Patient Profile 1: A 77-Year-Old Man with Advanced HCC Treated With Lenvatinib

Focusing on the first patient profile of advanced hepatocellular carcinoma, Andrea Casadei-Gardini, MD, reviews his selection and use of first-line lenvatinib therapy.


Josep Llovet, MD: Let’s address some of these issues with a presentation of the first case. Andrea, do you want to go through it?

Andrea Casadei-Gardini, MD: Thank you. This is the case of a man, 77 years old, whose past medical history is controlled by Basedow disease, or Graves’ disease. The patient has diabetes mellitus type 2, ischemic cardiopathy, and paroxysmal atrial fibrillation in TAO. The patient presents with stage BCLC [Barcelona Clinic Liver Cancer] stage B. We treated the patient with TACE [transarterial chemoembolization] but did not get a response. After 2 TACEs, the patient presented with a large nodule of 5 cm in segment 6 and a further nodule of about 1.5 cm. The patient has no microvascular invasion or extrahepatic spread, in stage BCLC-B with very good liver function, Child-Pugh A5. The histology of cirrhosis on the patient…is performed after a biopsy of the normal liver. The patient presents not typical imaging of HCC [hepatocellular carcinoma] with wash-in or washout. For this reason, before the TACE, we decided to perform a biopsy that confirmed the diagnosis of hepatocellular carcinoma. We have a case of BCLC-B that we treated with TACE without response.

We started with lenvatinib 8 mg in January 2021. This is the good liver function before we start with the treatment. This is the baseline CT scan. We see the largest lesion, and there are small lesions in the liver. After the first cycle, the patient presents with asthenia grade 3 and anorexia grade 2. The patient had hypertension grade 3, but we managed it very well with cooperation of their cardiologist. We reduced the dose of lenvatinib after the first cycle, particularly for grade 3. This was important for our patient.

After 5 months of treatment with lenvatinib, we see a complete response when we read the CT scan with a modified register of the largest lesion. We don’t see the wash-in or washout in the large legion of the liver. The alpha-fetoprotein decreased from 40 to 7 ng/mL. The patient has a good liver function, [Child-Pugh] A5. After 13 months of treatment with Lenvima, we saw that the largest lesion was complete avascular. The alpha-fetoprotein is 5 ng/mL, and the liver function is very good, Child-Pugh A5. The size of the other nodules isn’t visible after 3 months of treatment with Lenvima.

This is the last CT scan, from August [2022]. [We have a] mixed response because we have a complete response in terms of modified … of the larger lesion, but the smaller region increased. For this reason, we had stable disease when we sent the patient with the RECIST criteria. But we saw a mix of response because the smaller lesion has increased. The alpha-fetoprotein is the same as the last CT scan, a 7 to 8 ng/mL. We continue lenvatinib with clinical benefit. We’re waiting for the next CT scan evaluation for the site to continue with Lenvima or to change from the second-line [therapy].

This is a summary of this case, which is not responsive to TACE. We start with lenvatinib, and we have a partial response after 5 months…. The largest lesion is in complete response, and the small lesion is in partial response. Finally, we have a mixed response after about 17 months of treatment with lenvatinib, with the problems of hypertension and anorexia. We decreased the treatment, and now the patient doesn’t have that particular toxicity.

Josep Llovet, MD: Thank you very much. I think it’s a very interesting case. I understand that the patient has no symptoms now.

Andrea Casadei-Gardini, MD: Yes.

Josep Llovet, MD: Good.

Transcript edited for clarity.

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