A 52-year-old man with a 10-year history of cirrhosis due to hepatitis B presents with a 3 cm hypoattenuating lesion on contrast-enhanced CT of the liver. Serum AFP is 450 ng/mL (normal <20). What is the most appropriate next step in management?

Explanation

## Diagnostic Algorithm for HCC in Cirrhotic Liver **Key Point:** In a cirrhotic patient with nodule <2 cm or 2–3 cm with AFP <400 ng/mL, biopsy is required. However, when nodule is 2–3 cm AND AFP is significantly elevated (>400 ng/mL), imaging surveillance with repeat CT/MRI at 4 weeks is the next step per AASLD guidelines. **Clinical Pearl:** A single imaging modality showing arterial enhancement + washout in portal venous/delayed phase = HCC diagnosis in cirrhosis. If not met, repeat imaging or biopsy is needed. **High-Yield Table:** | Nodule Size | AFP Level | Next Step | |---|---|---| | <1 cm | Any | Ultrasound surveillance q3–4 months | | 1–2 cm | <400 | Biopsy or repeat imaging | | 1–2 cm | >400 | Repeat imaging at 4 weeks | | 2–3 cm | <400 | Biopsy or repeat imaging | | 2–3 cm | >400 | Repeat imaging at 4 weeks | | >3 cm | Any | Diagnosis by single imaging modality | In this case: 3 cm nodule + AFP 450 → repeat imaging at 4 weeks to confirm arterial enhancement and washout pattern.