Hepatocellular carcinomaDownloads

A 52-year-old man comes to the emergency department because of a 3-week history of abdominal distention, yellow coloring of the skin, and dark urine. He also reports malaise and progressive shortness of breath, associated with slight exertion, for several weeks. The patient is a chronic drinker, and he was diagnosed with cirrhosis 2 years ago. He was warned to stop drinking alcohol, but he continues to drink. He hasn't accepted any more testing and has refused to visit the doctor until now. His vital signs are heart rate 62/min, respiratory rate 26/min, temperature 37.4°C (99.3°F), and blood pressure 117/95 mm Hg. On physical examination, there is dyspnea and polypnea. Skin and sclera are jaundiced. The abdomen has visible collateral circulation and looks distended. There is diffuse abdominal pain upon palpation in the right hemiabdomen, and the liver is palpated 10 cm below the right costal border. The legs show significant edema. CT scan shows cirrhosis with portal hypertension and collateral circulation. During the fifth day of his hospital stay, the patient presents with oliguria and altered mental status. Laboratory studies show: Day 1 Day 5 Hemoglobin 12.1 g/dL 11.2 g/dL Hematocrit 33.3% 31.4% Leukocyte count 7,000/mm3 6,880/mm3 Platelet count 220,000/mm3 134,000/mm3 Total bilirubin 20.4 mg/dL 28.0 mg/dL Direct bilirubin 12.6 mg/dL 21.7 mg/dL Creatinine 2.2 mg/dL 2.9 mg/dL Albumin 3.4 g/dL 2.6 g/dL PT 15 s 16.9 s aPTT 19 s 35 s Urinalysis Negative for nitrite Negative for leukocyte esterase 0–2 RBCs per high power field 0–1 WBC per high power field No evidence of casts or proteinuria What is the most likely cause of this patient's increased creatinine?

The patient undergoes a mammogram, which shows a 6.5mm sized mass with an irregular border and spiculated margins. A subsequent core needle biopsy of the mass shows infiltrating ductal carcinoma with HER2-positive, estrogen-negative, and progesterone-negative immunohistochemistry staining. Blood counts and liver function tests are normal. Laboratory studies show: Hemoglobin 12.5 g/dL Serum Na+ 140 mEq/L Cl- 103 mEq/L K+ 4.2 mEq/L HCO3- 26 mEq/L Ca2+ 8.9 mg/dL Urea Nitrogen 12 mg/dL Glucose 110 mg/dL Alkaline Phosphatase 25 U/L Alanine aminotransferase (ALT) 15 U/L Aspartate aminotransferase (AST) 13 U/L Which of the following is the most appropriate next step in management?