1. 1. MULTIDISCIPLINARY CASE DISCUSSION Research Medical Centers Liver and Pancreas Institute Conference Panel of Physicians Cates, Joe MD Farber, Michael MD Freilich, Brad MD Jafri, Syed MD Mikhitarian, Kaidi MD Singh, Jaswinder MD
2. 2. PATIENT J.P. 58 year old Asian male Past Medical History: Chronic Hepatitis B Hypertension Type II diabetes mellitus Osteoarthritis Fatty liver No previous surgical history. No significant family history. Patient was a smoker and quit at age 42. He is a social drinker.
3. 3. PATIENT PRESENTATION October 2013 seen in PCP office with acute onset of sever right upper quadrant pain with radiation to the right scapular and shoulder area, mild nausea without emesis. Labs and CT ordered. Complete metabolic profile (10/7/2013): ALT: 67 iu/L Glucose: 234 mg/dL Lipase: 81 u/L CT Abdomen (10/8/2013) revealed several heterogeneously enhancing lesions present in the liver, the largest measuring 7 cm in size, suspicious for multifocal hepatocellular carcinoma. Small periportal and peripancreatic lymph nodes. Borderline splenomegaly. Small amount of abdominal ascites. US guided liver biopsy performed (10/15/2013) confirmed hepatocellular carcinoma.
4. 4. Liver, core biopsy: - Moderately differentiated HCC
5. 5. Liver, core biopsy: - Moderately differentiated HCC
6. 6. DIAGNOSIS Child Pugh score A, Barcelona B Stage III moderately differentiated hepatocellular carcinoma
7. 7. LIVER MRI WITH EOVIST PRIOR TO STARTING TREATMENT
8. 8. LABS PRIOR TO STARTING Y-90 THERAPY 11/11/2013 Total Bili: 0.9 mg/dL Direct Bili: 0.2 mg/dL AST: 47 U/L ALT: 79 U/L ALK Phos: 105 U/L Alpha-Fetoproteins: 106.6 ng/mL
9. 9. TREATMENT APPROACH FOR J.P. Due to his multifocal bi-lobed disease he was not a candidate for a liver transplant or surgery. 11/14/13 Y-90 radioembolization of right hepatic artery. (#1) 12/17/2013 Chemoembolization of left hepatic artery. 2/5/2014 Started on Sorafenib ( 2 tabs in a.m. and 2 tabs in p.m.) 4/2/2014 Y-90 radioembolization of right hepatic artery. (#2) October 2014 Sorafenib stopped and enrolled in a Phase I gene therapy trial under Dr. Freilichs care.
10. 10. MRI OF THE ABDOMEN AND PELVIS POST FIRST Y-90 TREATMENT
11. 11. LABS PRIOR TO STARTING GENE THERAPY 7/17/2014 Total Bili: 1.1 mg/dL Direct Bili: 0.4 mg/dL AST: 56 U/L ALT: 82 U/L Alk Phos: 145 U/L Alpha-Fetoprotein: 92.7 ng/mL
12. 12. LIVER MRI WITH EOVIST PRIOR TO STARTING GENE THERAPY
13. 13. DEVELOPMENT OF COMPLICATIONS 11/21/2014 Port-A-Cath removed due to infection; Staphylococcus aureus. 2/7/2015 Presented to emergency department with complaint of severe right abdominal pain and right chest pain with radiation to the back associated with shortness of breath and dizziness with a fever as high as 38.3. 2/7/2015 CT of the abdomen and chest showed abnormalities that included small right pleural effusion associated with a large collection of fluid around the necrotic lesion in his liver, abutting the right hemidiaphragm. 2/12/2015 underwent bronchoscopy, thracoscopy, right thoracotomy and decortication due to development of staph aureus empyema and necrotic hepatocellular tumor that spread to the right pleural space; a wedge biopsy of the liver was done at that time.
