Case Scenarios. 12/28/12 MRI Liver: multiple focal arterially enhancing liver lesions, indeterminate. Repeat MRI in 4 months.

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1 Case Scenarios Case Scenario 1 A 63 year old black female presented with a history of liver lesions present for the past three years being monitored by serial scans. The patient has a history of esophageal cancer diagnosed 5 years ago and treated with chemotherapy and radiation. 12/28/12 MRI Liver: multiple focal arterially enhancing liver lesions, indeterminate. Repeat MRI in 4 months. 4/27/13 MRI Liver: 1. Multiple arterial phase enhancing hepatic lesions most worrisome for multifocal hepatocellular carcinoma. The nodules have increased in number and size since prior exam and are confined to the right liver lobe. Largest nodule is 4.3 cm. 2. Hepatic cirrhosis 3. Indeterminate lymph node near the liver anteriorly which may be metastatic. 4. Indeterminate right lower lung pulmonary nodule and some atelectasis or infiltrate in the right lower lung posteriorly and paramediastinal distribution. 5/8/13 AFP: 6.9 WNL (range <10 NG/ML) 5/30/13 Liver Biopsy: Hepatocellular carcinoma, grade 2 of 4. Cirrhosis. 6/5/13 CT C/A/P: IMPRESSION: CT Chest: 1. 4 mm nodule at the periphery of the right middle lobe. 2. Paramediastinal changes, probably post-treatment change. 3. Complete occlusion of the left subclavian artery at its origin. CT abdomen pelvis: Multifocal hepatic lesions consistent with a known diagnosis of hepatocellular carcinoma. There is tumor invasion of central portal venous branches in the right hepatic lobe more inferiorly. Main portal vein remains patent. 10/9/13 Drug eluting bead hepatic chemoembolization: A Tracker 325 microcatheter was then inserted and directed into the mid to distal right hepatic artery. Repeat angiography demonstrates prominent neovascularization centrally as well as multiple satellite lesions. Approximately 1/2 of the Quadraspheres that had been reconstituted with doxorubicin (approximately 25 mg) were injected through this catheter. There is good uptake within the neovascularized portion of the liver. Forward flow had slowed considerably after the completion of this infusion, however, the vessel was not embolized to complete stasis.

2 The Tracker 325 microcatheter was then withdrawn and placed into the left hepatic artery distal to the gastroduodenal artery. A repeat angiogram demonstrates prominent central neovascularization; however, a branch perfusing the medial left hepatic lobe does not appear to have significant lesions enhancing at this time. Therefore, the catheter was advanced into the more central dominant branch that perfuses this tumor. With the catheter in a stable position approximately 1/4 of the drug-eluting beads (approximately 12.5 mg of doxorubicin) were injected. Subsequently, a repeat angiogram demonstrates prominent forward flow. PVA particles were then infused to slow forward flow. Again, this vessel was not embolized to complete stasis. The microcatheter, guiding catheter, and sheath were removed easily and intact. Stasis was achieved by holding direct pressure. The patient tolerated the procedure well and complained of no significant pain during or after embolization. She was observed in the nurses holding area for approximately 6 hours and then discharged to home in stable, satisfactory condition, without complaint. A repeat CT scan of the abdomen with contrast is recommended in approximately 60 days to determine the efficacy of this procedure. At that time I expect these large central lesions to be slightly smaller than the preprocedure CT revealed. As this patient was not embolized to complete stasis, a repeat chemoembolization procedure could be performed in the future minutes of 20 pulse per second fluoroscopy was used for this exam. 130 ml of Isovue 370 nonionic intravenous contrast was used for this exam. The patient received 37.5 mg of doxorubicin reconstituted Quadraspheres. Total sedation time was one and one half hours. Permanent fluoroscopic and ultrasound images were obtained and are made available for review.

3 Case Scenario 1 Worksheet Primary Site Morphology Grade Stage/ Prognostic Factors CS Tumor Size CS SSF CS Extension CS SSF CS Tumor Size/Ext Eval CS SSF CS Lymph Nodes CS SSF CS Lymph Nodes Eval CS SSF Regional Nodes Positive CS SSF Regional Nodes Examined CS SSF CS Mets at Dx CS SSF CS Mets Eval CS SSF CS SSF 1 CS SSF CS SSF 2 CS SSF CS SSF 3 CS SSF CS SSF 4 CS SSF CS SSF 5 CS SSF CS SSF 6 CS SSF CS SSF 7 CS SSF CS SSF 8 CS SSF Summary Stage Derived AJCC TNM Stage (indicate c or p in the space before the T, N, or M) Clinical AJCC TNM Stage Pathologic AJCC TNM Stage Diagnostic Staging Procedure Surgery Codes Surgical Procedure of Primary Site Scope of Regional Lymph Node Surgery Surgical Procedure/ Other Site Systemic Therapy Codes Chemotherapy Hormone Therapy Immunotherapy Hematologic Transplant/Endocrine Procedure Systemic/Surgery Sequence Treatment Radiation Codes Radiation Treatment Volume Regional Treatment Modality Regional Dose Boost Treatment Modality Boost Dose Number of Treatments to Volume Reason No Radiation Radiation/Surgery Sequence

