AUTUMN SEMINAR 2015 OF CTSR

Transcription

1 AUTUMN SEMINAR 2015 OF CTSR HCC FORUM INTERNATIONAL FORUM OF RECENT TREND IN DIAGNOSIS AND TREATMENT OF HEPATOCELLULAR CARCINOMA Hosted by Chinese Taipei Society of Radiology (CTSR) Department of Medical Imaging of Chi-Mei Medical Center, Tainan Co-Sponsored by Asian Oceanian School of Radiology (AOSOR) PROGRAMME Sunday, October 25, F Conference Room, Howard Civil Service International House No. 30, Sec. 3, Shin-Sheng South Road, Taipei

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3 1 Wan-You, GUO, M.D., Ph.D. President, The Chinese Taipei Society of Radiology (CTSR) WELCOME MESSAGE On behalf of CTSR, it is my great pleasure to welcome all of you to attend the CTSR Autumn Seminar 2015 in Taipei on October 25 (Sunday), It is the 7th Autumn Seminar of CTSR since year The goal of having Autumn Seminar from the beginning has been to provide our members another platform to share and exchange clinical experiences in imaging medicine, in addition to annual meetings (usually in March of a year). Moreover, in order to involve more members to participate the Seminar, traditionally, the venue of Autumn Seminar is selected at the area different from the Annual Meeting of the year. According to the original plan, the Autumn Seminar 2015 is hosted by Department of Medical Imaging, Chi-Mei Medical Center at Tainan. However, due to the outbreak of Dengue Fever, the organizing committee finally decided to move the venue to Taipei. It is challenging to change Seminar venue in a short time. Should participants find anything left to be desired to make the Seminar better, we ask your generous understanding and please feel free to let us know for timely action-taking. The main theme of Autumn Seminar 2015 is Recent Trend in Diagnosis and Treatment of Hepatocellular Carcinoma. We invite domestic experts in abdominal imaging and interventional radiology to participate and give lectures to share their valuable experience in HCC management. In addition, we also receive strong support from the Asian Oceanian School of Radiology (AOSOR) to co-host the AOSOR-CTSR conjoint Sessions in the Seminar. We are honored to have two invited speakers Co-sponsored by AOSOR to attend the conjoint sessions, Professor Kensaku MORI from Japan and Professor Jin Young CHOI from Korea. In the afternoon session, we have an invited speaker, Professor Masatoshi Tanaka, from Japan to speak on Guideline of HCC Treatment in Japan. On behalf of our Sister Society, Japanese Society of Interventional Radiology (JSIR), Professor Tanaka will share with us Japan experience. His speech will be followed by two domestic experts to talk on Taiwan s experience. We anticipate reaching consensus on setting the guideline of HCC treatment in Taiwan after the three speeches. The one day Seminar will be wrapped up at the last by a session of Interesting Case Discussion with interactive participation by all attendee. I am sure that you will find the one day program concise and rich. Special thanks are given to Dr. Yu-Ting Kuo, Head of Department of Medical Imaging, Chi-Mei Medical Center, Dr. Wen-Sheng Tzeng and Secretariat of CTSR their great works to make everything a reak. Last but not least, I would like to express our sincere appreciation to all sponsors and exhibitors for their kind supports and engagements. CTSR Autumn Seminar 2015 becomes a great success with the enthusiastic participates from all of you!! 2015 年中華民國放射線醫學會全國秋季會學術研討會由奇美醫院影像醫學部與學會共同主辦, 會議於 2015 年 10 月 25 日星期日在台北市福華大飯店公務人力發展中心福華文教會館的前瞻廳舉行 本學會舉辦秋季會主要的目的是 : 提供本會會員除了年會以外的另一個全國性學術活動, 增加會員之間互動與學習的機會 按照往例, 秋季會與年會於不同地區舉辦 本秋季會原訂在台南召開, 但因登革熱的疫情尚未獲得有效控制, 為顧及會員的安全與健康, 故改於台北舉行 在短時時間內更改會議地點, 有相當的挑戰性, 如有安排不周讓與會者感覺不便之處, 請不吝告知以便即時改善 在此本人謹代表學會及全體會員, 特別感謝奇美醫學中心影像醫學部郭禹廷主任及全體同仁和曾文盛前主任及學會秘書處的費心安排與調度 今年秋季會主題為腹部及介入放射醫學, 並以肝癌為題目主軸 節目的安排除了邀請國內腹部及介入放射線醫學的專家給予專題演講外, 同時也獲得 Asian Oceanian School of Radiology (AOSOR) 的支持, 特別選派來自日本的 Prof Kensaku Mori 及韓國的 Prof Jin Young Choi 共襄盛舉, 在會議中的 AOSOR-CTSR Conjoint Session 與我國專家同台演講, 切磋交流 另外我們也特別邀請姐妹會 日本介入放射線醫學會 (JSIR) 的 Prof Masatoshi Tanaka, 代表 JSIR 報告日本肝癌的診斷與治療準則, 藉此盛會與我國專家共同討論, 做為我國訂定肝癌的診斷與治療準則的參考 在會議的下午時段, 並安排有趣個案討論, 以與會者互動的方式, 討論交流腹部及介入放射線醫學的處理與新知 在會議召開的前夕, 也要藉這個機會感謝支持本次會議召開的參展廠商, 這些支持使本次會議可以更順利召開 最後, 特別祝各位與會者有一個豐富 充實及成功的 2015 年中華民國放射線醫學會全國秋季會學術研討會 Wan-You, GUO, M.D., Ph.D. President, The Chinese Taipei Society of Radiology

