The most appropriate next step in management is to refer this patient for liver transplantation evaluation. A diagnosis of hepatocellular carcinoma can be made in a patient with cirrhosis in the presence of lesions larger than 1 cm that enhance in the arterial phase and have washout of contrast in the venous phase. Patients who meet the Milan criteria (up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm) have excellent 5-year survival rates after liver transplantation. Patients who meet Milan criteria and have a tumor 2 cm or larger with arterial enhancement and venous washout on CT or MRI are eligible to receive Model for End-Stage Liver Disease (MELD) exception points, placing them at a higher priority for liver transplantation.

This patient does not require a biopsy of the liver masses because the radiographic characteristics of his liver tumors meet criteria for a diagnosis of hepatocellular carcinoma. The vast majority of hepatocellular carcinomas in the context of cirrhosis can be diagnosed with radiologic criteria alone. There is also a small risk (1%-3%) of seeding the needle track with tumor cells with percutaneous biopsy of hepatocellular carcinoma.

Sorafenib, a compound that targets growth signaling and angiogenesis, should be reserved for patients with Child-Turcotte-Pugh class A or B cirrhosis, good performance status, and vascular, lymphatic, or extrahepatic spread of the tumor. This patient has no evidence of angiolymphatic or extrahepatic involvement, and the tumor sizes are within Milan criteria; therefore, he should be evaluated for liver transplantation rather than started on sorafenib.

Surgical resection is not an appropriate option in this patient with evidence of hyperbilirubinemia and portal hypertension; he would be at high risk for postsurgical hepatic decompensation.

Transarterial chemoembolization (TACE) should not be performed before referral to a transplant center. Ultimately, patients who are expected to be on the waiting list for longer than 6 months are recommended to receive locoregional therapy such as TACE to control the tumor while awaiting a transplant. However, TACE should only be performed after the liver transplant evaluation is completed.