월 3일 PET-CT 시행

51. Case 2

52. Case 2 3월 15일 입원 : Rt. portal vein embolization 위해 입원
portal vein thrombosis 심해 시행하지 못함

53. Case 2

54. Case 2
2008년 3월 25일 : Rt. lobectomy & caudate lobectomy

55. Case 2 55

56. Case 2 56

57. Case 2 57

58. Post op. Case 2 GS에서 복용 5-FU(Cotacil 100mg, Uracil 224mg) 2T tid
상황균사체(mezai 500mg) 2T tid

59. Case 2
4월 30일 GI 외래 방문
HBV PCR : positive 115,000ul/ml
604,900 copies/ml
Entecavir 0.5mg qd 복용중
5월 28일 부터 5-FU, 상황균사체 복용 중지

60. Case 2
Follow up liver CT (6/5)

61. Case 2

62. Final diagnosis Case 2 HCC stage IV s/p TACE#1
s/p Rt. lobectomy & caudate lobectomy
2. B-viral LC child A 62