Richard Finn, MD: Consideration of Different Modalities

Dr. Finn believes that it is reasonable to continue with another chemoembolization procedure at this time, but the real question for the practicing clinician is, when does the patient go beyond a chemoembolization procedure? There would be several reasons for doing so; for example, if the patient has evidence of decompensation from his treatment or his disease, such as hyperbilirubinemia or ascites. He could develop vascular invasion, which could be a contraindication for chemoembolization and systemic treatment would then be appropriate, or he could develop extrahepatic disease, which would be an indication for systemic therapy as well, as would pure progression after chemoembolization, even intrahepatic progression, with other satellite lesions or growth at the main lesion.

CASE 1: Unresectable Hepatocellular Carcinoma

Jose V is a 73-year-old Filipino store owner from Queens, New York, with a history of chronic hepatitis B (HBV) infection and unresectable hepatocellular carcinoma (uHCC).

In May 2014, patient was referred to a hepatologist with an elevated ALT (68 IU/mL)

Medical history includes type II diabetes, previously treated with metformin and a sulfonylurea; currently controlled with diet and exercise regimen; other MH was unremarkable

Family history was relevant for a sister who was diagnosed with HCC and chronic HBV infection at age 60

No symptoms of liver disease were noted; patient had mild tenderness over the right upper quadrant

Ultrasound revealed a hyperechoic lesion in the left lobe; MRI with gadolinium showed an 11-cm mass in the left lobe with imaging characteristics consistent with HCC. No evidence of metastatic disease was noted on bone scan and uncontrasted CT scan of the chest.

Based on laboratory findings and clinical features, the patient was determined to have Child Pugh Class A, with a MELD score of 8

Consultation with the multidisciplinary team recommended surgical resection, however patient was fearful of surgery and opted for TACE procedure

In June of 2014, follow-up CT scan showed evidence of residual disease at the TACE site; a second TACE was scheduled for 10 weeks following the first TACE. In August of 2014, an MRI showed evidence of residual disease in the periphery of the tumor approximately 6 weeks following the second TACE procedure.