Delectable Diagnoses
This is the imaging study typically required to diagnose HCC
Bonus points for what you see on imaging
What is Abdominal Multiphasic CT or MRI
You will see arterial enhancement and venous washout
T/F
Adjuvant treatment in the localized setting has lead to survival benefit
F
Attempts at administration of systemic chemotherapy have been unsuccessful in improvement in survival for patient with localized disease
Treatment is generally transplant vs resection vs other local ablative options
The IMbrave050 trial showed that patients who could not undergo curative intent surgery could consider atezo/bev since it showed relapse free survival
This is the first drug approved for advanced HCC based on the SHARP study.
What is sorafenib?
The SHARP study compared Sorafenib to placebo in patients with good baseline liver function (mostly Child-Pugh A) who had advanced, unresectable HCC. The median survival favored the sorafenib arm (10.7 months vs. 7.9 months). In subgroup analysis patients with macroscopic vascular invasion, presumably largely consisting of PVT, had an overall survival of 8.1 months in the sorafenib group compared to 4.9 months in the control group.
T/F
Fibrolamellar variant of HCC carries a good prognosis
Patients with this type of HCC tend to be younger and have a generally better prognosis compared to patients with other types of HCC. However, recurrences following resection are common.
Fibrolamellar HCC is rarely associated with hepatitis, cirrhosis or elevated AFP levels.
Literature shows that those patients with HCC with fibrolamellar histology have an increased chance of having resectable disease. Fibrolamellar HCC makes up a small number of all HCC. Recurrences following resection are common.
One population-based study revealed that the 5-year survival rate was much improved for patients with the fibrolamellar variant of HCC compared to standard HCC (32% vs. 7%).
Having fibrolamellar features was associated with a 46% reduction in mortality at 5 years.
This is how long you should hold bevacizumab prior to surgeries
What is 4-6 weeks?
T/F a biopsy is required of a patient who a liver lesion 2 cm in a noncirrhotic patient with imaging showing arterial enhancement and venous washout
What is False
Biopsy is needed if the patient is a noncirrhotic/does not have other risk factors!
Not needed if > 1 cm in cirrhotic liver with arterial enhancement and venous washout on triple phase CT/MRI
These are some options for local ablative therapy - Name 3
Chemoembolization (transcatheter arterial chemoembolization= TACE) - improved outcomes in randomized trials
Transcatheter radioembolization (RCT showed similar outcomes to TACE)
Alcohol injection
Radiofrequency ablation (achieves CR > 80% of tumors less than 3 cm, only 50% of tumors 3-5 cm).
External-beam radiation therapy or stereotactic radiation therapy
These are your first two options for treatment of advanced HCC.
What is atezolizumab/bevacizumab and tremulimumab/durvalumab?
What is no difference in relapse free survival?
These are the MOA of lenvatinib, sorafenib, regorafenib, etc.
What are multi tyrosine kinase inhibitors?
In a patient with cirrhosis/Hep B who is found to have a liver nodule < 1 cm, this is the recommendation
What is ultrasound in 6 months
This is the criteria for resection in HCC
What is solitary lesion (no size cutoff)- future liver remnant has to be 20 if no prior cirrhosis
The future liver remnant a patient should have after undergoing surgery should be at least 30-40% if the patient has Child A cirrhosis.
%?
The REFLECT study lead to approval of this medication, which is first line for patients who are not candidates for immunotherapy?
What is Lenvatinib?
REFLECT showed noninferiority of lenvatinib
limited data for with ≥50% liver involvement, clear invasion of the bile duct, or main portal vein invasion
A - 5-6
B - 7-9
C > 9
These are the side effects of lenvatinimab (and other multikinase inhibitors)
Cardiac effects: Hypertension, QTC prolongation, etc.
Fistula formulation/GI perforation
GI toxicity: Diarrhea .
• Hemorrhage
• Hepatotoxicity
• Hypocalcemia
• Hypothyroidism
• Osteonecrosis of the jaw
• Renal toxicity:
• Reversible posterior leukoencephalopathy syndrome:
• Thromboembolic events
• Wound healing impairment
These are the components of CHILD PUGH scoring
ABCDE
Albumin
Bilirubin
Coagulation - INR
Dullness - ascites
Encephalopathy
Child Pugh
This is the criteria for consideration of liver transplant
What is single tumor < 5 cm or up to 3 tumors < 3 cm, no macrovascular invasion or metastasis; liver function does not matter.
Bridging therapies can be tried to keep them within this criteria
Milan criteria!!
These are second line options for advanced HCC
What are Cabozantinib, Regorafenib, Lenvatinib, Sorafenib, ipi/nivo, pembro
MSI high - dostarlimab
RET gene - Selpercatninib
These are the relative contraindications to chemoembolization.
1) Child Pugh C disease
2) Portal vein thrombosis
However, arterially directed therapy can be considered in those patients with limited
tumor invasion of the portal vein
3) Bilirubin > 3 mg/dL
This is the MOA of ramucirumab.
What is monoclonal antibody against VEGFR2?
This is the Barcelona stage in which you see end stage Liver Function.
What is Terminal Stage or D?
Barcelona staging system
Very early stage - single 2 cm, preserved liver function, PS 0
Early stage A - single, or < 3 nodules each < 3 cm, PS 0
Preserved liver function, PS 0
Intermediate stage B- multinodular, preserved liver function, PS 0
Advanced Stage C - portal invasion and/or extrahepatic spread, preserved liver function; end stage liver function, PS 3-4
This is the criteria for radio frequency ablation
What is the lesion < 4cm not near major vessel with preserved liver function?
Ablation as a sole treatment can offer a chance for a cure if the HCC lesion is ≤ 3 cm.
These are some paraneoplastic syndromes associated with advanced HCC
What are hypercholesterolemia, hypoglycemia, hypercalcemia and erythrocytosis.
Hypoglycemia is mediated in part due to compromised gluconeogenesis that occurs in patients with HCC.
One study showed that patients with HCC who had a paraneoplastic syndrome at diagnosis had a significantly worse 5-year Overall survival rate.
Ramucirumab can be given only at this Child Pugh stage and this AFP level.
What is A and 400?
T/F
Ipilimumab/nivolumab îs approved later line therapy for HCC
True
KEYNOTE/CHECKMATE trials positive in phase II showed response and survival benefits, which lead to FDA approval; also approved nivo+/- ipi, pembro in those who were previously treated; HOWEVER, the lead up phase III were negative though still listed in NCCN