Platelet count less than SHARP: what does a case series reveal?

Hepatocellular carcinoma (HCC) is increasing in numbers worldwide, and no effective systemic treatment existed for advanced HCC until SHARP (Sorafenib in HCC Assessment Randomized Protocol) study proved sorafenib (Nexavar((R)), Bayer Pharmaceuticals, Wayne, NJ, USA) prolonged survival versus placebo. Child-Pugh class A liver function and a platelet count of > or = 60,000/mm(3) were among the inclusion criteria for SHARP. No safety data in patients with < 60,000/mm(3) of platelets are present. Thrombocytopenia is one of the most frequent challenges faced in patients with chronic liver diseases. We report a series of three patients with HCC and platelet count < 60,000/mm(3) who were successfully treated with sorafenib with no complications. We describe the current data on sorafenib and challenges faced in patients with HCC. In addition, we emphasize the need for informed consent when facing factors that predispose to bleeding (esophageal varices, coagulopathy and thrombocytopenia), possible band ligation before the start of sorafenib, careful clinical monitoring and discontinuation of sorafenib when major bleeding occurs.