What is the best management approach for a patient with Hepatocellular Carcinoma (HCC) with a single nodule of 3 cm and a Child-Turcotte-Pugh (CTP) score of 11?

Management of HCC with Single 3 cm Nodule and Child-Pugh Score 11

This patient with Child-Pugh C cirrhosis (score 11) should receive only supportive palliative care, with liver transplantation being the sole potentially curative option if strict transplant criteria are met. 1

Critical Assessment: Why Active Treatment is Contraindicated

Child-Pugh score 11 indicates Child-Pugh class C cirrhosis, which represents severely decompensated liver disease with prohibitively high mortality risk from active interventions. 1

• Surgical resection is absolutely contraindicated due to excessive operative mortality in Child-Pugh C patients, even for small tumors. 1
• Systemic therapies (sorafenib, lenvatinib) are not recommended as oncology guidelines exclude Child-Pugh C patients from treatment algorithms. 1
• Locoregional therapies (RFA, TACE) are contraindicated as ablation guidelines specify Child-Pugh A or B as requirements, with Child-Pugh C patients receiving only supportive care. 2, 1
• Antiviral therapy is absolutely contraindicated in Child-Pugh C cirrhosis due to high risk of life-threatening complications. 1

Treatment Algorithm

Step 1: Assess Transplant Candidacy Immediately

If patient meets transplant criteria:

• Age <65 years AND tumor within Milan criteria (single nodule <5 cm) 1
• Performance status ≤2 3
• Liver transplantation is the ONLY potentially curative option and should be pursued urgently 3, 1
• The Indian National Association for the Study of Liver specifically modified BCLC staging to recommend that Child-Pugh C patients with tumors within Milan criteria and PS ≤2 should be considered for transplantation 3

If NOT a transplant candidate:

• Transition immediately to palliative care focus 1
• Median survival is measured in months without transplantation 1

Step 2: Manage Cirrhosis Complications

Focus on symptom control and preventing life-threatening complications:

• Ascites: Dietary sodium restriction <2 grams/day 1
• Hepatic encephalopathy: Lactulose titrated to 2-3 soft bowel movements daily 1
• Variceal hemorrhage prevention: Endoscopic management (band ligation or sclerotherapy) if bleeding occurs 1
• Spontaneous bacterial peritonitis prophylaxis: Norfloxacin for patients with ascites 1

Common Pitfalls to Avoid

• Do NOT attempt surgical resection even though tumor size (3 cm) would normally be resectable—the Child-Pugh C status makes operative mortality unacceptably high. 1
• Do NOT initiate systemic therapy (sorafenib, lenvatinib) as these agents are not indicated for Child-Pugh C patients despite being first-line for unresectable HCC in preserved liver function. 1, 4
• Do NOT pursue locoregional therapy (RFA, TACE) as guidelines explicitly require Child-Pugh A or B liver function. 2
• Do NOT delay transplant evaluation if patient is potentially eligible—this is the only window for curative treatment. 3, 1
• Do NOT attempt antiviral therapy even if viral hepatitis is the underlying etiology, as this carries life-threatening risks in Child-Pugh C. 1

Context: Why Tumor Characteristics Are Secondary

While this patient's tumor (single 3 cm nodule) would typically qualify for multiple curative options in Child-Pugh A/B patients:

• Single nodules ≤3 cm normally qualify for RFA with >90% complete response rates 3
• Single nodules <5 cm meet Milan criteria for transplantation with 75% 5-year survival 3
• Tumors 2-3 cm are ideal for resection in preserved liver function 3

However, the Child-Pugh C status completely overrides these favorable tumor characteristics, making the severely compromised liver function the dominant prognostic factor. 1