Considerations in Advanced HCC

Ghassan K. Abou-Alfa, MD:Another important factor in regard to the TACE, which even I would like to stress because this is a critical one, is patients with metastatic disease should not receive local therapy. There are exceptions to the rules for certain reasons, but, in general, they should not receive systemic therapy in the setting of metastatic disease. Because the argument that the disease is probably more responsible for outcome of patients, based on what’s in the liver and not outside the liver, is not necessarily true. We have seen situations, unfortunately, where the disease can worsen outside the liver and can cause certain impact in regard to patient outcome, simply because there was no systemic therapy applied and it was all focused on local therapy. The fact that worrying about the disease in the liver is more important than anything else is not really the case. It’s something to keep in mind.

Let’s assume this patient had the same scenario but with 1 caveat or difference where the major blood vessel, let’s say the portal vein, isn’t involved with the cancer—in other words, a tumor thrombus in the portal vein. TACE might not become a feasible option because, remember, TACE depends on the 2 blood flows that are available to the liver; ie, when we embolize on the arterial phase, we are dependent on the venous phase to allow the nourishment of the liver. And, as such, the venous part, which is a portal vein, is blocked. There’s a jeopardy to the liver over here.

Another approach would be possibly Yttrium-90 or radioembolization. There are lots of data that have shown it to be effective in the setting of portal vein thrombosis. Obviously, systemic therapy could be another appropriate option. Which one versus which, there are data that will be coming out at some point in time that probably would help guide us better for an option of that nature.

Transcript edited for clarity.

May 2015

• 64-year old obese female presented with fatigue and unexplained weight loss
• History of nonalcoholic fatty liver disease (NAFLD), then nonalcoholic steatohepatitis (NASH)
• Lab results: AFP= 1,500 IU/ml
• ECOG=1; Child-Pugh A
• CT revealed 1 large liver mass, right side of liver close to a major blood vessel
• No extrahepatic disease
• Liver-directed therapy with DEB-TACE was performed
• Patient reported abdominal pain following DEB-TACE and required analgesics; low-grade fever
• Patient had a complete response
• AFP= 200 IU/ml at follow up

February 2017

• Follow-up imaging showed progression and evidence of bone metastases
• Therapy was initiated with sorafenib at 400 mg BID
• Follow-up testing showed liver decompensation