Abstract
Introduction: HCC is the fifth most common malignant neoplasm in men and ninth most common in women worldwide. Although the incidence of HCC in the United States is rare, the incidence of this particular cancer is rising secondary to the increasing prevalence of hepatitis B, hepatitis C, alcohol abuse, and non-alcoholic steatohepatitis (NASH). In the setting of liver transplantation exclusion, surgical resection remains the gold standard for patients with resectable HCC. However, most patients with HCC present with unresectable tumors in the background of chronic liver disease. Furthermore, the underlying liver disease, such as cirrhosis, is a major confounding factor that contributes to its chemotherapy-resistant characteristic. In patients with unresectable HCC in the background of a normal liver, however, systemic chemotherapy has been shown to be somewhat effective, but its role in the neoadjuvant setting remains controversial. Additionally, transarterial chemoembolization (TACE) is an effective locoregional approach used to downsize tumors prior to surgical resection. Can the combination of systemic chemotherapy and TACE be utilized in the neoadjuvant setting to potentially preserve the surgical option for this patient population? We present a case study that details the unique role of systemic chemotherapy and TACE in down-staging patients with large and unresectable HCC in the background of a normal liver to resectability. Description: Case: 60-year-old gentleman with a solitary 17 cm left liver mass, encroaching the right liver with displacement of the main portal vein and involvement of the right hepatic vein, biopsy-proven HCC. He had no risk factors for HCC (negative for hepatitis B & C; nondrinker). The patient was deemed unresectable at that time and was dispositioned to systemic chemotherapy and TACE with the goal of down-sizing the tumor for surgical resection with good margins. Conclusion: In patients with initially unresectable and large HCC in the background of a normal liver, the role of systemic chemotherapy and TACE should be considered as a neoadjuvant treatment modality to convert the patient for surgical resection. Advanced practice providers play a vital role in the process of the treatment planning for each patient. We hope to provide an alternative and effective treatment plan for patients with HCC in the background of normal liver while preserving the surgical option to patients who were deemed initially unresectable.
