What are the management and follow-up options for a patient presenting with a liver mass?

Management and Follow-up of Liver Masses

Initial Diagnostic Approach

The management of liver masses depends critically on whether the patient has underlying cirrhosis, the size of the lesion, and AFP level—with this information determining whether biopsy can be avoided and treatment initiated directly. 1, 2

Essential Initial Workup

• Obtain AFP level, hepatitis panel (HBV/HCV), liver function tests, complete blood count, BUN, and creatinine immediately 2
• Assess hepatic functional reserve using Child-Pugh classification in all patients with known or suspected cirrhosis 1, 2
• Perform multiphasic contrast-enhanced CT or MRI as the primary diagnostic imaging modality 2

Diagnostic Algorithm Based on Clinical Context

For Patients WITH Known Cirrhosis

Lesions >2 cm:

• Diagnose as HCC without biopsy if AFP >400 ng/mL OR if one dynamic imaging study (triphasic CT or MRI) shows classic arterial enhancement 3, 1, 2
• If AFP is normal and imaging shows typical HCC features, proceed directly to treatment planning without biopsy 3
• The diagnostic certainty exceeds 95% in this scenario 3

Lesions 1-2 cm:

• Obtain at least two dynamic imaging studies (triphasic CT, MRI, or contrast-enhanced ultrasound) 3, 1
• If two techniques show typical HCC appearance (arterial enhancement with washout), interpret as HCC without biopsy 3, 1
• If imaging is discordant or atypical, proceed to biopsy or demonstrate lesion growth on serial imaging 3
• Diagnostic certainty is approximately 75% for nodules in this size range 3

Lesions <1 cm:

• Follow with ultrasound every 3-6 months—do NOT proceed to advanced imaging or biopsy at this stage 3, 1
• If enlargement occurs, re-evaluate according to the new size category 3
• If stable over 18 months, continue surveillance every 6-12 months 3

For Patients WITHOUT Cirrhosis

• Measure AFP first: if >400 ng/mL (excluding testicular primary), this confirms HCC diagnosis 3, 2
• If AFP is normal, perform multiphasic contrast-enhanced CT or MRI to characterize the lesion 3, 2
• Consider alternative diagnoses: hemangioma (most common benign mass), focal nodular hyperplasia, hepatic adenoma (especially in young women), or metastatic disease 4
• If the patient has known extrahepatic malignancy, biopsy is required when imaging cannot definitively characterize the liver lesion 2, 4
• Biopsy of non-tumor liver may be required to assess for occult cirrhosis before determining surgical approach 3

Role of MRI vs CT

• MRI has superior sensitivity and specificity compared to triphasic CT in patients with nodular cirrhotic livers 3, 1
• MRI provides better lesion characterization in cirrhotic patients with accuracy of 96-99% for HCC 2
• Triphasic CT is acceptable but has lower sensitivity in nodular cirrhotic livers 1

When to Avoid Biopsy

Critical caveat: Avoid biopsy when surgical therapy is possible, regardless of tumor size, due to risk of tumor seeding. 3, 2

• Do not biopsy when imaging and AFP are diagnostic for HCC in potentially resectable disease 3, 1, 2
• Do not biopsy lesions <1 cm—follow with surveillance instead 3, 1

Staging Evaluation Once HCC is Diagnosed

• Obtain chest imaging (X-ray or CT) to detect pulmonary metastases 3, 2
• Perform abdominal CT or MRI to assess tumor burden, vascular invasion, nodal disease, and portal hypertension 3, 1
• For transplant candidates, add chest CT and bone scintigraphy 3, 2
• Use BCLC or CLIP staging systems rather than TNM alone, as these incorporate both tumor characteristics and liver function 3, 1

Treatment Selection

Child-Pugh grade A patients and selected favorable grade B patients should be evaluated for curative treatment options. 3

Curative Options:

• Surgical resection: Standard for patients without cirrhosis with localized resectable disease 1, 2
• Liver transplantation: Preferred for cirrhotic patients meeting Milan criteria, with 5-year survival >75% 1
• Choice between resection vs transplantation in cirrhotic patients depends on hepatic functional reserve 1

Locoregional Therapies:

• Transarterial chemoembolization, percutaneous ethanol injection, and radiofrequency ablation for unresectable localized disease 1

Systemic Therapy:

• Atezolizumab plus bevacizumab is the preferred first-line regimen for advanced HCC 1

Post-Treatment Surveillance

After curative resection or ablation, perform AFP measurement and liver imaging every 3-6 months for the first 2 years, as curative therapy can still be offered at relapse. 1

• Use modified RECIST criteria for response assessment on dynamic CT or MRI 1
• Any deterioration in liver function in a cirrhotic patient should raise suspicion for HCC recurrence 3, 1

Surveillance for High-Risk Patients Without Known Masses

• Perform abdominal ultrasound every 6 months with concurrent AFP measurement for patients with cirrhosis or chronic hepatitis B 1, 5
• This approach demonstrated 37% reduction in HCC mortality in a randomized trial of 18,816 patients 1, 5
• Adding AFP to ultrasound increases early-stage detection from 45% to 63% 1, 5

Critical Pitfalls to Avoid

• Never use AFP alone for diagnosis—sensitivity is only 22-49% and 35-40% of HCC cases have normal AFP even with large tumors 1
• Never biopsy potentially resectable lesions when imaging and AFP are diagnostic 3, 2
• Do not use liver function tests for HCC screening—they assess synthetic function but do not detect malignancy 5
• Ensure ultrasound is performed by an experienced operator skilled in assessing chronic liver disease, as this modality is highly operator-dependent 1, 5