What are the principle treatment options for this patient with recurrent uHCC?
The treatment choices for patients who have recurrent, unresectable HCC once again largely depend on the degree of tumor burden when they have recurrence. If you have a small degree of tumor burden, you're actually within transplant criteria and that would actually be the ideal solution. It not only treats the underlying HCC but also the liver disease, and thus offers a cure rate of 60% to 70% at 5 years. This is the best long-term solution for HCC.
CASE 1: Unresectable Hepatocellular Carcinoma (uHCC)
Mario C is a 74-year-old retired steel worker from Allentown, Pennsylvania. His past medical history is notable for hepatitis B virus (HBV) infection (diagnosed in early 1990s).
In July 2013, patient was referred to a hepatologist with an elevated ALT (70 IU/mL) and AST (53 IU/mL).
Medical history is also notable for mild hypertension (currently controlled on antihypertensives) and hypercholesterolemia (currently controlled with diet); patient denies any alcohol use
Family history was relevant for an older brother who died of HCC and chronic HBV infection at age 70
On physical exam, no evidence of liver disease was noted and patient did not report any recent weight loss; patient reported some intermittent abdominal pain and there was mild tenderness in the lower right quadrant on palpation
Ultrasound revealed a poorly defined mass in the right lobe; contrast enhanced MRI showed a 12-cm mass in the lower right segment consistent with HCC and several smaller nodules. Bone scan and chest CT showed no evidence of metastatic disease
Patient presented to the Multidisciplinary Team (MDT) with Child Pugh Class A, with a MELD score of 7; patient’s performance status was 1
On surgical consult, the patient was deemed unresectable and the MDT recommended a TACE procedure for the larger lesion
In December of 2014, evidence of residual disease was detected on a follow up CT scan at the site of the first TACE procedure; smaller nodules also showed evidence of radiologic progression.