What is the recommended management for a patient with hepatocellular carcinoma who is Child‑Pugh class C?

Management of Child-Pugh C Hepatocellular Carcinoma

Best supportive care is the only recommended treatment for patients with Child-Pugh class C cirrhosis and hepatocellular carcinoma, with liver transplantation being the sole exception for highly selected candidates who meet strict transplant criteria. 1

Primary Treatment Recommendation

Child-Pugh C patients should receive only supportive care as their severely decompensated liver function (median survival <3-4 months) makes them ineligible for active cancer treatments that would likely accelerate hepatic decompensation and death rather than provide benefit. 1, 2

Liver Transplantation: The Only Curative Option

• Liver transplantation can be considered for Child-Pugh C patients with HCC within Milan criteria (solitary tumor ≤5 cm or up to 3 nodules each ≤3 cm) or expanded criteria such as 5-5-500 criteria used in some Asian centers. 1
• Living-donor liver transplantation may be pursued using the same eligibility criteria as cadaveric transplantation for patients who meet tumor burden requirements. 1
• Transplant evaluation should occur urgently as these patients have limited survival without transplantation, with 1-year mortality exceeding 50%. 1, 2

Contraindicated Interventions

Systemic Therapies Are Not Recommended

• Atezolizumab plus bevacizumab, the first-line standard for advanced HCC, is only validated in Child-Pugh A patients and should not be used in Child-Pugh C. 1, 3
• Sorafenib and lenvatinib are only approved for Child-Pugh A patients; there is no recommended dose for Child-Pugh C patients with HCC. 1, 4
• Lenvatinib specifically has no recommended dose for HCC patients with moderate or severe hepatic impairment (Child-Pugh B or C). 4

Locoregional Therapies Should Be Avoided

• Transarterial chemoembolization (TACE) is contraindicated in Child-Pugh C due to unacceptably high rates of liver toxicity and acute decompensation. 1, 2, 5
• Radiofrequency ablation and other percutaneous ablation techniques are not recommended as they require adequate hepatic functional reserve (Child-Pugh A or favorable B). 1
• Surgical resection is generally contraindicated as Child-Pugh C represents absolute contraindication to major hepatectomy due to prohibitive perioperative mortality. 1

Best Supportive Care Components

Symptom Management

• Pain control with opioids should not be withheld despite concerns about hepatic metabolism; dose adjustments may be needed. 2
• Manage ascites with dietary sodium restriction (<2 g/day), diuretics (spironolactone with or without furosemide), and large-volume paracentesis with albumin replacement as needed. 6, 2
• Treat hepatic encephalopathy with lactulose titrated to 2-3 soft bowel movements daily and consider rifaximin as adjunctive therapy. 6, 2

Prevention of Acute Decompensation

• Endoscopic variceal band ligation or sclerotherapy for acute variceal bleeding with adjunctive vasoactive drugs (octreotide or terlipressin). 6
• Prophylactic antibiotics for spontaneous bacterial peritonitis in patients with ascitic fluid protein <1.5 g/dL or prior SBP history. 6
• Nutritional support is important for quality of life in terminal HCC, though specific interventions should be tailored to tolerance. 2

Palliative and Hospice Care

• Early palliative care consultation is appropriate for patients with life expectancy <6 months, which applies to most Child-Pugh C HCC patients. 2
• Hospice referral should not be delayed as median survival is 3-4 months without transplantation, and most patients clearly meet hospice eligibility criteria. 1, 2

Special Circumstances: Japanese Experience

While Western guidelines uniformly recommend only supportive care, Japanese centers have reported treating selected Child-Pugh C patients with locoregional therapies (55-65% of cases in registry data), particularly to prevent HCC rupture or major vessel obstruction. 7

• This approach is not endorsed by major international guidelines and should be considered investigational. 7
• The Japanese experience suggests a small subgroup may benefit, but patient selection criteria remain poorly defined and outcomes are inferior to Child-Pugh A/B patients. 7, 8
• In the absence of uncontrollable ascites, marked jaundice, or encephalopathy, some Japanese centers have performed limited resections with acceptable perioperative outcomes, though this contradicts Western consensus. 8

Critical Pitfalls to Avoid

• Do not pursue aggressive systemic therapy in Child-Pugh C patients as this accelerates death through hepatic decompensation rather than providing oncologic benefit. 1, 2
• Do not perform TACE or radioembolization as liver toxicity and decompensation rates are unacceptably high in this population. 2, 5
• Do not delay transplant evaluation if the patient has favorable tumor characteristics, as this is the only potentially curative option. 1
• Do not withhold appropriate symptom management including opioids for pain control based on theoretical concerns about hepatic metabolism. 2