A 64-year-old man is evaluated for hepatitis C virus–related cirrhosis with decompensation, including previous variceal hemorrhage, and ascites. His medications are furosemide, spironolactone, and nadolol.
On physical examination, vital signs are normal; BMI is 25. Spider angiomata are seen over the chest, and palmar erythema is noted. The abdomen is distended with flank dullness to percussion. The left liver lobe is palpable 5 cm below the xiphoid process. The spleen is palpable. Bilateral lower-extremity edema is noted. The remainder of the examination is normal.
A screening ultrasound examination shows a 3-cm mass with poorly defined margins and coarse, irregular internal echoes in the right hepatic lobe. A CT scan of the abdomen with contrast shows a 3-cm arterial enhancing lesion with portal venous phase washout in the periphery of the right lobe. The chest is normal on CT.
Which of the following is the most appropriate next step in management?
A. Biopsy of the lesion
B. Liver transplantation
D. Surgical resection
MKSAP Answer and Critique
The correct answer is B. Liver transplantation. This content is available to MKSAP 18 subscribers as Question 69 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
Referral for liver transplantation is the most appropriate next step in management for this patient. A diagnosis of hepatocellular carcinoma can be made in a patient with cirrhosis in the presence of lesions larger than 1 cm that enhance in the arterial phase and have washout of contrast in the venous phase. This patient meets the Milan criteria (up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm) for liver transplantation. Patients who meet the Milan criteria and have a tumor 2 cm or larger with arterial enhancement and venous washout on CT or MRI are eligible to receive Model for End-Stage Liver Disease exception points, placing them at a higher priority for liver transplantation.
Liver transplantation is the only curative therapy for hepatocellular carcinoma and for end-stage liver disease. Patients meeting the Milan criteria have excellent 5-year survival rates after liver transplantation.
Biopsy of the lesion is not indicated in this patient. In the context of cirrhosis, a lesion larger than 1 cm with contrast enhancement in the arterial phase and portal venous washout meets radiologic criteria for hepatocellular carcinoma and, therefore, does not require a lesion biopsy. Additionally, there is potential for harm from a lesion biopsy due to coagulopathy or the very small risk for tumor seeding.
Sorafenib is a multikinase inhibitor that is reserved for patients with advanced hepatocellular carcinoma with vascular invasion or extrahepatic spread that is not amenable to surgery, liver transplantation, or locoregional therapies. Treatment of these patients with sorafenib confers a survival benefit. This patient is not a candidate for resection and should be evaluated for liver transplantation; sorafenib is not indicated.
Surgical resection would be dangerous for this patient, given the evidence of portal hypertension, which confers increased risk for intraoperative bleeding as well as risk for postoperative liver failure.
- Patients with cirrhosis and who meet the Milan criteria (up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm) are best treated with liver transplantation and have excellent 5-year survival rates.