Diagnosing HCC in the Recurrent HCV Setting

Anthony El-Khoueiry, MD:In this case, a nuance with the previous case that we discussed is the fact that the patient presented with a large liver lesion that had main portal vein invasion. So, the presence of a large lesion with main portal vein invasion is a contraindication to surgical resection, despite the fact that the patient had Child-Pugh grade A cirrhosis. This is because of the poor prognostic impact of main portal vein invasion. The other general impression is that the patient was started on systemic therapy appropriately, given the presence of main portal vein invasion and stabilization of disease initially, but that was short-lived with progression in April—about 3 months later with the presence of extrahepatic metastases. This generally is a suggestion of a relatively aggressive course of disease.

Patients like this are diagnosed with hepatocellular carcinoma in various types of settings. Patients who are undergoing appropriate screening because of their diagnosis of hepatitis C tend to have a diagnosis of hepatocellular carcinoma made with earlier stages of disease. Unfortunately, many patients do not undergo routine surveillance as indicated and either present with symptoms that lead to imaging or are seen by a hepatologist, usually because of the recurrent hepatitis C—such as in this case—or elevated liver enzymes. And, at that point, the hepatologist orders imaging, which, as in this case, showed incidental hepatocellular carcinoma.

There is not an indication for histologic confirmation in every case of hepatocellular carcinoma because there are accepted radiologic criteria for diagnosis, which consist of the presence of arterial enhancement in the arterial phase of the imaging study and venous or delayed phase washout on a multiphase scan. Histologic confirmation and biopsy are welcome and indicated because they allow us to have more tissue and do more biomarker studies, and hopefully advance the field in that way. But they’re not necessarily required for routine care and diagnosis.

Another question that arises nowadays is, with the new available treatments for hepatitis C, whether or not a patient with hepatocellular carcinoma diagnosis should have their hepatitis C treated. Unfortunately, this is an area that warrants additional investigation. We do not know, at the present time, whether or not treating hepatitis C will alter the patient course once they have a diagnosis of hepatocellular carcinoma and are undergoing anticancer therapy. There is also some controversy rising now, and this is an area of active investigation: whether or not the treatment of hepatitis C may accelerate the progression of hepatocellular carcinoma or recurrence in certain cases. Again, it’s an area that warrants further investigation, and all I can say is that there’s no clear indication to treat the hepatitis C once there is a diagnosis of hepatocellular carcinoma.

Transcript edited for clarity.

January 2017

• A 74-year old female with a history of HCV-infection
• Prior treatment with interferon, achieving sustained virologic response
• Had recurrence of HCV
• CT scan showed a 6.5-cm single liver mass with arterial enhancement, venous phase washout, and main portal vein invasion
• ECOG=1
• Child-Pugh A
• Therapy was initiated with sorafenib at 400 BID
• Patient experienced grade 3 hand-foot skin reaction; dose reduction to 400 QD
• Patient experienced grade 3 diarrhea; dose reduction to 400 QOD

April 2017

• Follow-up scans show radiographic progression with lung metastases