2016.03.18 Liver Conference 소화기 센터 회의실

Case 1 History 12410355 한O분 F/82 82/F. DM, HTN 있어 local med 중이며 HCC(mUICC stage III, T3N0M0) s/p TACE #2(15.07.14) , B-viral LC(Child A(5), MELD 11)로 본원 소화기내과(Pf. 김병호) 외래 f/u 중인 환자로 f/u 영상소견에서HCC exophytic growing 소견 보여 치료방침 결정 위해 선정함. 토의 목적 : 향후 치료방침 논의 DM (+), HTN (+) Alcohol Hx (-), Smoking Hx (-)

Underlying liver function and performance status Case 1 12410355 한O분 F/82 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A (5) MELD score 11 Esophageal varices - Ascites + Encephalopathy CBC/DC (2016.02.25) WBC (mm3) 6,050 Hb (g/dl) 10.6 PLT 185,000 PT (sec) 15.2 INR 1.20 Chemistry (2016.02.25) TB/DB (mg/dL) 0.46/- AST/ALT (IU/L) 27/14 ALP/rGT 58/62 Prot/Alb (g/dL) 6.2/3.3 BUN/Cr 20/0.8 Viral markers/ underlying liver disease HBV / HCV +/- HBeAg / HBeAb -/+ Virus titer not detected Antiviral Tx entecavir Alcohol - Tumor markers (2015.12.08) AFP (ng/mL) 113.5 CEA (ng/mL) 2.02(14.09) PIVKA II (mAU/mL) 2149 CA19-9 (U/mL) 9.11(14.09)

Clinical Course Case 1 ’14 ’15 ‘16.02 Liver CT (2016.02.17) 12410355 한O분 F/82 ’14 ’15 ‘16.02 B-viral LC, HCC TACE #1(14.05) 시행 f/u Liver CT 상 viable HCC in Lt lat seg 소견 TACE #2(15.07) 시행 Dyspnea로 ER 내원 → anemia(Hb 6.1) EGD : Isolated gastric varix CFS : colonic polyp ’14.05 ‘15.06 ‘15.12 AFP 2.09 128.6 113.5 PIVKA II 226 2336 2149 Liver CT (2016.02.17) Increased size of viable portion in left lateral segment with partial lipiodolized HCC. a/w fluid collection along superior and left margin of HCC. Scanty amout of pelvis ascites. No visible of bilobulated heterogeneously enhancing mass in anterior pelvic area. Otherwise, no interval changes.

Case 2 History 12253555 김O이 F/64 64/F. DM, HTN Hx 있으며 B-viral LC (Child A(6), MELD 7) c EV s/p EVL #2(15.08.04), HCC(mUICC stage II, T2N0M0) s/p RFA #1(12), s/p TACE #5(15.12.10) 시행 후 외래 f/u 중인 자로 f/u liver MRI 상 Slightly increased size of a suggested HCC at Rt lobe dome 소견 보여 영상검토 및 치료방침 결정 위하여 선정함. 토의 목적 : 영상 검토 및 향후 치료방침 논의 DM (+), HTN (+) Alcohol Hx (-), Smoking Hx (-)

Underlying liver function and performance status Case 2 12253555 김O이 F/64 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh A (6) MELD score 7 Esophageal varices + Ascites - Encephalopathy CBC/DC (2016.01.05) WBC (mm3) 3,680 Hb (g/dl) 12.0 PLT 97,000 PT (sec) 14.7 (‘15.12) INR 1.15 (‘15.12) Chemistry(2016.01.05) TB/DB (mg/dL) 0.69/- AST/ALT (IU/L) 29/21 ALP/rGT 73/78 Prot/Alb (g/dL) 7.6/4.1 BUN/Cr 14/0.5 Viral markers/ underlying liver disease HBV / HCV (+/-) HBeAg / HBeAb (-/-) Virus titer not detected Antiviral Tx entecavir Alcohol - Tumor markers (2015.11.03) AFP (ng/mL) 8.34 CEA (ng/mL) 1.03 PIVKA II (mAU/mL) 20 CA19-9 (U/mL) 3.17

Clinical Course Case 2 ‘08 ’12 ’13 ‘14 ‘15 Liver MR(2015.11.03) 10259334 조O복 F/57 Clinical Course 12253555 김O이 F/64 ‘08 ’12 ’13 ‘14 ‘15 B-viral LC 진단 (경상대) Entecavir 복용 Liver MRI 상 multiple HCC → TACE #1(‘12.02) 시행 Anemia → EGD 상 high risk → 예방적 EVL #1 (‘13.02) 시행 Liver MR 상 early HCC(S6/7) → TACE #3(‘14.07) 15.01 EGD 상 High risk → EVL #2(‘15.08) Liver MRI 상 HCC(S8) → TACE #5(‘15.12) f/u Liver CT 상 HCC(S7) → TACE #2(‘12.06) 시행 Liver MRI 상 HCC(S6) → TACE #4(‘14.10) f/u Liver MR 상 HCC(S6) → RFA #1(‘12.08) 시행 ’12.02 ‘12.08 ’14.04 ‘14.10 ‘15.07 ‘15.11 AFP 11.37 11.20 9.68 9.76 8.13 8.34 PIVKA II - 16 18 27 20 Liver MR(2015.11.03) Slightly increased size of a suggested HCC at right lobe dome. Equivocal change of a fat containing nodule at S6/7. No viable tumor tumor at lipiodolized HCC at posterior aspect of S6. Post-RFA necrosis without viable tumor at S6. Liver cirrhosis.

