Management of Unresectable HCC and Monitoring of Liver Function

Patients with unresectable hepatocellular carcinoma (HCC) face a unique clinical challenge, as they typically present with 2 concurrent life-threatening conditions: the cancer itself and underlying cirrhosis that caused the malignancy. Mark Yarchoan, MD, from Johns Hopkins, explains that while recent clinical trials have introduced numerous immunotherapy-based treatment options, most studies enrolled patients with preserved liver function (Child-Pugh A classification) and good performance status. However, in real-world clinical practice, many patients fall outside these criteria, presenting with Child-Pugh B liver function or compromised performance status, making treatment decisions more complex and requiring careful individualization of care.

Monitoring liver function in patients with HCC requires a nuanced approach beyond simple classification scores. While the Child-Pugh score remains widely used, Yarchoan emphasizes its limitations, noting that 2 patients with identical Child-Pugh B7 scores can be vastly different—one may have severe cirrhosis with ascites and encephalopathy, while another may have preserved liver function with symptoms primarily driven by tumor burden. The ALBI (albumin-bilirubin) score offers a more objective assessment, though clinicians must ultimately determine whether the cancer or the underlying liver disease represents the primary life-limiting problem. Patients presenting with encephalopathy or ascites typically have worse outcomes regardless of their overall score.

Treatment decisions for patients with impaired liver function require careful consideration of risks and benefits. Both physicians agree that patients with Child-Pugh A classification are excellent candidates for systemic therapy, while those with Child-Pugh C typically do not benefit from treatment. The Child-Pugh B population presents the greatest challenge due to its heterogeneity, though emerging retrospective data and limited prospective trials suggest potential benefits from immunotherapy-based regimens. Most patients with Child-Pugh B liver function and reasonable performance status, when counseled about treatment options, choose to proceed with anticancer therapy, highlighting the importance of multidisciplinary care involving both oncology and hepatology specialists.