Prognosis of Metastatic Liver Cancer

Richard S. Finn, MD:This is a 59-year-old gentleman who has a history of chronic liver disease. Actually, he has 2 risk factors for liver disease, one being chronic hepatitis C and the other being chronic alcohol use. The patient is presenting with a fairly large mass in the liver. We are not told what its imaging characteristics are. Given the chronic liver disease, we are concerned that this could represent a primary liver cancer or hepatocellular carcinoma, HCC. Had they told us that this tumor was hypervascular and had delayed washout on imaging, we could have said with high confidence that this is HCC. But in the absence of those characteristics, this patient underwent a liver biopsy, or a tumor biopsy, which was revealing of a grade 3 hepatocellular carcinoma.

We know that the majority of patients with HCC clearly have some risk factor for liver disease. We know that in assessing this patient’s stage, we need to take into account not only the characteristics of the tumor, but also the patient’s underlying liver disease. This patient does not have significant portal hypertension. We know his platelet count is 144,000. They do have some evidence of liver dysfunction with an elevated INR and bilirubin, but overall, the Child-Pugh score is A, which makes this patient an excellent candidate for treatment.

When I say early, I don’t mean necessarily early cirrhosis but early tumor burden. Given that the only way to find the disease and cure it is to find smaller tumors that are amenable to either curative resection or curative rate of frequency ablation, or even liver transplant, it’s really important that we screen patients at risk. This patient is the classic example of someone who’s at risk. They have chronic hepatitis C. The American Association for the Study of Liver Disease, or the AASLD, has a very clear set of recommendations for patients who should be screened for liver cancer. And it’s pretty broadly anybody who has chronic liver disease with the exception of patients with hepatitis B who can develop liver cancer in the absence of cirrhosis. And, therefore, there are recommendations to screen patients’ chronic Hepatitis B based on age as well as their hepatitis B status.

So, while the US Preventive Task Force does not necessarily recommend HCC screening because there aren’t well-done randomized perspective studies that have delineated that screening improves outcomes, most of the subspecialty societies still have a strong recommendation to screen. And screening in this case would be an ultrasound every 6 months. Alpha-fetoprotein can be added to that, but alpha-fetoprotein alone should not be used as a screening tool for patients at risk.

Unfortunately, this patient has a fairly poor prognosis. They’re presenting with an incurable lesion. That’s not to say it can’t be treated, and we can certainly extend this patient’s survival. And with the improvement in systemic therapy that we’ve seen in the past several months to a year or so, it’s hopeful that this patient can do well for some period of time. They’re a good candidate for treatment, they’re well compensated, but this is a fairly large tumor invading the portal vein, which you know means this patient will eventually probably die of advanced liver cancer.

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