Appropriate Management of Patients With Metastatic HCC

Ghassan K. Abou-Alfa, MD:As we heard, the patient did get quite a bit of time on the lenvatinib, which is great to hear, but on the other hand, developed some [adverse] effects. And the [adverse] effects of the lenvatinib, which already I have experience with [in] some patients, is the same…[as] what happened in the clinical trials. Maybe the key ones are the hypertension, and this is what we saw in our patient, potential decrease in appetite, weight loss, tiredness. But interestingly the sorafenib and what you are used to in regard to the hand-foot syndrome can happen but at all definitely not to the extent that we see to the sorafenib. And as such I would say that the drug was acceptably well tolerated. Management of the hypertension was easy to handle with a change of the antihypertensives, or additional antihypertensives, and patients can move on with therapy.

One thing, by the way, is to bring up here it was in the study…[that] I was fascinated that one of the patients pointed…[out] to me is lenvatinib—you can take it any time as you want as a patient. While the sorafenib, as we know, it has to be [taken] on an empty stomach, 2 hours before, and twice per day. While this is just one pill a day, and that’s it.

One variant over here, remember that the lenvatinib is guided by weight. I would say in the US, it’s less likely to be an issue because in general all patients who have HCC will have definitely more than 60 kilos in weight. But nevertheless, the dosing will differ based on weight—12 mg for patients who…[weigh] above 60 kilos, and 8 mg for… [those who weigh] less than 60 kilos.

I’m very happy to hear that this patient was managed rather very appropriately. If anything, it saddens me that he was not caught early in the game with the hepatitis C and the potential for HCC development. However, the embolization were appropriate, but I’m glad to see that the multidisciplinary approach and to the case was both relatively early in the game and patient was moved on smoothly from local therapy to systemic therapy. The choice of the lenvatinib is a valid one, and I’m happy to see that the patient did rather very well on it. The tolerance was acceptable, management of the blood pressure was pretty straightforward, and patient improved. And more importantly, the response rate is definitely something that patient and their physicians were very happy about.

Transcript edited for clarity.

A 60-Year-Old Male With Unresectable HCC and a History of HCV

• Medical History and Physical Exam
  • A 60-year-old Asian man presented to his gastroenterologist with abdominal pain (upper-right quadrant).
  • History of diabetes, hypertension controlled with ramipril, chronic hepatitis C virus (HCV), diagnosed and treated 9 years ago with interferon
  • ECOG Performance Status 0
• Work-up and Diagnosis
  • MRI abdomen: single 7-cm lesion on right hepatic lobe
  • Biopsy: confirmed hepatocellular carcinoma (HCC)
  • The tumor was deemed unresectable upon surgical evaluation.
• Initial Therapy
  • Transarterial chemoembolization performed (x3); excellent response
• Follow-up
  • Six months later: CT showed multifocal HCC in left abdominal wall, liver lesions, and lung metastases.
  • Child-Pugh score, A5
  • BCLC stage C (advanced stage)
  • Weight, 79 kg
  • Α-Fetoprotein level, 752 ng/mL
• Treatment of metastatic disease and follow-up
  • The patient received lenvatinib 12 mg QD