Question: A 68 year old female with PBC, Child-B cirrhosis was diagnosed with HCC on the grounds of MRI with typical HCC features and an AFP of 455. The 4.7 cm solitary lesion is at the periphery of segment 6. Which modality of treatment do you think she is most likely to receive next?
C. segmental resection
Answer: Being able to allocate treatment for HCC is important, and there are many variables that must be taken into consideration. Familiarizing yourself with the BCLC algorithm (seen below) will give you a general sense.
This patient is still within Milan criteria and therefore liver transplantation will be considered. However, if the tumor grows beyond 5 cm, she will not be eligible for bonus MELD points (termed exception points), so a locoregional treatment approach (TACE, RFA) is taken while the transplant evaluation is underway, if only to halt the growth while on the waiting list.
RFA is usually the preferred method for HCC < 3 cm, and is less successful at burning the entire lesion when 4-5 cm. The next option is TACE. After the procedure, CT or MRI is repeated in one month to ensure complete eradication, and every 3 months thereafter to surveil for tumor recidivism. Since the patient is a Child-B, you can guess that she has portal hypertension, which is a contraindication for segmental resection because those patients have high peri and post-operative mortality.