Later Line Therapeutic Decisions in Metastatic HCC - Episode 1
Anthony El-Khoueiry, MD: For the first case, we have a 63-year-old male with a hepatitis-B infection who presented with 2 liver lesions in the right lobe of the liver. Upon presentation, the patient was noted to have an elevated alpha-fetoprotein level of about 5400 and a normal liver function with albumin and bilirubin levels in the normal range. The CT scan showed a 1-cm lesion and a 5-cm lesion. The patient underwent a surgical resection of the 2 liver masses in February of 2014. The resection had negative margins, and the patient was then placed on surveillance until 2016, when he was noted to have recurrence in the liver as well as liver metastases.
There are some unique features of this case, one of them being that this is a patient with hepatitis B. Patients with hepatitis B tend to be unique in the sense that they have well-preserved liver function and can develop hepatocellular carcinoma without having had cirrhosis in the interim. So, the patient had well-preserved liver function and no major evidence of portal hypertension, which allowed him to undergo resection. From there on, the patient had a recurrence and was treated with 2 subsequent lines of systemic therapy. And that’s a relatively new development in this field since, for a long time, we only had 1 line of systemic therapywhich was sorafenib—and now we have another one.
Elevated AFP is certainly thought to be prognostic in hepatocellular carcinoma. So, the higher the alpha-fetoprotein, usually the worse the survivalboth the overall and progression-free survival. I would say that is the main significance of the elevated alpha-fetoprotein level. Elevated alpha-fetoprotein by itself is not a diagnostic criterion any more. So, to make the diagnosis of hepatocellular carcinoma, we either rely on histologic confirmation—as was the case here, the patient had a biopsy—or on the standard radiologic criteria, which briefly includes the presence of at least one 1-cm lesion that has arterial enhancement in the arterial phase and corresponding venous or delayed phase washout on a multi-phase imaging study, like a CT scan or MRI. And, of course, that has to happen in the right clinical setting of viral hepatitis or known cirrhosis.
Transcript edited for clarity.