Richard Finn, MD: Most Appropriate Treatment

recommend a biopsy of the lesion on his groin to make sure that it is malignant. If the patient does have extrahepatic disease, the backbone of his treatment will be systemic therapy.

Dr. Finn would

CASE 3: Unresectable Hepatocellular Carcinoma

Dale P is a 61-year-old Jamaican-American male from Houston, Texas, with a history of HCV infection and cirrhosis, who works in corporate cell-phone sales.

In February of 2012 the patient presented with upper right quadrant discomfort; CT scan showed the presence of a 4.1 × 3.9-cm mass consistent with HCC in the setting of cirrhosis; he was referred to the multidisciplinary team for further assessment.

Initial assessment showed a MELD score of 7 and Child Pugh A class

The patient was not considered appropriate for transplant based on prior history of successfully treated renal cancer (4 years prior) and patient declining to pursue a transplant evaluation

Medical history notable for heavy alcohol use and substance abuse approximately 30 years ago, stroke in mother, deep vein thrombosis in father

Other medical history included nonresponse to pegylated interferon and ribavirin for HCV 5 years earlier; current medications included antihypertensives and aspirin

Patient recommended for liver resection in April 2012

He underwent R0 resection. Pathology showed moderately differentiated HCC with negative margins and no evidence of microvascular invasion

On follow up in April 2013, patient shows no evidence of disease recurrence on MR which is performed every 3 months

On follow up in August of 2014, ~2 years post resection, there is imaging evidence of recurrence and metastasis.

MRI detects multiple lesions at the postsurgical site, largest ~1.7 cm, and a nodule in the inguinal lymph node, ~1.9 x 1.0 cm

Patient’s current assessment shows a MELD score of 9 and Child Pugh A