Diagnosing HCC in the Setting of HBV

Anthony El-Khoueiry, MD: For the first case, we have a 63-year-old male with a hepatitis-B infection who presented with 2 liver lesions in the right lobe of the liver. Upon presentation, the patient was noted to have an elevated alpha-fetoprotein level of about 5400 and a normal liver function with albumin and bilirubin levels in the normal range. The CT scan showed a 1-cm lesion and a 5-cm lesion. The patient underwent a surgical resection of the 2 liver masses in February of 2014. The resection had negative margins, and the patient was then placed on surveillance until 2016, when he was noted to have recurrence in the liver as well as liver metastases.

There are some unique features of this case, one of them being that this is a patient with hepatitis B. Patients with hepatitis B tend to be unique in the sense that they have well-preserved liver function and can develop hepatocellular carcinoma without having had cirrhosis in the interim. So, the patient had well-preserved liver function and no major evidence of portal hypertension, which allowed him to undergo resection. From there on, the patient had a recurrence and was treated with 2 subsequent lines of systemic therapy. And that’s a relatively new development in this field since, for a long time, we only had 1 line of systemic therapy—which was sorafenib—and now we have another one.

Elevated AFP is certainly thought to be prognostic in hepatocellular carcinoma. So, the higher the alpha-fetoprotein, usually the worse the survival—both the overall and progression-free survival. I would say that is the main significance of the elevated alpha-fetoprotein level. Elevated alpha-fetoprotein by itself is not a diagnostic criterion any more. So, to make the diagnosis of hepatocellular carcinoma, we either rely on histologic confirmation—as was the case here, the patient had a biopsy—or on the standard radiologic criteria, which briefly includes the presence of at least one 1-cm lesion that has arterial enhancement in the arterial phase and corresponding venous or delayed phase washout on a multi-phase imaging study, like a CT scan or MRI. And, of course, that has to happen in the right clinical setting of viral hepatitis or known cirrhosis.

Transcript edited for clarity.

February 2014

• A 63-year old male with HBV
• ECOG=0
• Child-Pugh A; platelet count 230,000 cells/mcL
• Bilirubin 1.0 mg/dL; Albumin 3.5 g/dL
• CT scan revealed liver lesions, 1 is 2-cm; 1 is 5-cm both in the right lobe
• No extrahepatic disease
• Biopsy confirmed HCC diagnosis
• AFP=5400 IU/ml
• Tumors were resected with RO margin

August 2016

• Imaging showed recurrence in the liver, metastatic disease in the lungs
• Therapy was initiated with sorafenib 400 mg BID
• Therapy was well-tolerated

April 2017

• Radiographic progression with multiple lung metastases
• ECOG=0
• Therapy with regorafenib initiated at 160 mg
• Starting dose was well-tolerated, patient experienced some fatigue