4 WELCOME MESSAGE Dear Colleagues, It is my great honor and pleasure to have this opportunity to host this meeting and to welcome all of you not only from different cities in Taiwan but also from other Asian countries. It is supposed to welcome you in my home town, Tainan. Unfortunately, Tainan is currently affected by an unexpected outbreak of Dengue fever since this summer. We therefore have to move the meeting to Taipei City. I apologize for any inconvenience caused, and thank you so much for your support and attending this meeting. Tainan is the old capital city of Taiwan, and is full of tradition and culture. There are still a lot of historical buildings worth visiting in the city center. Also, visitors from all over the world love to enjoy traditional Taiwanese cuisines in Tainan. I wish you do find an opportunity to visit Tainan in the near future. In this one-day imaging symposium, we would like to take this opportunity to have discussion about up-to-date imaging diagnosis and imaging-guided interventions of hepatocellular carcinoma (HCC), which is still prevalent in the Asia-Pacific region. We are very happy and excited to have invited experts from Japan and Taiwan to give their speeches and to share their knowledge and experiences with us. As part of tradition of this meeting, we will also have case discussion in the afternoon section. Yu-Ting Kuo, M.D., Ph.D. Director of Department of Medical Imaging Chi Mei Medical Center Tainan, Taiwan I wish you enjoy the meeting, and have a nice stay in Taipei. Sincerely, Yu-Ting Kuo, M.D., Ph.D. Director of Department of Medical Imaging Chi Mei Medical Center Tainan, Taiwan 2

5 WELCOME MESSAGE It is nice to know that the Chinese Taipei Society of Radiology (CTSR) Department of Medical Imaging of Chi-Mei Medical Center, Tainan is hosting the AOSOR-CTSR Conjoint Session titled International Forum of Recent Trends in the Diagnosis and Treatment of Hepatocellular Carcinoma on Sunday, October 25, 2015 at the Howard Civil Service International House in the beautiful city of Taipei. I congratulate and compliment Professor Wan-Yuo Guo and his entire team for organizing the one day seminar for the benefit of the radiologists and residents of Taiwan. Kundur Prabhakar Reddy, M.D. President, AOSR AOSOR is committed to organizing such symposiums and seminars in various affiliated society countries of AOSR to share the recent advances in the field of radiology for the benefit of the radiology community. I wish the AOSOR-CTSR conjoint session a grand success. Kundur Prabhakar Reddy, M.D. President AOSR 3

