Hepatocellular carcinoma (HCC) is one of the most common and lethal malignant tumors in the world. Therapeutic options for advanced HCC are limited. Systemic treatment, especially with conventional cytotoxic drugs, is usually ineffective. For more than a decade, sorafenib has been the only systemic drug that has been proven to be clinically effective for treating advanced HCC. However, over the past three years, the rapid progress of molecular targeted therapies has dramatically changed the treatment landscape for advanced HCC. Immune checkpoint therapies are now being incorporated into HCC therapies, and their combination with molecular targeted therapy is emerging as a tool to enhance the immune response. In this review, we summarize the development and progress of molecular targeted agents and immunotherapies in HCC.

1. Case discussion
AAICC Panel
members
• Presenter
• Dr Mona Quenawy
• M.D
• Ain Shams University

2. GIT MDT
Case study discussions
Case Discussions Educational Activity

3. Fifty-four years old gentleman with
background
of type-II
diabetes
mellitus He is
known to
have HCV
related liver
cirrhosis.
HCV relapse
on both
Sof/Riba &
Sof/Dac/Riba
During
routine
follow up he
was
discovered to
have HCC
September
2019
Co :Rt side
abdominal
pain Family
history:
irrelevant
History of
medical
value type II
DM
History of
past illness

4. • Sep 2017

5. Clinical presentation
CT triphasic
Large right liver lobe HCC (10x7cm) with right anterior branch malignant-PVT
Alpha-fetoprotein (AFP): 4000ng/ml ,
Child score
Child-Paugh score:B8 ,
MELD criteria
MELD-10 BCLC stage-C and in performance ECOG 0.

6. • Transverse Triphasic CT images of an
HCC nodule in rt liver lobe with
enhancement in arterial phase and (b)
washout in portal venous phase.

7. Question to
the panel
Is there is a role for
surgery
The role of
interventional therapy
The role of systemic
treatment

8. • Primary Decision
• He was advised to undergo trans-arterial radio embolization (TARE),
which failed due presence of hepato-pulmonary shunts
• He was advised to start full dose Sorafenib 400mg twice daily with
follow up after three month.

9. January 2018
• Contrast enhanced CT
• Mild tumor progression had occurred
increase in lesion diameters (10x9.7cm)
• Alpha-fetoprotein (AFP):
• 8562 ng/ml

10. Contrast enhanced ct with Mild tumor
progression had occurred increase in
lesion diameters (10x9.7cm)
Progressive disease

11. Question to
the panel
Is there is a role for
surgery
The role of
interventional therapy
The role of systemic
treatment

12. Second line
treatment
• He was shifted to second line
Regorafenib 160mg daily for 21
days of 28-day cycle. With
scheduled follow up after 3
month

13. by April 2018
Triphasic CT
revealed Significant reduction of the previously
described Rt lobar HCC was measuring (3.0 x 3.6 cm).
• AFP: 52ng/ml

14. Tumor Response to
second line
• Ct showed Significant reduction of the
previously described Rt lobar measuring
(3.0 x 3.6 cm).

15. On treatment
Patient achieved stable
disease with No time
interval changes with
regarding the previously
described right lobar HCC
(2.7 x 3.5cm)

16. Patient was advised to undergo
locoregional therapy together with
(Regorafenib) AFP:45ng/ml.Patient
underwent RFA of HCC
•July 2018

17. Further
management
• Patient was advised to undergo locoregional
therapy together with (Regorafenib)
AFP:45ng/ml.
• Patient underwent RFA of HCC

18. September
2018

19. More tumor response
• Large right lobe ablation zone with heterogenous area of coagulative
necrosis.
• No pathological enhancement is seen in the vicinity of the lesion
throughout the study, mild ascites
• AFP:24ng/ml
•

20. Stable disease
• No time interval changes with
stationary course regarding the
previously described right lobar HCC
(2.7 x 3.5cm

21. • Contrast enhanced ct with Large right
lobe ablation zone with heterogenous
area of coagulative necrosis. No
pathological enhancement is seen in the
vicinity of the lesion throughout the study

22. September 2018

23. Drug toxicity
•
• Patient was advised to stop Regorafenib cause of GIII fatigue with frequent assessment every
three month

24. • April 2019

25. De novo
lesion
• De novo segment VII HCC (3*2cm)
in diameter AFP: 37ng/ml

27. • April 2019 Patient underwent TACE for the
new HFL.
• May 2019 During scheduled follow up, the
patient underwent several imaging studies
(CT chest, bone scan and MRI pelviabdomen)
and All imaging modalities showed ablated
HFL, with no extrahepatic lesions and AFP:
6ng/ml
• Neither systemic chemotherapy was given
to the patient, nor did he undergo further
locoregional therapy.

28. Liver transplantation
June 2019 He underwent Live donner liver transplantation
where he received right lobe graft of GRWR:1.4 The patient
had smooth both intra and post-operative course
.The patient was scheduled to regular follow up every 6
month
Last follow up 25 MAY 2021 MRI. MRI and alpha
fetoprotein were normal