Management of HCC in Fatty Liver Disease

Ghassan K. Abou-Alfa, MD:This is a classic scenario of a lady with, unfortunately, morbid obesity and nonalcoholic steatohepatitis that led to hepatocellular carcinoma. She is a Child-Pugh A, thankfully, and still has options that are available. Unfortunately, the tumor is rather large, but more importantly, it’s really very close to blood vessels, deemed unresectable by an evaluation with the surgeon. And with the lack of metastatic disease, a local therapy might be appropriate over here.

This is a very classic scenario. We see it all the time, which is why chemoembolization, bland embolization, or some form of embolization would be totally appropriate. In that case, the patient did receive a chemoembolization with drug-eluting beads, which are now becoming more and more used in that domain. And it appears to be that she did rather very well. She obviously, the day after the intervention, had fevers, abdominal pain, and some elevation of the liver function tests, which are classic postembolization syndrome. She recovered from them, appropriately so. Within about 2 to 3 months, a certain CT scan did occur and it showed a very reasonable response to the embolization and the alpha-fetoprotein, if I heard, dropped from about 1500 to about 200. So, that’s a great story! If anything, there was totally appropriate management and the patient did receive the appropriate care over here.

Transcript edited for clarity.

May 2015

• 64-year old obese female presented with fatigue and unexplained weight loss
• History of nonalcoholic fatty liver disease (NAFLD), then nonalcoholic steatohepatitis (NASH)
• Lab results: AFP= 1,500 IU/ml
• ECOG=1; Child-Pugh A
• CT revealed 1 large liver mass, right side of liver close to a major blood vessel
• No extrahepatic disease
• Liver-directed therapy with DEB-TACE was performed
• Patient reported abdominal pain following DEB-TACE and required analgesics; low-grade fever
• Patient had a complete response
• AFP= 200 IU/ml at follow up

February 2017

• Follow-up imaging showed progression and evidence of bone metastases
• Therapy was initiated with sorafenib at 400 mg BID
• Follow-up testing showed liver decompensation