New York Presbyterian Brooklyn Methodist Hospital Brooklyn, NY, United States
Richy C. Chen, MD, Smruti Mohanty, MD, MS New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
Introduction: Unresectable hepatocellular carcinoma (HCC) is a challenging disease that requires multidisciplinary discussions to plan treatment to improve outcomes. Multi-kinase inhibitors have been demonstrated to increase overall survival in unresectable HCC. Case series have shown improvement in outcomes with combination systemic and local therapies for HCC. We present a case of unresectable HCC treated with multiple modalities.
Case Description/Methods: A 68-year-old male with treated chronic hepatitis C was found to have multiple liver lesions on ultrasound with alpha-fetoprotein (AFP) >20,000ng/mL. Magnetic resonance imaging of liver showed main portal vein thrombus with innumerable foci involving both lobes. Patient was classified as Barcelona Clinic Liver Cancer Stage C. After review at multidisciplinary tumor board, treatment with lenvatinib was started.
Repeat imaging in 4 months noted reduced tumor burden. Patient was determined to be a good candidate for radioembolization with Yttrium-90. Radioembolization was performed using TheraSphere.
Four months later, patient presented with abdominal pain. Upper endoscopy showed a cratered antral ulcer with biopsy showing microspheres in submucosa. His lenvatinib was stopped at that time, and patient was treated with proton pump inhibitor.
Two months later, repeat imaging showed area of hypoattenuation in left hepatic region. Patient’s case was reviewed at multidisciplinary tumor board with no evidence of HCC recurrence noted.
Six months later, patient noted resolution of abdominal pain with good oral intake and lived independently. Patient remained off lenvatinib, and AFP level was 1.2ng/mL at that time.
Discussion: After radioembolization, our patient had no further HCC progression after discontinuation of lenvatinib. This called into question the necessity of systemic therapy after radioembolization as two randomized trials showed no difference in overall survival when comparing sorafenib versus resin microsphere transarterial radioembolization.
Recently, treatment with atezolizumab-bevacizumab in unresectable HCC had demonstrated better overall survival outcomes compared to sorafenib. This suggested combining different treatments could potentially lead to better outcomes in unresectable HCC. Further research is needed to demonstrate benefits and risks of combination of systemic therapies and radioembolization compared to each counterpart alone.
Figure: A. Triphasic magnetic resonance imaging of liver before treatment: innumerable lesions focused around left lobe with main portal vein thrombus. B. Triphasic computed tomography of liver four months after lenvatinib: interval decrease in number of lesions with decrease in extent of portal vein thrombus. C. Triphasic computed tomography of liver nine months after Y90 radioembolization: interval decrease in size of hypodensity in left hepatic lobe. D. Upper endoscopy showing large cratered ulcer extending from antrum to pylorus. Biopsy showed microspheres in submucosa.
Richy Chen indicated no relevant financial relationships.
Smruti Mohanty indicated no relevant financial relationships.
Richy C. Chen, MD, Smruti Mohanty, MD, MS. P2879 - Treatment of Unresectable HCC With Yttrium-90 Radioembolization After Downsizing With Lenvatinib, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.