What is the most appropriate management step for a patient with hepatocellular carcinoma (HCC) and a large liver mass, with chronic hepatitis C (CHC) and preserved liver function?

Management of Large Hepatocellular Carcinoma with Preserved Liver Function

Referral for surgical resection (Option D) is the most appropriate management step for this patient with a 6 cm solitary HCC and preserved liver function, as surgical resection is considered first-line treatment for solitary HCC in cirrhotic liver of any size when liver function is maintained and adequate remnant liver volume can be preserved. 1

Rationale for Surgical Resection

The 2024 British Society of Gastroenterology guidelines provide clear direction for this clinical scenario:

• Surgical resection is first-line treatment for solitary HCC in cirrhotic liver of any size when liver function is maintained and adequate remnant liver volume can be preserved (evidence moderate; recommendation strong). 1

• The assessment for resection requires multiparametric evaluation considering liver function linked to severity of portal hypertension, extent of hepatectomy, volume of future liver remnant, patient comorbidity profile, and performance status. 1

• For this 6 cm solitary tumor, surgical resection offers 5-year survival rates of 50-68% in experienced centers, representing the only potentially curative option for tumors of this size. 2, 3

Why Other Options Are Inappropriate

Chemotherapy (Option A) is not appropriate because:

• Traditional systemic chemotherapy has shown limited efficacy with only 10% response rate and no proven survival benefit. 4
• Systemic therapy with atezolizumab plus bevacizumab or sorafenib is reserved for advanced, unresectable HCC, not for potentially resectable disease. 4, 5

Radiotherapy (Option B) is not standard treatment for HCC and is not mentioned in current guidelines as a primary treatment modality for resectable disease. 1

Palliative care referral (Option C) is premature because this patient has potentially curable disease with preserved liver function, making curative-intent surgery the appropriate approach rather than palliation. 1, 2

Critical Assessment Points Before Resection

The surgical team must evaluate:

• Liver function parameters: Child-Pugh classification (should be Class A for optimal outcomes), presence and severity of portal hypertension. 1, 2

• Future liver remnant (FLR) volume: Minimum requirements are ≥40% for cirrhotic liver, with portal vein embolization considered if FLR is inadequate. 6

• Tumor characteristics: Absence of macroscopic vascular invasion and extrahepatic metastases, which would contraindicate resection. 1

• Performance status and comorbidities: Patient must be fit enough to tolerate major hepatic surgery. 1, 7

Alternative Considerations

Liver transplantation could be considered as an alternative, but:

• This 6 cm tumor exceeds Milan criteria (one nodule <5 cm), making standard transplant listing inappropriate. 1
• With preserved liver function, resection is preferred over transplantation for solitary tumors. 1, 8

Ablative therapy is not appropriate because:

• Thermal ablation is recommended only for tumors <2 cm, not for a 6 cm mass. 1

Post-Resection Management

Following successful resection:

• Adjuvant therapy with atezolizumab and bevacizumab improves recurrence-free survival, though longer-term follow-up is required. 1
• Surveillance with AFP and liver imaging every 3-6 months for at least 2 years is essential, as recurrence rates reach 50-60% at 5 years. 2, 6