From the Guidelines
For a patient with left upper quadrant (LUQ) tenderness and a palpable hard mass that was unremarkable on ultrasound, the next steps should include a referral to a specialist Multidisciplinary Team (MDT) for further evaluation and consideration of a suspected cancer pathway referral, as per the UK guidelines for the management of soft tissue sarcomas 1. Given the presence of a hard mass, it is essential to consider the possibility of a soft tissue sarcoma, and the guidelines recommend a suspected cancer pathway referral if ultrasound findings are uncertain and clinical concern persists 1. The patient should undergo cross-sectional imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT) scan, to better visualize the mass and assess for potential invasion of surrounding tissues or metastases 1. Additionally, a pre-treatment histopathological diagnosis should be made, if possible, by percutaneous core biopsy, which should be reviewed by a specialist sarcoma pathologist for diagnostic confirmation, and appropriate molecular and genomic analysis 1. It is crucial to note that all patients with a suspected soft tissue sarcoma should be managed by a specialist Sarcoma MDT, as specified in the NICE guidance 1. Key considerations in the differential diagnosis for LUQ masses include splenomegaly, splenic infarct, gastric mass, pancreatic tail tumor, left adrenal mass, or colon cancer at the splenic flexure. However, given the potential for soft tissue sarcoma, it is essential to prioritize referral to a specialist MDT and further evaluation, rather than proceeding with empirical treatment or additional diagnostic tests without specialist input 1.
From the Research
Next Steps for LUQ Tenderness with Hard Mass
Given the unremarkable ultrasound results, the following options can be considered:
- Contrast-Enhanced Ultrasound (CEUS): CEUS has been shown to perform better than standard ultrasound in evaluating focal liver lesions, with a sensitivity of 95% and specificity of 82% in determining malignancy 2.
- Computed Tomography (CT): CT can be used to further evaluate the liver mass, especially if CEUS is not available or inconclusive 3, 4.
- Magnetic Resonance Imaging (MRI): MRI is becoming the gold standard in liver metastasis detection and treatment response assessment, and can be used to confidently diagnose treatment-related changes in the liver and enable differential diagnosis from primary liver tumors 5.
- Positron Emission Tomography/Computed Tomography (PET/CT): PET/CT can be used as a problem-solving method, especially in patients with high clinical suspicion of metastasis and normal ultrasonography, CT, and PET-CT findings 3, 5.
Considerations for Imaging Modalities
When choosing an imaging modality, consider the following:
- Advantages and limitations: Each modality has its own advantages and limitations, such as CEUS being operator-dependent and MRI having low sensitivity for metastases smaller than 3mm 2, 5.
- Patient factors: Patient factors, such as fatty liver, may affect the choice of imaging modality, with MRI being preferred over CT in such cases 6, 5.
- Clinical suspicion: High clinical suspicion of metastasis may warrant the use of MRI or PET/CT, even if other imaging modalities are normal 3, 5.