A case of nearly complete response in hepatocellular carcinoma with disseminated lung metastasis by combination therapy of nivolumab and ipilimumab after treatment failure of atezolizumab plus bevacizumab

Recently, the efficacy of immuno-oncologic agents for advanced hepatocellular carcinoma (HCC) has been proven in several trials. In particular, atezolizumab with bevacizumab (AteBeva), as a first-line therapy for advanced HCC, has shown tremendous advances in the IMBrave150 study. However, second or third-line therapy after treatment failure with AteBeva has not been firmly established. Moreover, clinicians have continued their attempts at multidisciplinary treatment that includes other systemic therapy and radiotherapy (RT). Here, we report a case that showed a near complete response (CR) of lung metastasis to nivolumab with ipilimumab therapy after achieving a near CR of intrahepatic tumor using sorafenib and RT in a patient with advanced HCC who had experienced treatment failure of AteBeva.

Complete response in hepatocellular carcinoma with lymph node metastasis by combination therapy of atezolizumab and bevacizumab: a case report

Sorafenib is the oldest first line systemic treatment in patients with advanced hepatocellularcarcinoma (HCC) and has been used exclusively for nearly 10 years. The superiority ofadministering a combination of atezolizumab plus bevacizumab (AteBeva) compared tosorafenib as first line systemic treatment for unresectable HCC was recently proven duringthe IMbrave150 Phase III randomized trial. While clinicians can expect improved responsesand treatment outcomes due to the good results of the IMbrave 150 trial, they must alsoconsider that atezolizumab can cause various immune-related adverse events (IrAEs). Basedon the above suggestions, we herein present a case of HCC with lymph node metastasiswho achieved complete remission following treatment with AteBeva and developed an IrAE(adrenal insufficiency). Further study of real-life data regarding combination therapy withAteBeva is needed to manage patients with advanced HCC.

Complete response in hepatocellular carcinoma with lymph node metastasis by combination therapy of atezolizumab and bevacizumab: a case report

Sorafenib is the oldest first line systemic treatment in patients with advanced hepatocellularcarcinoma (HCC) and has been used exclusively for nearly 10 years. The superiority ofadministering a combination of atezolizumab plus bevacizumab (AteBeva) compared tosorafenib as first line systemic treatment for unresectable HCC was recently proven duringthe IMbrave150 Phase III randomized trial. While clinicians can expect improved responsesand treatment outcomes due to the good results of the IMbrave 150 trial, they must alsoconsider that atezolizumab can cause various immune-related adverse events (IrAEs). Basedon the above suggestions, we herein present a case of HCC with lymph node metastasiswho achieved complete remission following treatment with AteBeva and developed an IrAE(adrenal insufficiency). Further study of real-life data regarding combination therapy withAteBeva is needed to manage patients with advanced HCC.

A Case of Achieving Partial Remission with the Combination of Sorafenib and Nivolumab in a Patient with Hepatocellular Carcinoma Showing Disease Progression after Nivolumab Therapy

Sorafenib is a well-known approved systemic therapeutic agent used in patients with advanced hepatocellular carcinoma (HCC). Regorafenib and nivolumab are approved as second-line therapeutic drugs in patients showing disease progression after sorafenib therapy. However, there is no established third- or fourth-line therapy in patients with progression after regorafenib or nivolumab treatment. Recently, the combination of tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICPIs) has been attempted as a first-line treatment strategy in advanced HCC patients based on the hypothesis that combination therapy may overcome resistance in ICPI monotherapy. On the basis of this suggestion, we herein describe the case of an HCC patient demonstrating macrovascular invasion, whereby partial remission was achieved via the combination of sorafenib and nivolumab following disease progression after nivolumab therapy. Further studies on the combination of TKIs and ICPIs are necessary to determine ways to manage HCC patients showing disease progression after ICPI therapy.