Case 3 History 11628736 황O진 M/77 77/M. Cryptogenic LC(Child A (5), MELD 9) c EV로 본원 IG (Pf.심재준) f/u 하는 자로 2016.01.19 Liver biopsy 시행 후 HCC 진단(mUICC stage IVa, T3N1M0)받은 자로 영상 소견 및 조직검사 결과 리뷰, 향후 치료 방침 논의 위해 선정함. 토의 목적 : 영상 소견 및 조직검사 review, 향후 치료 방침 결정 위해 선정 DM (-), HTN (-) Alcohol Hx (-) Smoking Hx (-) : 과거흡연 1 x 30 PY

Underlying liver function and performance status Case 3 11628736 황O진 M/77 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 (2016.02.15) WBC (mm3) 17,580 Hb (g/dl) 11.2 PLT 270,000 PT (sec) 14.4 INR 1.12 Chemistry (2016.02.15) TB/DB (mg/dL) 0.39/- AST/ALT (IU/L) 38/27 ALP/rGT 151/81 Prot/Alb (g/dL) 6.0/3.1 BUN/Cr 25/0.9 Viral markers/ underlying liver disease HBV / HCV -/- HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol Tumor markers (2016.01.04) AFP (ng/mL) 3.15 CEA (ng/mL) 2.23 PIVKA II (mAU/mL) 16 CA19-9 (U/mL) 2.00

Glypican3(+) Glutamine synthetase(+) CK7(-) CK20(-)

r/o cholangiocarcinoma Case 3 Clinical Course 11628736 황O진 M/77 ‘13 ‘16.01 AP sono 상 r/o LC EGD 상 EV 확인 AP CT 상 hepatic mass Liver CT 상 r/o HCC r/o cholangiocarcinoma Liver Bx 시행 : HCC Liver CT (2016.01.07) HCC at S5 with direct invasion of anterior branch of right PV. a/w multiple LNs metastases.

Case 4 11143669 조O향 F/67 History 67/F. B-viral LC(Child A(5), MELD 7)로 본원IG(Pf.김병호) f/u 하던 중 Liver CT 상 hepatic mass at S6(4.3cm) 보여 Lap posterior sectionectomy(‘15.12.29) 시행 후 biopsy 결과 HCC 확인되었고 최근 Liver MR(‘16.02)에서 arterial enhancing lesion 소견은 없으나 복강 내 LN가 큰 변화 없이 계속 관찰되어 영상학적 검토 위하여 선정함. 토의 목적 : 영상의학적 검토 DM (-), HTN (+) Alcohol Hx (-), Smoking Hx (-)

Underlying liver function and performance status Case 4 11143669 조O향 F/67 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 (2016.03.08) WBC (mm3) 7,000 Hb (g/dl) 14.6 PLT 176,000 PT (sec) 13.1 INR 1.02 Chemistry (2016.03.08) TB/DB (mg/dL) 0.80/- AST/ALT (IU/L) 41/25 ALP/rGT 75/- Prot/Alb (g/dL) 8.0/4.2 BUN/Cr 16/0.5 Viral markers/ underlying liver disease HBV / HCV +/- HBeAg / HBeAb -/- Virus titer Not detected Antiviral Tx entecarvir Alcohol - Tumor markers (2016.03.08) AFP (ng/mL) 55.77 CEA (ng/mL) 1.07 PIVKA II (mAU/mL) 24 CA19-9 (U/mL) 7.73

Lap posterior sectionectomy Case 4 Clinical Course 11143669 조O향 F/67 ‘13 ‘15.12 ‘16 B-viral LC Liver CT 상 hepatic mass at S6(4.3cm) Lap posterior sectionectomy (‘15.12.29) 시행 AFP mild elevation No HCC recur Equivocal change of LN ’16.01 ‘16.03 AFP 43.56 55.77 PIVKA II 30 24 Liver MR (2016.02.29) S/P posterior sectionectomy and cholecystectomy. - no abnormal finding at op bed. No evidence of arterial enhancing lesion in the liver. Liver cirrhosis. Slightly improved mild dilatation of CBD without definite intraluminal lesion. No change of tiny BK cysts. Equivocal change of borderilne porta hepatis, portocaval, and paraaortic LNs.

