What is the recommended treatment approach for a patient with hepatocellular carcinoma (HCC) who has a positive Computed Tomography (CT) dynamic scan but a negative Alpha-Fetoprotein (AFP) dynamic scan?

From the Guidelines

For a patient with hepatocellular carcinoma (HCC) confirmed by positive CT dynamic scan but with negative AFP, treatment should be based on tumor stage, liver function, and overall health status, following the Barcelona Clinic Liver Cancer (BCLC) staging system. The recommended approach typically includes curative treatments such as surgical resection, liver transplantation, or local ablation (radiofrequency ablation or microwave ablation) for early-stage HCC, transarterial chemoembolization (TACE) for intermediate-stage disease, and systemic therapy with sorafenib or lenvatinib for advanced HCC 1. It's essential to note that AFP negativity is not uncommon in HCC and does not alter the treatment algorithm significantly. Treatment decisions should be made by a multidisciplinary team considering liver function (Child-Pugh score), performance status, and comorbidities. Regular monitoring with imaging every 3-6 months is crucial to assess treatment response and detect recurrence early 1.

Some key points to consider in the treatment approach include:

• The BCLC staging system provides a framework for treatment decisions based on tumor stage and liver function 1.
• For early-stage HCC, curative treatments offer a potential cure, while for intermediate and advanced stages, treatments aim to control the disease and improve survival 1.
• Systemic therapies like sorafenib and lenvatinib have shown benefits in advanced HCC, and immunotherapy options are emerging as potential treatments 1.
• Regular follow-up with imaging is vital for monitoring treatment response and detecting recurrence, with recommendations for frequency and modality of imaging varying based on the patient's stage and treatment history 1.

Given the complexity of HCC treatment and the importance of individualized care, a multidisciplinary team approach is recommended to ensure the best possible outcomes for patients with HCC, regardless of AFP status.

From the FDA Drug Label

1.3 Hepatocellular Carcinoma LENVIMA is indicated for the first-line treatment of patients with unresectable hepatocellular carcinoma (HCC). 2.5 Recommended Dosage for Hepatocellular Carcinoma (HCC) The recommended dosage of LENVIMA is based on actual body weight: 12 mg for patients greater than or equal to 60 kg or 8 mg for patients less than 60 kg. Take LENVIMA orally once daily until disease progression or until unacceptable toxicity.

The recommended treatment approach for a patient with hepatocellular carcinoma (HCC) who has a positive Computed Tomography (CT) dynamic scan but a negative Alpha-Fetoprotein (AFP) dynamic scan is to use lenvatinib (PO) as a first-line treatment. The dosage is based on the patient's actual body weight:

• 12 mg for patients greater than or equal to 60 kg
• 8 mg for patients less than 60 kg. Take lenvatinib (PO) orally once daily until disease progression or until unacceptable toxicity 2.

From the Research

Diagnosis and Treatment of HCC

• The diagnosis of hepatocellular carcinoma (HCC) can be challenging, especially in cases where Alpha-Fetoprotein (AFP) levels are not elevated 3, 4.
• A study found that using AFP with a cut-off of 20 ng/mL, about 40% of HCC occurrences would be missed, and with ultrasound (US) alone, more than a quarter would be missed 5.
• The combination of AFP and US showed the highest sensitivity, with less than 5% of HCC occurrences being missed, and about 15% of false-positive results 5.
• For patients with AFP-negative HCC, new blood biomarkers are being researched to improve diagnosis and treatment outcomes 3, 4.

Treatment Approaches

• Sorafenib combined with transcatheter arterial chemoembolization (TACE) has shown some clinical benefits in the treatment of advanced HCC, but its efficacy and safety are still controversial 6.
• A meta-analysis found that sorafenib combined with TACE increased the objective response rate, disease control rate, and reduced the expression level of AFP and vascular endothelial growth factor (VEGF) in serum, but did not prolong overall survival 6.
• The optimal threshold for AFP in diagnosing HCC is still debated, with some studies suggesting a threshold of 400 ng/mL may be more accurate than 200 ng/mL or 20-100 ng/mL 7.

Recommendations

• For a patient with HCC who has a positive Computed Tomography (CT) dynamic scan but a negative AFP dynamic scan, a combination of imaging tests and biomarkers may be necessary for accurate diagnosis and treatment planning 5, 3, 4.
• Further research is needed to determine the most effective treatment approaches for AFP-negative HCC, including the use of new biomarkers and combination therapies 3, 6, 4.