Unresectable Hepatocellular Carcinoma: case 2 - Episode 1

Richard Finn, MD: Significance of Baseline AFP Levels

According to the American Association for the Study of Liver Disease (AASLD) Guidelines, imaging is recommended as the basis for liver cancer screening in patients at risk; however, the presence of elevated alpha-fetoprotein levels appears to be an important prognostic marker. Patients with markedly elevated AFP levels typically have poorer outcomes than those with low or normal levels. The definition of high is somewhat variable, but many studies have found that patients with levels above 400 nanograms/mL tend to have a poor prognosis. At this point, however, AFP levels do not factor into treatment decisions.

CASE 2: Unresectable Hepatocellular Carcinoma

Steve C is a 56-year-old Caucasian construction worker from Miami, Florida with a history of chronic hepatitis C virus (HCV) infection and alcohol abuse.

In January of 2013 the patient was diagnosed with unresectable hepatocellular carcinoma, with an encapsulated, 7-cm tumor identified in the right lobe on Gadolinium-enhanced MRI

Multidisciplinary team recommended TACE because of patient’s ongoing alcohol use, and patient achieved a partial response (>30% decrease by RECIST criteria)

In April 2014, the patient returns for follow up

Patient’s lab values include:

AFP: 1100 ng/mL; AST 322 IU/L

ALT: 195 IU/L

Total bilirubin: 1.8 mg/dL

Platelets: 85,000

At his current workup, the patient is classified as Child Pugh Class A, with a MELD score of 13; ECOG PS is 1

MRI with gadolinium is consistent with disease progression, with encapsulated lesion in the right lobe measuring 9 cm, consistent with HCC

A third TACE procedure is recommended by the MDT

Following the TACE procedure, imaging results show 65% necrosis in the treated area with residual 1.5-cm nodules