A 61-Year-Old Woman With Hepatocellular Carcinoma - Episode 1

61-Year-Old Female With Unresectable HCC

Pierre Gholam, MD, presents the case of a 61-year-old woman with hepatocellular carcinoma (HCC).

Pierre Gholam, MD: Hello, my name is Dr Pierre Gholam. I am a professor of medicine at Case Western Reserve University School of Medicine [in Cleveland, Ohio]. I lead our hepatobiliary tumor program, where we focus primarily on hepatocellular carcinoma, or HCC. Our task today is to discuss a case of unresectable HCC and go over treatment options, management, new updates in the field, which is rapidly evolving, and other questions related to this, now unfortunately, fairly common malignancy. Our case is a 61-year-old woman who complains of fatigue, right upper quadrant pain, nausea, and vomiting. She has a medical history of well-controlled hypertension on medication, obesity, and diabetes, which is managed with oral hypoglycemics. On physical examination she has hepatomegaly with some direct tenderness over the right upper quadrant.

Her work-up includes laboratory testing, which shows a normal alpha-fetoprotein of 1.5 ng/dL, a decent albumin of 3.9 [g/dL], an INR [international normalized ratio] of 1.4, a bilirubin of 1.1 [mg/dL], an [HbA1c glycated hemoglobin] of 7.0%, and a platelet count of 90,000. On her CT scan of the chest, abdomen, and pelvis, we are unfortunately faced with the findings of metastatic, concerning lesions in the lungs, a solitary lesion in the liver measuring 4.0 cm in greatest diameter, and a biopsy of the lung lesions confirms metastatic disease from a source of hepatocellular carcinoma.

When assessing this person’s ECOG performance status, she has a 1, which means that while she does not have a complete ability to perform activities of daily living, she is mostly capable of doing so. Based on the blood work I just shared with you, we would conclude that her Child-Pugh score, a time-honored system to determine how severe the liver disease is, is an A.

The patient has Child-Pugh A cirrhosis. This is a good sign in terms of her ability to tolerate established treatments for what we now surely would agree is unresectable HCC. That is the framework from which we will be taking it. It is decided that lenvatinib at a dose of 12 mg PO [by mouth] daily is the appropriate therapy, and that is initiated. I’ll remind this audience that in persons who weigh 60 kg or more, the starting dose of lenvatinib for the indication of unresectable HCC is 12 mg once a day.

Transcript edited for clarity.

A 61-Year-Old Woman with Hepatocellular Carcinoma

Initial Presentation

  • A 61-year-old woman complains of fatigue, RUQ pain and nausea and vomiting
  • PMH: medically controlled hypertension; obesity; diabetes managed with oral medication
  • PE: hepatomegaly with tenderness over the RUQ

Clinical Workup

  • CT scan of chest, abdomen and pelvis, with 4 phase liver evaluation: 4.0-cm hepatic mass in the right hepatic lobe
  • Labs: AFP: 1.5 ng/dL; Alb: 3.9 g/dL; INR: 1.45; Bili: 1.1 mg/dL , HbA1c: 7.0; platelet count 90,000
  • Biopsy of the lung metastasis demonstrated evident hepatocellular carcinoma
  • Child-Pugh A
  • ECOG PS 1

Treatment

  • Initiated lenvatinib 12 mg QD