2015.12.11 Liver Conference 소화기 센터 회의실

Case 1 History 11807662 이O복 F/61 64/F Alcoholic LC(child B 8, MELD 22)으로 본원 IG(pf.김병호) f/u, CKD(unknown cause)로 본원 IN(pf.임천규) f/u 중으로 2015.11.24 liver MR에서 2.9cm의 suggestive of early HCC소견보여 영상 진단 확인 및 향후 치료방침 결정 위해 선정함 토의 목적 : 영상소견 review 및 추후 치료방침 논의 DM (-), HTN (-) Alcohol Hx (+) 소주 1병 x 4회/주 Smoking Hx (+) ex-somker, 1x10 p-y

Underlying liver function and performance status Case 1 11807662 이O복 F/61 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh B, 8 MELD score 22 Esophageal varices - Ascites + Encephalopathy CBC/DC (2015.10.05) WBC (mm3) 7,190 Hb (g/dl) 8.1 PLT 65,000 PT (sec) 18.0 INR 1.50 Chemistry (2015.10.05) TB/DB (mg/dL) 2.01/- AST/ALT (IU/L) 44/13 ALP/rGT 294/105 Prot/Alb (g/dL) 7.7/3.1 BUN/Cr 27/2.3 Viral markers/ underlying liver disease HBV / HCV -/- HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol + Tumor markers (2015.08.05) AFP (ng/mL) 121.1 CEA (ng/mL) 6.55 PIVKA II (mAU/mL) - CA19-9 (U/mL) 17.23

Clinical Course Case 1 ’13.5 ’15.11 LIVER MR (2015.11.24) 11807662 이O복 F/61 ’13.5 ’15.11 Alcoholic LC Liver mass at S6/7 ‘14.6 ’14.9 ‘15.11 AFP 1.60 4.82 121.1 PIVKA II - LIVER MR (2015.11.24) A new visible nodule (2.9cm) at S6/7. --> suggestive of early HCC or high grade DN. Suggestive of AP shunts at both lobes. Liver cirrhosis. No significant change of multilocular cystic mass in the right ovary.

Case 2 History 11970021 안O성 55/M 55/M B-viral LC(child A 5, MELD 8) c esophageal varix s/p EVL #3(2015.12.9), HCC(LCSGJ stage II T2N0M0) s/p Lt. segmentectomy (2008.6) s/p RFA#1 s/p TACE #4 (2015.10.22)로 본원 IG(pf.김병호) f/u 하는 자로 2015.10.22 TACE #4 시행후 epigastric pain있어 익일 EGD에서 AGML 진단되어 high dose PPI 사용 후 증상 호전되어 퇴원한 Hx있음 AGML과 TACE와의 연관성 검토 위해 선정함 토의 목적 : 영상소견 review 및 추후 치료방침 논의 DM (+), HTN (+) Alcohol Hx (-) Smoking Hx (-)

Underlying liver function and performance status Case 2 11970021 안O성 55/M Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A, 5 MELD score 8 Esophageal varices + Ascites - Encephalopathy CBC/DC (2015.10.05) WBC (mm3) 2,080 Hb (g/dl) 13.5 PLT 42,000 PT (sec) 14.5 INR 1.13 Chemistry (2015.10.05) TB/DB (mg/dL) 0.99/- AST/ALT (IU/L) 29/24 ALP/rGT 78/69 Prot/Alb (g/dL) 7.5/4.4 BUN/Cr 11/1.0 Viral markers/ underlying liver disease HBV / HCV +/- HBeAg / HBeAb -/- Virus titer - Antiviral Tx Entecavir Alcohol Tumor markers (2015.08.05) AFP (ng/mL) 1.69 CEA (ng/mL) 3.26 PIVKA II (mAU/mL) 30 CA19-9 (U/mL) 2.00

Clinical Course Case 2 ’08.5 ‘10.4 ‘11.4 ‘12.3 ‘13.4 ‘15.10 11970021 안O성 55/M ’08.5 ‘10.4 ‘11.4 ‘12.3 ‘13.4 ‘15.10 CHB HCC s/p TACE #1 Esophageal Varix s/p EVL #1 s/p EVL #2 s/p TACE #2 New HCC S5 s/p RFA #1 New HCC S7/8 TACE #3 New HCC at S6 TACE #4 EGD : AGML ‘15.10 ‘14.9 13.8 11.4 10.11 08.5 AFP 3.48 1.20 2.79 24.03 1.99 3.80 PIVKA II 30 16 28 886 17 95 LIVER MR (2015.10.14) A HCC at S6 (1.4cm). Suggestive of no viable tumor at lipiodolized lesion of S8. Two small DNs or RNs at S8. No viable tumor at lipiodolized lesion of S4. No change of RF ablated lesion at segment 6. S/P left lateral segmentectomy.