6 WELCOME MESSAGE Goodwill Message from the Director of AOSOR Dear Colleagues: On behalf of the Asian Oceanian School of Radiology (AOSOR), it is my great pleasure to welcome you to the CTSR-AOSOR Conjoint Session titled International Forum of Recent Trend in Diagnosis and Treatment of Hepatocellular Carcinoma. It promises to be a truly outstanding symposium that is certain to offer a great educational experience for everyone and an opportunity to enhance the friendship between the experts of hepatic imaging and intervention. We owe the success of this HCC forum held in conjunction with the 2015 Autumn Seminar of CTSR to the excellent Organizing Committee led by Dr. Wan- Yuo Guo and Dr. Yu-Ting Kuo. CTSR recognizes the responsibility of physicians in promoting the full potential of radiologic diagnosis and intervention and utilizing it to help improve the medical condition of patients. Byung Ihn Choi, M.D. Director, AOSOR I would also like to express my thanks to all of the presenters who will share their knowledge and experience for the benefit of the attendees. With best wishes for a most enjoyable and beneficial experience, Byung Ihn Choi, M.D. Director, AOSOR 4

7 FACULITY OF SPEAKERS Jin Young Choi, M.D., Ph.D. Chen-Te Chou, M.D.,Ph.D. Kensaku Mori, M.D.,Ph.D. Po-Chin Liang, M.D. Associate Professor Department of Radiology Yonsei University College of Medicine Korea Director Department of Medical Imaging, Gastrointestinal Radiology Division, ChangHua Christian Hospital, Taiwan Associate Professor Department of Radiology, Faculty of Medicine, University of Tsukuba Japan Chief Division of Abdomen Radiology, Department of Medical Imaging, National Taiwan University Hospital Masatoshi Tanaka, M.D. Ran-Chou Chen, M.D. Jen-I Hwang, M.D. Director Department of Hepatology and Gastroenterology, Yokokura Hospital Japan Deputy Director General Health Promotion Administration, Ministry of Health and Welfare Taiwan Chief Section of Interventional Radiology, Department of Radiology, Taichung Veterans General Hospital, Taiwan. 5

8 INFORMATION General Information Title Theme Date Venue Hosted by Co-Sponsored by Website Secretariat Autumn Seminar 2015 of CTSR : HCC Forum International Forum of Recent Trend of Diagnosis and Treatment of Hepatocellular carcinoma Sunday, October 25, F Conference Room, Howard Civil Service International House Chinese Taipei Society of Radiology (CTSR) Department of Medical Imaging of Chi-Mei Medical Center, Tainan Asian Oceanian School of Radiology (AOSOR) Chinese Taipei Society of Radiology 2F, No. 63, Sec. III, Chong-Qing N. Road, Taipei, 10362, Taiwan rsroc.tw@gmail.com Tel: / Fax: AOSOR CTSR Conjoint Session : 09:50-11:00 / sponsored by Bayer Lunch Symposium : 11:30-12:30 / sponsored by Synmosa Map Exit from Exit 2 Taipei MRT Taipower Building Station, turn left and walk along Xinhai Road for 10 to15 minutes, turn left at the junction of Xingsheng S. Road. Howard Civil Service International House is right after the junction. 6