A Case of Achieving Partial Remission with Sequential Treatment of Transarterial Chemoemoblization after Transarterial Radioembolization in Old Patient with Hepatocellular Carcinoma with Multiple Metastasis

The number of older adults with hepatocelluar carcinoma (HCC) has been increasing with longer life expectancy and earlier diagnosis and treatment. However, older patients have lesser function reserve of multiple organ systems, more disability rate. Therefore, the treatment of elderly HCC patients remains a challenge worldwide. Recently, studies suggests that the survival outcome of older patients may be comparable to that of younger patients and active treatment may achieve promising rates of local and systemic control in selected patients. Based on above suggestions, we herein offer our experience of a case achieved partial remission by sequential therapy of transarterial chemoembolization after transarterial radioemoblization in elderly HCC patient with multiple metastasis. Further study, maybe regarding a combination of locoregional and systemic treatment, is necessary on how to manage HCC in elderly patients.

A Case of Achieving Complete Remission with Combination of Sorafenib and Tegafur in Patients with Hepatocellular Carcinoma with Progression of Disease after Sorafenib Therapy

Sorafenib is the only approved targeted agent as the first line systemic therapy for treatment of advanced hepatocellular carcinoma (HCC). However, the improvement of survival duration under 3 months is far from clinical satisfactory and most patients experience disease progression within 6 months after sorafenib therapy. Unfortunately, second line systemic therapy after treatment failure of sorafenib was not established and there were no clear guidelines for salvage treatment modalities. Recently, studies suggests that combination of sorafenib and single cytotoxic agent can be relatively effective and safe strategy that achieves promising rates of local and systemic control in advanced HCC patients. Based on above suggestions, we herein offer our experience of a case achieved complete remission by combination therapy of sorafenib and tegafur in the patient with progressed disease after sorafenib therapy.

Locoregional Treatment of Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

Hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) have a extremely poor prognosis. According to the Barcelona Clinic Liver Cancer guideline, sorafenib is a standard therapy in this situation, but many clinicians still select locoregional therapy (LRT) such as transarterial therapy, external beam radiation therapy (EBRT), even surgical resection (SR) or combination of LRTs because the survival improvement by sorafenib is unsatisfactory. Based on recent meta-analysis and prospective study, transarterial chemoembolization (TACE) and transarterial radioembolization seem to be effective and safe therapeutic option that have comparable outcome to sorafenib. Recently large nationwide studies demonstrated that SR can be a potentially curative treatment in selected patients. Hepatic arterial infusion chemotherapy (HAIC) can be also good option, especially in Child class B patients based on small volume prospective studies. Moreover, multidisciplinary strategies based on the combination of LRTs (SR plus TACE, TACE + EBRT, TACE + Sorafenib, HAIC + EBRT etc.) may improve survival of HCC patients with PVTT. Finally we discuss individualized and tailored treatment strategies for different clinical situations.

A Case of Achieving Complete Remission with Stereotactic Body Radiation Therapy in Patients with Hepatocellular Carcinoma with Macrovascular Invasion after Repeated Transarerial Chemoembolization

Transarterial chemoembolization (TACE) is the worldwide procedure performed for patients with various stage hepatoceullar carcinoma (HCC), but is not yet considered as curative treatment because of relatively high local recurrence rate. Moreover, many clinicians frequently experience treatment failure (incomplete necrosis or stage progression etc.) after repeated TACE, but no clear guidelines have been recommended about salvage treatment modalities for this situation. Recently, studies for combination of radiation therapy and TACE for HCC with TACE refractoriness have been tried and reported better therapeutic efficacy. Based on above suggestions, we herein offer our experience of a patient with macrovascular invasion developed after repeated TACE that achieve complete remission by stereotactic body radiation therapy. Further study, maybe regarding a combination of locoregional and systemic therapy, is necessary on how to manage HCC patients with TACE refractoriness.

