Can pancreatic enzymes be used in patients with hepatocellular carcinoma (HCC)?

Pancreatic Enzyme Supplementation in Hepatocellular Carcinoma

Pancreatic enzyme supplementation should be considered for HCC patients who develop malabsorption symptoms during systemic therapy with sorafenib, as it can effectively manage this adverse effect and improve quality of life. 1

Pancreatic Insufficiency in HCC Patients

• Pancreatic atrophy and insufficiency have been documented as adverse effects in HCC patients receiving sorafenib treatment, with studies showing up to 25% reduction in pancreatic volume 2
• Approximately 10% of HCC patients treated with sorafenib develop malabsorption symptoms related to pancreatic insufficiency 1
• Signs of malabsorption include decreased stool consistency lasting >4 weeks or ≥10% body weight loss without HCC progression 1
• Pancreatic volume loss can be detected as early as 3 months after initiating sorafenib treatment 2

Diagnostic Approach for Pancreatic Insufficiency in HCC

• Clinical suspicion should be raised when patients on systemic therapy (particularly sorafenib) develop:
  • Persistent diarrhea
  • Unexplained weight loss
  • Steatorrhea
  • Nutritional deficiencies 1
• Laboratory evaluation may reveal vitamin D deficiency with secondary hyperparathyroidism 1
• Imaging studies (CT or MRI) can demonstrate gradual decrease in pancreatic volume 2

Management Recommendations

• For HCC patients with symptoms of malabsorption during sorafenib treatment, pancreatic enzyme supplementation should be initiated 1
• Complete symptomatic recovery has been documented in patients receiving pancreatic enzyme supplementation 1
• Pancreatic enzyme supplementation can stabilize pancreatic volume and prevent further atrophy 1
• Recognizing and treating this adverse event can improve medication tolerability and potentially allow patients to continue necessary systemic therapy 1

Treatment Considerations Based on HCC Stage

• For early-stage HCC (BCLC 0/A), curative treatments like resection, transplantation, or ablation remain the standard of care 3
• For intermediate-stage HCC (BCLC B), transarterial chemoembolization (TACE) is the recommended treatment 3
• For advanced HCC (BCLC C), systemic therapy is indicated:
  • Atezolizumab plus bevacizumab is now the first-line standard of care for patients with preserved liver function 3
  • Sorafenib remains an alternative first-line option for patients with contraindications to immunotherapy 3

Monitoring and Follow-up

• Patients receiving pancreatic enzyme supplementation should be monitored for:
  • Resolution of malabsorption symptoms
  • Weight stabilization
  • Improvement in nutritional parameters 1
• Regular imaging (CT or MRI) can be used to assess pancreatic volume changes 2
• Continued monitoring of liver function and tumor response should follow standard guidelines for HCC management 3

Clinical Pitfalls and Caveats

• Malabsorption symptoms may be incorrectly attributed to disease progression rather than treatment-related pancreatic insufficiency 1
• Pancreatic enzyme deficiency may contribute to reduced quality of life and treatment discontinuation if not properly recognized and managed 1
• This adverse effect may occur with other tyrosine kinase inhibitors used in HCC treatment, not just sorafenib 1
• Pancreatic enzyme supplementation should be considered as supportive care alongside primary HCC treatment strategies 1