A 65-year-old man with known chronic hepatitis C cirrhosis (Child-Pugh A) presents with a 4.2 cm arterially enhancing hepatic lesion with washout on portal venous phase CT. AFP is 850 ng/mL. Staging is within Milan criteria. What is the MOST appropriate treatment with curative intent?

• A Surgical resection — Child-Pugh A cirrhosis permits resection and AFP elevation makes transplant contraindicated
• B Liver transplantation — within Milan criteria, transplant offers best long-term outcome in cirrhotic patients ✓
• C TACE (transarterial chemoembolisation) as bridging therapy only
• D Sorafenib targeted therapy as first-line curative treatment

Explanation

The Milan criteria (single HCC ≤5 cm or up to 3 nodules each ≤3 cm, no macrovascular invasion, no extrahepatic spread) define the threshold for liver transplantation in cirrhotic HCC patients. Transplant removes both the tumour and the cirrhotic liver, offering the best long-term recurrence-free survival (~70% at 5 years). Surgical resection is an alternative in well-compensated (Child-Pugh A) cirrhosis without portal hypertension, but carries higher recurrence rates due to the underlying cirrhosis. AFP elevation alone does not contraindicate transplantation (though very high AFP may prompt TACE bridging). Sorafenib is palliative for advanced disease.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.