A 61-Year-Old Man With Stage 4 Hepatocellular Carcinoma - Episode 2

Patient Prognosis of Metastatic HCC

Pierre Gholam, MD: Those who have a diagnosis of metastatic HCC [hepatocellular carcinoma] from the get-go used to have a dismal prognosis not longer than a decade ago. In fact, we had very limited treatments that would enable these patients to pursue any type of meaningful treatment that would extend life or improve it with systemic therapy and certainly with locoregional therapy.

We have come a long way, as we will discuss in the questions in subsequent intervals of this discussion, in that we have improved dramatically our ability to treat these patients with systemic therapy. We now have multiple lines of therapy that we can offer these patients.

Realistically, with 2 lines of therapy we have multiple examples that can tell us that a patient like this—assuming maintenance of good liver function and a reasonably good performance status—might be able to achieve a significant survival benefit, assuming they respond to first-line and ultimately second-line therapy. In fairness, not every patient with metastatic HCC at this point would realistically expect a 2-plus-year survival. Although I have seen that many times, I think the take-away message here is that treatment options are available in terms of systemic therapy and can help patients live longer. We now know from recent evidence that we can reduce the decrement in quality of life that can incur what patients have in cancer and experiencing a burden of adverse effects.

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