Approaching a Case of Unresectable HCC with Extrahepatic Involvement

Catherine Frenette, MD:This case that we have is a 77-year-old gentleman with hepatocellular carcinoma and extrahepatic involvement. He has a history of alcohol use and is still drinking 3 to 4 alcoholic drinks a day. He presented to his primary care doctor with abdominal pain and a 10-pound weight loss.

He has some fatigue, but his performance status is normal, and he’s got good liver function with no decompensation, as well as Child-Pugh A cirrhosis. On imaging, he was found to have hepatocellular carcinoma in his liver, a 4.5-cm lesion with arterial enhancement, portal venous washout, and a pseudocapsule with a LI-RADS [Liver Imaging Reporting and Data System] 5 lesion. He also has what looks like a metastatic lesion to his iliac crest. His chest CT was clear. His weight was 72 kilos, so he had BCLC-C [Barcelona Clinic Liver Cancer-stage C] hepatocellular carcinoma. He was started on lenvatinib [Lenvima] at 12 mg a day. During the initial period of his treatment, he experienced increased weight loss and was sent to nutritional therapy to help with his appetite. He did have a partial response at 16 weeks of imaging. Unfortunately, after 8 months of treatment, the therapy was discontinued because he had progressive disease.

This is a standard presentation for patients with HCC. Unfortunately, a lot of patients who have underlying cirrhosis, especially those who aren’t decompensated, may not know they have cirrhosis and liver disease, and instead present symptoms of liver cancer. By the time they’re diagnosed with symptoms, they already have advanced disease, like this gentlemen with metastatic disease. He does have excellent liver function, so that gives us some options because he’s able to tolerate the systemic treatments that are available.

When I’m seeing a patient for the first time with liver cancer, usually the initial imaging studies were done in an emergency room or through their primary care doctor. They may not have had multiphase imaging for the arterial, portal venous, and washout phases of the liver. Oftentimes we do more advanced imaging, so that we can identify all of the different pieces in the liver that they may have because you can have lesions in the liver that are hidden on just a single-phase imaging. We then do some metastatic workup; I typically do a chest CT and a nuclear medicine bone scan initially. Sometimes we’ll do a PET scan, although they are not as sensitive for HCC, so this is not a standard imaging test that we’ll do.

With patients who have advanced liver cancer and metastatic liver cancer, I tell them liver cancer is different from other cancers because, especially in the United States, over 90% of these diseases occur in people who have underlying liver disease. When we’re thinking about the prognosis and treatment options, we have to take into account the cancer and underlying liver disease. The fact that this patient has a Child-Pugh A cirrhosis with no decompensation gives him a plus as far as his prognosis; however, he unfortunately had advanced disease with metastatic lesions. Without any treatment, his survival is probably around 6 to 12 months.

Transcript edited for clarity.

A 77-Year-Old Male With Unresectable HCC and Extrahepatic Involvement

• History and physical exam
  • An otherwise healthy, 77-year-old Caucasian male with a history of alcohol use
  • Presented to his PCP complaining of abdominal pain, fatigue and an unexplained 10-lb weight loss
  • Currently consumes 3-4 alcoholic drinks per day
  • ECOG PS 0
• Imaging
  • CT scan: 4.5-cm hepatic lesion with arterial hypervascularity, portal venous washout, and a pseudocapsule indicative of hepatocellular carcinoma; no evidence of vascular invasion
  • Bone scan: left-sided iliac mass (3.1 cm)
  • Chest CT: clear
• Diagnosis: unresectable HCC with extrahepatic involvement
  • BCLC stage C
  • Child-Pugh A
  • AFP Level: 3548.4 ng/mL
  • Weight: 72 kg
• Lenvatinib 12 mg QD was initiated.
  • He experienced modest weight loss and reported loss of appetite for which he was referred for nutritional therapy
  • Imaging at 16 weeks: partial response (0.5 cm)
  • 8 months after initiation of therapy: treatment discontinued due to disease progression