What is the life expectancy for a patient with multifocal hepatocellular carcinoma (HCC) secondary to cirrhosis, multiple Liver (LR) 5 lesions, significantly elevated Alpha-Fetoprotein (AFP) levels, and an Eastern Cooperative Oncology Group (ECOG) status of 1?

Prognosis for Multifocal HCC with Elevated AFP and ECOG 1

This patient has advanced-stage hepatocellular carcinoma (BCLC Stage C) with an expected median survival of approximately 6-10 months without systemic therapy, or 9.5-10.7 months with sorafenib-based treatment. 1

Prognostic Classification

This patient falls into BCLC Stage C (Advanced HCC) based on:

• Multifocal disease (multiple LR5 lesions indicating definite HCC) 1
• Markedly elevated AFP of 11,000 ng/mL (>400 ng/mL threshold) 1
• ECOG performance status of 1 (symptomatic but ambulatory) 1

The extremely elevated AFP level (11,000 ng/mL) is an independent poor prognostic factor associated with increased risk of tumor recurrence, poor response to therapies, and decreased survival. 1

Expected Survival Without Treatment

Untreated patients with advanced HCC (BCLC Stage C) have a median survival of 6 months, with only 25% surviving to 1 year. 1

The prognosis varies by liver function:

• Child-Pugh A: median survival 7 months 1
• Child-Pugh B: median survival 5 months 1

Expected Survival With Systemic Therapy

First-line systemic therapy with sorafenib or lenvatinib extends median survival to approximately 9.5-10.7 months in BCLC Stage C patients. 1

Specific outcomes from pivotal trials:

• Sorafenib: median overall survival 9.5 months in BCLC C patients 1
• Lenvatinib: median overall survival 13.6 months (non-inferior to sorafenib) 2

Second-line therapy with regorafenib (after sorafenib progression) provides median survival of 10.6 months versus 7.8 months with placebo in patients who tolerated sorafenib. 3

Critical Prognostic Factors in This Case

The following features independently predict poor outcome:

• AFP >400 ng/mL: This patient's AFP of 11,000 is far above the threshold associated with poor prognosis 1
• Multifocal disease: Multiple tumor nodules indicate advanced disease burden 1
• ECOG 1: Cancer-related symptoms reflect tumor burden 1

Patients with AFP ≥400 ng/mL specifically have worse outcomes across all treatment modalities, including increased risk of drop-out from transplant waiting lists, poor response to loco-regional therapies, and reduced survival with systemic therapy. 1

Treatment Eligibility

This patient is a candidate for systemic therapy (sorafenib or lenvatinib) if liver function is Child-Pugh A and ECOG remains 0-1. 1, 2

Key eligibility criteria:

• Child-Pugh A liver function is mandatory for systemic therapy 1, 3, 2
• ECOG 0-1 required (this patient qualifies) 1, 3, 2
• No contraindications: absence of refractory ascites, spontaneous bacterial peritonitis, recurrent encephalopathy 1

If liver function deteriorates to Child-Pugh B/C or ECOG declines to 3-4, the patient transitions to terminal stage (BCLC D) with median survival of 3-4 months and only 11% one-year survival, warranting best supportive care only. 1

Common Pitfalls

Do not misclassify this patient as intermediate stage (BCLC B) simply because of multifocal disease—the ECOG 1 status and extremely elevated AFP indicate advanced disease. 1

Avoid offering loco-regional therapies (TACE) as primary treatment—these are contraindicated in symptomatic patients (ECOG 1) and provide no survival benefit compared to systemic therapy in advanced stage. 1

Patients with temporary events indicating end-stage liver disease (renal failure, spontaneous bacterial peritonitis, hyponatremia, recurrent encephalopathy) should be classified as terminal stage (BCLC D) even if Child-Pugh score appears acceptable. 1