What is the latest treatment for a Filipino elderly patient with liver cirrhosis and hepatocellular carcinoma (HCC) presenting with elevated Alpha-Fetoprotein (AFP) and Carcinoembryonic Antigen (CEA) levels?

Latest Treatment for Liver Cirrhosis and Hepatocellular Cancer in Filipino Elderly with High AFP and CEA

Atezolizumab plus bevacizumab is the first-line treatment of choice for advanced hepatocellular carcinoma (HCC) in elderly Filipino patients with preserved liver function (Child-Pugh A), elevated AFP and CEA levels. 1

Assessment and Staging

• Initial evaluation should include thorough assessment of liver function with complete blood count, liver function tests (AST/ALT, ALP, GGT, bilirubin, albumin), and coagulation profile 1
• Imaging studies should include dynamic CT or MRI of the abdomen and chest X-ray or CT scan to assess tumor extent and potential metastases 1
• Staging should follow the Barcelona Clinic Liver Cancer (BCLC) classification system, which provides important prognostic information 1
• Alpha-fetoprotein (AFP) levels >400 ng/ml have prognostic significance and can help guide treatment decisions, particularly for second-line therapy options 1

Treatment Algorithm Based on Disease Stage

Early Stage HCC (BCLC 0-A)

• For resectable tumors in patients with preserved liver function:
  • Surgical resection is the first-line option for patients with localized tumors and well-preserved liver function (Child-Pugh A) 1
  • Liver transplantation should be considered for patients meeting Milan criteria (single tumor ≤5 cm or up to 3 tumors ≤3 cm) 1

Intermediate Stage HCC (BCLC B)

• Transarterial chemoembolization (TACE) is recommended for patients with multinodular asymptomatic tumors without macroscopic vascular invasion or extrahepatic spread 1
• TACE with selective administration of doxorubicin-eluting beads is recommended to minimize systemic side effects 1

Advanced Stage HCC (BCLC C)

1. First-line therapy:

   • Atezolizumab plus bevacizumab is the preferred first-line treatment for patients with advanced HCC, Child-Pugh A liver function, and ECOG PS 0-1 1
   • For patients with contraindications to atezolizumab/bevacizumab, sorafenib or lenvatinib may be offered 1

2. Second-line therapy (after progression on sorafenib):

   • For patients with AFP >400 ng/ml: Ramucirumab is recommended 1
   • For all patients regardless of AFP: Pembrolizumab may be considered 1

Terminal Stage HCC (BCLC D)

• For patients with end-stage disease with heavily impaired liver function or poor performance status, only symptomatic treatment is advocated 1

Special Considerations for Filipino Elderly Patients

• Age alone should not be a contraindication for systemic therapy, as studies have shown comparable efficacy of sorafenib in elderly and younger patients 2, 3
• However, elderly patients ≥80 years are at higher risk of severe adverse events with sorafenib (OR: 13.3) 4
• More vigilant monitoring is warranted in elderly patients as they are more susceptible to neutropenia, malaise, and mucositis 3
• Consider starting with reduced doses of systemic therapies in very elderly patients (≥80 years) with poor performance status 4

Management of Adverse Events

• Hand-foot skin reaction and rash are common adverse reactions with sorafenib that typically appear during the first six weeks of treatment 5
• Management may include topical therapies, temporary treatment interruption, dose reduction, or in severe cases, permanent discontinuation 5
• Monitor blood pressure weekly during the first 6 weeks of sorafenib treatment and treat hypertension according to standard medical practice 5
• For patients on sorafenib who take warfarin, monitor prothrombin time, INR, and clinical bleeding episodes regularly 5

Response Evaluation and Follow-up

• Response assessment should be based on dynamic CT or MRI studies using modified RECIST criteria that consider the viable tumor component 1
• AFP levels may be helpful for monitoring response, particularly in cases of not easily measurable disease 1
• Follow-up of patients who underwent radical treatments should consist of clinical evaluation and dynamic CT or MRI studies every 3 months for the first 2 years, then every 6 months thereafter 1
• Patients treated with TACE or systemic agents should be evaluated clinically for signs of liver decompensation and by imaging for tumor progression every 2 months 1

Potential Pitfalls and Caveats

• Sorafenib can cause tumor lysis syndrome in patients with large tumor burden, requiring close monitoring of electrolytes and renal function 6
• Patients with Child-Pugh B liver function may have similar rates of adverse events but shorter overall survival compared to Child-Pugh A patients when treated with tyrosine kinase inhibitors 1
• Combination of sorafenib with hepatic arterial infusion chemotherapy may benefit specific patient populations, particularly those with Child-Pugh B score and AFP <400 ng/ml 7
• Withhold sorafenib for at least 10 days prior to elective surgery due to potential adverse effects on wound healing 5