kc hcc case study

CONFIDENTIAL AND PROPRIETARY © 2014 Sarah Cannon. 1

HCC: A CASE STUDY

BRADLEY FREILICH, MDJASWINDER SINGH, MDGERARDO VERGARA, MDDEION DEPAOLIS, MDDAVID 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• Total Bili: 1.1 mg/dL

• 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 GENETHERAPY AND SURGICAL CHANGES


MOST RECENT LAB RESULTS

7/21/15• Total Bili: 0.8 mg/dL

• 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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