What is the treatment for an elderly patient with a 3 cm liver mass, increased arterial phase on computed tomography (CT) scan, and recurrent ascites?

Treatment for Elderly Patient with 3 cm Liver Mass, Increased Arterial Phase on CT, and Recurrent Ascites

Liver transplantation is the most appropriate treatment for this elderly patient with a 3 cm liver mass showing arterial enhancement and recurrent ascites, as it offers definitive treatment for both the suspected hepatocellular carcinoma (HCC) and the underlying cirrhosis. 1

Diagnostic Assessment

The clinical scenario strongly suggests hepatocellular carcinoma (HCC) in the setting of decompensated cirrhosis:

• 3 cm liver mass with arterial phase enhancement on CT is highly suggestive of HCC
• Recurrent ascites indicates decompensated cirrhosis
• Elderly patient status requires careful consideration of treatment options

Treatment Algorithm

Step 1: Confirm Diagnosis and Assess Liver Function

• Perform diagnostic paracentesis to:
  • Rule out spontaneous bacterial peritonitis (SBP)
  • Determine ascitic fluid protein and cell count 1
• Calculate MELD score to assess liver function and transplant priority

Step 2: Manage Ascites While Preparing for Definitive Treatment

• Perform large-volume paracentesis (LVP) for immediate relief of tense ascites 2, 1
• Administer albumin (8 g per liter of ascites removed) if >5L is removed 1
• Initiate sodium restriction (88 mmol/day or 2000 mg/day) 2, 1
• Start diuretic therapy:
  • Spironolactone 100 mg/day (can be increased up to 400 mg/day) 2, 3
  • Add furosemide 40 mg/day (can be increased up to 160 mg/day) 2, 4

Step 3: Definitive Treatment Options

Option A: Liver Transplantation (Preferred)

• All patients with cirrhosis and ascites should be considered for liver transplantation evaluation 2, 1
• Liver transplantation offers definitive treatment for both HCC and cirrhosis 1
• The presence of a 3 cm HCC is within Milan criteria for transplantation

Option B: Lobar Hepatectomy (Alternative if transplant contraindicated)

• Can be considered in selected patients with:
  • Well-compensated cirrhosis (MELD <10)
  • Adequate future liver remnant
  • Absence of significant portal hypertension 5, 6
• However, in elderly patients with ascites, postoperative complications are significantly higher 5
• 5-year survival rates for patients >70 years after liver resection for HCC are only 6.7% compared to 47.1% in younger patients 5

Option C: Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• Can be considered for management of refractory ascites if:
  • MELD score <18
  • No contraindications (overt hepatic encephalopathy, severe pulmonary hypertension, heart failure) 2
• Not a definitive treatment for HCC
• Age >70 years is a relative contraindication 2

Option D: Chemotherapy

• Not first-line therapy for localized HCC
• May be considered for unresectable HCC not amenable to local therapies
• Limited efficacy in the setting of decompensated cirrhosis

Important Considerations and Contraindications

Contraindications to Liver Transplantation

• Advanced age alone is not an absolute contraindication but requires careful assessment
• Severe cardiopulmonary disease
• Active infection
• Recent malignancy outside the liver

Contraindications to Hepatic Resection

• Decompensated cirrhosis (Child-Pugh B or C)
• Significant portal hypertension
• Inadequate future liver remnant
• Multiple comorbidities common in elderly patients 5

Medication Precautions

• Avoid NSAIDs as they can reduce urinary sodium excretion and induce azotemia 2, 1
• Monitor for hyperkalemia with spironolactone, especially in elderly patients 3
• In hepatic cirrhosis with ascites, furosemide therapy should be initiated in the hospital setting 4

Conclusion

Liver transplantation represents the optimal treatment for this elderly patient with a 3 cm liver mass and recurrent ascites, as it addresses both the suspected HCC and the underlying cirrhosis. While awaiting transplantation, ascites should be managed with large-volume paracentesis, sodium restriction, and diuretic therapy. If transplantation is contraindicated, lobar hepatectomy could be considered in highly selected patients with well-preserved liver function, but outcomes are significantly worse in elderly patients with decompensated cirrhosis.