Refractory Hepatocellular Carcinoma - Episode 1

65-Year-Old Man With Hepatocellular Carcinoma

Ahmed Kaseb, MD:Our case today is on a 65-year-old gentleman with an established history of cirrhosis—for 10 years—who has been referred for further evaluation for the onset of jaundice. This is a common scenario, especially in patients with known chronic liver disease, and the work-up is basic. It starts with blood work and scans. This is exactly what our patient had done.

Imaging showed an 8-cm tumor in the left side of the liver. The tumor showed the characteristic imaging pattern of hepatocellular carcinoma, which is basically hypervascularity in the arterial phase and rapid washout in the venous phase.

This brings up a very common question: When it comes to hepatocellular carcinoma patients, when do we need a biopsy to establish the diagnosis? In patients with established cirrhosis with those typical tumor characteristics, the American Association for the Study of Liver Diseases guidelines typically do not recommend a biopsy because of the risk of complications in patients with cirrhosis, in terms of bleeding, for example.

Our patient’s stage is stage I because this patient has only 1 tumor with no vascular invasion and scans showed no evidence of any metastatic disease. So any tumor of any size, if it is a single tumor with no invasion of vasculature on imaging and no metastases would be classified as stage I. The dilemma here is the concomitant liver disease, specifically cirrhosis. These patients are not candidates for surgical resection because of the advanced cirrhosis, which would have been curative. The next best option for patients with cirrhosis, in terms of being curative, is liver transplant. However, this patient does not fall within transplant criteria. The typical transplant criteria are called Milan Criteria, and they specify 1 tumor up to 5 cm in diameter, 3 tumors up to 3 cm in diameter, with no vascular invasion on imaging or metastases. So clearly, this patient doesn’t fall under transplant criteria.

Since this patient is not a candidate for surgical resection or liver transplant, the treatment goal here is palliative. Unless we get our patient to a point where transplant or surgical options could come back to the table, the treatment goal remains palliative. And the prognosis here, as well, would be dependent on the course of the therapy, in terms of response to therapy. However, the prognosis is poor, with no curative options available for our patient.

Transcript edited for clarity.


Case: A 65-year-old Man With Cirrhosis and HCC

A 65-year-old man with 10-year history of cirrhosis was seen for routine follow-up; referred for further lab and imaging studies based on enlarged lymph nodes and new-onset jaundice.

H & P

  • PE: Yellowing of the skin and sclerae
  • Social History: drinks 20+ alcoholic beverages/ week for the past 15 years
  • ECOG: 0

Labs

  • AFP: 550 IU/mL
  • Child-Pugh B
    • Bilirubin: 3 mg/dL
    • Albumin: 3.5 g/dL
    • No hepatic encephalopathy
    • Grade 1 ascites

Imaging

  • Multiphasic contrast MRI of the abdomen revealed an 8-cm encapsulated mass in the left hepatic lobe showing hypervascularity on arterial phase and washout on venous phase
  • Further imaging of CAP revealed no metastasis
  • Diagnosis: unresectable hepatocellular carcinoma

Treatment

  • Underwent TACE; follow-up imaging at 1 month showed no response
  • Started on lenvatinib 12 mg once daily; follow-up imaging at 3 months showed no response
  • Received nivolumab 3 mg/kg every 2 weeks

Follow-up

  • 3 months later; patient complained of increasing fatigue
  • AFP; 600 IU/mL
  • MRI showed disease progression in the liver, one new adrenal lesion