Transplant vs. Surgery for Early HCC Rajesh Ramanathan, MD Surgical - PowerPoint PPT Presentation

Transplant vs. Surgery for Early HCC Rajesh Ramanathan, MD Surgical Oncology ISIGO October 10 th , 2019

HPI • 56yo with NAFLD undergoing HCC surveillance with AFP elevation to 22. HBV and HCV negative. • CT scan with 1.3 cm hepatic dome hyperenhancing lesion without washout 1.3cm. LiRADS 3.

HPI F/u MRI with two LiRADS 4 lesions: 1.3 x 1.2cm Segment 8 & 1.4 x 1.2 Segment 4A/B

What would you do? a) PET/CT scan b) Biopsy one lesion c) Biopsy both lesions d) PET and Biopsy e) Neither

What treatment would you suggest? What treatment would you suggest? (AFP: 26.4, PLT: 137, INR: 1.2, TBILI: 0.8, ALB: 4.6) a) Transplant referral b) Resection c) Ablation d) TACE e) Y90 f) Something else

Tumor board recommendation Segment 4 lesion too deep to be resected. Ablation and Transplant evaluation recommended Patient not interested in transplantation due to lifelong immunosuppression Laparoscopic biopsy and ablation to both lesions performed (Bx: Moderately differentiated HCC)

Follow-up 5 months later MRI with area of arterial hyperenhancement in the posterior aspect of the Segment 4 ablation site AFP 38

What would you do next? Summary: Two lesions treated with two RFAs. Local recurrence at the segment 4 RFA site within 5 months. a) Liver resection b) Repeat ablation c) TACE d) Y90 e) Sorafenib

Tumor board recommendation Patient now open to transplantation TACE performed as a bridge to transplant

Transplant waitlist 14 months after diagnosis and 8 months after TACE: Three new LiRADS 4 lesions and progression of recurrence.

Transplant waitlist 2 months later, AFP 602 & continued increase in bilobar lesions Referred for Y90 and lenvatinib (REFLECT)

Summary 0 months: Diagnosed with HCC 2 months: RFA x2 7 months: Recurrence 9 months: TACE and transplant evaluation 12 months: Transplant approval and listing (no HCC exception) 14 months: Progression, not candidate Was this a missed opportunity for earlier transplant listing and approval?

Thank you Rajesh Ramanathan MD Surgical Oncology Banner MD Anderson Cancer Center Rajesh.Ramanathan@bannerhealth.com (217) 721 1495