From the Guidelines
For a 79-year-old female with newly discovered liver mass, lung nodules, and vertebral lesion on CT scan, I recommend ordering a comprehensive panel of laboratory tests and tumor markers to evaluate for potential malignancy, as suggested by the most recent guidelines 1. Start with complete blood count, comprehensive metabolic panel (including liver function tests), and coagulation studies. For tumor markers, order carcinoembryonic antigen (CEA), cancer antigen 19-9 (CA 19-9), cancer antigen 125 (CA-125), alpha-fetoprotein (AFP), and prostate-specific antigen (PSA) as these are commonly used in the diagnosis of various cancers, including breast, lung, colorectal, and pancreatic cancers, which are potential primary sources given the pattern of metastases 2, 3. Additional important tests include serum protein electrophoresis, thyroid function tests, and urinalysis. These findings suggest metastatic disease, with common primary sources including breast, lung, colorectal, and pancreatic cancers. The pattern of metastases involving liver, lung, and bone is particularly concerning for breast or lung primary tumors. While tumor markers can provide valuable diagnostic information, they should be interpreted cautiously as they vary in sensitivity and specificity, as noted in studies on hepatocellular carcinoma diagnosis 4, 5. Tissue diagnosis through biopsy of the most accessible lesion is ultimately necessary for definitive diagnosis and to guide treatment decisions, as emphasized in guidelines for the management of hepatocellular carcinoma and other liver lesions 1, 6. Prompt referral to oncology is essential while these diagnostic tests are being completed, to ensure timely initiation of appropriate treatment based on the diagnosis and staging of the cancer.
From the Research
Laboratory Tests and Tumor Markers
The following laboratory tests and tumor markers may be indicated for a 79-year-old female with a new liver mass, lung nodules, and a vertebral lesion detected on computed tomography (CT) scan:
- Blood tests to evaluate liver function, such as alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP) 7
- Tumor markers, such as alpha-fetoprotein (AFP) for hepatocellular carcinoma, and carcinoembryonic antigen (CEA) for colorectal cancer metastasis 7
- Imaging studies, including contrast-enhanced ultrasound (CEUS), CT, and positron emission tomography (PET)-CT to characterize the liver mass and lung nodules 8, 7
Diagnostic Considerations
The diagnosis of a liver mass and lung nodules requires consideration of various benign and malignant conditions, including:
- Hepatocellular carcinoma, which is typically characterized by increased arterial flow with frequent dysmorphic tumor vessels and decreased portal venous flow 7
- Metastasis, which shows prompt brief arterial hypervascularity, with either a rim or diffuse pattern and rapid washout 7
- Epithelioid hemangioendothelioma (EHE), a rare malignant tumor that affects multiple organs, particularly lung and liver 9
- Benign lesions, such as focal nodular hyperplasia and steatotic hepatitis, which can mimic malignant tumors on imaging studies 8
Management Options
The management of a liver mass and lung nodules depends on the diagnosis and the patient's overall health status, and may include:
- Surgical resection of the liver mass and lung nodules, which is a viable treatment option for resectable lesions 9
- Surveillance imaging, including repeat CT scans, to monitor for growth or changes in the liver mass and lung nodules 10, 11
- Biopsy, either percutaneous or surgical, to obtain a tissue diagnosis 8, 9