9 2015 Autumn Seminar of CTSR: HCC Forum Program PROGRAMME 08:45 09:00 09:00 09:05 09:05 09:10 09:05 11:00 09:10 09:15 Registration Welcoming Remarks Hosting Remarks AOSOR-CTSR Conjoint Session Opening Remarks Wan-Yuo Guo, M.D., Ph.D. Yu-Ting Kuo, M.D., Ph.D. AOSOR Session I Diagnosis of Hepatocellular Carcinoma Moderator : Yu-Ting Kuo 09:15 09:35 09:35 09:55 09:55 10:10 10:10 10:30 CT and MRI diagnosis of HCC: development, growth, and spread Jin Young Choi, M.D., Ph.D. (Korea) MR imaging of HCC with primovist Chen-Te Chou, M.D. (Taiwan) Q & A Coffee Break Session II RFA treatment of Hepatocellular Carcinoma Moderator : Huei-Lung Liang 10:30 10:50 10:50 11:10 11:10 11:20 Assessment of ablative margin after radiofrequency ablation for HCCs using superparamagnetic iron oxide Kensaku Mori, M.D., Ph.D. (Japan) RFA following TACE for treatment of HCC Po-Chin Liang, M.D. (Taiwan) Q & A 11:30 12:30 Lunch Symposium Session III: Guidelines of Diagnosis and Treatment of Hepatocellular Carcinoma Moderator : Yu-Fan Cheng, Wen-Sheng Tzeng 12:45 13:05 Guideline of HCC treatment in Japan Masatoshi Tanaka, M.D. (Delegate from JSIR) 13:05 13:20 Consensus of diagnosis of HCC in Taiwan Ran-Chou Chen, M.D. 13:20 13:35 Consensus of treatment of HCC in Taiwan Jen-I Hwang, M.D. 13:35 13:45 13:45 14:00 Q & A Coffee Break Session IV Interesting Case Discussion (All Speakers and Moderators) Moderator : Jer-Shyung Huang, Ding-Kwo Wu 14:00 15:00 15:00 15:10 15:10 16:10 16:10 16:20 16:00 16:30 Abdominal Imaging Q & A Interventional Radiology Q & A Closing Remarks Wan-Yuo Guo, M.D., Ph.D.or Yu-Ting Kuo, M.D., Ph.D. 7