Case 3 History 12410355 한O분 F/82 81/F DM, HTN local에서 f/u 하며, B-viral LC(child A 5, MELD 8), HCC(stage II, T2N0M0) s/p TACE #2(2015.7.14)로 본원 IG(pf.김병호) f/u 하는 자로 2015.12.1 f/u CT에서 viable tumor소견 보여 향후 치료방침 결정 위해 선정함 토의 목적 : 추후 치료방침 논의 DM (+), HTN (+) Alcohol Hx (-) Smoking Hx (-)

Underlying liver function and performance status Case 3 12410355 한O분 F/82 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A, 5 MELD score 8 Esophageal varices - Ascites Encephalopathy CBC/DC (2015.10.05) WBC (mm3) 5,550 Hb (g/dl) 11.7 PLT 154,000 PT (sec) 15.2 INR 1.20 Chemistry (2015.10.05) TB/DB (mg/dL) 0.65/- AST/ALT (IU/L) 23/12 ALP/rGT 77/- Prot/Alb (g/dL) 7.7/4.1 BUN/Cr 22/0.8 Viral markers/ underlying liver disease HBV / HCV +/- HBeAg / HBeAb -/+ Virus titer Antiviral Tx Entecavir Alcohol - Tumor markers (2015.08.05) AFP (ng/mL) 113.5 CEA (ng/mL) 2.02 PIVKA II (mAU/mL) 2149 CA19-9 (U/mL) 9.11

Clinical Course Case 3 ‘14.9 LIVER-TACE CT (2015.12.1) 12410355 한O분 F/82 ‘14.9 CHB 진단 Entecavir 복용 At local clinic HCC at S3 TACE #1 Liver abscess PCD insertion Viable tumor TACE #2 Viable tumor ’01 ’14.5 ’14.9 ‘15.6 ‘15.12 AFP - 2.09 11.52 128.6 113.5 PIVKA II 226 2336 2149 LIVER-TACE CT (2015.12.1) S/P partial lipiodolized HCC with increased size of viable portion at left lateral segment. Otherwise, no interval changes.

Case 4 History 11764134 양O웅 M/68 68/M DM, HTN, DM CKD로 local f/u 중 건강검진으로 시행한 Abd. US에서 liver mass진단되어 본원 IG로 refer되어 시행한 liver CT, MR상 r/o HCC S6/7로 RFA #1(2015.9.7) 시행한 자로 post-RFA CT에서 hepatic rupture with hematoma소견으로 seeding가능성에 대해 논의 위해 선정함 토의 목적 : post-RFA rupture의 seeding가능성 논의 DM (+), HTN (+) Alcohol Hx (+) : 소주 1~2병 x 4~5회/주 Smoking Hx (+) : ex-smoker, 1x20 p-y

Underlying liver function and performance status Case 4 11764134 양O웅 M/68 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A, 5 MELD score 8 Esophageal varices - Ascites Encephalopathy CBC/DC (2015.10.05) WBC (mm3) 8,280 Hb (g/dl) 13.7 PLT 152,000 PT (sec) 12.5 INR 0.93 Chemistry (2015.10.05) TB/DB (mg/dL) 0.70/- AST/ALT (IU/L) 41/15 ALP/rGT 74/107 Prot/Alb (g/dL) 7.9/4.4 BUN/Cr 26/1.5 Viral markers/ underlying liver disease HBV / HCV -/- HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol + Tumor markers (2015.08.05) AFP (ng/mL) 2.68 CEA (ng/mL) 5.28 PIVKA II (mAU/mL) 19 CA19-9 (U/mL) -

Clinical Course Case 4 ’15.9 HCC at S6/7 RFA #1 post-RFA Hematoma 11764134 양O웅 M/68 ’15.9 HCC at S6/7 RFA #1 post-RFA Hematoma ’15.9 AFP 2.82 PIVKA II 19 Liver MR (2015.12.1) Post RFA state with surrounding hematoma. IHD dilatation at S6. Liver cirrhosis.

