Multidisciplinary Approach to Treating Hepatocellular Carcinoma

Ahmed Kaseb, MD:In this era of hepatocellular carcinoma management where our patients now have more than 1 option in both the frontline and second-line settings, in addition to the complexity of those patients with low tumor load who could also have some options related to local therapy up front, the management has to be linked to a multidisciplinary approach up front, looking at the tumor load and correlating that with the patient’s performance status, nutritional status, and liver function status. If the patient is not a candidate for resection or transplant, the next option should be a local therapy approach based on the tumor load. That should be followed by systemic therapy. If the patient is not responding to localized therapies or they didn’t tolerate localized therapy well, for example, in a multidisciplinary setting, the decision would be made to start systemic therapy.

Frontline and second-line therapies are going to be dependent on the specific practice and specific level of comfort, and also the patient's baseline in terms of their liver status and comorbidities—for example, uncontrolled hypertension or autoimmune disease that would exclude immunotherapy options in routine practice of clinical trials. Again, this is a disease that needs to be managed by a multidisciplinary team of oncologists, hepatologists, surgeons, interventional radiologists, in addition to our dietitian and supportive care team.

Third-line therapy is going to come up because we have been managing our patients in a better way in the last few years. Patients, if they are managed appropriately and in a multidisciplinary manner, could remain in good shape through frontline and second-line therapy and could still be, in Child-Pugh A, candidates for clinical trials or even third-line options.

We don’t have any evidence with medicine yet in terms of which sequence to follow or which third-line options to pick and choose from. But in the next few years, we’re going to have more data in this space. Who would have thought that hepatocellular carcinoma patients would be going for a third-line therapy 10 years ago when we didn’t have anything other 1 drug in the frontline setting? So it’s definitely an exciting time for our patients as well as our treating physicians.

Transcript edited for clarity.

Case: A 65-year-old Man With Cirrhosis and HCC

A 65-year-old man with 10-year history of cirrhosis was seen for routine follow-up; referred for further lab and imaging studies based on enlarged lymph nodes and new-onset jaundice.

H & P

• PE: Yellowing of the skin and sclerae
• Social History: drinks 20+ alcoholic beverages/ week for the past 15 years
• ECOG: 0

Labs

• AFP: 550 IU/mL
• Child-Pugh B
  • Bilirubin: 3 mg/dL
  • Albumin: 3.5 g/dL
  • No hepatic encephalopathy
  • Grade 1 ascites

Imaging

• Multiphasic contrast MRI of the abdomen revealed an 8-cm encapsulated mass in the left hepatic lobe showing hypervascularity on arterial phase and washout on venous phase
• Further imaging of CAP revealed no metastasis
• Diagnosis: unresectable hepatocellular carcinoma

Treatment

• Underwent TACE; follow-up imaging at 1 month showed no response
• Started on lenvatinib 12 mg once daily; follow-up imaging at 3 months showed no response
• Received nivolumab 3 mg/kg every 2 weeks

Follow-up

• 3 months later; patient complained of increasing fatigue
• AFP; 600 IU/mL
• MRI showed disease progression in the liver, one new adrenal lesion