10 ABSTRACTS CT and MRI diagnosis of HCC: development, growth, and spread Choi Jin-Young / Yonsei University College of Medicine, Seoul, Korea CT and MRI play important roles in the diagnosis and staging of HCC. The major role of CT and MRI is detection, characterization of HCC, and assessment of treatment response. Moreover, some MR findings are associated with prognosis of HCC. This article briefly summarizes key concepts of diagnosis of HCC, its development, growth, and prognosis emphasizing imaging aspects. Hepatocarcinogenesis is a complex, multistep process characterized by the progressive accumulation of genetic and epigenetic alterations. Pathologically, multistep hepatocarcinogenesis is characterized by progressive dedifferentiation of phenotypically abnormal nodular lesions. Repeated cycles of clonal development and expansion eventually produce lesions with malignant phenotype. Cirrhotic nodules or cirrhosis-associated regenerative nodules are innumerable well-defined rounded lesions of the cirrhotic parenchyma surrounded by fibrous tissue and typically measuring 1-15 mm in diameter. Grossly and microscopically, cirrhotic nodules are indistinguishable from other cirrhotic nodules. Cirrhotic nodules usually are considered benign. These nodules are usually isointense on unenhanced T1-, T2-weighted images. Occasionally they may be hyperintense on T1-weighted images and hypointense on T2-weighted images. Dysplastic nodules are nodular lesions, usually cm in diameter, that differ in both macroscopic and microscopic appearance from background parenchyma. Dysplastic nodules are classified as low grade or high grade, depending on the presence of cytologic and architectural atypia. Clinically, low-grade dysplastic nodules are considered preneoplastic nodules with slightly elevated risk of malignant transformation, while high-grade dysplastic nodules are considered advanced precursor of HCC with high risk of transformation. CT and MR imaging have limited ability to identify and characterize dysplastic nodules. However, some imaging features may be helpful in the differential diagnosis. Dysplastic nodules almost never are hyperintense on T2- weighted images or show restriction. Thus, the presence of mild to moderate T2 hyperintensity or restricted diffusion strongly favors the diagnosis of HCC. Early HCCs are an initial stage of HCC development. Early HCC grow by gradually replacing the parenchyma. As the cells spread, they surround neighboring portal tracts and central veins but do not displace or completely destroy these structures. Macroscopically, most early HCCs are vaguely nodular with indistinct margins and without a capsule. The key distinguishing feature of early HCC is stromal invasion, defined as infiltration of tumor cells into the fibrous tissue surrounding portal tracts within the nodule. Conventional CT and MR imaging have limited sensitivity for the detection of early HCCs, but hepatobiliary phase MR imaging shows promise for this purpose. Progressed HCCs are overtly malignant lesions with the ability to invade vessels and metastasize. Progressed tumors tend to have higher histologic grade, more aggressive biologic behavior, and higher frequency of vascular invasion and metastasis. Most large HCC are expansile tumors with nodular morphology and surrounded by tumor capsules. About 5% of large HCCs have an infiltrative rather than an expansile growth pattern. Although progressed HCCs may spread contiguously into the surrounding liver by expansile or infiltrative growth, the most important mechanism of spread is intrahepatic metastasis. These metastases develop in progressed HCC when malignant cells enter portal venules draining the primary tumor and spread into the surrounding parenchyma. The resulting metastases usually manifest as small satellites within the venous drainage area around the primary tumor. Intrahepatic metastases also may form outside the drainage area, including in other segments or in the contralateral lobe. Vascular invasion is a characteristic feature of progressed HCC. Portal veins are invaded more commonly than hepatic vein. Microvascular or macrovascular invasion have potentially poor prognosis as they provide the route by which HCC cells access the circulation to metastasize. Regarding the prognosis of HCC, it is widely accepted that tumor size, multifocality, and vascular invasion are the most important prognostic factors. These variables are incorporated into various staging systems, and imaging plays a major role in the assessment of these variables. Therefore, the established roles of imaging include not only screening and surveillance of at-risk patients, but also diagnosis, staging, and prognostication of HCC. MRI can not only be used for non-invasive diagnosis and staging, but also for predicting tumor biology. Favorable findings on MRI include small size, presence of fibrous capsule/ pseudocapsule, intralesional fat, high ADC value, and smooth margins or hyperintensity on hepatobiliary phase images. Unfavorable findings include large size, multifocality, low ADC value, non-smooth margins or hypointensity on hepatobiliary phase images. MRI findings may be used as an imaging biomarker in patients with HCC. CT and MR imaging are essential in the diagnosis and staging of HCC. They reflect the key concepts of HCC development, growth, and prognosis. Some MRI findings may be used as an imaging biomarker in HCC. 8

11 MR imaging of HCC with Primovist ABSTRACTS Chen-Te Chou / Department of Medical Imaging, Director of Gastrointestinal Radiology Division, ChangHua Christian Hospital, Taiwan Gadoxetic acid is a liver-specific MR imaging contrast medium with combined perfusion and hepatocyte-selective properties. The agent has been demonstrated to increase the detection of focal liver lesions and to provide differential diagnostic information comparable to nonspecific extracellular gadolinium chelates. According to the most recent recommendations by the American Association for the Study of Liver Diseases (AASLD), a diagnosis of HCC can be made if a mass larger than 1 cm shows features typical of HCC (hypervascularity in the arterial phase and washout in the venous/delayed phase) on contrast material-enhanced computed tomography (CT) or magnetic resonance (MR) imaging. However, some types of HCC, such as well-differentiated HCC as well as a few types of moderately and poorly differentiated HCC may show atypical features on dynamic contrast-enhanced images. There are 20 ~ 40 percent HCC might present atypical features during dynamic study. These atypical HCCs, therefore, are challenging to diagnose. According to our study, gadoxetic acid-enhanced MR images of tumors taken during the hepatocyte-specific phase could differentiate between HCC and dysplastic nodules in patients with atypical cirrhotic nodules detected on dynamic images. 9