Case 5 11252880 윤O숙 F/72 History 72/F. DM, HTN, old CVA Hx 있으며 내원 1주 전부터 시작된 fever, RUQ pain 주소로 타병원 방문하여 시행한 Abd CT 결과 IHD dilation 보이고 LFT 상승하여 r/o acute cholangitis, r/o Klatskin tumor imp 하에 본원 IG(Pf.동석호) 외래 통해 입원하여 Klatskin tumor(Bismuth type IIIb) 진단 후 GS 협진하여 수술 계획 중인 자로 수술 관련 향후 치료방침 논의 위해 선정함. 토의 목적 : 향후 치료방침 결정 DM (+), HTN (+) Alcohol Hx (-), Smoking Hx (-)

Underlying liver function and performance status Case 5 11252880 윤O숙 F/72 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh - MELD score Esophageal varices Ascites Encephalopathy CBC/DC (2016.03.14) WBC (mm3) 7,650 Hb (g/dl) 10.2 PLT 348,000 PT (sec) 12.8 INR 0.99 Chemistry (2016.03.14) TB/DB (mg/dL) 0.72/0.49 AST/ALT (IU/L) 81/104 ALP/rGT 312/286 Prot/Alb (g/dL) 7.2/3.8 BUN/Cr 11/0.7 Viral markers/ underlying liver disease HBV / HCV -/- HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol Tumor markers (2016.03.11) AFP (ng/mL) - CEA (ng/mL) 2.08 PIVKA II (mAU/mL) CA19-9 (U/mL) 178.26

Clinical Course Case 5 ‘16.03 GB & biliary CT (2016.03.11) 11252880 윤O숙 F/72 ‘16.03 Klatskin tumor (Bismuth type IIIb) GB & biliary CT (2016.03.11) Klatskin tumor with an adjacent LN enlargement. (Bismuth-Corlette type type IIIb rather than II) a/w upstream dilatation of IHD, both. (Lt. IHD is more dilatated than Rt. IHD) A few cyst at both kidney. Low attenuated lesion at the posterior cortex of Lt. kidney. Several calcificated fecalith in ascending colon. Neurogenic bladder with both hydronephrosis.

Case 6 12296400 최O철 M/56 History 56/M. AGC(adenoca, stage IV, pT4aN3bM0) s/p open DG(‘12.09) s/p Xelox #7(‘13.02.28) <#1:’12.10.22> 로 본원 IH(Pf.백선경) 외래 f/u 중인 자로 내원 2주 전부터 jaundice 있어 외래 통해 입원하여 시행한 GB & billiary CT 결과 suggestive of hilar cholangiocarcinoma(Bismuth type IIIA) c hepatic parenchymal(S4) invasion 확인되었으며 수술 시기 및 Rt portal vein embolization 시기 결정 관련하여 향후 치료방침 논의 위해 선정함. 토의 목적 : 향후 치료방침 결정 DM (+), HTN (+) Alcohol Hx (+) : 매일 소주 2병 이상, Smoking Hx (+) : 15PY(0.5x30)

Underlying liver function and performance status Case 6 12296400 최O철 M/56 Underlying liver function and performance status Performance status: Grade 0 LC & Stage Child-Pugh - MELD score Esophageal varices Ascites Encephalopathy CBC/DC (2016.03.17) WBC (mm3) 4,550 Hb (g/dl) 11.0 PLT 323,000 PT (sec) - INR Chemistry (2016.03.17) TB/DB (mg/dL) 4.32/4.03 AST/ALT (IU/L) 42/17 ALP/rGT 366/513 Prot/Alb (g/dL) 6.6/3.5 BUN/Cr 8/0.6 Viral markers/ underlying liver disease HBV / HCV -/- HBeAg / HBeAb Virus titer - Antiviral Tx Alcohol Tumor markers (2016.02.24) AFP (ng/mL) 3.90 CEA (ng/mL) 2.68 PIVKA II (mAU/mL) - CA19-9 (U/mL) 25.90

Clinical Course Case 6 ‘12 ‘16.02 GB & biliary CT (2016.02.23) 12296400 최O철 M/56 ‘12 ‘16.02 AGC(adenoca, stage IV, pT4aN3bM0) s/p open DG(‘12.09) s/p Xelox #7(‘13.02.28) <#1:’12.10.22> Cholangiocarcinoma (Bismuth type IIIA) c hepatic parenchymal(S4) invasion PTBD insertion, Rt(2/23) PTBD change, Rt(3/4) GB & biliary CT (2016.02.23) Suggestive of hilar cholangiocarcinoma (Bismuth-Corlette classification type IIIA), R/O Peribiliary metastasis(least likely). - with hepatic parenchymal invasion A small thrombus in the main portal vein at the bifurcation. No significant interval change of ; A tiny left renal cyst. Cecal diverticulosis.