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A 62-year-old man with HCV-related Child-Pugh A cirrhosis has a 4 cm single HCC in the right lobe on 6-monthly surveillance USS. He has portal hypertension with grade 2 oesophageal varices. CT confirms typical arterial enhancement and washout.
Questions
a) What is the diagnosis and staging? (2 marks)
Hepatocellular carcinoma (HCC), 4 cm, solitary. BCLC stage A (early). Child-Pugh A but WITH portal hypertension (grade 2 varices). Portal hypertension is a contraindication to surgical resection.
b) What is the optimal treatment? (3 marks)
Liver transplantation (Milan criteria: single tumour under 5 cm). The patient meets criteria (single 4 cm HCC, no vascular invasion, no extrahepatic spread). Transplant treats BOTH the cancer and the underlying cirrhosis. 5-year survival: 70-80%. Bridging therapy (TACE or RFA) while waiting for transplant to prevent tumour progression.
c) What are the alternatives if transplant is not available? (3 marks)
- TACE (transarterial chemoembolisation) — palliative, slows progression
- RFA (radiofrequency ablation) — for tumours under 3 cm; may be suboptimal for 4 cm
- TARE (transarterial radioembolisation) with Y-90 microspheres
- Systemic therapy (sorafenib or atezolizumab+bevacizumab) if disease progresses
d) What surveillance led to detection? (2 marks)
6-monthly liver ultrasound +/- serum AFP. Recommended for ALL cirrhotic patients regardless of aetiology. Early detection through surveillance is the single most important factor in improving HCC outcomes.