A Farmer With Pruritus and a Strange Suntan

Eric Fox, DO; Neal T. Patel; Anand D. Patel, MD


September 07, 2023

No evidence of distant metastatic disease was found in this patient. A multidisciplinary team that included surgeons, interventional radiologists, and oncologists discussed his treatment plan. Options for patients with HCC include transplant, surgery, local ablative therapies, and systemic therapies. Curative strategies include transplant, surgery, and sometimes locoregional therapies. These procedures, to varying degrees, require adequate reserve liver function, good performance status, and limited involvement of the liver parenchyma. Criteria have been established for making this determination[4]; however, consultation with a procedural specialist is recommended.

In this case, the patient had an increased bilirubin level and thus an elevated Model for End-stage Liver Disease (MELD) score. An additional concern was the vascular involvement of the tumor, which precluded initial treatment with locally ablative therapy. This left systemic therapy as the primary option for this patient. The options for systemic therapy included combination immunotherapy and biologic therapy, chemotherapy, and either a tyrosine kinase inhibitor (TKI) or immunotherapy alone. The immunotherapy and biologic therapy combination of atezolizumab and bevacizumab, which was approved for use in unresectable HCC, has become a first-line option and a category 1 recommendation based on the National Comprehensive Cancer Network guidelines in patients with an A classification on the Child-Pugh liver function scale.[5]

This patient had a B classification on the Child-Pugh liver function scale. Thus, systemic therapy with the TKI sorafenib was initiated. After 6 months of oral TKI therapy, the patient has stable disease and is being evaluated for a liver transplant from a related donor. He has achieved a goal ferritin level < 100 ng/mL by means of phlebotomy for his hemochromatosis.


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