A 68-Year-Old Man With Hepatocellular Carcinoma - Episode 5

Key Takeaways for the Treatment of Unresectable HCC

Ghassan K. Abou-Alfa, MD, MBA, shares clinical pearls and advice for the management of patients with unresectable HCC.

Ghassan K. Abou-Alfa, MD, MBA: What did we learn today? We learned that HCC [hepatocellular carcinoma] is sadly a common disease, and we’re still seeing the patients. The risk factors are alcohol, as we saw in our patient today. We know about hepatitis B, hepatitis C, and NASH, or nonalcoholic steatohepatitis, which is mainly because of morbid obesity and diabetes. It’s very important to remember that even though there are different risk factors, the disease is the same. It doesn’t matter what the etiology is. At the end of the day, the therapy will be beneficial regardless. There has been some detail that was reportedly there about potentially less or more benefit based on the etiology. But we still don’t have a clear delineation that we should use a certain drug vs the other based on the etiology.

As we mentioned, it’s important to preserve patients within the functionality status of their liver that allow those options to be given. When we talk about patients with liver cancer, it’s very important to say liver cancer and then liver function. For example, liver cancer stage IV, Child-Pugh A. Stage this, Child-Pugh X. Very important also: Biopsy is key. We have to confirm the disease. We very much know about the potential for combined disease of HCC plus cholangiocarcinoma, which can occur in at least 15% of patients. Certain targeted therapy might be applicable. As such, a biopsy is a critical component to evaluate.

The LI-RADS [Liver Reporting & Data System] story is definitely true. I had the great honor to talk to our colleagues who have written the LI-RADS. The way of understanding of the etiology, it’s a language for them to talk to each other. It’s the same for a radiologist, pathologist, or even ourselves. Stage IV, stage III. But it’s not all the same. Pathology is key for the diagnosis.

We also spoke about the different lines of therapy. We mentioned the first-line treatments, like atezolizumab plus bevacizumab. We spoke about sorafenib. We spoke about lenvatinib. We gave quite a bit of pluses for the excellent outcome of atezolizumab plus bevacizumab, even though the limitation of the potential of bleeding from the bevacizumab, and more importantly, the recent data that showed 30% of the patients on that study, or about one-third of the patients, won’t benefit from the treatment.

Sorafenib would be an appropriate option. We don’t like the adverse events. That’s why lenvatinib adds to a good tolerance, but more important, a triple increase in progression-free survival and an excellent response rate grew 25%-plus in regard to RECIST 1.1. It was close to 41% in regard to modified RECIST, which would be very appealing. Lastly, we spoke about the checkpoint inhibitors we needed, but we don’t have any signs that oblige us to place them in rule No. 1 or No. 2. As such, if we’re in a situation where the patient was already offered lenvatinib or started on it, if the second-line is bevacizumab, it will by all means still be beneficial to the patients.

Thank you very much for listening.

Transcript edited for clarity.