A Case of Achieving Complete Remission with Combination of Stereotac-tic Body Radiation Therapy and Transarterial Chemoemoblization in Pa-tients with 4.8 cm Sized Infiltrative Hepatocellular Carcinoma with Arte-riovenous Shunt

Infiltrative hepatocellular carcinoma (HCC) patients have a poor prognosis because most patients present with advanced disease. Although tumor size is small, ablation therapy is difficult because it is difficult to delineate tumor boundary and tumor often combined vascular invasion. Therefore many clinicians still try locoregional therapy (LRT) such as transarterial chemoembolization (TACE), radiation therapy (RT), or combination with LRT and sorafenib in this situation. Stereotactic body radiation therapy (SBRT) is new technology providing very highly conformal ablative radiation dose and is expected to salvage modality for HCC showed incomplete response of TACE due to combined arteriovenous (AV) shunts. Based on above suggestions, we herein offer our experience of a complete remission of tumor by combination of SBRT and TACE in a patient with infiltrative HCC. Further study, maybe regarding a combination of locoregional and systemic therapy is necessary on how to manage infiltrative HCC with AV shunts.

Extramedullary Plasmacytoma of the Pancreas Diagnosed Using Endoscopic Ultrasonography-Guided Fine Needle Aspiration

Extramedullary plasmacytoma involves organs outside the bone marrow; however, involvement of the pancreas is rare. We recently experienced a case of extramedullary plasmacytoma of the pancreas that was diagnosed by endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). EUS-FNA, which has a high diagnostic accuracy and an excellent safety profile, is the modality of choice for establishing tissue diagnosis. We report a case of extramedullary plasmacytoma of the pancreas diagnosed using EUS-FNA.

A Case of Cholangiocarcinoma Suspected by Continuous Elevation of CA 19-9 after Surgery of Xanthogranulomatous Cholecystitis / 대한소화기학회지

Xanthogranulomatous cholecystitis (XGC) is an unusual and destructive inflammatory process that is characterized by thickening of the gallbladder (GB) wall with a tendency to adhere to neighboring organs. XGC is often mistaken for GB carcinoma, and the frequency of the coexistence of these two lesions is approximately 10%. Therefore, in case of severe XGC, there is chance of either overlooking the carcinoma or other significant lesions. CA 19-9 is commonly measured in the serum of patients with hepatobiliary malignancies. Although CA 19-9 can be elevated in benign conditions such as cholestasis, pancreatitis, tuberculosis, thyroid disease etc., malignancy should be considered at first in setting of its significant and persistent elevation. We report a case of a 62-year-old man who showed continuously rising level of CA19-9 over 2000 U/mL after cholecystectomy for xanthogranulomatous cholecystitis and finally was diagnosed as cholangiocarcinoma by short-term follow up.

A Case of Gastric, Duodenal and Colonic Metastases from Adenocarcinoma of the Lung / 대한소화기내시경학회지

Gastrointestinal metastasis of primary lung carcinoma is very rare, although this is found in about 4.7~14% of cases at autopsy. An 81-year-old man was admitted with masses in the lung, adrenal gland, bladder and colon on his CT scans. We suspected metastases of an unknown origin and we carried out EGD and colonoscopy to differentiate the primary origin of the metastases. The examination revealed a submucosal tumor-like mass with central erosion on the gastric antrum and colonic splenic flexure, and polypoid lesions with a central fissure on the second portion of the duodenum. All the endoscopic forcep biopsies showed poorly differentiated adenocarcinoma without evidence of foci of the preinvasive surface glandular lesions. Immunochemical analysis of the tumor cells showed positivity for thyroid transcription factor-1 and cytokeratin 7, and negativity for cytokeratin 20 and caudal-related homeobox 2. Therefore, we diagnosed this case as multiple gastrointestinal metastases of primary lung cancer. This is first case of gastric, duodenal and colonic metastases from adenocarcinoma of the lung in the medical literature.

