From the Guidelines
The management of malignant ascites from hepatocellular carcinoma (HCC) primarily involves palliative treatments, with a focus on symptom relief and improving quality of life, as outlined in the ESMO-ESDO clinical practice guidelines for diagnosis, treatment, and follow-up of HCC 1.
Management Options
The primary goal in managing malignant ascites from HCC is to alleviate symptoms and improve the patient's quality of life. The options include:
- Large volume paracentesis for immediate relief of tense, symptomatic ascites
- Diuretic therapy, although its efficacy may be limited in malignant ascites
- Targeted oncologic treatments, such as sorafenib, which is the standard systemic therapy for patients with advanced HCC and well-preserved liver function (BCLC stage C) 1
- Palliative measures, including best supportive care for patients with end-stage disease or those who have progressed or are intolerant to sorafenib 1
Palliative Treatments
Palliative treatments play a crucial role in the management of malignant ascites from HCC. According to the guidelines, sorafenib is recommended as the standard systemic therapy for patients with advanced HCC and well-preserved liver function (BCLC stage C) 1. Other palliative treatments, such as external beam radiotherapy, can be used to control pain in patients with bone metastases 1.
Symptomatic Treatment
For patients with end-stage disease and heavily impaired liver function or a poor performance status, only symptomatic treatment is advocated 1. This approach prioritizes the patient's comfort and quality of life, focusing on managing symptoms rather than attempting curative treatments.
Role of Other Therapies
Other therapies, such as TACE (transarterial chemoembolization) and radioembolization, may be considered in specific subsets of patients, but their role in managing malignant ascites from HCC is less clear and should be decided on a case-by-case basis, considering the patient's overall condition and the extent of their disease 1.
From the FDA Drug Label
The clinical efficacy and safety of STIVARGA were evaluated in an international, multicenter, randomized (2:1), double-blind, placebo-controlled trial [Study “REgorafenib after SORafenib in patients with hepatoCEllular carcinoma” (RESORCE); NCT 01774344] The study enrolled adults with Child-Pugh A and Barcelona Clinic Liver Cancer Stage Category B or C hepatocellular carcinoma, with documented disease progression following sorafenib.
The management options for malignant ascites from hepatocellular carcinoma (HCC) are not directly addressed in the provided drug label. Key points:
- The label discusses the efficacy and safety of regorafenib (STIVARGA) in patients with HCC who have progressed on sorafenib.
- It does not provide information on the management of malignant ascites specifically.
- The study results show improved overall survival and progression-free survival with regorafenib compared to placebo in patients with HCC, but do not address ascites management 2.
From the Research
Management Options for Malignant Ascites from Hepatocellular Carcinoma (HCC)
The management of malignant ascites from HCC involves a multidisciplinary approach, including medical, interventional, and surgical options.
- Medical Management:
- Interventional Management:
- Paracentesis, or the removal of fluid from the abdomen, can provide symptomatic relief for patients with malignant ascites 6.
- Transjugular intrahepatic portosystemic shunt (TIPS) placement can also be used to manage refractory ascites, but its use in malignant ascites is limited by the risk of hepatic encephalopathy and other complications.
- Surgical Management:
- Liver transplantation is a potentially curative option for patients with HCC and malignant ascites, but it is limited by the availability of donor organs and the risk of recurrence 3, 7.
- Surgical shunting procedures, such as peritoneovenous shunting, can also be used to manage malignant ascites, but their use is limited by the risk of complications and the potential for tumor dissemination.
Sorafenib in the Management of Malignant Ascites from HCC
Sorafenib has been shown to improve overall survival in patients with advanced HCC, including those with malignant ascites.
- Efficacy: Sorafenib has been shown to improve overall survival and delay radiologic progression in patients with advanced HCC 4, 5.
- Safety: Sorafenib is generally well-tolerated, but it can cause adverse events such as diarrhea, fatigue, and hand-foot skin reaction 6, 5.
- Combination Therapy: The combination of sorafenib with other agents, such as mTOR inhibitors, may improve outcomes in patients with HCC and malignant ascites 7.