A 52-year-old man from Delhi presents with a 3-month history of right upper quadrant pain and jaundice. Imaging reveals a 4 cm solitary mass in hepatic segment VII with no evidence of cirrhosis or portal hypertension. The mass is hyperenhancing in the arterial phase and shows washout in the portal venous phase on contrast-enhanced CT. AFP is 8 ng/mL and liver function tests show mild elevation of transaminases. What is the most appropriate next step in management?

Explanation

## Clinical Context The patient presents with a solitary hepatic mass meeting imaging criteria for hepatocellular carcinoma (HCC) in a non-cirrhotic liver with normal AFP. ## Diagnostic Criteria Met **Key Point:** In a non-cirrhotic liver, a solitary nodule >1 cm with arterial phase hyperenhancement and portal venous phase washout on CT or MRI is diagnostic of HCC without need for biopsy [cite:AASLD HCC Diagnosis Guidelines 2018]. ## Anatomical Consideration The mass is located in **segment VII** (posterior superior segment of right lobe). Segment VII lies within the right hepatic lobe and is supplied by the right hepatic artery and right portal vein. **Mnemonic:** **Couinaud Segments — Right Lobe Posterior Section** = Segments V (inferior) and VIII (superior) in the anterior section; Segments VI (inferior) and VII (superior) in the posterior section. ## Management Algorithm ```mermaid flowchart TD A[Solitary HCC <br/> Non-cirrhotic liver]:::outcome --> B{Resectable?}:::decision B -->|Yes: Good PS,<br/>adequate liver reserve| C[Hepatic resection]:::action B -->|No: Advanced,<br/>poor reserve| D[Systemic therapy<br/>or TACE]:::action C --> E[Right hepatectomy<br/>Segments V-VIII]:::action E --> F[Curative intent]:::outcome ``` ## Why Resection Is Optimal - **Curative potential:** Resection offers the only chance for cure in early-stage HCC in non-cirrhotic liver. - **Preserved liver function:** Non-cirrhotic liver tolerates major resection well (can safely remove up to 70% of liver volume). - **Child-Pugh status:** No mention of cirrhosis or portal hypertension indicates preserved synthetic function. - **Performance status:** No contraindications mentioned; patient is a surgical candidate. **High-Yield:** In non-cirrhotic HCC, surgical resection is the gold standard and offers 5-year survival rates of 40–60% [cite:Harrison 21e Ch 297]. ## Surgical Extent Segment VII is in the **right posterior superior section**. Complete resection requires **right hepatectomy** (removal of segments V, VI, VII, VIII) to achieve adequate margins and ensure complete lymphadenectomy.