4 Case Scenario 2 83 year old white male presents with a history of a liver mass. 11/29/13 MRI Abdomen: There is a large mass within the central portion of liver measuring 14.6 x 16.7 x 10.9 cm extending into both the right and left hepatic lobes. There is sparing of segment 6 and segment 7. There are nodular foci of hemorrhage scattered throughout the lesion. There is delayed peripheral enhancement without central enhancement. There is obliteration of the left portal vein and middle hepatic vein by tumor. There is bile duct invasion resulting in dilated intrahepatic ducts which are more prominent in the left hepatic lobe. The extrahepatic biliary ducts are normal in caliber. The main portal vein is patent. There is portal hypertension with multiple surface collateral vessels as well as recannulization of the umbilical vein. Esophageal varices are noted. No nodal metastases are identified. No bony metastatic disease is identified. There is mass effect effacing the retrohepatic vena cava. Incidental note of pancreatic divisum. No pancreatic duct dilatation. There is splenomegaly with presumed epithelial cysts present. There are left peripelvic renal cysts. Infrarenal abdominal aortic aneurysm measuring 3.2 x 3.2 cm. IMPRESSION: 1. Large central hepatic mass measuring 16.7 x 14.6 x 10.9 cm as described. Differential diagnosis includes cholangiocarcinoma, hepatocellular carcinoma or atypical neoplasm such as sarcoma. Tissue sampling should be considered. 2. Portal hypertension is likely secondary to outflow obstruction or alternatively obliteration of the left portal vein. 3. Mild splenomegaly. 4. Infrarenal abdominal aortic aneurysm measuring 3.2 x 3.2 cm. 12/7/13 Liver FNA: hepatocellular carcinoma, grade 2 arising in a cirrhotic liver 1/11/14 Sorafenib 1/18/14 Hepatic artery drug-eluting bead tumor embolization: Using ultrasound guidance and micropuncture technique, percutaneous puncture of the right common femoral artery was performed in a retrograde direction. A 4 French sheath was then placed. A Cobra 2 catheter was then used to selectively cannulate the right phrenic artery and initial angiogram demonstrates a hypertrophied right phrenic artery with collateral flow to the large hepatic tumor. Subsequently, the Cobra 2 catheter was placed into the celiac artery in a standard angiogram performed. This demonstrates hypertrophy of the hepatic artery with splaying of the right and left main hepatic vessels. A large predominately round tumor is noted within the head liver demonstrating considerable neovascular changes as well as the venous puddling. No evidence of shunting was seen during this exam.

5 A microcatheter was inserted through the guiding Cobra 2 catheter and advanced into a branch supplying the posterior right hepatic aspect of this large tumor. With the microcatheter in stable position one half of the total dose (approximately 80,000) Quadraspheres reconstituted with doxorubicin were administered. This vessel was not embolized to stasis, rather, slow forward flow persisted after embolization. The catheter was then repositioned into a large branch perfusing the central and left lateral aspect of this tumor. The remaining half dose of Quadraspheres was administered. Again, this vessel was not embolized to stasis. A repeat angiogram demonstrates significantly less neovascular vessels throughout the distribution of the tumor signifying the previous embolization. The microcatheter and guiding catheter were removed intact. The 4 French vascular sheath was then removed and hemostasis was achieved holding direct pressure. A safeguard device was also applied. The patient tolerated the procedure well. He experienced no symptoms during this procedure. The patient will be admitted minutes of 20 pulse per second fluoroscopy was used throughout this exam. One hour total sedation time. Permanent fluoroscopic and ultrasound images were acquired and are made available for review. Sterile barrier technique was used throughout this exam. The patient should have a CT scan of the abdomen with contrast approximately 2 months (March 18) and probable additional embolization. 2/19 PET/CT: 1. Patchy regions of abnormally increased FDG accumulation predominantly in the periphery of the patient's large liver mass. This is consistent with patchy regions of viable malignancy surrounding more central regions of successfully treated tumor. 2. No sites of abnormally increased FDG accumulation outside of the liver to suggest distant metastases. 2/21/13 Hepatic artery drug-eluting bead tumor embolization: Using ultrasound guidance and micropuncture technique, percutaneous puncture of the right common femoral artery was performed in a retrograde direction. A 4 French sheath was then placed. A Cobra 2 catheter was then used to selectively cannulate the common phrenic artery ostia and initial angiogram demonstrates a hypertrophied bilateral phrenic arteries with collateral flow to the large hepatic tumor. The Cobra 2 catheter was placed into the celiac artery in a standard angiogram performed. This demonstrates hypertrophy of the hepatic artery with splaying of the right and left main hepatic vessels. A large predominately round tumor is noted within the middle of the liver demonstrating considerable neovascular changes as well as the venous puddling. No evidence of shunting was seen during this exam.

