A 55-year-old man with hepatitis C cirrhosis (Child-Pugh A) achieves sustained virological response (SVR12) after DAA therapy. Three years later, surveillance ultrasound reveals a 2.2 cm arterially enhancing nodule with washout on portal venous phase. AFP is 45 ng/mL. LI-RADS category is LR-5. What is the appropriate management?

• A Percutaneous biopsy before any treatment
• B Repeat imaging in 3 months
• C Curative treatment (resection, ablation, or transplant listing) without biopsy ✓
• D Systemic therapy with sorafenib

Explanation

LI-RADS category LR-5 has >95% probability of hepatocellular carcinoma (HCC) based on major imaging features (arterial hyperenhancement + washout appearance in a nodule >20 mm in cirrhosis). Per AASLD 2022 guidelines, LR-5 observations do not require biopsy before curative treatment — treatment can proceed based on imaging alone. For a solitary ≤3 cm lesion in a Child-Pugh A patient, curative options include resection, radiofrequency ablation, or liver transplant listing (Milan criteria met). Sorafenib is reserved for advanced/unresectable HCC.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.