Hepatocellular Carcinoma Update, Issue 1, 2017 (Video Program)Case discussion: A 74-year-old man with chronic hepatitis B presents with a single lesion, is diagnosed with HCC and remains disease free 4 years after surgical resection
4:52 minutes.
TRANSCRIPTION:
DR LOVE: 74-year-old man with chronic hepatitis, no evidence of portal hypertension or cirrhosis, who presented with a single lesion. Can you talk about what happened? DR EL-KHOUEIRY: Yes. This is, again, a patient, as you summarized, with a single lesion and no overt cirrhosis and no portal hypertension — and interesting that the etiology is hepatitis B, where we know this is one etiology that could result in the development of hepatocellular carcinoma without necessarily having developed cirrhosis. And because this was a solitary lesion, because it was in the setting of absence of portal hypertension and liver cirrhosis, this was a great candidate for liver resection. So the patient underwent surgical resection. And, again, we found a single mass, 6.5 centimeters, with moderately differentiated hepatocellular carcinoma with microscopic vascular invasion on histology. The margins were negative. And then subsequently the patient was placed on surveillance and now is alive 4 years later with no disease recurrence. One of the things that I wanted to highlight here is that many oncologists would be concerned. This is a tumor that’s above 5 centimeters in size, that has microscopic vascular invasion. These are high-risk features for a resection. But, nonetheless, we did not give any adjuvant treatment because currently there is no standard adjuvant therapy. As we know, the STORM trial, which evaluated sorafenib postresection or post-RFA, was negative. So we currently do not have standard adjuvant therapies, and surveillance is what’s indicated. DR LOVE: Just out of curiosity, what did you estimate his risk of recurrence after surgery when you evaluated him? If you had to come up with a number, what do you think it would be? DR EL-KHOUEIRY: It’s somewhere between 50% and, probably, 60%. DR LOVE: And are there any situations with a patient at higher-risk therapy, that you would consider adjuvant therapy, sorafenib? Are there any adjuvant trials? Are there any adjuvant checkpoint trials? DR EL-KHOUEIRY: Adjuvant checkpoint trials are being discussed. DR LOVE: I guess there are not that many patients in this situation in a year. Is that true? Or how many — DR EL-KHOUEIRY: Well, worldwide there’s a large patient population because resection is very commonly used in Asia. And in Asia the pattern of resection is quite a bit more liberal than is done in the United States. But also, resection is, I think, gaining momentum in larger centers that have multidisciplinary teams in the United States, as well. So it is a big patient population. There is an unmet need there. But to answer your question, no, despite high-risk features, there’s really no data to support any adjuvant treatment at this point. DR LOVE: So this patient seems like he really fits the perfect criteria for a resection. How would you describe a perfect scenario for transplant? DR EL-KHOUEIRY: The benefit of transplant is treating 2 problems at once, right? The underlying liver cirrhosis and decompensation as well as the tumor burden. So patients who are within the Milan criteria, 1 solitary below 5 centimeters or up to 3 tumors with the largest one being 3 centimeters or less, and have liver dysfunction, right? These are patients who have, usually, portal hypertension, maybe Child-Pugh B cirrhosis, elevated bilirubin, low platelets. So they have things that would be at least relative contraindications to resection. These are the patients who are directed more towards liver transplant and are the ideal candidates. We now have enough experience, both in the US and worldwide, that there is a group of patients who are beyond the Milan criteria that can be downstaged. And if they are downstaged appropriately, they can do quite well with liver transplant. Now there are different criteria that are used. In the United States, most commonly, we refer to them as the UCSF criteria, the expanded criteria. But if these patients, again, can be downstaged with local-regional therapy such as chemoembolization, Y-90, et cetera, and can come down within Milan criteria and stay there, they tend to do well. There are some high-risk features that are concerning for these patients and make it unlikely that we’ll downstage appropriately. If they have an elevated alpha-fetoprotein above 1,000, if they don’t respond well to chemoembolization, these are ominous signs that the prognosis is not great and it’s unlikely that they would make it to transplant or benefit from transplant. |