Unresectable Hepatocellular carcinoma with Amit Singal, MD and Richard Finn, MD: Case 2 - Episode 5

Amit Singal, MD: Possible Systemic Therapy in a uHCC Patient

Would you consider systemic therapy in this patient?

If you just took this as a snapshot in time at this point, you could say that he's eligible for chemoembolizatio because he does not have any evidence of vascular invasion, or distant metastases. However, if you take a look at how he's progressed over time, that it doesn't make sense to keep doing chemoembolization or locoregional therapy. They say the definition of insanity is doing the same thing over and over again and expecting a different outcome, and I think this is a perfect case for that. That's why when you start to see someone progress despite doing chemoembolization, you should really consider switching to systemic therapy at that point.


CASE 2 : Unresectable Hepatocellular carcinoma (uHCC)

Richard G is a 64-year-old Caucasian night club owner from New Orleans, Louisiana with a history of alcohol and substance abuse, and alcohol-induced cirrhosis.

In April of 2012 the patient was diagnosed with unresectable hepatocellular carcinoma (uHCC), with a 4.6 x 4.3 cm mass detected in segment 6 of cirrhotic liver and evidence of macroscopic vascular invasion and extrahepatic spread to regional lymph nodes

TACE was recommended by the multidisciplinary team and the patient underwent a total of 2 TACE procedures, with a partial response observed (30% decrease in sum of greatest unidimensional diameters of target lesions compared to baseline) by RECIST criteria

In July 2013, follow up laboratory values were:

Albumin: 3.9 g/dL;

Bilirubin: 0.7 mg/dL

Alpha fetoprotein: 53.2 ng/mL

Platelets: 179,000

AST: 370 IU/mL

ALT: 189 IU/mL

The patient is classified as Child Pugh Class A at the current visit, with, with a MELD score of 10, and the patients ECOG performance status is 1

Contrast-enhanced MRI showed disease progression, with increases observed in diameter of multiple target lesions