Case 5 History 10918020 박O환 M/79 79/M. DM,HTN으로 IE f/u 중이며 14년전 MUO of Lt. neck LN s/p RND, Lt진단 받았던 자로 2015.7월 TA로 인한 Lt. tibial Fx. 로 정형외과 입원하여 수술을 위한 검사 중에 발견된 3개의 hepatic mass로 op delay되었으며 Liver MR 진행 후 conservative Mx. 중 hepatorenal syndrome환자 사망함 영상 review위해 선정함. 토의 목적 : 영상 review DM (+), HTN (+) MUO(SqCC) of Lt. neck LN s/p RND Lt(2002.9) Alcohol Hx (+) : 현재 금주, 20년 전 소주 2병, daily Smoking Hx (+) : ex-smoker, 1x30 p-y B-viral LC c esophageal varix, HCC 환자로 s/p TACE #5(2014.11) 등 여러 번의 TACE 시행으로 혈관상태 좋지 못해 우측하엽에 2015.4월 RT 시행한 분임. 2015년 8월 f/u CT 상 우측상부에 viable tumor 가 커져 RT 재치료 고려하고 있으나pancytopenia 등 부작용이 우려되는 환자로 향후 치료방침 논의 위해 선정함

Underlying liver function and performance status Case 5 10918020 박O환 M/79 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh - MELD score Esophageal varices Ascites Encephalopathy CBC/DC (2015.10.05) WBC (mm3) 6460 Hb (g/dl) 15.4 PLT 146,000 PT (sec) 14.2 INR 1.10 Chemistry (2015.10.05) TB/DB (mg/dL) 1.70/- AST/ALT (IU/L) 50/42 ALP/rGT 160/98 Prot/Alb (g/dL) 7.4/4.0 BUN/Cr 13/0.7 Viral markers/ underlying liver disease HBV / HCV -/- HBeAg / HBeAb - Virus titer Antiviral Tx Alcohol Tumor markers (2015.08.05) AFP (ng/mL) 18.17 CEA (ng/mL) 22.19 PIVKA II (mAU/mL) 41 CA19-9 (U/mL) 2.00

Focal bulging at Lt. adrenal gland 10918020 박O환 M/79 Case 5 Clinical Course 15.07 15.08 ‘15.11 <Abd CT> 3 hepatic masses. Focal bulging at Lt. adrenal gland <Liver MR> Hepatic masses at S7/8 and Lt. lateral segment Hepatorenal syndrome →expire 2015.08 AFP 18.17 PIVKA II 41 Liver MR(2015.11.2) Aggravation of cholangiocarcinoma. a/w multiple intrahepatic metastasis. a/w ischemic change of S2. Multiple conglomerated metastatic LNs at porta hepatis, portocaval, aortocaval, left paraaortic areas. a/w encasement of celiac trunk. Aggravation of left adrenal metastasis. R/O left abdominal metastasis. Large amount of ascites. Multiple tiny nodules in visible lungs, R/O lung metastasis. Clinical course보시면 c-viral LC 환자로 HCC로 TACE 8차까지 시행하고 f/u 중 2013년 6월 Liver CT 상 viable HCC 소견 보여 RTx 시행 후 9월 26일 liver MR 시행하였으며 10.21 APN으로 입원 치료 중 Brain MR 상 multiple bone metastasis 확인되었습니다. Alfa-fetoprotein 은 다음과 같이 지속적인 상승 소견 보이고 있고 2013. 3월 시행한 PET CT 상에서는 distant metastasis는 보이지 않았습니다.

Case 6 History 11790917 최O윤 M/21 21/M Pulmonary atresia 로 본원 소아과 f/u 중인 자로 r-GT 상승으로 시행한 abd.US상 r/o 2nd cirrhosis 소견 보여 IG로 refer되었으며 liver CT상 cirrhosis RA enlargement소견 보여 Cardiac cirrhosis 관련 영상 검토 위해 선정함 토의 목적 : cardiac cirrhosis 가능성에 대해 영상 검토 DM (-), HTN (-) Alcohol Hx (-) Smoking Hx (-)

Underlying liver function and performance status Case 6 11790917 최O윤 M/21 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A, 5 MELD score 9 Esophageal varices - Ascites Encephalopathy CBC/DC (2015.10.05) WBC (mm3) - Hb (g/dl) PLT PT (sec) 13.8 INR 1.06 Chemistry (2015.10.05) TB/DB (mg/dL) 1.63/0.51 AST/ALT (IU/L) 27/30 ALP/rGT 74/92 Prot/Alb (g/dL) 8.0/4.8 BUN/Cr 13/0.8 Viral markers/ underlying liver disease HBV / HCV -/- HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol Tumor markers (2015.08.05) AFP (ng/mL) 1.12 CEA (ng/mL) - PIVKA II (mAU/mL) CA19-9 (U/mL)

<Abd. US, liver CT> Case 6 Clinical Course 11790917 최O윤 M/21 ’15.8 Elevated rGT <Abd. US, liver CT> Liver cirrhosis ’15.8 AFP 1.12 PIVKA II - Liver CT (2015.8.26) Liver cirrhosis. RA enlargement. Mesenteric LNs enlargement.

