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Dr. He:
This is CME on ReachMD. I'm Dr. Ruth He from Georgetown University Hospital from Washington, DC. Let's start our discussion by looking at a case.

So, here I have a case of a 66-year-old male with a history of cryptogenic cirrhosis diagnosed in 2016. He was monitored with routine surveillance for hepatocellular carcinoma. A recent scan in November of last year showed a LIRAD5 lesion, bridging segment 7 and 8, you can see here on the CT scan, approximately 2.3 times 1.7 centimeter.

We also noticed thrombosis of the right portal vein, questionable tumor in vein. If you look at the laboratory finding, patient has elevated alpha fetoprotein of close to 3000. Patient has normal white cells, hemoglobin, hematocrit, however, his platelet count was low at 54,000. If you look at the liver function, patient actually has Child-Pugh A liver function, and patient has normal pressure. And on the scan, you also see enlarged liver and spleen. 

So, this patient, due to the tumor in vein, patient has no curative treatments because of the vascularization and that makes patient BCLC stage C disease. And, now we have four FDA-approved treatment options – bevacizumab/atezolizumab, durvalumab/tremelimumab, the STRIDE regimen, or two TKIs, lenvatinib and sorafenib.

And so, in this patient from the baseline work up, we also have noticed on the CT scan the beaded varices around the esophagus. This patient with portal hypertension, enlarged spleen, and low platelet counts, patient will need to have an EGD. And as you can see on this slide I provided; patient does have enlarged varices. And so, patient is at the risk of variceal bleeding, required variceal banding. For this kind of patient, we should stay away from anti-VEGF therapy. Patient was treated with tremelimumab/durvalumab with the STRIDE regimen, and patient had a great response to the treatment with tumor shrinkage and also, receding of the tumor in vein. And alpha fetoprotein has a deep decline from close to 3,000 to the single digits.

And, so, from this case, the teaching points are, in patients with cirrhosis, and you need to really assess the portal pressure, and understand sometimes you can see enlarged varices. And if patient has evidence of cirrhosis on scan, all those patients need to have an endoscopy. And the telltale sign is low platelet counts, enlarged spleen, and the varices on the scan.

Patients who get the endoscopy to evaluate the risk of varices and require treatment for those varices. In that case, we should stay away from anti-VEGF therapy and pick an IO/IO combination. And, fortunately, there are many treatment options these days for patients.

With that, my time is up. I hope this was a brief but hopefully useful case review. Thank you so much for listening. 

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