Effectiveness and Complications of Combination Therapy with Interferon Alpha and Ribavirin in Patients with Chronic Hepatitis C / 대한소화기학회지

BACKGROUND/AIMS: The effectiveness of combination therapy with conventional or pegylated interferon alpha and ribavirin in patients with chronic hepatitis C is well understood. However, the profound investigation about complications of the treatment has been rarely reported in Korea, where patients have broader spectrum of disease manifestations. The aim of this study was to evaluate the effectiveness and complications of the combination therapy of interferon alpha and ribavirin in patients with chronic hepatitis C. METHODS: Two hundred and forty patients with chronic hepatitis C were included. All patients were treated with interferon alpha (3 million units thrice a week) in combination with ribavirin (800-1,200 mg, depending on body weight). Patients were treated for 6 or 12 months according to the genotypes (genotype 1; 12 months, non-1; 6 months). We retrospectively evaluated ETR (end of treatment response) and SVR (sustained virologic response) on the basis of intent-to-treat in patients completing the therapy. RESULTS: In 154 patients who had completed the therapy, ETR was 79.2% and SVR was 61.0%. Multivariate analysis showed that genotype and early virologic response at 3 months of treatment were indepedent predictive factors of SVR. Due to insufficient response, 11.3% of the patients discontinued the therapy. In addition, 24.5% of the patients prematurely discontinued the therapy due to adverse events including aggravated liver function (15.4%), failure to return (7.9%), and others (1.2%). Dose modifications of interferon alpha or ribavirin were required due to anemia (15.4%), neutropenia (8.8%), or thrombocytopenia (4.6%). CONCLUSIONS: The overall SVR of patients who had completed the combination therapy with interferon alpha and ribavirin was 61.0%. However, about one third of the patients discontinued the therapy prematurely due to insufficient response, adverse events and/or noncompliance.

A Case of Rectal Schwannoma Presenting with Hematochezia / 대한소화기학회지

Rectal schwannoma is a rare mesenchymal tumor originating from Schwann's cell. We experienced a 61- year-old female patient who complained of blood tinged and narrow calibered stool for several years, and found a 4 cm sized submucosal tumor with a central ulcer on the rectal wall during colonoscopy. She underwent transanal excision. Microscopically, the tumor was composed of fasciculating bundles of spindle cells with benign nuclear atypia and peripheral lymphoid cell cuffing. Tumor cells showed a diffuse strong immunoreactivity to S-100 protein, but not stain for CD 34, desmin and smooth muscle actin. This is the first case report of rectal schwannoma in Korea.

A Case of Primary Angiosarcoma of Small Intestine Presenting as Recurrent Gastrointestinal Bleeding / 대한소화기학회지

Angiosarcoma is a rare malignant tumor which occurs frequently in the skin and soft subcutis. Moreover, primary gastrointestinal angiosarcomas are very rare. This tumor manifests as non-specific symptoms such as gastrointestinal bleeding, abdominal pain and nausea. The diagnosis is often made at an advanced stage. Surgery, chemotherapy and radiotherapy are the mainstay of treatment. However, the prognosis is very poor. We report a case of primary angiosarcoma of the small intestine presenting as recurrent gastrointestinal bleeding. A 54-year-old man was admitted with recurrent gastrointestinal bleeding. An abdominal CT scan revealed an ileo-ileal intussusception. Segmental resection was performed with ileo-ileal anastomosis. The ileal mass was diagnosed as angiosarcoma on immunohistochemical stain. He received 3 cycles of chemotherapy, but died 5 months after the diagnosis.

