HCC: Multidisciplinary Assessment and Liver Transplant

Richard S. Finn, MD:So, liver cancer is really 2 diseases. It’s a malignancy and carries all the anatomic problems that having cancer come with—metastases or obstructing bile ducts or causing pain. But it also carries the risk of progressing of their cirrhosis and underlying liver disease. And the 2 will play off each other; that is the tumor and the cirrhosis and liver function. And, therefore, having a team that has a lot of experience in the management of patients like this, it’s critical.

There are a lot of key players in the management of patients with liver cancer. One would be a hepatobiliary surgeon or transplant surgeon, given the importance of that modality of treatment in curing patients. Diagnostic and interventional radiology play a very important role in imaging and liver-directed therapies. Hepatology or gastroenterology play a pivotal role in managing complications of liver disease assessing for risk of decompensation with procedures. And then a medical oncologist to help manage systemic treatments and supportive care for a patient with cancer.

This patient is presenting with several characteristics that would preclude liver transplant. Liver transplant has evolved over the past 20 years and is now broadly accepted as a curative modality for liver cancer. But the critical aspect that will determine if a patient is curable is really the size of their tumor and tumor characteristics going into transplant. Initially, the Milan criteria was used to establish the optimal patients for transplant—that was 3 tumors up to 3 cm or 1 tumor up to 5 cm—and these tumors could not have any evidence of vascular invasion.

Over time, it has been identified that that might be a little too restrictive, and in the past several years, there has been a movement to go up to larger tumor burdens, and this is somewhat regional, whereas Milan criteria is broadly accepted, the so-called UCSF criteria is not as broadly accepted. But many places do accept that and that takes a total tumor burden up to 8 cm, individual tumors up to 6 ½ cm, and up to 3 tumors as long as none of them are greater than 4½ cm.

Even with the broader criteria in this case of UCSF, this patient is beyond criteria. They have vascular invasion, which uniformly precludes transplant. Also, they have a single tumor that is infiltrative; that is a sign of an advanced tumor that, again, is beyond all criteria, let alone the satellite lesions they mentioned.

Transcript edited for clarity.

February 2017

• A 59-year-old man with presented with RUQ pain and fatigue.
• PMH: Cirrhosis, HCV infection
• SH: lives alone, drinks alcohol daily (~15 drinks/week)
• ECOG, 0
• Laboratory findings:
  • AFP: 677 IU/mL
  • Platelets: 144,000 cells/mm³
  • INR, 1.7
  • Bilirubin: 1.8 mg/dL
  • Albumin: 3.9 g/dL
  • Hepatic encephalopathy: none
  • Ascites: mild
• Child-Pugh A
• Abdominal CT scan showed a large mass (8.6 cm) involving hepatic segments IV and VIII with portal vein infiltration, diffuse 1.0-cm to 1.5-cm nodules in the right hepatic lobe; 1.5-cm left portal vein thrombosis
• Surgical consult, unresectable based on tumor size and portal vein invasion
• Biopsy findings showed grade 3 hepatocellular carcinoma, marked fibrosis  
• The patient was treated with TACE; dynamic liver computed tomography at 1 month showed a partial response; repeat TACE showed no additional response
• The patient was started on sorafenib
• Imaging at 2 and 6 months showed a partial response with marked regression of the hepatic mass and smaller nodules.

February 2018

• The patient reports feeling fatigue, requiring rest during the day, but continues to work full-time
• CT of chest, abdomen, and pelvis showed new pulmonary nodules (2.0 cm and 3.1 cm) consistent with metastatic disease
• ECOG, 1
• He was started on regorafenib 160 mg daily
• After 2 weeks on therapy he developed grade 2 hand-foot syndrome which resolved after dose reduction to 120 mg daily
• After 3 months the patient has stable disease and improvement of symptoms