What is the diagnosis for a 58-year-old female with cirrhotic and/or pseudocirrhotic liver morphology, heterogeneous appearance, and enhancement of the liver suggestive of an underlying diffuse neoplastic process, such as metastatic disease or primary hepatic neoplasm, with liver function affected by Impaired liver function?

From the Guidelines

I strongly recommend proceeding with a percutaneous liver biopsy to evaluate the cirrhotic/pseudocirrhotic liver changes and heterogeneous enhancement pattern seen on imaging, as this is necessary to determine whether you have diffuse metastatic disease, a primary liver cancer, or another cause of these liver abnormalities. The imaging findings are concerning for an underlying neoplastic process, but only a tissue sample can provide a definitive diagnosis. According to the EASL-EORTC clinical practice guidelines 1, pathological diagnosis of HCC is based on the definitions of the International Consensus Group for Hepatocellular Neoplasia, and is recommended for all nodules occurring in non-cirrhotic livers, and for those cases with inconclusive or atypical imaging appearance in cirrhotic livers.

The biopsy procedure involves using a thin needle to extract small tissue samples from different areas of your liver under imaging guidance (typically ultrasound or CT), as described in the guidelines for liver biopsy 1. This is generally performed as an outpatient procedure with local anesthesia. You'll need to avoid blood-thinning medications for 5-7 days before the procedure and fast for 6-8 hours prior. After diagnosis, treatment options can be determined based on the specific type of disease identified, which may include targeted therapies, immunotherapy, chemotherapy, or other interventions depending on the findings, as outlined in the ESMO-ESDO clinical practice guidelines for diagnosis, treatment, and follow-up of hepatocellular carcinoma 1.

Some key points to consider when evaluating the need for a liver biopsy include:

• The risk of tumor seeding after liver biopsy, which is estimated to be around 2.7% with a median time interval between biopsy and seeding of 17 months 1
• The importance of discussing the decision to perform a biopsy with a multidisciplinary team, including a hepatobiliary and transplant surgeon, as recommended in the ESMO-ESDO guidelines 1
• The potential benefits of liver biopsy in determining the underlying cause of liver abnormalities and guiding treatment decisions, as highlighted in the British Society of Gastroenterology guidelines on the use of liver biopsy in clinical practice 1

Overall, the benefits of proceeding with a percutaneous liver biopsy outweigh the risks, and this diagnostic step is crucial in determining the underlying cause of the liver changes and guiding treatment decisions.

From the Research

Liver Morphology and Neoplastic Process

• The patient's liver morphology is described as cirrhotic and/or pseudocirrhotic with a heterogeneous appearance and enhancement, suggesting an underlying diffuse neoplastic process, either metastatic disease or primary hepatic neoplasm 2, 3.
• Pseudocirrhosis is a poorly understood acquired morphologic change of the liver that occurs in the setting of metastatic malignancy and radiographically resembles cirrhosis 3.
• The development of pseudocirrhosis has been described in various primary malignancies, including breast cancer, melanoma, renal cell carcinoma, appendiceal carcinoid, and cholangiocarcinoma 3.

Diagnosis and Assessment

• Liver biopsy is considered the gold standard for staging chronic liver diseases and assessing fibrosis and cirrhosis 2, 4.
• Histopathologic evaluation of liver biopsy can help assess potential underlying causes of cirrhosis and distinguish between cirrhotic and noncirrhotic features of portal hypertension 2.
• Quantitative assessment of hepatic fibrosis in liver biopsy specimens holds promise as a prognostic marker and a means to validate noninvasive markers of fibrosis 4.

Management and Treatment

• Coagulation testing and management in liver disease patients are crucial, and global tests of clot formation, including viscoelastic testing and thrombin generation analysis, can guide management decisions 5.
• Transfusion thresholds targeting platelet and fibrinogen goals may provide an effective strategy to optimize clot formation in patients with advanced liver disease 5.