What is the best treatment option for a patient with hepatitis B cirrhosis and a 6 cm hepatocellular carcinoma (HCC) lesion with arterial enhancement in the right lobe of the liver?

Treatment Recommendation

Liver transplantation is the best treatment option for this patient with hepatitis B cirrhosis, Child-Pugh B status, and a 6 cm HCC lesion. 1

Rationale for Liver Transplantation

This patient meets criteria for transplantation and has decompensated cirrhosis (Child-Pugh B with ascites requiring diuretics), making transplantation the only curative option that addresses both the tumor and underlying liver disease. 2, 1

Patient Classification

• Child-Pugh B status (based on: INR 1.5, albumin 30 g/L, bilirubin 16 µmol/L, controlled ascites) 1
• Single 6 cm lesion falls within expanded UCSF criteria (single tumor ≤6.5 cm) 2
• Patent portal and hepatic veins (no vascular invasion documented) 2
• Preserved performance status (asymptomatic) 2

Why Other Options Are Inappropriate

Surgical resection (Option C) is contraindicated in this patient because:

• Child-Pugh B cirrhosis with ascites indicates significant portal hypertension 2
• Resection requires Child-Pugh A status with normal bilirubin and either hepatic venous pressure gradient ≤10 mmHg or platelet count ≥100,000 2
• This patient has thrombocytopenia (123 × 10⁹/L) and ascites, both indicating portal hypertension 2
• Perioperative mortality would be unacceptably high (>10%) in Child-Pugh B patients 1

TACE (Option D) is not optimal because:

• TACE is palliative for intermediate-stage disease, not curative 2
• While TACE can serve as bridging therapy to prevent tumor progression during transplant waiting time, it should not replace transplantation as definitive treatment 3
• TACE alone in advanced tumors (>5 cm) has poor long-term outcomes compared to transplantation 3

Sorafenib (Option A) is inappropriate because:

• Sorafenib is indicated only for unresectable HCC in patients not candidates for locoregional therapy 4
• This patient has potentially resectable/transplantable disease 2
• Sorafenib provides only modest survival benefit (2.8 months) and is reserved for advanced-stage disease with vascular invasion or extrahepatic spread 2, 4

Transplantation Strategy

The patient should be listed for liver transplantation immediately with consideration of bridging therapy:

• Milan criteria (single tumor ≤5 cm) are exceeded, but UCSF criteria (single tumor ≤6.5 cm) are met 2
• 3-year survival post-transplant: up to 88% for patients meeting UCSF criteria 2
• Bridging TACE should be considered if waiting time exceeds 6 months to prevent tumor progression and dropout from the list 2, 3

Critical Monitoring While Awaiting Transplant

• Serial imaging every 3 months to monitor for tumor progression 2
• AFP monitoring - levels >400 ng/ml associated with poor post-transplant outcomes 2
• MELD score calculation for organ allocation priority 2
• Antiviral therapy for hepatitis B to prevent post-transplant viral reinfection 2

Important Caveats

If transplantation is not available or significantly delayed:

• TACE can be used as primary therapy, though with inferior long-term survival compared to transplantation 3
• Radiofrequency ablation is technically challenging for 6 cm lesions (optimal for tumors <3 cm) 2, 1
• Do not pursue surgical resection given Child-Pugh B status and portal hypertension 2, 1

Post-transplant considerations:

• Effective hepatitis B prophylaxis is mandatory to prevent graft reinfection 2
• Immunosuppression regimens may include mTOR inhibitors to reduce recurrence risk 2
• Tumor recurrence risk is approximately 10-15% at 5 years when within UCSF criteria 2