A 61-Year-Old Man With Stage 4 Hepatocellular Carcinoma - Episode 8

Future Treatment Landscape for Advanced HCC

Pierre Gholam, MD: The landscape of HCC [hepatocellular carcinoma] is really evolving at a very rapid speed, as evidence by all these improvements in care. I would not hesitate to use that term. There are all these improvements in outcomes, including the very hard outcome of overall survival but also progression-free survival. There are even some recent data related to patient-reported outcomes—slowing the decrement of quality of life, and so forth.

The way to go moving forward appears to be with combinations of the immuno-oncology drugs and TKIs [tyrosine kinase inhibitors]. In some cases, combinations of immuno-oncology drugs together as in more than 1 immuno-oncology drug in combination.

These studies are fast and furious. There are too many to list right now, but certainly this audience should be on the lookout for approvals in the first line and exciting data in second line for various combinations of therapies that will hopefully enable patients to live longer and better.

There will be more clarity about the BCLC [Barcelona Clinic Liver Cancer] stage B patients. Those are patients who don’t have metastatic disease but have a large burden of illness. These have historically been less well served by local-regional therapies as we would like. Systemic therapy has not necessarily been the mainstay based on societal guidelines. But as overall survival in those patients is demonstrated to be better and treatment be better tolerated, we will see more and more of those patients receiving therapy earlier and hopefully benefiting longer from the outcome of treatment.

Transcript edited for clarity.

Case: A 61-Year-Old Man with Stage 4 Hepatocellular Carcinoma

Initial presentation

  • A 61-year-old man presented with nausea, vomiting, decreased appetite and occasional generalized itching
  • PMH: diabetes, medially controlled; hepatitis C and B coinfection diagnosed and treated 6 years ago; diagnosed with HCC December 2018
  • PE: scleral icterus; jaundice; spleen palpable 4-cm below the costal margin

Clinical workup

  • Labs: AFP 436 ng/mL, bilirubin 1.6 mg/dL, AST 105 U/L, ALT 110 U/L, ALP 390 U/L, INR 1.9, albumin 3.8 g/dL, BUN 13 mg/dL, creatinine 1 mg/dL, plt 95,000
  • HBV+, HCV+
  • Abdominal ultrasound revealed 3 small hepatic lesions
  • Chest/abdominal/pelvic CT scan confirmed 2 focal nodules in the right and 1 in the left hepatic lobe measuring 3.6 cm, 4.9 cm and 5.2 cm, a suspicious lesion in the right lower lung lobe; wide-spread lymphadenopathy was noted
  • Biopsy findings showed grade 3 hepatocellular carcinoma with marked fibrosis
  • Surgical consult: unresectable due to tumor size and location
  • Child-Pugh A; BCLC stage C
  • ECOG 1

Treatment and Follow-Up

  • 2018: treated with lenvatinib 400 mg PO q12hr; he experienced diarrhea for 2 weeks which resolved; achieved PR
  • 2020: Imaging showed a new lung lesion
    • Treatment was with cabozantinib 60 mg PO qDay was initiated