KC HCC case study

CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 1
HCC: A CASE STUDY
BRADLEY FREILICH, MD
JASWINDER SINGH, MD
GERARDO VERGARA, MD
DEION DEPAOLIS, MD
DAVID SHAEFFER, MD

PATIENT J.P.
58 year old Asian male
Past Medical History:
 Chronic Hepatitis B
 Hypertension
 Type II diabetes mellitus
 Osteoarthritis
 Fatty liver
No Previous Surgical History
No significant Family History
Social History:
 Previous smoker, quit at age 42
 Social drinker

PATIENT PRESENTATION
• October 2013 seen in PCP office with acute onset of severe right upper
quadrant pain with radiation to the right scapular and shoulder area, mild
nausea without emesis. Labs and CT ordered.
• Complete Metabolic Profile (10/7/2013):
– ALT: 67 iu/L
– Glucose: 234 mg/dL
– Lipase: 81 u/L
• CT Abdomen (10/8/2013) revealed several heterogeneously enhancing
lesions present in the liver, the largest measuring 7 cm in size,
suspicious for multifocal hepatocellular carcinoma. Small periportal and
peripancreatic lymph nodes. Borderline splenomegaly. Small amount of
abdominal ascites.
• US guided liver biopsy performed (10/15/2013) confirmed hepatocellular
carcinoma.

LIVER, CORE BIOPSY: MODERATELY DIFFERENTIATED HCC

DIAGNOSIS
• Child Pugh Score A, Barcelona B
• Stage III moderately differentiated hepatocellular carcinoma

LIVER MRI WITH EOVIST PRIOR TO STARTING TREATMENT

LABS PRIOR TO STARTING Y-90 THERAPY
11/11/2013
• Total Bili: 0.9 mg/dL
• Direct Bili: 0.2 mg/dL
• AST: 47 U/L
• ALT: 79 U/L
• ALK Phos: 105 U/L
• Alpha Feto proteins: 106.6 ng/mL

TREATMENT APPROACH
Due to his multifocal bi-lobed disease he was not a candidate for a liver
transplant or surgery.
 Y-90 radioembolization of right hepatic artery (#1) 11/14/13
 Chemoembolization of left hepatic artery 12/17/13
 Started on Sorafenib (2 tabs in a.m. and 2 tabs in p.m.) 02/05/14
 Y-90 radioembolization of right hepatic artery (#2) 04/02/14
 October 2014 Sorafenib was stopped and patient was enrolled in a Phase I gene
therapy trial under Dr. Freilich’s care.

MRI OF THE ABDOMEN AND PELVIS POST FIRST Y-90 TREATMENT

LABS PRIOR TO GENE THERAPY
7/17/2014
• Direct Bili: 0.4 mg/dL
• AST: 56 U/L
• ALT: 82 U/L
• Alpha Feto protein: 92.7 ng/mL

LIVER MRI WITH EOVIST PRIOR TO STARTING GENE THERAPY

DEVELOPMENT OF COMPLICATIONS
• 11/21/2014 Port-A-Cath removed due to infection; Staphylococcus
aureus.
• 2/07/2015 Presented to ED with complaint of severe right abdominal pain
and right chest pain with radiation to back associated with shortness of
breath and dizziness with a fever as high as 38.3.
• 2/07/2015 CT of the abdomen and chest showed abnormalities that
included small right pleural effusion associated with a large collection of
fluid around the necrotic lesion in his liver, abutting the right
hemidiaphragm.
• 2/12/2015 underwent bronchoscopy, thracoscopy, right thoracotomy and
decortication due to development of staph aureus empyema and necrotic
hepatocellular tumor that spread to the right pleural space; a wedge
biopsy of the liver was done at that time.

CT OF ABDOMEN AND PELVIS DEMONSTRATING NECROTIC MASS

LIVER, TUMOR, RESECTION: RESIDUAL MODERATELY
DIFFERENTIATED HCC

CT OF THE ABDOMEN AND PELVIS DEMONSTRATING GENE
THERAPY AND SURGICAL CHANGES

MOST RECENT LAB RESULTS
7/21/15
• AST: 43 U/L
• ALT: 65 U/L
• Alpha Feto Protien: 4.6 ng/mL

MOST RECENT CT OF THE ABDOMEN AND PELVIS

CURRENT STATUS
• Currently on Phase I clinical trial under the care of Dr. Freilich, with a
good response.
• Liver and lung abscess have resolved.
• He has gained weight.
• Recent scans have shown stable to improving disease process.
• CMP and CBC are unremarkable with his platelet count 96,000.

KC HCC case study

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