A 45-year-old man with chronic hepatitis C (genotype 1b) is treated with sofosbuvir/ledipasvir for 12 weeks. His cirrhosis status is Child-Pugh A. He achieves SVR12. Three years later, his AFP rises to 65 ng/mL and a 3 cm hepatic nodule is detected showing arterial enhancement and portal venous washout on MRI. LI-RADS category is 5. What is the recommended first-line treatment?
- A Repeat MRI at 3 months to monitor progression
- B Transarterial chemoembolization (TACE) as definitive therapy
- C Resection or ablation if meeting Milan criteria; transplant if not ✓
- D Systemic therapy with sorafenib (Stage C BCLC)
Explanation
A 3 cm nodule meeting LI-RADS 5 criteria in cirrhosis is HCC. The Barcelona Clinic Liver Cancer (BCLC) algorithm guides management: Stage 0/A (single or up to 3 nodules <3 cm, Child-Pugh A/B, ECOG 0) → curative therapy. For a 3 cm single nodule in Child-Pugh A: surgical resection is preferred if technically feasible with adequate liver reserve; ablation (RFA/MWA) is alternative for <3 cm; liver transplantation applies if within Milan criteria (single ≤5 cm or ≤3 nodules each ≤3 cm). TACE is bridging or intermediate-stage (multiple HCC). Sorafenib is BCLC Stage C (portal invasion/metastases).
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.