Initial Strategies in Advanced HCC

Richard Finn, MD: In this case, the patient does have some cancer-related symptoms: fatigue and weight loss. She is otherwise fairly well compensated based on her blood work and exam. She would be considered Child-Pugh A. But, on imaging, she has invasion of the vasculature and also enlarged lymph nodes, which are suggestive of metastatic disease, not to mention the lesions in her chest as well.

So, this is a patient who is presenting with advanced liver cancer who is well compensated, and by the Barcelona criteria, this would be considered BCLC-C liver cancer. The question then becomes, what is the next step in managing this patient? In this case scenario, the patient is referred for liver biopsy—though it is not required—and that shows poorly differentiated histology, which is a negative prognostic factor in the setting of a patient who already has portal vein invasion and metastatic disease.

This is a good candidate for systemic treatment. Currently, the only agent that has been shown to improve survival for advanced liver cancer and is approved for that indication is sorafenib. Sorafenib is a multikinase inhibitor that hits the VEGF receptor, as well as other intracellular proteins felt to be important in oncogenesis. That, for many years, has been shown repeatedly to have a survival advantage in patients with Barcelona Class-C liver cancer who are well compensated or Child-Pugh A.

This patient has advanced liver cancer, and we had discussed that the treatment options are really going to be sorafenib or consideration for a clinical research study. This patient has a history of some noncompliance with her medications and, therefore, is not felt to be a good candidate for a clinical study. She is started on a standard of care, sorafenib at 400 mg/twice a day orally.

Transcript edited for clarity.

June 2015

• A 62-year old female smoker with a history of alcoholism and type 2 diabetes, HTN is experiencing fatigue
• ECOG=1
• Child-Pugh A
• T bilirubin 1.4; albumin 3.8; INR 1.1; no ascites, no encephalopathy; platelets 94
• CT scan reveals one 6-cm liver mass with invasion into the right branch of the portal vein, metastatic disease involving the abdominal lymph nodes and lung
• Biopsy confirmed HCC diagnosis; poorly differentiated
• Patient admitted nonadherence to anti-hypertensive medications
• Therapy was initiated with sorafenib at 400 mg BID
• Patient experienced grade 1 HTN, fatigue, dyspepsia, grade 3 diarrhea
• Dose was reduced to 400 mg QD, antimotility agents were given
• Patient was counselled regarding diet

July 2016

• Follow-up imaging has shown stable disease
• ECOG=1
• Patient is now Child-Pugh B