J.P. is a 58-year-old man diagnosed with hepatitis B and hepatocellular carcinoma. He underwent various treatments including Y-90 radioembolization, chemoembolization, and sorafenib, but later developed complications including a staph infection and a necrotic liver tumor. V.B. is a 75-year-old woman diagnosed with pancreatic cancer. She received neoadjuvant chemotherapy and radiation, then a Whipple procedure which showed a complete response with no residual tumor. Both patients are being monitored for recurrence.

1. MULTIDISCIPLINARY
CASE
DISCUSSION
Research Medical Center’s
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. 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. 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. Liver, core biopsy:
- Moderately differentiated HCC

5. Liver, core biopsy:
- Moderately differentiated HCC

6. DIAGNOSIS
 Child Pugh score A, Barcelona B
 Stage III moderately differentiated hepatocellular carcinoma

7. LIVER MRI WITH EOVIST PRIOR TO STARTING TREATMENT

10. 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

11. 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. Freilich’s care.

12. MRI OF THE ABDOMEN AND PELVIS POST FIRST Y-90 TREATMENT

14. 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

15. LIVER MRI WITH EOVIST PRIOR TO STARTING GENE THERAPY

16. 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.

17. CT OF ABDOMEN AND PELVIS DEMONSTRATING NECROTIC MASS

18. Liver, tumor resection:
- Residual moderately differentiated HCC

19. Liver, tumor resection:
- Residual moderately differentiated HCC

20. CT OF THE ABDOMEN AND PELVIS DEMONSTRATING GENE
THERAPY AND SURGICAL CHANGES

21. 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

23. LI-RAD EXAMPLE CASE #1

25. LI-RAD EXAMPLE CASE #2

26. 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

27. 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

28. 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

29. EUS

30. Pancreatic head mass, FNA:
- Positive for malignant cells;
compatible with adenocarcinoma

31. Pancreatic head mass, FNA:
- Positive for malignant cells;
compatible with adenocarcinoma

32. CT OF THE ABDOMEN AND PELVIS PRE NEOADJUVANT
THERAPY 10/14/2013

33. 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)

34. CT OF THE ABDOMEN AND PELVIS POST
NEOADJUVANT THERAPY

35. RE-STAGING FOR V.B.
 1/20/14 CT of the Abdomen and pelvis was done to determine
patient’s resectability for surgery candidacy.
 1/29/14 Whipple procedure performed by Dr. Cates.

36. CT OF THE ABDOMEN AND PELVIS POST WHIPPLE RECOVERY

37. 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

38. Whipple resection:
- No residual carcinoma identified
- Negative lymph nodes (0/17)

39. 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.