Diagnostic Workup in HCV-Positive HCC

Richard Finn, MD: Today we’re discussing a case, which is not that uncommon, of a 64-year-old gentleman who has a long-standing history of hepatitis C and presents to his primary care doctor with an episode of nausea, vomiting, ill-feeling, and lightheadedness. On evaluation, his serum chemistries are notable for some liver dysfunction. He has mildly elevated AST and ALT; his bilirubin count is 2.1 mg/dL; his albumin is a little decreased at 3.3 g/dL; his INR is 1.1; he has no stigmata of end-stage liver disease, such as ascites or history of encephalopathy; and he’s never had any GI bleeding in the past. Given the condition of his liver disease, the patient undergoes imaging, and this reveals a 4-cm mass in the liver, at which time the patient is referred to a hepatologist or oncologist for further evaluation and workup.

I think there are some very important points to take away from this case. One is the diagnosis of hepatoid-CR carcinoma, or liver cancer. We know that this patient is at risk for liver cancer. He has a long history of hepatitis C. Whether or not he’d been screened on a regular basis is an important fact to note. The fact that he’s coming in the door with this degree of liver function and a 4-cm mass tells me that he probably was not screened, and we know that screening is important for patients with chronic liver disease. Because the best way to cure HCC—or really the only way to cure it—is to find it early.

Even without being screened, this patient is found with a relatively early tumor. We learn that further staging studies do not indicate any evidence of vascular invasion in the liver. We also see that the patient has no disease outside of the liver. At the end of the day, we now have a patient who has a 4-cm mass and the question comes up, does he need a biopsy? We learn that his alpha-fetoprotein is elevated at 400 ng/mL. That by itself is not diagnostic of liver cancer, though it is obviously very suggestive. Really, the diagnosis of liver cancer can be made noninvasively with a triple-phase CT scan or a dynamic contrast MRI scan, which identify very typical characteristics in a patient with chronic liver disease. That is to say, the lesion’s hypervascular, has delayed washout, and in that setting, we can say with fair confidence whether or not this is a liver cancer. And, in this case, the patient does have those characteristics.

Transcript edited for clarity.

December 2014

• A 64-year old male positive with HCV presents to his PCP with nausea, vomiting, syncope
• ECOG=1
• Child-Pugh B
• T bilirubin 2.1; albumin 3.2; INR 1.1; no ascites, no encephalopathy; platelets 78
• CT scan revealed one 4-cm lesion in the liver
• No extrahepatic disease; no portal vein invasion
• Laboratory results: AFP=400 ng/ml
• Patient is within Milan criteria
• Bridge using TACE until liver transplantation