12 10 ABSTRACTS Assessment of ablative margin after radiofrequency ablation for HCCs using superparamagnetic iron oxide Kensaku Mori / Department of Radiology, Faculty of Medicine, University of Tsukuba, Japan According to the clinical practice guidelines for hepatocellular carcinoma (HCC) 2013 by the Japan Society of Hepatology, radiofrequency ablation (RFA) is recommended in the patients with liver function of Child-Pugh classification A or B, having 3 or less HCC nodules measuring 3cm or less in diameter, because the survival rate is not significantly different between RFA and surgical resection in such patients. However, local recurrence rate has been reported higher in RFA than in surgical resection. The resection margin can be histopathologically assessed and when it is secured enough, the local recurrence rate is kept low. Theoretically, the local recurrence rate after RFA can be held down low as well, if the ablative margin (AM) is obtained sufficiently. In RFA, contrast-enhanced CT is widely used for the assessment of the AM. However, it is impossible to distinguish the AM from the ablated tumor, because both show areas lacking contrast enhancement. Some investigators recommended a 5 mm-thick AM on contrast-enhanced CT; however, in fact, only radiologists can do is to imagine the invisible ablated tumor in the dark ablated area and to guess the thickness of the AM subjectively. This uncertainty may cause the underestimation and overestimation of the AM, resulting in unnecessary additional therapy and local recurrence, respectively. In 2009, we proposed a new method to assess the AM after RFA using superparamagnetic iron oxide (SPIO). SPIO is a kind of liver specific contrast agents for MR imaging and is accumulated in Kupffer cells resulting in signal decay of normal liver parenchyma due to its susceptibility effect. Most of HCCs contain no or sparse Kupffer cells and shows hyperintensity lacking signal decay compared to the surrounding liver. In our method, RFA is performed in the SPIO-enhanced liver within 8 hours after injection. The AM is assessed on T2*-weighted images acquired after 3 days or later. At this time point, the normal liver parenchyma returns to normal hyperintensity due to the clearance of SPIO; however the ablated liver parenchyma, i.e. the AM, remains showing hypointensity, because the Kupffer cells has been damaged by RFA and lose their cellular function, leading to the excretion of SPIO. Accordingly, the AM is revealed as hypointense rim surrounding the hyperintense tumor and surrounded by the liver parenchyma of normal signal intensity. In this lecture, I will present the principle of MR imaging with impaired SPIO clearance proven by the animal experiments and the results of the clinical studies including the recommended thickness of the AM in RFA for HCCs.

13 11 RFA ablation for caudate lobe HCC ABSTRACTS Po-Chin Liang / Division of Abdomen Radiology, Department of Medical Imaging, National Taiwan University Hospital Hepatocellular carcinoma (HCC) in the caudate lobe has been known to be the most difficult tumor to treat for either surgical resection, transarterial chemoembolization (TACE) or radiofrequency ablation (RFA). The recurrence rate are significantly higher than HCCs in other part of the liver using the above treatments. In this article, we would like to discuss the pros and cons and provide a brief reviews between surgical resection, TACE and RFA. We would also like to share our experiences of CT-guided RFA for the 42 cases with caudate lobe HCC between 2007/10/31 and 2015/6/3.

