What is the protocol for managing a patient with a liver mass?

Management Protocol for Liver Mass

The management of a liver mass should follow a systematic diagnostic approach based on imaging characteristics, patient factors, and laboratory findings to determine the appropriate treatment strategy. 1

Initial Diagnostic Workup

Laboratory Testing

• Alpha-fetoprotein (AFP) measurement
  • Elevated AFP >400 ng/ml in cirrhotic patients with a focal hypervascular liver lesion >2cm is diagnostic of hepatocellular carcinoma (HCC) 1
  • A rising AFP over time, even if below 400 ng/ml, is virtually diagnostic of HCC 1

Imaging Studies

1. First-line imaging: Contrast-enhanced CT of abdomen and pelvis with maximum 5mm collimation 1
2. Chest imaging: CT scan of chest to evaluate for pulmonary metastases 1
3. Additional imaging based on initial findings:
   • Multiphase contrast-enhanced MRI for better characterization of indeterminate lesions 2
   • Doppler ultrasound if vascular malformations are suspected 1

Diagnostic Algorithm Based on Patient Characteristics

In Patients with Known Cirrhosis

• Mass >2cm with elevated AFP: Diagnosis of HCC confirmed, proceed to treatment planning without biopsy 1
• Mass >2cm with normal AFP: Further radiological imaging (CT, MRI, or lipiodol angiography with follow-up CT) 1
• Mass <2cm: Lower diagnostic certainty (approximately 75% are HCC)
  • Options include repeat examination to show enlargement, other radiological techniques, or biopsy if diagnosis remains unclear 1

In Patients without Known Cirrhosis

1. Measure AFP
2. If AFP elevated: Confirms diagnosis of HCC (in absence of testicular primary) 1
3. If AFP normal:
   • Further radiological assessment
   • Search for other primary malignancies if metastasis is suspected
   • Biopsy of non-tumor liver may be required to determine surgical approach 1

Important: Biopsy of hepatic lesions should not be performed without discussion with a regional hepatobiliary unit, as there is risk of tumor seeding. 1

Management Planning

Multidisciplinary Approach

• All cases should be discussed at a multidisciplinary meeting with experience in liver mass management 1
• Hepatobiliary MDT should be based in a cancer center serving a population of at least 2 million 1

Treatment Options Based on Diagnosis

For Hepatocellular Carcinoma

1. Localized Resectable Tumors:

   • Surgical resection (partial hepatectomy) for patients without cirrhosis 1
   • For cirrhotic patients: surgical resection or liver transplantation depending on hepatic reserve 1

2. Localized Unresectable Tumors:

   • Total hepatectomy with liver transplantation as first consideration 1
   • Alternative options:
     • Chemoembolization for multifocal HCC with adequate hepatic reserve
     • Percutaneous ethanol injection for <3-4 tumor nodules, maximum 5cm size
     • Radiofrequency ablation for tumors <5cm or fewer than four in number 1
     • Sorafenib (400mg orally twice daily) for unresectable HCC 3

For Metastatic Colorectal Cancer to Liver

• Aim of resection: remove all macroscopic disease with clear margins and leave sufficient functioning liver 1
• Patients with solitary, multiple, and bilobar disease who have had radical treatment of primary colorectal cancer are candidates 1
• Residual functioning volume should be approximately one-third of standard liver volume 1

Special Considerations

Vascular Malformations

• If vascular malformations are suspected, Doppler ultrasound is the first-line investigation 1
• Avoid liver biopsy in patients with suspected vascular malformations due to bleeding risk 1

Monitoring and Follow-up

• For patients who have undergone curative resection of primary colorectal cancer:
  • CT scan of abdomen and pelvis at minimum in the two years following treatment 1
  • Colonoscopy repeated after five years 1

Common Pitfalls to Avoid

1. Performing biopsy without specialist consultation: May lead to tumor seeding and reduced survival prospects 1
2. Inadequate imaging: Radiological imaging with ultrasound, CT, and angiography usually understages HCC 1
3. Missing extrahepatic disease: Complete staging with chest and abdominal imaging is essential before planning definitive treatment 1
4. Overlooking non-HCC diagnoses: Consider the full differential of liver masses including benign lesions (cysts, hemangiomas, adenomas, focal nodular hyperplasia) 1