A 58-year-old man with a 15-year history of hepatitis B cirrhosis undergoes surveillance CT with multiphase contrast imaging. A 2.2 cm nodule is identified in the right lobe. The structure marked **A** in the diagram demonstrates arterial phase hyperenhancement with portal venous phase washout and an enhancing capsule. The patient's alpha-fetoprotein is 180 ng/mL. Based on the imaging characteristics shown, what is the most appropriate next step in management according to current BCLC staging guidelines?

Explanation

## Why Resection, liver transplantation, or radiofrequency ablation is correct The imaging pattern shown at **A** — arterial hyperenhancement with portal venous washout and enhancing capsule — meets LI-RADS 5 criteria for definite hepatocellular carcinoma in a cirrhotic patient, requiring no biopsy. This 2.2 cm solitary lesion corresponds to BCLC Stage 0/A (very early to early HCC). According to Harrison 21e Chapter 78 and AASLD guidelines, Stage 0/A disease is managed with curative-intent therapies: resection (if preserved liver function), orthotopic liver transplantation (if within Milan criteria: 1 lesion ≤5 cm), or ablation (radiofrequency or microwave ablation). The choice depends on the degree of cirrhosis, portal hypertension, and transplant candidacy. ## Why each distractor is wrong - **Transarterial chemoembolization (TACE)**: TACE is the standard first-line therapy for BCLC Stage B (intermediate HCC with multinodular disease without vascular invasion). This patient has a single small lesion (Stage 0/A), which is amenable to curative therapy, not palliative TACE. - **Systemic therapy with atezolizumab plus bevacizumab**: This combination is first-line for BCLC Stage C (advanced HCC with vascular invasion or extrahepatic metastases), as demonstrated in the IMbrave150 trial. Stage 0/A disease should not receive systemic therapy as initial management. - **Repeat imaging in 3 months**: LI-RADS 5 imaging findings in a cirrhotic patient are diagnostic of HCC without need for biopsy or confirmatory imaging. Delaying treatment by 3 months is inappropriate and risks tumor progression; threshold growth ≥50% in ≤6 months also defines HCC, but a lesion meeting LI-RADS 5 criteria requires immediate staging and treatment planning. **High-Yield:** Arterial wash-in + venous washout + enhancing capsule in a cirrhotic liver = LI-RADS 5 HCC; BCLC Stage 0/A (solitary ≤5 cm) → curative intent (resection/transplant/ablation); Stage B (multinodular) → TACE; Stage C (vascular invasion) → atezolizumab + bevacizumab. [cite: Harrison 21e Ch 78 (Liver and Biliary Tract Cancers)]