Multidisciplinary Management and Diagnostic Work-up of HCC

Pierre Gholam, MD: HCC [hepatocellular carcinoma] is a unique cancer. I think medical oncologists, surgeons, and hepatologists agree on this point. It not only needs to address the stage of cancer, the extent of cancer, and the burden that cancer brings on the patients and the caregiver, but it also needs to very carefully assess the burden of liver disease, which is a competing risk for morbidity and death.

It is critically important that we have an effective multidisciplinary team that has the expertise and the breadth of knowledge to address all these issues in 1 patient. Invariably in most settings of care, especially where HCC is a focus and an area of expertise, a multidisciplinary team would include a medical oncologist, a hepatologist, and a surgeon—typically a hepatobiliary surgeon, and sometimes that person doubles as a transplant surgeon. Ideally it would be highly desirable to have radiation oncologists or a pathologist review any pathological findings, a survivorship person, and a tumor board navigator. All these folks are very important in ensuring that the care is consistent, is thorough, and enables the patient to benefit from the best outcome possible.

One critically important issue in a patient with HCC is our ability to maintain good liver function, which would in turn enable the patient to navigate hopefully 1 or more lines of therapy and benefit in terms of survival and hopefully quality of life. This requires a fairly typical work-up at the outset, which includes a work-up for liver function with what we call the MELD [model for end-stage liver disease] score. That’s the score that factors in both the coagulation profile; the INR [international normalized ratio]; the creatinine, or kidney function, which often deteriorates in people with advanced liver disease; and the bilirubin, which is a reflection of liver function.

It is important to stage disease frequently to assess any response to therapy in addition to a baseline. This is typically done for dynamic imaging. At some centers, a CT [computed tomography] scan with portal maintenance phase is the main expertise, and that’s perfectly appropriate for baseline and follow-up. At other centers, an MRI with gadolinium, with and without gadolinium, is the way to go, as is the case at our center. But certainly dynamic imaging over time is very important.

The interval of imaging is somewhat debatable, although in any person who is actively pursuing treatment, an interval of anywhere from 8 to 12 weeks is a very reasonable time frame to follow, because we definitely need to know if the patient is experiencing progression of disease. We also want to know if the patient is responding adequately to therapy, because that provides reassurance that we’re on the right track. It is also great encouragement for the patient in knowing that they are able to hopefully benefit from the treatment we are offering them.

It is important to understand that while we may need to pursue a liver biopsy in some patients, this is only a very small number of patients who have a presenting picture of cirrhosis and a liver lesion that meets imaging criteria for HCC. There are a number of societies that have put up criteria for what determines a diagnosis of HCC in a patient with cirrhosis with a high degree of certainty. I would say that in a setting such as ours, of every 100 patients with HCC, you might have to biopsy fewer than 10 of them to confirm a diagnosis.

Of course, when the imaging does not exactly meet the criteria enhancement and rapid washout capsule formation, with a LI-RADS [Liver Imaging Reporting and Data System] score that is certainly less than 4, one would indeed recommend the biopsy. But as I said, this is really not a common thing, and I definitely would want to avoid it to the greatest extent possible in most patients.

Transcript edited for clarity.

Case: A 61-Year-Old Man with Stage 4 Hepatocellular Carcinoma

Initial presentation

• A 61-year-old man presented with nausea, vomiting, decreased appetite and occasional generalized itching
• PMH: diabetes, medially controlled; hepatitis C and B coinfection diagnosed and treated 6 years ago; diagnosed with HCC December 2018
• PE: scleral icterus; jaundice; spleen palpable 4-cm below the costal margin
  
  

Clinical workup

• Labs: AFP 436 ng/mL, bilirubin 1.6 mg/dL, AST 105 U/L, ALT 110 U/L, ALP 390 U/L, INR 1.9, albumin 3.8 g/dL, BUN 13 mg/dL, creatinine 1 mg/dL, plt 95,000
• HBV+, HCV+
• Abdominal ultrasound revealed 3 small hepatic lesions
• Chest/abdominal/pelvic CT scan confirmed 2 focal nodules in the right and 1 in the left hepatic lobe measuring 3.6 cm, 4.9 cm and 5.2 cm, a suspicious lesion in the right lower lung lobe; wide-spread lymphadenopathy was noted
• Biopsy findings showed grade 3 hepatocellular carcinoma with marked fibrosis
• Surgical consult: unresectable due to tumor size and location
• Child-Pugh A; BCLC stage C
• ECOG 1
  
  

Treatment and Follow-Up

• 2018: treated with lenvatinib 400 mg PO q12hr; he experienced diarrhea for 2 weeks which resolved; achieved PR
• 2020: Imaging showed a new lung lesion
  • Treatment was with cabozantinib 60 mg PO qDay was initiated