A 62-year-old man comes to the physician with complaints of vague abdominal discomfort. He has a history of liver cirrhosis due to hepatitis C infection and prior heavy alcohol use. He failed hepatitis C treatment 6 years ago. The patient has no vomiting, weight loss, rectal bleeding, or dark stools. He is an ex-smoker with a 35-pack-year history.
His blood pressure is 102/65 mm Hg and pulse is 90/min. Lungs are clear on auscultation. The abdomen is nontender with presence of a small fluid wave. There is trace bilateral lower-extremity edema.
Laboratory results are as follows:

Abdominal ultrasound shows a nodular, cirrhotic liver and a 2-cm dominant nodule with poorly defined borders in the right lower lobe. There is mild splenomegaly.
What is the best next step in management of this patient?

Question

A 62-year-old man comes to the physician with complaints of vague abdominal discomfort.  He has a history of liver cirrhosis due to hepatitis C infection and prior heavy alcohol use.  He failed hepatitis C treatment 6 years ago.  The patient has no vomiting, weight loss, rectal bleeding, or dark stools.  He is an ex-smoker with a 35-pack-year history.
His blood pressure is 102/65 mm Hg and pulse is 90/min.  Lungs are clear on auscultation.  The abdomen is nontender with presence of a small fluid wave.  There is trace bilateral lower-extremity edema.
Laboratory results are as follows:

Abdominal ultrasound shows a nodular, cirrhotic liver and a 2-cm dominant nodule with poorly defined borders in the right lower lobe.  There is mild splenomegaly.
What is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9803_1876_853d_9f3d7b156f3a_MD0002_00 This patient with known cirrhosis has abdominal pain, elevated alpha-fetoprotein (AFP), and a 2-cm mass found on ultrasound. He needs an MRI of the liver as it has better sensitivity and specificity than CT scan or ultrasound in differentiating malignant nodules from the regenerative nodules associated with cirrhosis. Most cases (80%) of hepatocellular carcinoma (HCC) are due to underlying chronic hepatitis B and C virus infection. Routine surveillance for HCC in high-risk patients (eg, those with chronic hepatitis B infection and/or cirrhosis) is done with abdominal ultrasound every 6 months. AFP is not routinely checked due to high false-positive rates. Early detection of HCC (tumors < 2 cm) offers the advantage of several treatment options for these patients. (Choice B) Bleeding and tumor seeding (via needle track) are risks associated with percutaneous biopsy. Therefore, it is recommended only when initial imaging studies do not provide a clear diagnosis. (Choice C) Sorafenib is an oral tyrosine-kinase and vascular endothelial growth factor inhibitor approved for the treatment of advanced and unresectable HCC and advanced renal cell carcinoma. Because diagnosis is pending, it is too early to start this patient on systemic chemotherapy. (Choice D) Surgical resection of the lesion requires anatomic delineation, which is best achieved with multiphase CT or MRI scanning. Chest CT and bone scan are also frequently used to determine tumor spread. Once imaging studies are available, a decision regarding surgery can be made depending on patient and tumor characteristics. (Choice E) Ultrasound follow-up in 3 months is recommended for patients with lesions < 1 cm. However, in this patient with known cirrhosis, 2-cm tumor, and elevated AFP, follow-up with ultrasound would not be appropriate. Educational objective: Current guidelines suggest routine surveillance with ultrasound every 6 months in patients with chronic hepatitis B infection and/or cirrhosis. MRI of the liver has better sensitivity and specificity than CT scan or ultrasound in differentiating malignant nodules from the regenerative nodules associated with cirrhosis. Lesions < 1 cm can be managed with ultrasound follow-up in 3 months. __________ References: Alpha fetoprotein, ultrasound, computerized tomography and magnetic resonance imaging for detection of hepatocellular carcinoma in patients with advanced cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/17944733) APASL and AASLD consensus guidelines on imaging diagnosis of hepatocellular carcinoma: a review (http://www.ncbi.nlm.nih.gov/pubmed/22007313)

A 62-Year-Old Man Comes to the Physician with Complaints of Vague