A 62-year-old man comes to the office due to fatigue and weight loss. Over the last 6 months, he has lost 9 kg (20 lb) and can no longer walk long distances without sitting down to rest. The patient has not seen a physician in 15 years. He has smoked a pack of cigarettes daily for the last 35 years but does not use alcohol or illicit drugs. He has not recently traveled. Temperature is 36.9 C (98.4 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 12/min. Lungs are clear to auscultation, and abdominal examination shows a liver span of 14 cm with no tenderness. Rectal examination reveals normal sphincter tone but a slightly enlarged prostate that is nontender to palpation. Chest x-ray is unremarkable. CT scan of the abdomen with contrast is shown in the image below. Which of the following is most likely to establish the diagnosis in this patient?

Question

A 62-year-old man comes to the office due to fatigue and weight loss.  Over the last 6 months, he has lost 9 kg (20 lb) and can no longer walk long distances without sitting down to rest.  The patient has not seen a physician in 15 years.  He has smoked a pack of cigarettes daily for the last 35 years but does not use alcohol or illicit drugs.  He has not recently traveled.  Temperature is 36.9 C (98.4 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 12/min.  Lungs are clear to auscultation, and abdominal examination shows a liver span of 14 cm with no tenderness.  Rectal examination reveals normal sphincter tone but a slightly enlarged prostate that is nontender to palpation.  Chest x-ray is unremarkable.  CT scan of the abdomen with contrast is shown in the image below.  Which of the following is most likely to establish the diagnosis in this patient?

Quizplus · Accepted Answer

This patient with weight loss and fatigue has multiple liver lesions on CT scan, suggesting metastatic disease to the liver rather than primary liver cancer. Colorectal cancer is the most common source of liver metastases (as blood from the colon moves through the portal circulation directly to the liver) and should be excluded in this patient, even in the absence of specific symptoms (eg, alteration in bowel habits, gastrointestinal bleeding). Abdominal CT is a useful screening test but can often miss primary intraluminal tumors. Colonoscopy is the most appropriate next diagnostic step as it both localizes the tumor and provides a tissue diagnosis. multiple liver lesions Lung and breast cancers also metastasize to the liver, although less commonly than gastrointestinal malignancies. This patient is a smoker; however, he has a normal chest x-ray and no respiratory symptoms (eg, cough), making metastatic lung cancer unlikely. (Choice A) Alpha-fetoprotein measurement is used along with imaging studies in the diagnosis of hepatocellular carcinoma, which most commonly occurs in the setting of chronic liver disease and presents as a solitary mass. (Choice B) With pyogenic liver abscesses, aspiration and culture can guide antibiotic therapy. However, abscesses typically present acutely with fever, right upper quadrant pain, anorexia, and weight loss. Serologic studies can distinguish between pyogenic and amebic liver abscesses. (Choice C) Bone marrow biopsy is useful in establishing a diagnosis of myeloproliferative or lymphoproliferative disorders. It would be uncommon for these disorders to cause multiple liver masses. (Choice E) Prostate-specific antigen measurement is a useful marker for prostate cancer. However, prostate cancer tends to be an indolent malignancy that commonly metastasizes to the pelvic lymph nodes and bones rather than the liver. (Choice F) Liver flukes can be diagnosed with ova and parasite stool tests. However, they tend to invade the biliary tree rather than the liver parenchyma, and the patient has no history of recent travel abroad, making this diagnosis unlikely. Educational objective: Multiple liver masses are much more likely to be the result of metastatic disease than infectious causes or primary liver malignancy. Primary tumors of the gastrointestinal tract, lung, and breast are the most common diseases causing liver metastases.

A 62-Year-Old Man Comes to the Office Due to Fatigue