## HCC Management in Cirrhotic Liver: Transplantation vs. Resection **Liver transplantation** offers the best long-term survival for HCC in a cirrhotic liver, even with preserved liver function. ### Key Point: - **Milan Criteria** (gold standard for transplant candidacy): Single HCC ≤5 cm OR up to 3 HCCs each ≤3 cm, no extrahepatic metastases, no macrovascular invasion - **This patient meets Milan Criteria**: 3 cm solitary HCC, Child-Pugh B, preserved synthetic function - **Transplantation benefit**: Removes both cancer AND cirrhotic liver; 5-year survival ~70% - **Resection in cirrhosis**: High recurrence (>70% at 5 years) due to underlying cirrhosis; 5-year survival ~40–50% ### Why Transplantation > Resection in Cirrhosis: 1. **Removes the diseased liver** (source of HCC recurrence) 2. **Restores normal liver function** (reverses portal hypertension risk) 3. **Superior long-term survival** in cirrhotic patients 4. **Resection in cirrhosis** leaves behind cirrhotic parenchyma prone to HCC recurrence ### Resection Indications: - **Non-cirrhotic liver** with HCC - **Cirrhosis with preserved function** AND **no portal hypertension** (not this patient—he has cirrhosis) - **Solitary HCC** in non-cirrhotic liver ### Clinical Pearl: **Transplantation is the curative option for HCC in cirrhosis.** Resection is reserved for non-cirrhotic livers. TACE and sorafenib are palliative, not curative. ### Comparison: | Intervention | 5-Year Survival | Indication | |--------------|-----------------|------------| | **Transplantation** | ~70% | HCC in cirrhosis, Milan Criteria | | **Resection** | ~40–50% (cirrhosis) | Non-cirrhotic liver | | **TACE** | ~20–30% | Unresectable, not transplant-eligible | | **Sorafenib** | ~10–15% | Advanced HCC, palliative |
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