Background: Liver cancer is the sixth most common cancer worldwide, and hepatocellular cancer makes up ~90% of them. It is the fourth leading cause of global cancer mortality. Majority of cases (~80%) are caused by chronic hepatitis B & C virus infections. Most patients in sub-Saharan Africa present with advanced and unresectable disease at diagnosis only amenable to systemic therapy. The first-line systemic therapy has been with sorafenib since 2007 or lenvatinib since 2018. Immunotherapy with atezolizumab and bevacizumab has been approved as the first-line therapy in 2020 and adopted by several regional guidelines.
Aim: We present a Nigerian male with advanced hepatocellular carcinoma secondary to chronic hepatitis B infection in BCLC stage C managed with immunotherapy.
Case Report: A 47-year-old man with chronic HBV who presented in August 2020 with advanced HCC, Barcelona Clinic Liver Cancer (BCLC) stage C, Eastern Cooperative Oncology Group/World Health Organization (ECOG/WHO) performance status 1 was diagnosed in January 2020. He could not tolerate the adverse effects of sorafenib. He was evaluated including endoscopy to rule out varices and commenced on atezolizumab/bevacizumab 1200 mg/1200 mg in March 2021, which was administered every 3–6 weeks depending on the availability. The drugs were well tolerated by him with only difficulty controlling blood pressure as the notable adverse event. He had 11 courses of atezolizumab and bevacizumab before he began to deteriorate with marked weight loss, tumor progression, diarrhea, and weakness. After the 12th course, he developed jaundice, anorexia, generalized body pains, marked elevation of the liver enzymes, and bilirubin. He was commenced on steroids but he died June 2022.
Discussion: Atezolizumab and bevacizumab compared with sorafenib in the management of advanced and unresectable HCC (IMbrave 150) revealed a median progression free survival of 6.9 months vs. 4.3 months and a median overall survival of 19.2 vs. 13.4 months, respectively. Our patient lived for 15 months from the commencement of immunotherapy, and computed tomographic (CT) scan done after 11 months showed slowed progression. Median time to deterioration in physical functioning from the IMbrave 150 study was 13.1 vs. 4.9 months, respectively, whereas our patient was able to function effectively for 12 months before he deteriorated.
Conclusion: Compared with sorafenib, immunotherapy with atezolizumab and bevacizumab has a better overall and progression free survival for advanced and unresectable hepatocellular carcinoma (HCC) as demonstrated by our patient and was also better tolerated by our patient. Unfortunately, the high cost of these medications makes it largely unaffordable by a majority of our patients although the benefits are enormous.
Keywords: Chronic hepatitis B virus infection, hepatocellular carcinoma, immunotherapy
