Dr Al Hallak on the Associated Risks of Cirrhosis and Portal Hypertension in HCC

“Cirrhosis is a major problem [in HCC], and cirrhosis [often leads to] portal hypertension, esophageal varices, and bleeding. When I see a patient who has active esophageal varices [and] bleeding, despite [attempts at] banding, this is not a good patient to give bevacizumab. For those patients, I will go straight to a durvalumab and tremelimumab combination.”

Mohammed Najeeb Al Hallak, MD, MS, hematologist/oncologist, Karmanos Cancer Institute-Wayne State, discusses treatment considerations for hepatocellular carcinoma (HCC) patients with esophageal varices and bleeding, plus the associated risks of cirrhosis and portal hypertension.

Al Hallak explains that cirrhosis is a primary driver of portal hypertension, and it can lead to the development of esophageal varices, placing patients at risk for potentially life-threatening bleeding. This complication presents unique challenges in selecting systemic therapies for HCC, particularly in patients with active or high-risk esophageal varices.

For patients with active variceal bleeding or a history of bleeding despite repeated banding, bevacizumab (Avastin)-containing regimens, such as atezolizumab (Tecentriq) and bevacizumab, could increase the risk of bleeding due to the antiangiogenic properties of the regimen. Al Hallak emphasizes the importance of assessing varices via esophagogastroduodenoscopy (EGD) before initiating bevacizumab-based therapy. This pretreatment evaluation allows clinicians to determine the need for banding to reduce bleeding risk. However, the requirement for EGD may delay treatment initiation.

In patients with active bleeding or those unsuitable for bevacizumab therapy, durvalumab (Imfinzi) in combination with tremelimumab (Imjudo) is often the frontline therapy of choice, Al Hallak continues, adding that this combination does not carry an increased bleeding risk. He explains that the durvalumab plus tremelimumab treatment can be easier to manage because of the lack of bleeding risk. Whereas an EGD is necessary to assess bleeding risk in patients with HCC prior to the start of atezolizumab plus bevacizumab, Al Hallak says that this is not always required for patients ahead of treatment with durvalumab plus tremelimumab, allowing for patients to begin treatment sooner.

Al Hallak explains that this is his current approach for patients with HCC. However, each patient must be evaluated on a case-by-case basis to determine the optimal treatment approach, he concludes.