Determining Need for Biopsy in Suspected Hepatocellular Carcinoma

Daneng Li, MD (Moderator)

Associate Professor

Department of Medical Oncology & Therapeutics Research

Co-Director, Neuroendocrine Tumor Program

City of Hope Comprehensive Cancer Center

Duarte, CA

CASE SUMMARY

A 77-year-old White woman presented to her primary care physician complaining of abdominal pain and fatigue.​ She had cirrhosis due to heavy alcohol use; Crohn disease, controlled with infliximab (Remicade); and a history of variceal bleeding, with banding 2 months ago​. She had an ECOG performance status of 1. A CT scan of the chest, abdomen, and pelvis with triphasic liver evaluation revealed a 4.5-cm LR5 [LI-RADS score of 5] hepatic mass in the right lobe and metastatic disease in the lung​. She had a Child-Pugh status of A. Her α-fetoprotein level was 380 ng/mL. ​

DISCUSSION QUESTION:

• Would you recommend a biopsy for this patient?

DANENG LI, MD: Can someone comment why they would choose to do a biopsy or not?

ANDREW PHAM, MD: I think if it's just a liver lesion, then maybe you wouldn't need it, but it depends how concerned you are with the pulmonary metastasis. If you're concerned pulmonary metastasis is likely from the hepatocellular carcinoma [HCC], then I would maybe confirm that it is. I think if it's some other process, or if it's not related to HCC, then it would dictate your management options, but with biopsy, it would be more so for the pulmonary lesion, if there's anything amenable to biopsy.

LI: So you would just be trying to confirm metastatic disease specifically. If it was just a liver mass, you might potentially forgo a biopsy?

PHAM: Yes.

LI: Are there other circumstances where that might change?

ANDY JANG, MD: If you're pretty sure the patient has etiology of cirrhosis, then with LR5, you don't need a biopsy. But if you have any issue, you definitely need to have a biopsy because even with a LR5, without cirrhosis, your positivity for the biopsy to be HCC goes down to about 60% to 70%. If you have cirrhosis with LR5, that's virtually 100%. So we would have to be sure that the patient does have underlying cirrhosis.

LI: I agree…that potentially having something else in the setting of a LR5 lesion with typical characteristics of cirrhosis, as well as other risk factors, will make it less likely to have another cause. While rare, there's certainly the possibility of a potential mixed phalangeal carcinoma HCC and things like that. That has sometimes been an argument for us to potentially biopsy more [often], even for a LR5 lesion.

CASE UPDATE

Biopsy was obtained and confirmed the diagnosis of HCC.

DISCUSSION QUESTIONS

• Would your decision whether to biopsy differ if the lesion was LR4?​
• Since a biopsy was obtained and confirmed HCC, would you suggest any further genetic analyses of the biopsy tissue? ​
• Would you recommend any further imaging?​

LI: Would you suggest any further genetic analysis of the biopsy tissue?

VEENA CHARU, MD: If we have a biopsy already, then I may consider sending it for next-generation sequencing. I don't know how much difference it will make, but it's good to know.

LI: Has anyone else been routinely sending [tissue] for genomic analysis?

CURTIS CHONG, MD: Yes. I do liquid biopsy on everybody.

LI: Have you found anything interesting on the results for your patients with HCC?

CHONG: Sometimes the tumor mutational burden [TMB] is high, so I might start with an immunotherapy in those patients, but now that durvalumab [Imfinzi] plus tremelimumab [Imjudo] is [approved for the] first line, I tend to just use that in everybody who can tolerate it.

MUJAHID RIZVI, MD: I'll sometimes send off a bone scan as well.

LI: That is definitely one of the sites for metastasis. Dr Rizvi is certainly correct…to make sure there’s no metastatic disease, especially if you see a lesion that's in question on traditional anatomic imaging. The role of genomic profiling for HCC is debated. A lot of the genomic alterations that we find on genomic profiling might not necessarily be targetable.

These tumors might express things like TP53 or TERT [promoter], where we don't have necessarily a lot of actionable targets. But…you might get some type of predictors of response in terms of a higher TMB or sometimes you might find certain types of FGFR alterations, for which we have tyrosine kinase inhibitors that can target those.