Would you rechallenge with cabozantinib in a patient with HCC after the development of a 6 mm gastrohepatic fistula without perforation or communication with the peritoneal cavity?

This is a tough situation. Based on the package insert for Cabozantinib, it can cause GI fistula and perforation in about 1% of patients and any grade 4 should prompt discontinuation of the drug label. The current gastrohepatic fistula without perforation could lead to recurrent abscesses in the liver and if this is the case, I would not rechallenge with Cabozantinib. If the gastrohepatic fistula has been present for quite some time, causes no issues, and there is no other alternative treatment left for HCC, one could consider rechallenge with very close monitoring.