14 12 ABSTRACTS Two treatment guidelines of hepatocellular carcinoma in Japan Masatoshi Tanaka / Department of Hepatology, Yokokura Hospital In Japan, we have two treatment guidelines for hepatocellular carcinoma (HCC) patients. One is a systematic evidence-based clinical practice guideline (EB-GL) supported by the Japanese Ministry of Health, Labor and Welfare reported and updated from 2005, and other is a Consensus-Based Clinical Practice Manual (CB-GL) proposed and updated by the Japan Society of Hepatology from Why do we, Japanese, have two guidelines in one country? A reason is due to complicated conditions of HCC patients with liver functions (Child-Pugh A to C) and wide varieties of tumor burden of HCC from a very early HCC to an advanced HCC with vascular invasion and extra-hepatic spread (EHS). Our EB-GL is very simple, however, a complicated tumor burden of HCC such as vascular invasion and EHS were excluded. On the contrary, CB-GL includes all tumor status, however, is a pretty much complicated with many additional comments depended on different conditions of HCC patients. But, framework of these two guidelines are, I believe, same. A hepatic resection and a liver transplantation are still fundamental, and curative treatments for HCC, and an ablation therapy such as RFA for a very early HCC is an effective alternative of a curative treatment. Intra-arterial treatment such as TACE using various new materials is still main stay of palliative treatment for advanced and non-surgical HCC patients. Other options such as molecular targeting drug such as Srafenib, extraand internal radiotherapy and cytotoxic chemotherapy are still under investigation to make evidence and consensus for HCC treatment. In this lecture, I explain a progress of Japanese two guidelines comparing other guidelines for HCC in elsewhere in the world such as BCLC staging and treatment guideline.

15 13 Consensus of diagnosis of HCC intaiwan Ran Chou Chen / Health Promotion Administration, Ministry of Health and Welfare ABSTRACTS The current diagnosis recommendation in Taiwan is based on the consensus meeting held by Taiwan Liver Cancer Association (TLCA), The Gastroenterological Society of Taiwan (GEST), and The Radiological Society Republic of China (RSROC). The recommendation is similar to AASLD, EASL, APASL and other guidelines with some differences. For nodule > 1cm in patient with liver cirrhosis or chronic hepatitis B, they should be investigated with dynamic images (MDCT, MRI). For nodules with characteristic vascular patterns (hypervascular in the arterial phase with washout in the portal venous or delayed phases) on a 4-phase MDCT or contrast enhanced MRI, HCC could be diagnosed without biopsy. However, tissue proof asked by physician is acceptable. For nodules without characteristic imaging patterns, histology or liver biopsy should be performed. If conventional CT or MRI is not diagnostic, Gadoxetic acid enhanced MRI could be considered. If biopsy showed no evidence of malignancy, the nodule should be followed with US or CT/MR every 3-6 months until nodule either disappears, enlarges, or displays diagnostic characteristics of HCC for 2 years. For nodules less than 1 cm in diameter that malignancy cannot be confirmed should be followed with US at 3-6 months interval for two years. According to most of the guidelines, a diagnosis of HCC can be made by nodules > 1cm with typical enhancement on dynamic CT or conventional MRI. However, typical dynamic enhancement pattern is reportedly seen in only 33 61% of small HCCs. The current guidelines of the Japan Society of Hepatology (JSH) have already incorporated the use of Gd-EOB-DTPA for atypical lesions. Combination of gadoxetic acid-enhanced dynamic study and hepatocyte-phase could provide better diagnostic performance than conventional MR imaging using Gd- DTPA. The use of Gadoxetic acid enhanced MRI as the 2nd techniques is recommended during the vote. However, Gadoxetic acid is not cover by National Health Insurance in Taiwan. Therefore, the term could be considered is used in the guideline.

