Hepatocellular Carcinoma Update, Issue 1, 2017 (Video Program)Case discussion: A 68-year-old woman with metabolic syndrome, diabetes and nonalcoholic steatohepatitis-related HCC receives transarterial chemoembolization (TACE) as first-line therapy
5:19 minutes.
TRANSCRIPTION:
DR EL-KHOUEIRY: This is a 68-year-old female with no viral hepatitis. So this is a metabolic syndrome, diabetes and known nonalcoholic steatohepatitis, NASH-related liver disease. DR LOVE: Just out of curiosity, how obese was she? DR EL-KHOUEIRY: Well, this is a lady who tells me — because, at the time I saw her, she had lost some weight, et cetera, but had been even kind of visibly overweight for the majority of her life, had high cholesterol, had hypertension, diabetes, so the whole metabolic syndrome-type situation, and no decompensated cirrhosis. And, again, the reason for this case selection is to highlight NASH as an emerging etiology for hepatocellular carcinoma. The other thing that we’re starting to see, that NASH may not need to pass through the obligatory step of liver cirrhosis before leading to hepatocellular carcinoma — may not. This lady had no varices, normal platelet count, so definitely Child-Pugh A. DR LOVE: Before you go on, any new theories about the pathophysiology, in terms of NASH and HCC, like what’s going on? DR EL-KHOUEIRY: No. I mean, again, the theory seems to be linked to the chronic inflammation that results from NASH and the upregulation of multiple pre-oncogenic or oncogenic pathways as a result. So, the patient had right upper-quadrant pain, weight loss. She had 2 liver masses on ultrasound. Appropriately, this was evaluated outside our institution. A multiphase CT scan was done showing 2 arterially enhancing lesions with washout, so she met the radiologic criteria for diagnosis. One measured 6.5 centimeters. The other one measured 4 centimeters. There were also 2 indeterminate 1-cm lesions, no evidence of metastatic disease. She was treated with TACE, so chemoembolization using doxorubicin beads. This is a typical patient where there’s no extrahepatic disease, there’s no vascular invasion, only 2 definitive tumors. So it’s certainly appropriate to evaluate chemoembolization. But one thing I want to mention here related to chemoembolization is, where do you draw the line? And what we know from the data related to chemoembolization is that the larger the tumors, the more multifocal the disease is, the higher the bilirubin, the lower the albumin, the less the chance of response from chemoembolization, even when it’s liver-limited disease. So patient selection is important. This patient had a great response. Well, actually — I’m sorry — after her first chemoembolization, the first scan showed unchanged size of both tumors. However, there was necrosis in up to 50% of the larger tumor that measured 6.5 centimeters. Based on this sign of response, she had another TACE, which targeted both lesions this time. The scan showed complete resolution of the enhancement in the 6.5-cm lesion, which now decreased in size to 3.8. The 4-cm lesion decreased to 2 centimeters, so cut by half, but still had residual enhancement. At that point we chose to go to radiofrequency ablation of this 2-cm lesion. And then the patient was observed for 14 months with no active disease, so a very nice outcome here. Unfortunately, at that point she developed evidence of a new liver lesion adjacent to the treated large mass, but this time with invasion into the main portal vein, which is an indication for systemic therapy, so she was started on sorafenib. DR LOVE: What happened then, once she got started on the sorafenib? DR EL-KHOUEIRY: The patient is actually still on sorafenib at this point. She’s about 8 months into treatment, with stable disease. DR LOVE: And how has she tolerated therapy? And how was it dosed? DR EL-KHOUEIRY: Very good. The patient, when starting sorafenib, had still Child-Pugh A cirrhosis and a bilirubin of 1.8. So we certainly gave the full standard dose of 400 milligrams BID, twice daily. And during, I think, week 3 to 4, she had the hand-foot skin reaction: painful blisters. She couldn’t walk. So we gave a treatment holiday of about 10 days, restarted at the reduced dose of 400 milligrams and did more aggressive local therapy for her hands and feet. And she’s been able to tolerate the 400 milligrams daily since then. DR LOVE: What are you thinking about in terms of her future therapy, if she does develop disease progression? I guess it’ll depend upon the circumstance, but theoretically, I guess, you could think about not only regorafenib but maybe a checkpoint inhibitor. DR EL-KHOUEIRY: Absolutely. Both would be options in this situation. She, though, at this point does fit the bill, so to speak, for a regorafenib candidate. She’s been on sorafenib. She’s tolerated the 400-mg dose. And if we can prove radiologic progression, she’ll be a good candidate for that, as well. |