What is the management for HCC (Hepatocellular Carcinoma) with a large tumor, CPT (Child-Pugh Turcotte) A, PS (Performance Status) 1, and portal vein thrombus?

Management of HCC with Large Tumor, CPT A, PS 1, and Portal Vein Thrombus

For HCC with a large 11 cm tumor, Child-Pugh A, PS 1, and portal vein thrombus, the recommended first-line treatment is systemic therapy with atezolizumab plus bevacizumab or durvalumab plus tremelimumab. 1

Disease Classification and Staging

• This case represents advanced stage HCC (BCLC Stage C) due to the presence of portal vein thrombosis (PVT), despite preserved liver function (Child-Pugh A) and good performance status (PS 1) 1
• Portal vein tumor thrombosis (PVTT) is present in 10-40% of HCC at the time of diagnosis and is an adverse prognostic factor 2
• The extension of PVTT directly affects patient prognosis regardless of treatment approach 1

Systemic Therapy Options

First-line Treatment

• Atezolizumab plus bevacizumab is the recommended first-line systemic therapy for patients with advanced HCC with Child-Pugh A and good performance status (ECOG 0-1) 1
• Durvalumab plus tremelimumab is an alternative first-line combination therapy with similar indications 1
• If these combination therapies cannot be applied, sorafenib or lenvatinib can be considered as alternative first-line options 1, 3

Considerations for Systemic Therapy

• Sorafenib has shown efficacy in prolonging time to progression and survival in advanced HCC 1
• Lenvatinib has demonstrated non-inferiority to sorafenib for overall survival in previously untreated unresectable HCC 3
• The presence of portal vein invasion was a stratification factor in clinical trials evaluating systemic therapies 3

Alternative Treatment Approaches

Transarterial Chemoembolization (TACE)

• In cases of HCC with portal vein invasion, conventional TACE alone can be considered for patients with intrahepatic localized tumors and well-preserved liver function 1
• TACE combined with external beam radiation therapy (EBRT) may be more effective than TACE alone for patients with portal vein invasion 1
• However, TACE has shown a high incidence of complications in patients with PVT and should be used selectively 2

External Beam Radiation Therapy (EBRT)

• EBRT can be performed for the treatment of HCC with portal vein invasion 1
• EBRT can be combined with systemic therapy for HCC treatment 1
• Radiation therapy to PVTT followed by other treatments has shown promising results in some studies 4

Surgical Options

• Liver resection (LR) can only be considered for PV1/2 extension of HCC (segmentary or secondary order branch involvement), and only then as an option to be tested within research settings 1
• LR is not considered standard practice for patients with main portal vein involvement 1
• Despite some promising results in highly selected patients, no prospective comparison of LR vs. systemic treatments has been reported for HCC with PVTT 1

Treatment Algorithm Based on PVTT Extent

1. Assess the extent of portal vein invasion:

   • PV1 (segmentary), PV2 (secondary order branch), PV3 (first-order branch), or PV4 (main trunk/contralateral branch) 1

2. For PV1/PV2 (limited involvement):

   • Consider systemic therapy as first-line treatment 1
   • TACE combined with EBRT may be considered in selected cases 1
   • Surgical resection may be considered only in research settings for highly selected patients 1

3. For PV3/PV4 (extensive involvement):

   • Systemic therapy is the recommended approach 1, 2
   • Consider atezolizumab plus bevacizumab or durvalumab plus tremelimumab as first-line options 1
   • Sorafenib or lenvatinib if combination immunotherapy is contraindicated 1, 3

Prognosis and Monitoring

• The prognosis of HCC with PVTT is generally poor if left untreated, with a median survival time of 2.7-4.0 months 5
• With appropriate systemic therapy, survival can be extended significantly 1, 3
• Regular monitoring of treatment response using modified RECIST criteria for HCC is recommended 3

Important Considerations and Pitfalls

• Avoid using TACE as monotherapy in patients with main portal vein involvement due to risk of liver decompensation 2
• Carefully assess liver function before initiating any treatment, as Child-Pugh classification is an independent prognostic factor for patients with HCC and PVTT 6
• Treatment may not improve survival in Child-Pugh C patients, highlighting the importance of accurate liver function assessment 6
• Multidisciplinary tumor board discussion is essential for optimal management decisions in these complex cases 1