68-year-old man with hepatocellular carcinoma

Ghassan K. Abou-Alfa, MD, MBA: Hello, I am Ghassan Abou-Alfa from Memorial Sloan Kettering Cancer Center in New York, New York. I am delighted to introduce and discuss the case of a 68 year old man with hepatocellular carcinoma. Let’s see what we can learn together.

Our patient is a 68 year old man who complains of fatigue and pain in the right upper quadrant. His medical history includes medically controlled hypertension and cirrhosis due to binge drinking for 20 years. He also smokes cigarettes: 20 pack-years. On physical examination, the patient presented with hepatomegaly and some tenderness in the right upper quadrant. As we all could, we had a chest and pelvic CT scan, including a 4 phase liver. A phase 3 could also have been acceptable, but phase 4 was good enough to delineate the evaluation of the liver in detail. He showed a 6.5 cm liver injury in the right hepatic lobe, but also unfortunately several sites of metastatic disease in the lung. The alpha-fetoprotein was mandated to find 490 µg / L.

But at the same time, the good news is that the liver function was adequate. Albumin was 3.5 g / dL, bilirubin was 1.9 mg / dL, and INR [international normalized ratio] was 1.5, which is normal. However, the platelet count was reduced, down to 79,000 per mm3. A biopsy was taken for the site of the lung metastases. This is the norm. We need a biopsy to confirm the diagnosis. We would still like to go to the metastatic site to prove that it is metastatic disease. This biopsy confirmed hepatocellular carcinoma. According to the assessment I presented on the physical examination, there was no ascites, no encephalopathy. Blood tests included normal bilirubin, normal albumen, normal PT [prothrombin time] and INR, and the patient is Child-Pugh A. The performance index was appropriate, ECOG 1, with upper quadrant pain that he has occasionally. The patient was started on lenvatinib 12 mg per day.

Let’s discuss all of this. You can ask me my impression of this story, which can happen every day. We often hear about patients like this 1. Unfortunately, the incidence of liver cancer continues to rise. This is the norm. Most patients will have metastatic disease to begin with. We hope to take care of the patients while they are still in the Child-Pugh A arena, like our patient. As such, this can be reflected rather positively with regard to the prognosis of this patient. In the past, when there were no therapies available, unfortunately the prognosis was somewhat limited. Nowadays, with the advent of many therapies, we have first, second and third line therapies. Regarding the prognosis, there is no doubt that we should think positively that we can definitely help this patient, especially when the patient is performing well in regards to functionality and good liver function.

Transcription edited for clarity.

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