HCC –Case Presentation€¦ · HCC –Case Presentation Zhang Zewen Registrar, Medical Oncology...

ESMO Preceptorship Programme

HCC – Case Presentation

Zhang Zewen

Registrar, Medical Oncology

HCC – Singapore – 20/11/19

ESMO PRECEPTORSHIP PROGRAMME

DISCLOSURE OF INTEREST

� Nil


History

� 62yo Chinese Male

� Ex-smoker

� Ex-alcohol user stopped around 4 years ago

� Hypertension, Diabetes

� Nil family history of cancer

� Works as Electrician

- found to have elevated AFP at 1857 UG/L on medical check-up


Nov 2017

� CT showed 5.1. x 4.8 x 4.8 cm HCC at segment 6/7. Another small arterial enhancing focus with at segment 4A near the liver dome is also suspicious for HCC.

� Nil distal disease

� Biochemical:

� Alb: 45, Bil: 29, ALP: 109

� ALT: 77, AST: 65

� AFP: 2653

� Clinically Child Pugh A5


What would you do next?


Nov 2017

� Multi-disciplinary meeting

� Functional test including imaging and ICG

demonstrated poor liver reserve – deemed not for

resection

� Recruited for Y90-Nivo Trial - if good response,

reconsider resection if able to have enough reserve.


Jan 2018

� Post 3# Y90-Nivo

� CT showed decrease in size of the dominant nodule

5.6 to 3.9cm, indeterminate bilateral lung nodules

� AFP 2653 -> 799 -> 279


Feb 2018

� Post 5# Y90-Nivo

� CT showed continue response in liver nodule

� However increase in bilateral lung nodules and new

right adrenal lesion (1.5 cm) suspicious for mets

� AFP 458 -> 1280


Mar 2018

� Y90-Nivo was delayed in view of herpes

opthalamicus

� Repeated CT shows progression of lung and

adrenal lesions. Liver nodule has interval decrease

� AFP 1280 -> 4933

� Clinically remains CPA5 with good ECOG

� Offered standard treatment – Sorafenib, Levantinib

� Offered Adrenal biopsy for molecular testing study


Apr 2018

� Adrenal nodule; biopsy:

poorly differentiated carcinoma with hepatocytic

differentiation:

- CK19 reactivity present

Comment: The previous biopsy report was reviewed.

The morphology is different and should give rise to the

consideration of a combined hepatocellular-

cholangiocarcinoma.


Apr 2018

� AFP: 7600 -> 10950; CA 199: 70

� Options offered and discussed with patients

� 1) Gem-Cis for cholangio component

� 2) Levantinib in view of rapid rise in AFP, and may

be contributed more by HCC component

� Started Levantinib 12mg/day


May 2018

� 4 weeks of Levantinib

� G1 anorexia

� G1 transaminitis ALT 34 -> 69, AST 36 -> 64

� G1-2 HFS

� AFP: 10950 -> 7623; CA 199 70 -> 71


Jun 2018

� 6 weeks of Levantinib with breaks for PPE

� G1 HFS, G1 anorexia. G1 transaminits stable

� AFP 7623 -> 16941; CA 199 71 -> 66

� CT showed stable liver lesion, progression in lung and

adrenal mets


Jun 2018

� Offered Ramucirumb 10mg/kg q3wk + Gem/Cis std

dose to treat both cancers


Jul 2018

� After 2#

� AFP 16941 -> 30533; CA 199 74

� CT showed progression lung, adrenal and new

nodule in segment 6


Jul 2018

� Impression of HCC progression rather than

cholangio

� Discussed regarding Atezeo + Bev

� Atezolizumab1200mg on day 1 of each 21-day

cycle and Avastin15mg/kg on day 1 of each 21-day

cycle.


Sep 2018

� Post 2# Atezeo + Bev

� AFP 30533 -> 37789 -> 53693

� CA 199 74 -> 90 -> 79

� CT showed lung mets some stable some smaller, liver nodule slightly smaller, adrenal lesion stable, new small volume aortocaval nodes

� Impression: although there is some PD, rate appeared to have slowed down

� Decided to continue treatment and monitor for delayed response


Nov 2018

� Post 4# Atezeo + Bev

� AFP > 60500, CA 199 86

� Imaging shows progression lung, adrenal,

aortocaval nodes


Nov 2018

� Impression: progression is likely HCC component

� Discussed Cabozantinib; not for regorafenib in view

of previous PPE with Levantinib

� Discussed ipi + nivo – agreed to start


Feb 2019

� AFP 60500 -> 261; CA 199 64 -> 110

� Decided for PET-CT imaging in view of back pain to evaluate bone lesions

� Reduction in size of known hypodensities in segment 5\6 of the liver which do not show significant FDG avidity. Likely to represent metsgiven the improvement post-treatment.

� Decrease right adrenal nodule, lung mets, aortocaval nodes

ESMO Preceptorship Programme

HCC –Case Presentation€¦ · HCC –Case Presentation Zhang Zewen Registrar, Medical Oncology...

Documents

Transcript of HCC –Case Presentation€¦ · HCC –Case Presentation Zhang Zewen Registrar, Medical Oncology...