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Regression of Hepatocellular Carcinoma With Right Atrial Extension AfterSorafenib and Transarterial Chemoembolization

MADHU SUBRAMANIAN,* AMIT G. SINGAL,‡ and ADAM C. YOPP*‡

*Department of Surgery, Division of Surgical Oncology, and Department of Medicine, Division of Gastroenterology, University of Texas

Southwestern Medical Center, Dallas, Texas

A 57-year-old man with a past medical history of hepatitis Binfection presented for evaluation of a liver mass found

on surveillance abdominal ultrasound. On history and physicalexamination, he was a healthy-looking man with no pertinentsigns or symptoms of abdominal pain, ascites, hepatic enceph-alopathy, or lower-extremity swelling. Laboratory results in-cluded the following: alanine aminotransferase level, 60 U/L;total bilirubin level, 1.2 mg/dL; serum albumin level, 4.5 g/dL;prothrombin time, 11.1 s; and international normalized ratio,1.1. His �-fetoprotein level was 5 ng/mL. Magnetic resonanceimaging of the abdomen with gadolinium contrast showed a7.3-cm hypervascular mass with washout consistent with hep-atocellular carcinoma occupying segments 7 and 8 of the rightlobe of the liver with tumor thrombus invasion (Figure A,arrow) into the right hepatic vein, inferior vena cava, and rightatrium.

The patient underwent selective transarterial chemoemboliza-tion consisting of Lipiodol (Guerbet LLC, Bloomington, IN), cis-platin (100 mg), doxorubicin (50 mg), and mitomycin (10 mg),

with particle embolization (300 –500 �m embospheres) of the

C

arterial supply (Figure B, arrowhead) of the tumor (Figure B, longarrow) and the tumor thrombus (Figure B, short arrow). Post-procedure noncontrast computed tomography of the abdomenshowed uptake of Lipiodol within the parenchymal tumor(Figure C, long arrow) and tumor thrombus extending from theinferior vena cava into the right atrium (Figure C, short arrow).Periprocedurally, the patient was started on sorafenib therapy(400 mg orally twice a day) because of the concern for potentialsystemic spread. At 1 year after a single transarterial chemoem-bolization treatment, magnetic resonance imaging of the abdo-men showed not only a decrease in size of the parenchymal

Conflicts of interestThe authors disclose the following: Yopp and Singal are on the

speakers board for Bayer and Onyx pharmaceuticals. The remainingauthor discloses no conflicts.

© 2012 by the AGA Institute1542-3565/$36.00

http://dx.doi.org/10.1016/j.cgh.2012.06.031

LINICAL GASTROENTEROLOGY AND HEPATOLOGY 2012;10:e83–e84

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e84 IMAGE OF THE MONTH CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 10, No. 10

mass but also no evidence of hypervascularity either in theparenchymal mass (Figure D, arrow) or the inferior vena cava/ight atrial tumor thrombus (Figure E, arrow). The patient

remains asymptomatic at 1 year with no further evidence ofviable tumor, metastatic disease, propagation of tumor intopulmonary vasculature, or findings from chronic liver disease,and he remains on sorafenib.

Hepatocellular carcinoma, the fifth most common cancerworldwide, is the fastest growing cause of cancer-related deathsin the United States.1 Vascular invasion including malignanttumor thrombus in the portal vein or hepatic vein/inferior venacava occurs in 31% to 38% of patients at initial presentation.2

The prognosis for patients with vascular invasion is dismal,with the median overall survival generally less than 7 months.2

Traditionally seen as a harbinger for systemic spread, treatmentfor vascular invasion of the hepatic venous/inferior vena cava

system has relied on systemic chemotherapy with limited sur-

vival benefit. With the efficacy of sorafenib and transarterialchemoembolization in systemic and locoregional disease con-trol, a combined treatment approach offers potential new mo-dalities in treating patients with a dismal prognosis.3,4

References1. El-Serag HB, Mason AC. Rising incidence of hepatocellular carci-

noma in the United States. N Engl J Med 1999;340:745–750.2. Marrero JA, Fontana RJ, Barrat A, et al. Prognosis of hepatocellular

carcinoma: comparison of 7 staging systems in an American cohort.Hepatology 2005;41:707–716.

3. Llovet JM, Real MI, Montaña X, et al. Arterial embolisation or che-moembolisation versus symptomatic treatment in patients with un-resectable hepatocellular carcinoma: a randomised controlled trial.Lancet 2002;359:1734–1739.

4. Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hep-

atocellular carcinoma. N Engl J Med 2008;359:378–390.