Hepatocellular carcinoma

Question 1

Variant of HCC more common in women and occurring at younger age

Answer 1

fibrolamellar variant

Question 2

presentation

Answer 2

• typically asymptomatic

- Advanced stage → upper abdominal pain, weight loss, generalized weakness, anorexia or early satiety, emesis

Question 3

Other things causing AFP elevation

Answer 3

1) chronic liver disease (acute or chronic viral hepatitis)
2) pregnancy
3) germ cell and non germ cell tumors

Question 4

purpose of Child-Pugh classfication

Answer 4

classifies severity of liver disease

Question 5

surgical therapies available for HCC treatment

Answer 5

Surgical resection (otpimal)

Question 6

patients eligible for surgical resection

Answer 6

1) solitary HCC
2) confined to liver
3) no evidence of invasion into hepatic vasculature
4) no portal hypertension
5) preserved hepatic function (bili<1)

Question 7

Locoregional therapies for HCC

Answer 7

1) Radiofrequency ablation
2) Transarterial chemoembolization (TACE)
3) External beam radiation
4) Radioembolization (y90)

Question 8

management of patients with localized disease who aren’t surgery or transplant eligible

Answer 8

Locoregional therapies (preferred by NCCN guidelines)

Question 9

targeted therapies for HCC?

Answer 9

several studies have shown a role for targeting EGFR/EGF (HER1), VEGF, and MEK/ERK pathways

Question 10

classic enhancement pattern of HCC on imaging

Answer 10

arterial: increased
venous: decreased
delayed: persistent washout

Question 11

What is Y90 for HCC?

Answer 11

• Radioembolization
  Radioembolization is a minimally invasive procedure that combines embolization and radiation therapy to treat liver cancer. Tiny glass or resin beads filled with the radioactive isotope yttrium Y-90 are placed inside the blood vessels that feed a tumor.

Question 12

most common sites of mets

Answer 12

• lung
• intra-abdominal lymph nodes
• bone
• adrenal gland

Question 13

AFP threshold triggering evaluation for HCC

Answer 13

20

Question 14

Imaging criteria for HCC diagnosis in high risk patient

Answer 14

1) non-rim hyperenhancement in the arterial phase + fulfills size criteria given

Question 15

First-line systemic therapy for Child-Pugh Class A

Answer 15

Atezolizumab + bevacizumab

Question 16

First line for metastatic HCC (Child Pugh Class A)

Answer 16

Atezo + bev

Question 17

Other recommended regimens for metastatic HCC

Answer 17

1) sorafenib

2) lenvatinib

Question 18

Sorafenib MOA

Answer 18

Targets RAF/MEK/ERK

And VEGF/PDGFR

Question 19

Second line therapies for HCC

Answer 19

1) regorafenib
2) cabozantinib
3) ramucirumab
4) lenvatinib
5) sorafenib
6) ipi-nivo

Question 20

Adequate liver remnant s/p surgery in patient with healthy liver (by percentage)

Answer 20

20%

Question 21

Transplant eligibility criteria

Answer 21

1) ≤5 cm in diameter OR up to three separate lesions, none of which is larger than 3 cm
2) **no gross vascular invasion
3) no regional nodal or distant metastases (the Milan criteria
4) **no portal vein thrombosis

Question 22

Local therapies for HCC + categories

Answer 22

1) Ablative — RFA, Cryoablation, Percutaneous EtOH injection
2) Arterial-directed therapies —
OR chemoembolization (TACE or drug-eluting beads)
3) SBRT

Question 23

Contraindications to chemoembolization

Answer 23

• Child Pugh C
• portal vein thrombosis (obstructs chemo)
• bilirubin >3

Question 24

How does chemoembolization work?

Answer 24

• chemotherapy is administered into the hepatic artery

Question 25

Typical regimen for chemoembolization

Answer 25

doxorubicin-based

Question 26

Name of criteria used to determine if patient is eligible for transplant

Answer 26

Milan/UNOS criteria

Question 27

Radiographic criteria for diagnosis of HCC

Answer 27

- hyperenhancement in arterial phase - venous or delayed phase washout appearance - enhancing capsule appearance

Question 28

Only systemic treatment option for patients with Child-Pugh Class B disease

Answer 28

Sorafenib (confirm this)

Question 29

Preferred immunotherapy in second line

Answer 29

Ipi/nivo (pembro is category 2B)

Question 30

Algorithm for managing localized disease

Answer 30

Determine if 1) Surgical candidate 2) IF not surgical candidate, consider whether transplant candidate 3) IF not surgical or transplant candidate, evaluate if eligible for local therapies

Question 31

What are the ablative therapies

Answer 31

- radiofrequency (RFA) - cryoablation - percutaneous alcohol injection (confirm) - microwave

Question 32

what are the arterially directed therapies?

Answer 32

- bland transarterial embolization - chemoembolization (TACE) - radioembolization (Y-90 microspheres)

Question 33

Child Pugh C management

Answer 33

Hospice, systemic therapy never recommended

Question 34

alternative to Child Pugh C that has better interobserver reliability

Answer 34

ALBI score

Question 35

primary problem with child pugh score

Answer 35

Low interrater reliability given variability in grading encephalopathy and ascites

Question 36

best option for a cirrhotic

Answer 36

transplant (fix cirrhosis and HCC)

Question 37

why surgical resection is much less common in the US

Answer 37

cirrhotics in US have EtOH or NASH, as opposed to hep b. Thus, they have much lower hepatic reserve. Less than 5% are eligible for surgery in the US! Typicallly only realistic options for patients with hep b cirrhosis.

Question 38

Drug that doesn't work for NASH cirrhosis

Answer 38

immunotherapy (TKI's better first line, possibly followed by immunotherapy (TKIs increase immunogenicity))

Question 39

Ipi, Nivo formulation approved for second line

Answer 39

Nivo1 +/- Ipi3, thus more toxic

Question 40

evidence for adjuvant treatment

Answer 40

There is no robust data that suggest a benefit of adjuvant therapy following resection

Question 41

LI-RADS 4, biopsy?

Answer 41

Typically don't

Question 42

First line for immunotherapy ineligible

Answer 42

Lenvatinib (highest response rates)

Question 43

When is regorafenib indicated second line?

Answer 43

Only for patients who tolerated sorafenib frontline

Question 44

Preferred second line

Answer 44

Cabozantinib (best tolerated and broad eligibility vs. other second line studies only approved for patients who tolerated frontline sorafenib, etc)

Question 45

Term for criteria for transplantation

Answer 45

Barcelona Clinic Liver Cancer (BCLC) OR Milan

Question 46

When is TACE used

Answer 46

Not transplant or surgical candidate and LARGE tumors (greater than 3cm)