A Case of Gastric Metastasis of Breast Carcinoma Resembling Early Gastric Cancer / 대한소화기학회지

Many patients suffering from breast carcinoma have metastases at initial diagnosis. The common metastatic sites are skeleton, liver and lung. Metastases to stomach are rare and only three cases have been reported in Korea. The endoscopic features of gastric metastases from breast carcinoma can be divided into three main categories: diffuse infiltration, external compression, and localized tumor deposition with ulceration or with a polypoid mass. However, metastatic gastric lesions which resemble early gastric carcinoma are rare. Typically, gastric metastases are confined to submucosa and muscularis, so that mucosal biopsy specimens might be false-negative. We report a case of gastric metastasis from infiltrative lobular carcinoma of the breast in a 66-year-old woman who had undergone left mastectomy with postoperative radiotherapy 17 years earlier. Initial diagnosis was early gastric carcinoma, signet ring cell type on gastric biopsy findings. However, definitive diagnosis of metastatic breast cancer was confirmed after endoscopic mucosal resection of a presumed primary early gastric carcinoma.

A Case of Common Bile Duct Stone Caused by Foreign Body in Patient with Adenoma of the Ampulla of Vater / 대한소화기내시경학회지

Choledocholithiasis caused by a foreign body is rare. The most common type of foreign body in the common bile duct is a residual object from previous surgery such as a metal clip or suture material. Foreign body may enter the biliary system after choledochointestinal anastomosis or endoscopic sphincterotomy. Rarely, penetrating missile fragment or gunshot shrapnel account for another type of foreign body. We experienced a case of common bile duct (CBD) stone caused by foreign meterial in 75-years-old women who had a plant foreign body in the common bile duct. She had no past history of abdominal surgery or penetrating trauma. The foreign body and stone were successfully extracted with Dormia basket after the endoscopic sphincterotomy.

A Case of Kikuchi's disease accompanied by Hemophagocytic Lymphohistiocytosis / 감염과화학요법

Kikuchi's disease usually occurs in young women and is characterized by localized lymphadenitis (mostly cervical) usually associated with fever. It is considered a self-limited disease and most patients recover spontaneously within a few weeks to 6 months without any serious sequelae. However, patients with Kikuchi's disease require a systemic survey and regular follow-up for several years because it may be associated with other diseases such as systemic lupus erythematosus. To our knowledge, there are very few reports of Kikuchi's disease accompanied by hemophagocytic lymphohistiocytosis. Biopsy of a right cervical lymph node in a 35-year-old female who presented with fever and masses in the right cervical region showed necrotizing lymphadenitis and a diagnosis of Kikuchi's disease was reached. She was started on methylprednisolone pulse therapy (500 mg for 3 days) but developed generalized rash and fever. Laboratory data showed pancytopenia, elevation of serum transaminase and ferritin levels. Bone marrow and liver biopsy showed proliferation of histiocytes and Kupffer's cells engulfing lymphocytes, platelets and red blood cells, respectively. We report a case of Kikuchi's disease accompanied by hemophagocytic lymphohistiocytosis.

A Case of Kikuchi's disease accompanied by Hemophagocytic Lymphohistiocytosis / 감염과화학요법

Kikuchi's disease usually occurs in young women and is characterized by localized lymphadenitis (mostly cervical) usually associated with fever. It is considered a self-limited disease and most patients recover spontaneously within a few weeks to 6 months without any serious sequelae. However, patients with Kikuchi's disease require a systemic survey and regular follow-up for several years because it may be associated with other diseases such as systemic lupus erythematosus. To our knowledge, there are very few reports of Kikuchi's disease accompanied by hemophagocytic lymphohistiocytosis. Biopsy of a right cervical lymph node in a 35-year-old female who presented with fever and masses in the right cervical region showed necrotizing lymphadenitis and a diagnosis of Kikuchi's disease was reached. She was started on methylprednisolone pulse therapy (500 mg for 3 days) but developed generalized rash and fever. Laboratory data showed pancytopenia, elevation of serum transaminase and ferritin levels. Bone marrow and liver biopsy showed proliferation of histiocytes and Kupffer's cells engulfing lymphocytes, platelets and red blood cells, respectively. We report a case of Kikuchi's disease accompanied by hemophagocytic lymphohistiocytosis.

Transfusion Therapy in a Patient with Hemolytic Transfusion Reaction due to Anti-Jka / 대한수혈학회지

No abstract available.