Sorafenib-induced Acute on Chronic Liver Failure in a Patient with Hepatocellular Carcinoma After Microwave Ablation

Abstract

Hepatocellular carcinoma (HCC) is becoming a rapidly prevalent hepatic tumor throughout the world. Initially, liver transplantation and resection were the only available options. But there is a recent advent of new treatment modalities like ablative embolization techniques and chemotherapy. Guidelines are available regarding the use of these techniques according to the stage of the tumor. Sorafenib is a chemotherapeutic agent approved for the management of advanced HCC. It works by inhibiting different tyrosine kinases, which halt the progression of the tumor. The common side effects associated with it are diarrhea, hand-foot skin reaction, and alopecia. Acute on chronic liver failure (ACLF), defined as the development of acute liver failure, in the setting of chronic liver disease, is a rare adverse event associated with sorafenib. Here, we present a case of a 65-year-old male presented to Nishtar Hospital Multan, Pakistan, who developed advanced-stage HCC due to underlying liver cirrhosis. There was no metastasis or vascular involvement. After discussing the options, he selected microwave ablation (MWA). There was a recurrence of the tumor after the procedure so he was started on sorafenib. A week after the initiation of a low dose drug (200 mg twice daily), he developed signs and symptoms of ACLF, which included hyperbilirubinemia, prolonged prothrombin time (PT), and flapping tremors. He was admitted to the intensive care unit (ICU) and was successfully managed. He was discharged with a follow-up scheduled after two weeks. This is a unique and rare adverse event of sorafenib.

Keywords: acute on chronic liver failure; microwave ablation; sorafenib.

Figure 1. Triphasic CT abdomen

Showing one lesion in segment VIII (A) and another in segment VI (B) of the liver in successive plain (A1/B1), arterial (A2/B2), and venous (A3/B3) phases of the study. A hypodense lesion (A1) in segment VIII was consistent with previous successful microwave ablation. This lesion is neither showing arterial hyperenhancement (A2) nor any washout (A3). A new arterialized lesion (B2) is seen in segment VI of the liver, showing washout of contrast on the venous phase (B3). No evidence of thrombosis in the portal vein or extrahepatic metastasis seen. Gross ascites is also evident. CT: computed tomography