HCC Second-Line Therapy — RACP Adult Medicine MCQ

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ModerateMedical OncologyHCC Second-Line TherapyRACP Adult Medicine

A 55-year-old man with advanced hepatocellular carcinoma (BCLC stage C) on first-line atezolizumab + bevacizumab progresses after 8 months. He has Child-Pugh A liver function and good performance status. What is the recommended second-line systemic therapy?

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Correct answer: E — Any TKI (sorafenib, lenvatinib, cabozantinib, or regorafenib)

After progression on first-line atezolizumab + bevacizumab for advanced HCC, second-line options include multikinase inhibitors: sorafenib, lenvatinib, cabozantinib, or regorafenib. The choice depends on prior exposure, side effect profile, and local PBS listing. Cabozantinib (CELESTIAL trial) and regorafenib (RESORCE trial) have evidence specifically in the second-line setting after sorafenib, but data after ICI+bevacizumab progression are extrapolated. Ramucirumab (anti-VEGFR2) is another option for patients with AFP ≥400 µg/L (REACH-2 trial). There is no strong evidence favouring one TKI over another in this setting.

Reference: Cancer Council Australia – 2020 – HCC Guidelines; AASLD – 2023 – HCC