Richard Finn, MD: Systemic Therapy in a uHCC Patient

Would you consider systemic therapy in this patient?

I think my sense in the way this case is going, this patient is going to require systemic treatment. In regards to that, the only agent that’s been proven to extend survival is sorafenib. And this paint would be a candidate for sorafenib from the beginning, from the presentation given they had symptomatic disease. It’s confined to the liver which is a group of patients that seem to get a greater benefit from sorafenib versus those who had more advanced disease.

This is in retrospective subgroup analysis of the SHARP study or they should be referred for a clinical study that would also be an acceptable option for systemic treatment in this patient. When to start systemic treatment is not written in stone. Again, that could have done at the presentation. It could be considered after the first TACE, but, again, whether it’s done after the first TACE or second TACE, my sense, given the large nature of this tumor, the fact that it sounds like they have progression outside of the larger lesion, this patient will soon require systemic therapy.

It’s also important to keep in mind, for most patients who get chemoembolization, if they don’t die of their underlying liver disease or something else, they will eventually progress beyond disease that can be controlled with chemoembolization. They’ll develop portal vein thrombosis, clear progression outside of the liver, or even recurrence in a prior chemoembolization site.

CASE 1: Unresectable Hepatocellular Carcinoma (uHCC)

Mario C is a 74-year-old retired steel worker from Allentown, Pennsylvania. His past medical history is notable for hepatitis B virus (HBV) infection (diagnosed in early 1990s).

In July 2013, patient was referred to a hepatologist with an elevated ALT (70 IU/mL) and AST (53 IU/mL).

Medical history is also notable for mild hypertension (currently controlled on antihypertensives) and hypercholesterolemia (currently controlled with diet); patient denies any alcohol use

Family history was relevant for an older brother who died of HCC and chronic HBV infection at age 70

On physical exam, no evidence of liver disease was noted and patient did not report any recent weight loss; patient reported some intermittent abdominal pain and there was mild tenderness in the lower right quadrant on palpation

Ultrasound revealed a poorly defined mass in the right lobe; contrast enhanced MRI showed a 12-cm mass in the lower right segment consistent with HCC and several smaller nodules. Bone scan and chest CT showed no evidence of metastatic disease

Patient presented to the Multidisciplinary Team (MDT) with Child Pugh Class A, with a MELD score of 7; patient’s performance status was 1

On surgical consult, the patient was deemed unresectable and the MDT recommended a TACE procedure for the larger lesion

In December of 2014, evidence of residual disease was detected on a follow up CT scan at the site of the first TACE procedure; smaller nodules also showed evidence of radiologic progression.