Case 7 History 10206962 이O영 M/78 78/M Alcoholic LC(child A 5, MELD 7) c esophageal varix, HCC s/p TACE #1(2013), RFA #1(2013)으로 본원 IG (pf.김병호) f/u 중인 자로 f/u CT상 viable tumor관찰되지 않으나 f/u lab상 PIVKA-II 수치 증가하여 영상 재검토 위해 선정함 토의 목적 : 영상 재검토 DM (-), HTN (-) Alcohol Hx (+) : 소주 1.5병 x 7회/주 Smoking Hx (+) : 0.5 x 55 p-y

Underlying liver function and performance status Case 7 10206962 이O영 M/78 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A, 5 MELD score 7 Esophageal varices + Ascites - Encephalopathy CBC/DC (2015.10.05) WBC (mm3) 5280 Hb (g/dl) 14.4 PLT 106,000 PT (sec) 15.2 INR 1.20 Chemistry (2015.10.05) TB/DB (mg/dL) 1.55/- AST/ALT (IU/L) 45/29 ALP/rGT 147/98 Prot/Alb (g/dL) 6.6/3.5 BUN/Cr 11/1.0 Viral markers/ underlying liver disease HBV / HCV -/- HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol + Tumor markers (2015.08.05) AFP (ng/mL) 7.01 CEA (ng/mL) 5.80 PIVKA II (mAU/mL) 165 CA19-9 (U/mL) 7.35

Clinical Course Case 7 ’04 ‘05 ‘13.4 ‘13.11 Duodenal Alcoholic LC 10206962 이O영 M/78 ’04 ‘05 ‘13.4 ‘13.11 Alcoholic LC c esophageal varix Duodenal diverticulum perforation early HCC at S5 TACE #1 Viable tumor RFA #1 ’04 ’05 ’08 ‘13.4 ‘14.3 ‘15.9 AFP 6.13 5.28 6.71 4.98 4.15 7.01 PIVKA II - 81 19 165 Liver-TACE CT (2015.9.11) No significant interval change of RFA area without viable tumpr portion at S5. No change of focal enhancing lesion at S6 subcapsular portion, possible benign lesion. Suggestive of chronic cholecystitis. Mild IHD dilatation..

Case 8 History 11826126 배O국 M/38 38/M 초등학교때 HBV 감염자라는 이야기 들었으나 특별한 evaluation 하지 않고 지내던 자로 11/25일 경부터 abd.pain있어 성바오로 병원에 입원(11/29~12/2)하여 시행한 검사 상 liver mass(r/o HCC, r/o intrahepatic cholangiocarcinoma)소견 있어 F/E위해 본원으로 refer되어 입원 중이며 op 예정인 자로 영상학적 검토 위해 선정함 토의 목적 : 영상 검토 DM (-), HTN (-) Alcohol Hx (+) : 소주 0.5병 x 5회/주 Smoking Hx (+) : 1 x 20 p-y

Underlying liver function and performance status Case 8 11826126 배O국 M/38 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh - MELD score Esophageal varices Ascites Encephalopathy CBC/DC (2015.10.05) WBC (mm3) 5,810 Hb (g/dl) 15.7 PLT 195,000 PT (sec) 12.6 INR 0.94 Chemistry (2015.10.05) TB/DB (mg/dL) 0.36/- AST/ALT (IU/L) 48/73 ALP/rGT 92/158 Prot/Alb (g/dL) 7.9/4.4 BUN/Cr 10/0.8 Viral markers/ underlying liver disease HBV / HCV +/- HBeAg / HBeAb -/- Virus titer 23,700,000 Antiviral Tx Entecavir Alcohol + Tumor markers (2015.08.05) AFP (ng/mL) 469.4 CEA (ng/mL) 3.11 PIVKA II (mAU/mL) 2157 CA19-9 (U/mL) <2.50

r/o cholangiocarcinoma Case 8 Clinical Course 11826126 배O국 M/38 ‘15.11 Liver mass r/o HCC r/o cholangiocarcinoma ’15.11 AFP 469.4 PIVKA II 2157 Liver MR (2015.11.30, 외부) Hepatic mass at S5/8 (about 7.2x6.4x7.4cm) --> Suggestive of malignant tumor, R/O intrahepatic cholangiocarcinoma, R/O atypical HCC.