June 5, 2020
Anthony El-Khoueiry, MD


Case: A 69-Year-Old Man with Stage 4 Hepatocellular Carcinoma

Initial presentation

  • A 69-year-old man presented with vague right upper quadrant abdominal discomfort, decreased appetite and occasional nausea and vomiting
  • PMH: diabetes, medially controlled; hepatitis B virus diagnosed and treated 8 years ago
  • SH: moderate amount of alcohol use (2-3 drinks a day)
  • PE: abdominal discomfort on palpation

Clinical workup

  • Labs: AFP 425 ng/mL, bilirubin 1.2 mg/dL, AST 102 U/L, ALT 116 U/L, ALP 380 U/L, INR 1.6, albumin 3.6 g/dL, BUN 15 mg/dL, creatinine 1.5 mg/dL, plt 205,000
  • HBV+, HCV-
  • Abdominal ultrasound revealed 2 hepatic lesions
  • Chest/abdominal/pelvic CT scan confirmed 2 lesions in the right hepatic lobe measuring 3.2 cm and 5.5 cm, a suspicious lesion in the left lung lobe, and wide-spread lymphadenopathy noted
  • Biopsy findings showed grade 3 HCC with marked fibrosis
  • Surgical consult: unresectable due to tumor size and location
  • Child-Pugh A; BCLC stage C
  • ECOG 1

Treatment and Follow-Up

  • Treatment with atezolizumab + bevacizumab was initiated
    • First imaging shows stable disease at 2 months; imaging at 4-month follow-up showed 2 new lung lesions
    • Treatment was subsequently changed to cabozantinib 60 mg PO qDay