Case Study: Advanced Hepatocellular Carcinoma With Tumor Thrombus

Watch a video presentation of this article

Watch the interview with the author

Abbreviations

BCLC

Barcelona Clinic Liver Cancer

CT

computed tomographic

ECOG PS

Eastern Cooperative Oncology Group Performance Status

HCC

hepatocellular carcinoma

IVC

inferior vena cava

TACE

transarterial chemoembolization

On November 21, 2011, a 65‐year‐old African American man was referred to the outpatient hepatology clinic from an outside gastroenterology practice with a new diagnosis of a positive hepatitis C antibody, Child‐Pugh A cirrhosis, and findings of a liver lesion. The patient reported nonspecific right upper quadrant abdominal pain on October 10, 2011, prompting the patient to be seen in the emergency department for further evaluation. At that time, a computed tomographic (CT) scan of the abdomen was performed, which noted a liver lesion. It was described as a “large, solid lesion in the tip of the right lobe of the liver measuring 8 cm in diameter.” A follow‐up CT scan including the chest, abdomen, and pelvis with and without intravenous contrast was completed on November 30, 2011, and revealed multifocal hepatocellular carcinoma (HCC) (Fig. 1) with associated tumor thrombus extending into the right hepatic vein, inferior vena cava (IVC), and extensively into the right atrium (Fig. 2). Based on the Barcelona Clinic Liver Cancer (BCLC) system, this degree of disease was classified as advanced stage (C) (Fig. 3).1

Figure 1.

CT scan‐arterial phase imaging.

Figure 2.

Tumor thrombosis.

Figure 3.

Barcelona Clinic Liver Cancer staging system for hepatocellular carcinoma. *Patients with end‐stage cirrhosis due to heavily impaired liver function (Child‐Pugh stage C or earlier stages with predictors of poor prognosis or high a MELD score) should be considered for liver transplantation. In these patients, hepatocellular carcinoma might become a contraindication if it exceeds enlistment criteria. ^†Currently, sorafenib followed by regorafenib has been shown to be effective.

Results and treatment plans were discussed with the patient in clinic on December 2, 2011, including the use of sorafenib. Therapy was started on December 2, 2011, at 400 mg twice daily. Despite the development of mild tenderness in the soles of the feet, bilaterally, consistent with the known adverse event of hand‐foot‐skin reaction,2 treatment was continued. Supportive topical therapies were used with good response. The patient also underwent radiation therapy of the tumor thrombus in the IVC, which was completed on December 16, 2011. Follow‐up CT imaging was completed on January 18, 2012, noting significant improvement in the right atrial tumor/thrombus; however, development of pulmonary thromboembolic disease to the right pulmonary artery with a small area of right lung infarct required treatment with enoxaparin injections. The multifocal HCC within the liver was unchanged.

After hepatobiliary multidisciplinary committee review, locoregional therapies, specifically Y‐90 radioembolization, were selected and the patient received this to the right hepatic artery on March 13, 2012. Despite this, a follow‐up CT scan on May 14, 2012, noted continued progression of disease within the liver and the development of new liver lesions and increased size of existing lesions. However, there was evidence of continued regression of the IVC and atrial thrombus. Additional therapies, including transarterial chemoembolization (TACE) to the left hepatic artery on June 7, 2012, to the right hepatic artery on August 23, 2012, and an additional TACE on December 21, 2012, to the left hepatic artery were completed. Despite this aggressive treatment, follow‐up CT imaging on January 28, 2013, revealed the development of new tumor burden with the liver. Given progression, it was felt that locoregional therapies were of no future benefit, and it was decided to defer any additional therapies with TACE. Sorafenib was continued and the patient was referred back to radiation oncology for additional radiation therapy, completed March 7, 2013, but with no improvement. The decision was made that the patient should continue receiving sorafenib only, because no alternative first‐ or second‐line therapies were available, which he did until December 2014, when the patient passed away.

This case highlights the complex nature of HCC and treatment. Although the patient presented with BCLC stage C tumor burden, it was decided to use a variety of treatment modalities, including those not typically considered for this stage of disease. Starting with systemic therapies including sorafenib and radiation was in agreement with the American Association for the Study of Liver Disease treatment guidelines at the time, as well as the current guidelines.3 Yet, given the positive, although unexpected, response to these therapies, it presented the opportunity to introduce other treatments typically reserved for BCLC stage B tumor burden.1 Treatment advanced for the management of HCC has improved in the years since this case. The Food and Drug Administration approval of new first‐ and second‐line agents might have changed the approach with this patient. The patient tolerated sorafenib well throughout the duration of treatment as the adverse events experienced were expected, mild, and easily managed. However, the ability to use an alternative second‐line option, such as regorafenib, cabozantinib, or nivolumab,3 might have been helpful given the ultimate progression while receiving sorafenib.

The case also demonstrates the advantage of a multidisciplinary team approach and the ability to access and use multiple treatment modalities, and the potential effectiveness of this approach. Every case of HCC is different, and every patient is unique and must be treated that way. Multiple factors have to be taken into consideration, including underlying liver disease, as well as the HCC itself. This is a patient who likely had a short life expectancy at the time of initial diagnosis; however, with the ability to provide a multitude of treatment options, was able to extend the patient’s life 3 additional years.