Targeting Cancer With Tyrosine Kinase Inhibition in Frontline HCC
During a live virtual event, Richard S. Finn, MD, discussed the process of diagnosing liver cancer after a CT scan detected tumors and whether a biopsy was needed.
A 77-year-old White woman was complaining of abdominal pain and fatigue. She had a history of cirrhosis due to heavy alcohol use, Crohn disease controlled with infliximab, and a history of variceal bleeding, with banding 2 months prior and an ECOG performance score of 1. A CT scan of the chest, abdomen, and pelvis with triphasic liver evaluation showed a 4.5-cm LR5 hepatic mass in the right lobe plus metastatic disease in the lung. Her Child-Pugh score was an A with an α-Fetoprotein (AFP) tumor level of 380 ng/mL.
RICHARD S. FINN, MD: This patient has cirrhosis and on the CT scan [has a tumor of] 4.5 cm and a LI-RADS [Liver Imaging Reporting and Data System] score of 5 [LR5]. When we see LR5 it means the patient almost definitely has liver cancer and a biopsy is not required. LI-RADS is like Breast Imaging Reporting and Data System [BI-RADS] in mammography. It is how the radiologist assesses the likelihood of something being liver cancer and only applies to patients who have cirrhosis.
If someone does not have cirrhosis, you can’t apply the LI-RADS criteria. On a triple-phase scan, a hypervascular tumor with delayed washout is characteristic of LR5 and you do not technically need a biopsy for management. The AFP of 380 ng/mL is suggestive, but AFP is not among the criteria for making this diagnosis. I would say that this patient does not require a biopsy for standard-of-care treatment.
MARK KARWAL, MD: I would like to add [that] if you look at the data, sensitivity and specificity do not change with adding a biopsy, but you add risk. The biopsy is going to show you a normal liver if they miss, but if it comes as [HCC], it tells you what you already know. You do not gain in sensitivity or specificity in this case by adding a biopsy and it should not be done because you do not add to the data.
FINN: I guess the only reason to do a biopsy would be perhaps in the context of research or some molecular understanding of the tumor, which really does not impact standard-of-care treatment.
ARATI CHAND, MD: What if the AFP were in the thousands—would you still do a biopsy?
FINN: No…because [the tumor] is LR5.
FINN: If the patient was not cirrhotic, and even with an elevated AFP level, I think you are obligated to do a biopsy. I think very likely it could be liver cancer, but I had a case recently of a patient in his 40s who had cirrhosis and came down for a second opinion and had already been started on treatment for his advanced liver cancer.
They had biopsied him there and said it was liver cancer, but I would not have necessarily done the biopsy based on the imaging. However, he already had a biopsy when he came to see the surgeon, who had our pathologist at the [University of California, Los Angeles] review it and they said it is not exactly consistent with HCC.
When we looked back at the outside imaging, it was not completely vascular and a repeat biopsy was recommended. [The patient’s] AFP was 15,000 to 30,000 and it turns out he had a germ cell tumor. Lucky for him, he got BEP [bleomycin (Blenoxane), etoposide (Toposar), and cisplatin (Platinol)], had a great response, and is going for curative resection.
KARWAL: Did the biopsy show cirrhosis?
FINN: He did have some cirrhotic changes. He had hepatitis C and a little portal hypertension. He did not have a normal biopsy; he just had a biopsy of his tumor.
KARWAL: Didn’t the background liver test results include that?
FINN: There was no background. It was an 18-cm mass. A very bizarre case, especially for a patient with an LR4 lesion; regardless of the AFP, they most likely have liver cancer. In practice, I do not think we would do a biopsy, to be honest. Keep in mind, if you are thinking of liver transplants, at least get another opinion. This disease is best managed at a tertiary center. To get a liver transplant, you need an LR5 lesion. If it is LR4, which is potentially curable, usually we do not ablate them until they become LR5 if we are thinking curative transplant. In practice, in a patient who is cirrhotic, even if it is LR4, it is most likely liver cancer.
You must ask yourself what you are going to find that is a better diagnosis. Is there any evidence of disease elsewhere? Cholangiocarcinoma does not typically have vascular characteristics like liver cancer. This is still most likely going to be liver cancer.