ONCAlert | Upfront Therapy for mRCC

Case 1: 58-Year-Old Man With Newly Diagnosed HCC

Targeted Oncology
Published Online:1:00 PM, Mon December 2, 2019


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Ghassan Abou-Alfa, MD, MBA: Thank you for joining us for this Targeted Oncology™ Virtual Tumor Board® focused on hepatocellular carcinoma [HCC]. In today’s Targeted Oncology™ Virtual Tumor Board® presentation, my colleagues and I will review 4 clinical cases. We will discuss an individualized approach for the treatment of each patient, and we’ll review key trial details that impact our decisions.

I’m Ghassan Abou-Alfa, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, New York, and the chair of the NCI [National Cancer Institute] Hepatobiliary Task Force. Joining me today are Dr Amit Singal, the medical director of the liver tumor program and clinical chief of hepatology at UT [The University of Texas] Southwestern Medical Center in Dallas, Texas; Dr Riad Salem, chief of vascular interventional radiology in the Department of Radiology and a professor of radiology at Northwestern University Feinberg School of Medicine in Chicago, Illinois; and Dr Farshid Dayyani, a medical oncologist at UCI [University of California, Irvine] Medical Center and clinical associate professor of medicine in the Division of Hematology and Oncology at the University of California, Irvine in Irvine, California. Thank you for joining us. Let’s get started with our first case.

Amit Singal, MD: Thanks, Ghassan. Our first patient we’ll discuss today is a 58-year-old man with a history of NASH, nonalcoholic steatohepatitis, who presents for evaluation. He’s a nonsmoker. He drinks socially—about 5 to 8 alcoholic drinks per week—and he’s active. He golfs 6 times per week. When he sees us, he’s believed to have cirrhosis, so he undergoes HCC screening, he receives an ultrasound, he undergoes AFP, and he’s actually found to have a liver lesion on ultrasound. When you take a look at his laboratory results, you can see here he has Child-Pugh A cirrhosis. With his platelet count, he has a little bit of thrombocytopenia with 142,000. Bilirubin is normal at 1.0 mg/dL; albumin is normal at 3.5 g/dL. He has no hepatic encephalopathy nor ascites, and his AFP is also elevated at 217 ng/mL.

He undergoes further diagnostic evaluation with a CT [computed tomography] scan, which confirms that he has a lesion in the right hepatic lobe measuring 3½ cm. No extra hepatic disease. He undergoes biopsy, which confirms that this lesion is HCC, and the background liver disease shows advanced fibrosis, F3, F4. Overall in terms of staging, he’s a BCLC [Barcelona Clinic Liver Cancer] stage A. He has good performance status, 0.

So he undergoes liver resection and does quite well. He has negative margins at that time. Of course, he has a high risk of recurrence, so he undergoes surveillance after the resection. He does well at the 3-month scan but then at 6 months, he actually is found to have recurrence. He has a new liver lesion, 2 cm, consistent with HCC.

The patient is rediscussed at tumor board, and at that point the best therapy was believed to be a radiofrequency ablation. Once again he achieves a complete response at that time. He continues to be followed up on routinely and then does well until about 12 months later, at which time he’s unfortunately found to have multifocal disease. He’s found to have 4 liver lesions. The largest is just over 3 cm. And more worrisome is that he has 2 lesions in the lung that are worrisome for metastatic disease.

Ghassan Abou-Alfa, MD, MBA: Thanks so much, Amit. This is bread-and-butter, but at the same time there are quite a bit of learning thoughts for us. I’ll start with you just because the perspective from the hepatology standpoint will be very critical in regard to decision making for a patient like this. The first question I have is, how critical is it for a patient like your case here to be screened for HCC?

Amit Singal, MD: Yes, 1 of the things we have is an identifiable patient population. Over 80% to 90% of people who develop HCC in the United States have cirrhosis. These patients are extremely high risk with an annual incidence, somewhere right around 3% to 4%. And we have effective screening tools. If you do an ultrasound and you do an AFP test, and you do these every 6 months, you significantly increase the likelihood of applying the HCC at an early stage when we have curative options available. And there have been several studies that show that you actually have an association with improved survival. I think this is critical that we actually identify these patients and put them in a surveillance program.

Ghassan Abou-Alfa, MD, MBA: Fair enough. Farshid, with regard to that screening process that we heard of, and both of us are medical oncologists, what is your diagnostic work-up that you’d need for a patient like this? Now there is a mass. It smells like liver cancer. What’s your diagnostic work-up that you’d to see when you see patients?

Farshid Dayyani, MD: The first thing we would do is try to make sure we get the high-quality imaging, triphasic imaging with an MRI [magnetic resonance imaging]. Usually based on criteria, there is an enhancement in arterial case, but the LI-RADS [Liver Image Reporting and Data System] score we would do for the diagnosis obviously. A lot of colleagues will also check the AFP levels. And in certain cases, if it’s a trial patient, for example, we would even proceed with biopsy if the patient was not a surgical candidate for a curative intent patient.

Ghassan Abou-Alfa, MD, MBA: I like what you say. If anything, as you already suggested, with a CT scan, we like to favor triphasic or 4-phase CT or an MRI in that regard, but at the same time there’s definitely quite a bit of interest and focus not only on the imaging but also on the blood work to see what kind of extent of cirrhosis could be there.

