Triphasic CT Scan of the Abdomen
The most appropriate next step is D. Triphasic CT scan of the abdomen 1, 2. This patient presents with clinical features of chronic liver disease (pruritus, fatigue, jaundice, splenomegaly, ascites, clubbing) and laboratory evidence of cirrhosis (thrombocytopenia, leukopenia, anemia, elevated INR, cholestatic pattern), making hepatocellular carcinoma (HCC) the primary concern for the 3 cm focal liver lesion.
Why Triphasic CT is the Correct Choice
For indeterminate liver lesions >1 cm in patients with chronic liver disease or cirrhosis, the American College of Radiology recommends proceeding directly to multiphase contrast-enhanced imaging using the Liver Imaging Reporting and Data System (LI-RADS) algorithm, with triple-phase contrast CT (arterial, portal venous, delayed phases) as the preferred option 1, 2.
Key Supporting Evidence:
Triphasic CT enables characterization of focal liver lesions with 95.5% diagnostic accuracy in differentiating benign from malignant lesions, with 100% sensitivity and 80% specificity 3.
The triphasic protocol specifically evaluates arterial hypervascularity followed by contrast washout—the classic imaging profile of HCC—which derives most of its blood supply from the hepatic artery unlike surrounding cirrhotic liver 1.
In cirrhotic patients with lesions ≥10 mm (this patient has a 3 cm lesion), definitive HCC diagnosis can be made by imaging alone when characteristic enhancement patterns are present, potentially eliminating the need for biopsy 1, 2.
Why Other Options Are Incorrect
Alpha-fetoprotein (AFP) - Option A:
While AFP can support HCC diagnosis, it is not the next diagnostic step because imaging characterization takes priority 1.
AFP alone has only 69% detection rate with 5.0% false-positive rate and 3.3% positive predictive value for HCC screening 1.
AFP is most useful when combined with imaging, not as a standalone next step 1.
Biopsy for the Lesion - Option B:
Biopsy should be reserved only for cases where imaging remains indeterminate after triphasic CT or MRI 1, 4.
In cirrhotic patients with lesions >2 cm showing characteristic enhancement patterns on triphasic imaging, there is >95% probability of HCC, making biopsy unnecessary 2.
Biopsy carries 9-12% bleeding risk and potential needle-track seeding risk, making it inappropriate as a first-line diagnostic tool 4, 5.
The American College of Radiology explicitly states that percutaneous biopsy should only be performed when imaging features remain indeterminate after optimal contrast-enhanced imaging 5.
Doppler Ultrasound of Liver - Option C:
Doppler ultrasound evaluates vascular patency and portal hypertension but does not adequately characterize focal liver lesions 1.
The patient already has clinical evidence of portal hypertension (splenomegaly, ascites), so Doppler would not change management 1.
For lesion characterization in cirrhosis, contrast-enhanced cross-sectional imaging (CT or MRI) is required, not Doppler 1, 2.
Clinical Context Supporting This Decision
This patient's presentation strongly suggests cirrhosis with possible HCC:
Chronic liver disease stigmata: Pruritus and fatigue (suggesting cholestatic liver disease), jaundice, clubbing, splenomegaly, ascites 1.
Laboratory decompensation: Pancytopenia (portal hypertension with hypersplenism), elevated INR (synthetic dysfunction), cholestatic enzyme pattern with elevated transaminases 1.
High-risk lesion: 3 cm focal lesion in a cirrhotic liver requires immediate characterization as HCC is the primary concern 1, 2.
Common Pitfalls to Avoid
Do not obtain AFP first and delay imaging—imaging characterization is the priority and AFP results will not change the need for triphasic CT 1, 2.
Do not proceed directly to biopsy—this exposes the patient to unnecessary bleeding risk when triphasic CT can establish the diagnosis non-invasively in most cases 4, 5.
Do not order single-phase CT or non-contrast imaging—only triphasic (arterial, portal venous, delayed) imaging provides adequate characterization for HCC diagnosis 1, 2.
Ensure 2.5-5 mm slice thickness is used for optimal lesion characterization on the triphasic CT protocol 2.