6 A microcatheter was inserted through the guiding Cobra 2 catheter and advanced into a branch supplying the lateral right hepatic aspect of this large tumor. With the microcatheter in stable position one half of the total dose (approximately 80,000) Quadraspheres reconstituted with doxorubicin were administered. This vessel embolized to stasis. The catheter was then repositioned into a large branch perfusing the inferior and anterior right lateral aspect of this tumor. The remaining half dose of Quadraspheres was administered. A repeat angiogram demonstrates persistent forward flow. Therefore, embospheres were used to embolize this vessel to near stasis. A repeat angiogram demonstrated significantly reduced forward flow. The microcatheter and guiding catheter were removed intact. The 4 French vascular sheath was then removed and hemostasis was achieved holding direct pressure. A safeguard device was also applied. The patient tolerated the procedure well. He experienced no symptoms during this procedure minutes of 20 pulse per second fluoroscopy was used throughout this exam. One hour 30 minutes total sedation time. Permanent fluoroscopic and ultrasound images were acquired and are made available for review. Sterile barrier technique was used throughout this exam. The patient should continue p.o. broad-spectrum antibiotics for 10 days after this procedure. A repeat CT should be performed in approximately 2 months to evaluate the efficacy of this including drugeluting bead chemoembolization.

7 Case Scenario 2 Worksheet Primary Site Morphology Grade Stage/ Prognostic Factors CS Tumor Size CS SSF CS Extension CS SSF CS Tumor Size/Ext Eval CS SSF CS Lymph Nodes CS SSF CS Lymph Nodes Eval CS SSF Regional Nodes Positive CS SSF Regional Nodes Examined CS SSF CS Mets at Dx CS SSF CS Mets Eval CS SSF CS SSF 1 CS SSF CS SSF 2 CS SSF CS SSF 3 CS SSF CS SSF 4 CS SSF CS SSF 5 CS SSF CS SSF 6 CS SSF CS SSF 7 CS SSF CS SSF 8 CS SSF Summary Stage Derived AJCC TNM Stage (indicate c or p in the space before the T, N, or M) Clinical AJCC TNM Stage Pathologic AJCC TNM Stage Diagnostic Staging Procedure Surgery Codes Surgical Procedure of Primary Site Scope of Regional Lymph Node Surgery Surgical Procedure/ Other Site Systemic Therapy Codes Chemotherapy Hormone Therapy Immunotherapy Hematologic Transplant/Endocrine Procedure Systemic/Surgery Sequence Treatment Radiation Codes Radiation Treatment Volume Regional Treatment Modality Regional Dose Boost Treatment Modality Boost Dose Number of Treatments to Volume Reason No Radiation Radiation/Surgery Sequence