Transcript edited for clarity.


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Ghassan Abou-Alfa, MD, MBA: Thank you for joining us for this Targeted Oncology™ Virtual Tumor Board® focused on hepatocellular carcinoma [HCC]. In today’s Targeted Oncology™ Virtual Tumor Board® presentation, my colleagues and I will review 4 clinical cases. We will discuss an individualized approach for the treatment of each patient, and we’ll review key trial details that impact our decisions.

I’m Ghassan Abou-Alfa, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, New York, and the chair of the NCI [National Cancer Institute] Hepatobiliary Task Force. Joining me today are Dr Amit Singal, the medical director of the liver tumor program and clinical chief of hepatology at UT [The University of Texas] Southwestern Medical Center in Dallas, Texas; Dr Riad Salem, chief of vascular interventional radiology in the Department of Radiology and a professor of radiology at Northwestern University Feinberg School of Medicine in Chicago, Illinois; and Dr Farshid Dayyani, a medical oncologist at UCI [University of California, Irvine] Medical Center and clinical associate professor of medicine in the Division of Hematology and Oncology at the University of California, Irvine in Irvine, California. Thank you for joining us. Let’s get started with our first case.

Amit Singal, MD: Thanks, Ghassan. Our first patient we’ll discuss today is a 58-year-old man with a history of NASH, nonalcoholic steatohepatitis, who presents for evaluation. He’s a nonsmoker. He drinks socially—about 5 to 8 alcoholic drinks per week—and he’s active. He golfs 6 times per week. When he sees us, he’s believed to have cirrhosis, so he undergoes HCC screening, he receives an ultrasound, he undergoes AFP, and he’s actually found to have a liver lesion on ultrasound. When you take a look at his laboratory results, you can see here he has Child-Pugh A cirrhosis. With his platelet count, he has a little bit of thrombocytopenia with 142,000. Bilirubin is normal at 1.0 mg/dL; albumin is normal at 3.5 g/dL. He has no hepatic encephalopathy nor ascites, and his AFP is also elevated at 217 ng/mL.

He undergoes further diagnostic evaluation with a CT [computed tomography] scan, which confirms that he has a lesion in the right hepatic lobe measuring 3½ cm. No extra hepatic disease. He undergoes biopsy, which confirms that this lesion is HCC, and the background liver disease shows advanced fibrosis, F3, F4. Overall in terms of staging, he’s a BCLC [Barcelona Clinic Liver Cancer] stage A. He has good performance status, 0.

So he undergoes liver resection and does quite well. He has negative margins at that time. Of course, he has a high risk of recurrence, so he undergoes surveillance after the resection. He does well at the 3-month scan but then at 6 months, he actually is found to have recurrence. He has a new liver lesion, 2 cm, consistent with HCC.

The patient is rediscussed at tumor board, and at that point the best therapy was believed to be a radiofrequency ablation. Once again he achieves a complete response at that time. He continues to be followed up on routinely and then does well until about 12 months later, at which time he’s unfortunately found to have multifocal disease. He’s found to have 4 liver lesions. The largest is just over 3 cm. And more worrisome is that he has 2 lesions in the lung that are worrisome for metastatic disease.

Ghassan Abou-Alfa, MD, MBA: Thanks so much, Amit. This is bread-and-butter, but at the same time there are quite a bit of learning thoughts for us. I’ll start with you just because the perspective from the hepatology standpoint will be very critical in regard to decision making for a patient like this. The first question I have is, how critical is it for a patient like your case here to be screened for HCC?

Amit Singal, MD: Yes, 1 of the things we have is an identifiable patient population. Over 80% to 90% of people who develop HCC in the United States have cirrhosis. These patients are extremely high risk with an annual incidence, somewhere right around 3% to 4%. And we have effective screening tools. If you do an ultrasound and you do an AFP test, and you do these every 6 months, you significantly increase the likelihood of applying the HCC at an early stage when we have curative options available. And there have been several studies that show that you actually have an association with improved survival. I think this is critical that we actually identify these patients and put them in a surveillance program.

Ghassan Abou-Alfa, MD, MBA: Fair enough. Farshid, with regard to that screening process that we heard of, and both of us are medical oncologists, what is your diagnostic work-up that you’d need for a patient like this? Now there is a mass. It smells like liver cancer. What’s your diagnostic work-up that you’d to see when you see patients?

Farshid Dayyani, MD: The first thing we would do is try to make sure we get the high-quality imaging, triphasic imaging with an MRI [magnetic resonance imaging]. Usually based on criteria, there is an enhancement in arterial case, but the LI-RADS [Liver Image Reporting and Data System] score we would do for the diagnosis obviously. A lot of colleagues will also check the AFP levels. And in certain cases, if it’s a trial patient, for example, we would even proceed with biopsy if the patient was not a surgical candidate for a curative intent patient.

Ghassan Abou-Alfa, MD, MBA: I like what you say. If anything, as you already suggested, with a CT scan, we like to favor triphasic or 4-phase CT or an MRI in that regard, but at the same time there’s definitely quite a bit of interest and focus not only on the imaging but also on the blood work to see what kind of extent of cirrhosis could be there.

Transcript edited for clarity.
Copyright © TargetedOnc 2020 Intellisphere, LLC. All Rights Reserved.