A 68-Year-Old Man With Hepatocellular Carcinoma - Episode 1
Ghassan K. Abou-Alfa, MD, MBA, presents the case of a 68-year-old man with hepatocellular carcinoma (HCC) and shares his initial impressions.
Ghassan K. Abou-Alfa, MD, MBA: Hello, I’m Ghassan Abou-Alfa from Memorial Sloan Kettering Cancer Center in New York, New York. I’m delighted to present to you and discuss a case of a 68-year-old gentleman with hepatocellular carcinoma. Let’s see what we can learn together.
Our patient is a 68-year-old man who complains of fatigue and right upper quadrant pain. His past medical history includes medically controlled hypertension and cirrhosis due to a 20-year history of heavy alcohol use. He smokes cigarettes as well: 20 pack-years. On physical exam, the patient had hepatomegaly and some tenderness over the right upper quadrant. As we all might do, we had a chest and pelvis CT scan, including a 4-phase of the liver. A 3-phase could have been OK as well, but the 4-phase was good enough to delineate the liver evaluation in detail. It showed a 6.5-cm liver lesion in the right hepatic lobe, but also sadly, several metastatic disease sites in the lung. Alpha-fetoprotein was commissioned to that finding 490 µg/L.
But at the same time, the good news is that the liver function was appropriate. The albumin was 3.5 g/dL, bilirubin was 1.9 mg/dL, and the INR [international normalized ratio] was 1.5, which is normal. However, the platelet count was reduced, up to 79,000 per mm3. A biopsy did occur for the lung metastases site. This is standard. We need a biopsy to confirm the diagnosis. We would always like to go to the metastatic site to prove it’s metastatic disease. That biopsy did confirm hepatocellular carcinoma. Based on the evaluation that I presented in regard to the physical exam, there was no ascites, no encephalopathy. The blood work included normal bilirubin, normal albumen, a normal PT [prothrombin time] and INR, and the patient is Child-Pugh A. Performance status was appropriate, ECOG 1, with upper quadrant pain that he has every now and then. The patient started on lenvatinib 12 mg daily.
Let’s discuss all this. You can ask me about my impression of that story, which can happen every day. We often hear about patients like this 1. Sadly, the incidence of liver cancer continues to increase. This is standard. Most patients will have metastatic disease to begin with. We hope to take care of patients when they’re still within the Child-Pugh A arena, like our patient. As such, this can reflex rather positively in regard to the prognosis of this patient. In the old days, when there were no therapies available, sadly, the prognosis was somewhat limited. Nowadays, with the advent of many therapies, we have first-, second-, and third-line therapy. As far as the prognosis, there’s no question that we would have to think positively that we can definitely help that patient, especially when the patient has good performance in regard to the functionality altogether and the good liver function.
Transcript edited for clarity.