2012. 10. 12 Liver Conference 점상출혈 소화기 센터 회의실

History <Brief History> Case 1 12302486 이O욱 M/48 History <Brief History> 2012 건강검진에서 HBV carrier, Abdomen sono에서 liver mass 소견 보임.  본원 소화기내과 방문해서 2012.9.27 Liver CT 시행 해서 HCC at S8 r/o hypervascular metastasis (neuroendocrine tumor or hepatic adenomoa) 보임. 2012.10.9 Liver MRI 시행 함. 2012.10.9 Liver MRI 시행소견 및 향후 치료 방향 논의. DM/HTN/TBc/Hepatitis(+/-/-/+) Op Hx(-)

Last Lab. Finding Case 1 CBC/DC WBC (mm3) 6230 Hb (g/dl) 16.0 PLT 199K 12302486 이O욱 M/48 Last Lab. Finding CBC/DC WBC (mm3) 6230 Hb (g/dl) 16.0 PLT 199K PT (sec) 14.9 INR 1.17 Viral markers Anti-HCV Ab (-) HBsAg (+) HBeAg Anti-HBe Ab Antiviral Tx Chemistry T Bil. (mg/dL) 0.4 AST/ALT (IU/L) 24/40 ALP/rGT 103/165 Prot/Alb (g/dL) 7.5/4.1 BUN/Cr 11/0.7 LC & Stage Child-Pugh A(5) MELD score 5.53 EV - ascites encephalopathy Performance status Grade Tumor markers AFP (ng/mL) 4.19

Case 1 12302486 이O욱 M/48 Clinical Course 2012.08 2012.09.27 2012.10.09 Abdomen sono Liver CT Liver MRI Hepatic mass HCC at S8 r/o hypervascular metastasis (neuroendocrine tumor or hepatic adenomoa) 2012.09 AFP 4.19 Liver CT (2012.09.27) : Hepatocellular carcinoma at S8(about 2.6cm in size), r/o hypervascular metastasis such as neuroendocrine tumor or hepatic adenoma. Focal ill-defined low density lesion on S5 are not against with eosinophilic infiltration, sclerosed hemangioma etc. Low density lesions at both hepatic lobes, too small to characterize. Rec) liver MRI

History <Brief History> Case 2 11418857 전O규 M/65 History <Brief History> Heavy alcoholics로 2009본원 소화기내과에서 alcoholic LC, HCC 진단 TACE#1 ~ #3 (2009.02 ~ 09) 시행 함. f/u Liver CT에서 incomplete lipiodolization 소견 보여 2009.10 본원 외과에서 seg 8 segmentectomy c cholecystectomy 시행 함. 그 후 HCC recur 소견 보여서 2011.4 월 ,8월 TACE #5, #6 시행 함. f/u liver MR 상 medial and lateral segment에서 Three viable HCC소견 보여 RFA 2012.04.03일 시행 함. f/u liver MRI 2012.07에 시행한 것에서 Suggested small sized HCCs (at the caudate lobe and segment 4) 보여 3개월 뒤에 짧게 f/u 하기로 결정 함. 10월 2일 Liver MRI에서 Suggested a large HCC at the inferior aspect to resection margin, Increased size of three nodular HCCs (at caudate lobe, segment 4 and 8) 소견 보여서 TACE #7 (2012.10.10) 시행 함. 2012년 10월 2일 Liver MRI 소견과 향후 치료 방향에 대해서 논의 DM/HTN/TBc/Hepatitis(-/-/-/+) Op Hx(-) Personal Hx: Smoking (-) Alcohol (+) : daily 소주 1병씩 마심. 2년전 금주 함.

Last Lab. Finding Case 2 CBC/DC WBC (mm3) 6410 Hb (g/dl) 14.3 PLT 176K 11418857 전O규 M/65 Last Lab. Finding CBC/DC WBC (mm3) 6410 Hb (g/dl) 14.3 PLT 176K PT (sec) 13.6 INR 1.05 Viral markers Anti-HCV Ab (-) HBs Ag HBs Ab Chemistry T/D Bil. (mg/dL) 0.70/0.28 AST/ALT (IU/L) 43/49 ALP/rGT 99/115 Prot/Alb (g/dL) 7.5/4.0 BUN/Cr 13/0.7 LC & Stage Child-Pugh A(5) MELD score 2.35 EV - ascites encephalopathy Performance status Grade Tumor markers AFP (ng/mL) >60500 PIVKA Ⅱ 18056

Case 2 11418857 전O규 M/65 Clinical Course 09.02 09.06 09.09 09.10 11.04 11.08 12.04 HCC TACE #1 Recurred TACE #2 TACE #3 GS op TACE #5 TACE #6 Recurred HCC Remained HCC Recurred HCC Recurred HCC Liver MRI - Three viable HCCs RFA #1 09년10월 10년01월 10년12월 11년03월 11년11월 12년02월 12년07월 12년10월 AFP 964.1 3.76 126.8 12.71 51.15 162 2471 >60500 PIVKA Ⅱ 54 15 78 2 35 136 656 18056 12.07 12.10 Liver MRI Liver MRI (2012.10.02) : Suggested a large HCC at the inferior aspect to resection margin with tumor thrombosis within the left and right portal vein. Increased size of three nodular HCCs at caudate lobe, segment 4 and 8. Stable state of RFA site on the left medial and lateral segment. Liver MRI 2009.9 right lobe에 2.7cm and 2.8cm 크기의 2개의 mass TACE #7 Small HCCs (caudate lobe & Seg 8) AP shunt or early HCC (Seg 8)