14. 14. CT OF ABDOMEN AND PELVIS DEMONSTRATING NECROTIC MASS
15. 15. Liver, tumor resection: - Residual moderately differentiated HCC
16. 16. Liver, tumor resection: - Residual moderately differentiated HCC
17. 17. CT OF THE ABDOMEN AND PELVIS DEMONSTRATING GENE THERAPY AND SURGICAL CHANGES
18. 18. MOST RECENT LAB RESULTS 3/2015 Total Bili: 0.6 mg/dL Direct Bili: 0.2 mg/dL AST: 56 U/L ALT: 43 U/L ALK Phos: 377 U/L Alpha-Fetoprotein: 3.1 ng/mL
19. 19. LI-RAD EXAMPLE CASE #1
20. 20. LI-RAD EXAMPLE CASE #2
21. 21. LI-RAD CASE EXAMPLES Example Case #1 Cirrhotic liver, F4 fibrosis on elastography 17 mm lesion with arterial phase enhancement, washout, pseudocapsule HCC LI-RADS 5 Example Case #2 HCC LI-RADS 5V
22. 22. PATIENT V.B. 75 year old African American female Past Medical History: Hypertension Degenerative joint disease/ osteoarthritis Hyperlipidemia Gastroesophageal reflux disease (GERD) Hypothyroidism Previous Surgeries: Right leg surgery as a child Right lens implant Family History: Sister with uterine cancer First cousin with breast cancer Brother and children with diabetes
23. 23. PATIENT PRESENTATION In October 2013 she went to her PCP complaining of abdominal pain, upper back pain, decreased appetite, a 10-15 pound weight loss and jaundice that had been ongoing for two weeks. CT and labs were ordered. Comprehensive Metabolic Panel (10/11/2013): Creatinine: 1.09 mg/dL Total Bilirubin: 6.3 mg/dL Alkaline Phosphatase: 418 U/L AST: 435 U/L ALT: 758 U/L CA 19-9: 261.6 Units/mL CT of the Abdomen and pelvis (10/14/2013) revealed dilation of the biliary tree and pancreatic duct and distention of the gallbladder secondary to a mass of the head of the pancreas measuring 4.7 cm. Underwent EUS with FNA and ERCP with biliary sphincterotomy and placement of stent (10/16/2013) that showed a focal 4 x 3.5 cm irregular hypoechoic fullness of the head of the pancreas, showing malignant cells surrounding peripancreatic lymphadenopathy. EUS stage T3 N1 M0
24. 24. EUS
25. 25. Pancreatic head mass, FNA: - Positive for malignant cells; compatible with adenocarcinoma
26. 26. Pancreatic head mass, FNA: - Positive for malignant cells; compatible with adenocarcinoma
27. 27. CT OF THE ABDOMEN AND PELVIS PRE NEOADJUVANT THERAPY 10/14/2013
28. 28. NEOADJUVANT APPROACH FOR V.B. Based on EUS staging, pathology and imaging V.B. was determined to be borderline resectable and it was decided to place her on Neoadjuvant Chemotherapy concurrent with Radiation. 11/12/13 Started Neoadjuvant chemotherapy with Gemzar 11/19/13 Started radiation in combination with Gemzar chemotherapy 12/3/13 Stopped chemotherapy treatment (completed 4 cycles) 12/24/13 Ended radiation treatment (completed 5 weeks)
29. 29. CT OF THE ABDOMEN AND PELVIS POST NEOADJUVANT THERAPY
30. 30. RE-STAGING FOR V.B. 1/20/14 CT of the Abdomen and pelvis was done to determine patients resectability for surgery candidacy. 1/29/14 Whipple procedure performed by Dr. Cates.
31. 31. CT OF THE ABDOMEN AND PELVIS POST WHIPPLE RECOVERY
32. 32. DIAGNOSIS EUS FNA pathology: Pancreatic adenocarcinoma Surgical pathology: Tumor site: cannot be determined Additional sites involved by tumor: none identified Histologic type: other, no residual tumor Histologic grade: cannot be assessed secondary to therapeutic effect Tumor size: cannot be determined; no residual tumor Microscopic tumor extension: no evidence of primary tumor Margins: margins uninvolved by invasive carcinoma Treatment effect: present, no residual tumor (complete response, grade 0) Stage: T0 N0 M0
33. 33. Whipple resection: - No residual carcinoma identified - Negative lymph nodes (0/17)
34. 34. ADJUVANT TREATMENT Due to complications with her Whipple recovery, the patient did not receive any adjuvant chemotherapy. The patient is doing well with no evidence of pancreatic adenocarcinoma recurrence at this time.