8 Case Scenario 3 A 67 year old white male presents with vomiting and back pain. 6/10/13 CT C/A/P: Chest Impression: 1. Lytic metastasis, T9 vertebral body. Causing spinal canal stenosis. 2. Multiple liver lesions identified. 3. No suspicious lung nodules, mass, or consolidation. 4. Coronary artery disease. A/P Impression: CT abdomen: Visualized portions of the lung bases are unremarkable. The liver is mildly enlarged. There are numerous hypodense partially enhancing lesions replacing a large portion of the right lobe of the liver. These are worrisome for malignancy, either metastatic disease of unknown primary or a large multifocal hepatocellular carcinoma. No definite left lobe liver lesions are demonstrated. There is a small stone in the gallbladder. There is no gallbladder wall thickening or pericholecystic fluid. No biliary duct dilatation. The spleen is unremarkable. The pancreas is normal in appearance. Adrenal glands are unremarkable. No significant focal renal calcifications are demonstrated. There is a small cyst in the mid-left kidney. No significant focal solid renal lesions are demonstrated. There is no evidence of acute inflammatory change, abscess or ascites. No evidence of adenopathy. No evidence of bowel obstruction. Diffuse atherosclerotic calcifications are noted involving the abdominal aorta is branches. No evidence of aneurysm. CT pelvis: There are changes of sigmoid colon diverticulosis. No evidence of diverticulitis. No evidence of focal inflammatory change, abscess or ascites. There is a lytic destructive bone lesion involving the left sacral ala extending into the left S1 neural foramen. This has the appearance of a malignant lesion, most likely a metastasis. An additional lytic lesion consistent with metastasis is noted involving the spinous process and right lamina of the T9 vertebra with expansile tumor extending through the bone into the right posterior aspect of the spinal canal at T9. IMPRESSION: 1. Numerous ill-defined partially enhancing low attenuation lesions replacing the majority of the right lobe of the liver. These represent malignant lesions, most likely metastatic disease of unknown primary. Correlation with chest radiograph/chest CT would be recommended for further evaluation. 2. Lytic destructive bone lesions are noted involving the left sacral ala extending into the left S1 neural foramen and also involving the right posterior elements of T9 extending into the T9 spinal canal. These are also malignant lesions and metastatic disease. 3. Extensive atherosclerotic vascular calcification above the abdominal aorta and its branches with no evidence of aneurysm.

9 4. Cholelithiasis, no secondary signs of cholecystitis. 6/11/13 T-Spine MRI: There is a significant patient motion artifact. The thoracic vertebral alignment is normal. Facet alignment is preserved. There is diffuse abnormal heterogeneity of the marrow signal seen in the lower cervical and thoracic vertebral elements. There is an expansile 5.8 x 3.2 x 2.9 cm mass involving the posterior elements of the T9 vertebral level, with infiltration of the underlying dorsal epidural fat. There is flattening and anterior displacement of the T9 cord segment. No gross signal abnormalities are seen in this cord segment, though assessment is limited due to motion artifact. The soft tissue mass extends posteriorly into the more superficial overlying subcutaneous soft tissues. Otherwise the remainder of intervertebral levels reveal a focal central disc protrusion at T4- T5, which compresses the ventral cord contour. There is a sebaceous cyst in the posterior subcutaneous fat at the T5 level. Heterogeneous masses involving the right lobe of the liver are partly seen. IMPRESSION: 1. Expansile 5.8 cm mass involving the posterior elements of T9, infiltrating the posterior dorsal epidural fat, with flattening and anterior displacement of the cord. No definite cord signal abnormality, though assessment is limited by motion. Heterogeneous masses in the right lobe of the liver, partly imaged. 2. Diffuse abnormal heterogeneity of the marrow signal throughout the thoracic vertebral levels, non-specific. Focal central protrusion T4-T5. 6/13/13 Liver FNA/Bx: Positive, hepatocellular carcinoma, grade 2 Radiation Oncology Patient has completed his planned course of palliative irradiation. He received 30 Gy in 10 treatments to both T8-T10 and his sacrum. Both areas were treated utilizing parallel opposed anterior and posterior portals and 18 mv photons. Treatments proceeded from June 14, 2013, to June 29, He tolerated treatments well and noticed a decrease in his back pain in the last week of treatment. 7/13/13 Patient began treatment of Nexavar

10 Case Scenario 2 Worksheet Primary Site Morphology Grade Stage/ Prognostic Factors CS Tumor Size CS SSF CS Extension CS SSF CS Tumor Size/Ext Eval CS SSF CS Lymph Nodes CS SSF CS Lymph Nodes Eval CS SSF Regional Nodes Positive CS SSF Regional Nodes Examined CS SSF CS Mets at Dx CS SSF CS Mets Eval CS SSF CS SSF 1 CS SSF CS SSF 2 CS SSF CS SSF 3 CS SSF CS SSF 4 CS SSF CS SSF 5 CS SSF CS SSF 6 CS SSF CS SSF 7 CS SSF CS SSF 8 CS SSF Summary Stage Derived AJCC TNM Stage (indicate c or p in the space before the T, N, or M) Clinical AJCC TNM Stage Pathologic AJCC TNM Stage Diagnostic Staging Procedure Surgery Codes Surgical Procedure of Primary Site Scope of Regional Lymph Node Surgery Surgical Procedure/ Other Site Systemic Therapy Codes Chemotherapy Hormone Therapy Immunotherapy Hematologic Transplant/Endocrine Procedure Systemic/Surgery Sequence Treatment Radiation Codes Radiation Treatment Volume Regional Treatment Modality Regional Dose Boost Treatment Modality Boost Dose Number of Treatments to Volume Reason No Radiation Radiation/Surgery Sequence