16 14 ABSTRACTS Consensus of Treatment of HCC in Taiwan Jen-I Hwang / Section of Interventional Radiology, Veterans General Hospital Taichung According to the guidelines of American Academic Society of Liver Disease (AASLD), European Association for the Study of the Liver (EASL), and Asia-Pacific Primary Liver Cancer Expert (APPLE), the consensus of HCC treatment in Taiwan has been established in 2015 after several sessions of discussion. More than 50 members in 6 different groups of experts including general surgeons, hepatologists, interventional radiologists, medical and radiation oncologists make an agreement of the final HCC treatment algorithm as the figure shown below. In general, surgical resection or liver transplantation is considered the first choice of curative treatment modality for early stage (BCLC-A) of HCC. Local ablation, either radiofrequency (RFA) or microwave (MWA) can provide the same result as surgical resection for very early stage of HCC (BCLC-0) and has greater than 90% of complete tumor necrosis rate if the tumor less than 3cm in diameter. For the intermediate stage (BCLC-B) unresectable HCC, transarterial chemoembolization (TACE) either conventional or drug eluted beads TACE is the standard of care. Sorafenib is currently recommended for the management of advanced HCC (BCLC-C/D) with acceptable liver reserve. However, radioembolization (Y-90 SIRT), hepatic arterial infusion chemotherapy (HAIC) or TACE with external beam radiotherapy (EBRT) may also provide benefit for Child A/B HCC patients without extrahepatic metastasis. Today, I will focus on the non-surgical treatment of HCC, including RFA, TACE and combined methods. TLCA HCC treatment guideline 2015 (after coordinator consensus meeting at Taipei) HCC Extrahepatic spread No Yes Child-Pugh A/B C C A/B Vascular invasion No Yes No Yes HCC No. Single Within Milan 65y/o; 2. Within UCSF 70 y/o Size 3 cm > 3 cm Rx 1.Resection 2. LA<5cm 3. TACE 4. RT* (inaccessible to above Rx) 1.Resection 2.LA (PEI, RFA, MWA) 3.TACE 4.RT* 1.Resection 2.RFA/MWA 3.TACE 4.Y90-SIRT 5.RT* 1.Resection 2.TACE 3.Y90-SIRT TACE refractory, C-P A/B: # Sorafenib, LA, RT, Y90-SIRT 1.Resection 2.Sorafenib# 3.TACE+RT, Y90-SIRT, or HAIC 1.DDLT 2. LDLT Bridge Rx: Resection, TACE,LA,RT Palliative Care 1. Sorafenib ( # cautious in C-P B) with or without RT/TACE or Y90-SIRT or resection 2. Chemotherapy (C-P A, WBC >4000, pl >100K)

17 15 FLOOR PLAN Conference Room Registration Elsevier BTG tea break Desk Size(cm): 180(W)x45(D)x75(H) Synmosa Best

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20 專為醫師設計, 領先全球之線上診斷決策工具 提升效率與準確性以改善預後 取得最完整且值得信賴的資源 即使面對最複雜的影像病例也能有信心診斷 主要功能 : 主題預覽 (Topic Previews) 在目錄 搜尋結果 以及診斷模組中瀏覽主題標題時, 可預覽相關內容 鑑別診斷清單 (Differential Diagnosis Lists) 超過 1,300 份以影像表現為基礎之鑑別清單, 可協助您決定應考量那些病症 瀏覽工具 (Browse Tool) 在完整臨床情境下瀏覽相關診斷, 並由分層功能引導選擇各種類型的疾病 隨時比較 (Compare Anywhere) 可並列對照兩個診斷影像以上, 方便您快速而清楚的交互參考 RADTools (RADTools) 醫師常用工具之彙整, 包含 TNM 和癌症分期表等圖表, 各式診斷程序, 對齊角度之參考與分類資訊, 以及各種計算工具 全系統搜尋 (System-wide Search) STATdx 先進的搜尋引擎可協助您快速找到需要的診斷 鑑別診斷 解剖影像 醫療程序 影像表現 以及 RADTools 等等 患者案例 (Patient Cases) 各項診斷均提供參考案例讓您與自己的患者進行比較 立即前往 體驗以專家作為後盾之決策支援!

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24 AUTUMN SEMINAR 2015 OF CTSR HCC FORUM Chinese Taipei Society of Radiology (CTSR) 2F., No.63, Sec. 3, Chong-Qing N. Road, Taipei 10362, Taiwan Tel: , Fax: WebSite: Sponsors 百世生醫科技有限公司 Best Biomedical Supply Co., Ltd.