History <Brief History> Case 3 10599691 문O욱 M/78 History <Brief History> 2009.9월 B-viral LC, HCC 진단 후 entecavir 1Tgd 복용 중이며 2009.10.15 TACE #1 시행 함. 2012.1.26 까지 TACE #6, 12.3.7 RFA #1 시행 받은 환자 2012.6.8 f/u MR 에서 HCC 의심되는 병변 보여 2012.6.26 TACE #7 시행 함.     2012.9.27 f/u liver CT상 recurrent atypical HCC 소견 보여 2012.10.09 TACE #8 시행 함. 2012.9.27 f/u liver CT 소견 및 향후 치료 방향 DM/HTN/TBc/Hepatitis(-/-/-/+) B-viral LC (+) : baraclude 0.5mg qd Op Hx(+) 2006년 Lt lower lobe segmentectomy d/t lung cancer (SqCC, stage Ia) 1999년 LAR d/t rectal cancer

Last Lab. Finding Case 3 CBC/DC WBC (mm3) 8210 Hb (g/dl) 10.7 PLT 198K 10599691 문O욱 M/78 Last Lab. Finding CBC/DC WBC (mm3) 8210 Hb (g/dl) 10.7 PLT 198K PT (sec) 14.9 INR 1.19 Viral markers Anti-HCV Ab (-) HBsAg (+) HBeAg Anti-HBe Ab Antiviral Tx Tumor markers AFP (ng/mL) 50.55 PIVKA Ⅱ 43 Chemistry T/D Bil. (mg/dL) 0.40/0.16 AST/ALT (IU/L) 23/12 ALP/rGT 91/75 Prot/Alb (g/dL) 7.2/3.7 BUN/Cr 21/1.0 LC & Stage Child-Pugh A(5) MELD score 3.98 EV - ascites encephalopathy Performance status Grade 1

Case 3 10599691 문O욱 M/78 Clinical Course 09.10 10.10 11.01 11.05 11.08 11.01 12.02 Liver CT HCC, Rt lobe TACE #1 HCC ,S6 TACE #2 Viable tumor , S6 TACE #3 Liver MRI Hypovascular HCC, S3 HCC,S7 TACE #4 S3 HCC, PS TACE #5 TACE #6 Viable tumor RFA#1 09년10월 10년03월 10년10월 11년03월 11년06월 11년10월 12년05월 12년9월 AFP 9.22 176.8 271.6 388 26.2 3.97 7.55 50.55 PIVKA Ⅱ 47 48 33 54 3.96 44 7 43 12.6 12.9 Liver CT Recurrent HCC TACE #7 Liver CT (2012.09.27) : New hypoattenuated nodules ranging from 1.6 cm to 3 cm in long diameter at left lateral segment may suggest metastasis from rectal cancer?, recurrent atypical HCC or CHCC Relipiodolization of HCC in right PI segment No interval changes in peribiliary cysts with left lateral duct dilatation Liver CT Recurrent HCC 2009.9 right lobe에 2.7cm and 2.8cm 크기의 2개의 mass TACE #8

History <Brief History> Case 4 11776576 정O자 F/54 History <Brief History> 2008년 B-viral LC, HCC 진단받고 Baraclude 0.5T qd 지속적으로 복용 중인자 TACE #1 ~ #7 (2008.5 ~ 2012.3.9) 시행 받은 자 2012.05.23 liver MRI에서 Recurred HCC 소견 보여 TACE #8 (2012.5.23) 시행 그 후 2012.09.18 Liver CT에서 remained HCC 소견 보여서 TACE #9(2012.10.10) 시행 함. 2012.10.10 TACE #9 Lipiodolization 여부와 시행 소견 및 향후 치료 방향 DM/HTN/TBc/Hepatitis(-/-/-/+) B-viral LC (+) : baraclude 0.5mg qd Op Hx(+) 2011. cataract op

Last Lab. Finding Case 4 CBC/DC WBC (mm3) 4150 Hb (g/dl) 10.5 PLT 51K 11776576 정O자 F/54 Last Lab. Finding CBC/DC WBC (mm3) 4150 Hb (g/dl) 10.5 PLT 51K PT (sec) 16.3 INR 1.32 Viral markers Anti-HCV Ab (-) HBsAg (+) HBeAg Anti-HBe Ab Antiviral Tx Tumor markers AFP (ng/mL) 8.46 PIVKA Ⅱ 35 Chemistry T/D Bil. (mg/dL) 1.06/0.44 AST/ALT (IU/L) 41/20 ALP/rGT 98/32 Prot/Alb (g/dL) 7.6/3.9 BUN/Cr 8/0.5 LC & Stage Child-Pugh A(5) MELD score 7.01 EV - ascites encephalopathy Performance status Grade

Case 4 11776576 정O자 F/54 Clinical Course 08.05 09.06 10.12 11.03 11.05 11.11 12.03 HCC TACE #1 Recurred TACE #2 TACE #3 TACE #4 TACE #5 TACE #6 Recurred HCC Recurred HCC Recurred HCC Recurred HCC Recurred HCC TACE #7 08년04월 09년03월 09년06월 10년01월 11년03월 11년09월 12년05월 12년9월 AFP 7.16 5.76 5.68 5.71 10.05 4.67 6.41 8.46 PIVKA Ⅱ 30 28 2 9 35 12.5 12.9 Liver MRI Recurrent HCC TACE #8 Liver CT (2012.09.18) : Incomplete lipiodolization of HCC at right PS segment with partial lipiodol uptake. Liver cirrhosis with collateral vessels. No change of splenomegaly and GB stones. Scanty pelvic ascites. Liver CT Remained HCC 2009.9 right lobe에 2.7cm and 2.8cm 크기의 2개의 mass TACE #9