Treatment Insights in Intermediate and Advanced Stage Unresectable Hepatocellular Carcinoma: The Case of a 60-Year-Old Man

The panelist discusses the case of a 60-year-old man diagnosed with unresectable hepatocellular carcinoma (HCC). The patient has a history of metabolic dysfunction-associated steatohepatitis managed with lifestyle changes and medication. Initially, there was no clinical or radiographic evidence of cirrhosis. The patient recently presented to his gastroenterologist complaining of abdominal pain in the upper right quadrant and fatigue.

The panelist discusses first-line options including atezolizumab plus bevacizumab, lenvatinib, and sorafenib. Second-line treatments include regorafenib, cabozantinib, and ramucirumab. Clinical trials should be prioritized when available.

The panelist discusses how the patient underwent transarterial chemoembolization (TACE) 3 times with an initial partial response. However, at the end of the 6-month treatment period, the patient had disease progression. The panelist advises that the best treatment option for the patient would be systemic therapy.

The panelist discusses how for patients initially eligible for embolization, systemic therapy may be combined with transarterial chemoembolization (TACE) upfront for high-risk disease (ie, large tumor burden, elevated AFP) or reserved for progression after regional therapy in lower-risk cases. Treatment decisions should be individualized based on tumor characteristics, liver function, and patient preferences.

The panelist discusses, for intermediate-stage unresectable hepatocellular carcinoma (uHCC), key clinical pearls include prioritizing transarterial chemoembolization (TACE) as a first-line therapy, with systemic options for TACE-ineligible patients or progression; consider lenvatinib or atezolizumab plus bevacizumab based on liver function and risk factors. Evaluate treatment success via a radiologic response (mRECIST criteria), AFP levels, and toxicity profiles; modify treatment upon radiologic progression, prohibitive toxicity, or declining performance status.