Diagnostic Workup & Initial Treatment for HCC

Ghassan K. Abou-Alfa, MD:The workup that was done for the patient is very appropriate. Actually, I’m very happy to see that the patient, other than the MRI [magnetic resonance imaging], did have a biopsy. Biopsies are very critical. We definitely should not treat patients with extensive disease without knowing really what they have. Biopsies nowadays are critical for HCC because, number one, you want to make sure that we’re really treating HCC, not necessarily that things might look, based on LI-RADS [Liver Imaging Reporting and Data Systems] as HCC, but sometimes they might differ. Add to this, in about 10[%] to 20% of the cases combined HCC plus cholangiocarcinoma can occur. And add to this also some genetic evaluation of the tumor can be helpful. It’s not necessarily up to gear in HCC compared [with] other diseases, but nonetheless, some choices of therapy might be really driven by the general evaluation of the genetic makeup of the tumor.

With this, again, imaging could be a CAT Scan, chest, abdomen, and pelvis. A CT [computed tomography] of the chest, MRI…[of]the pelvis if patient’s allergic to contrast, or despite intervention, or if it’s a preference. These are all good. And, of course a biopsy is appropriate, per se.

No doubt that the patient did very well on the embolizations that happened three times. And truly in general we don’t have a limitation how many embolizations or how frequent should they happen. Maybe I would say short of Japan that really have defined a little bit of guidance in regard to how many and how frequent. Nonetheless, I think reasoning is very important to make sure that the patient, if they are benefiting, by all means do it, but if the recurrence of the disease happened rather more frequent in between the embolization or they required so many embolization, time to really talk to other experts in the field. And this is really what brings in the multidisciplinary approach to therapy and to the management of patients with HCC. This required the involvement and the contribution of the hepatologist, the medical oncologist, and of course the interventional radiologist, and of course if there was a resectable disease the surgeon, transplant surgeon, if needed, and many others as well.

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