A 61-Year-Old Man With Stage 4 Hepatocellular Carcinoma

June 24, 2020
Pierre Gholam, MD

Pierre Gholam, MD, provides insight on the case of a 61-year-old man with stage 4 hepatocellular carcinoma and evaluates current treatment options on TKIs.


Case: A 61-Year-Old Man with Stage 4 Hepatocellular Carcinoma

Initial presentation

  • A 61-year-old man presented with nausea, vomiting, decreased appetite and occasional generalized itching
  • PMH: diabetes, medially controlled; hepatitis C and B coinfection diagnosed and treated 6 years ago; diagnosed with HCC December 2018
  • PE: scleral icterus; jaundice; spleen palpable 4-cm below the costal margin

Clinical workup

  • Labs: AFP 436 ng/mL, bilirubin 1.6 mg/dL, AST 105 U/L, ALT 110 U/L, ALP 390 U/L, INR 1.9, albumin 3.8 g/dL, BUN 13 mg/dL, creatinine 1 mg/dL, plt 95,000
  • HBV+, HCV+
  • Abdominal ultrasound revealed 3 small hepatic lesions
  • Chest/abdominal/pelvic CT scan confirmed 2 focal nodules in the right and 1 in the left hepatic lobe measuring 3.6 cm, 4.9 cm and 5.2 cm, a suspicious lesion in the right lower lung lobe; wide-spread lymphadenopathy was noted
  • Biopsy findings showed grade 3 hepatocellular carcinoma with marked fibrosis
  • Surgical consult: unresectable due to tumor size and location
  • Child-Pugh A; BCLC stage C
  • ECOG 1

Treatment and Follow-Up

  • 2018: treated with lenvatinib 400 mg PO q12hr; he experienced diarrhea for 2 weeks which resolved; achieved PR
  • 2020: Imaging showed a new lung lesion
    • Treatment was with cabozantinib 60 mg PO qDay was initiated