EVALuATION OF LIVER MASS LESIONS

Clinical Evaluation The clinical evaluation of liver mass lesions begins with a careful history and physical examination. Historical features will often give clues to the underlying diagnosis. For example a history of chronic hepatitis or the features or complications of liver cirrhosis is helpful in determining if individuals are at risk for hepatocellular carcinoma and intrahepatic cholangiocarcinoma. A history of primary sclerosing cholangitis is helpful for determining if an individual is at risk for cholangiocarcinoma and a history of long term contraceptive use is helpful in identifying those women at risk for hepatic adenoma. Similarly, individuals with a family history of young onset diabetes mellitus may be at risk for hepatic adenomatosis. In general a history of abdominal pain tends to be nonspecific and unhelpful but pain caused by non-intraabdominal causes such as abdominal wall pain is sometimes the reason that a patient with a liver mass will initially present for evaluation. Individuals with biliary obstruction will typically present with jaundice with associated pruritus, dark urine and pale stools. A history of constitutional symptoms such as fever may be useful in the diagnosis of hepatic abscesses; fever can also be associated with malignancy. Other features of malignancy include anorexia, weight loss, and fatigue. The history is complemented by the results of the physical examination. The physical examination can reveal features of chronic liver disease such as spider angiomas, a periumbilical caput medusa indicative of portal hypertension, hepatomegaly or splenomegaly. The finding of jaundice in a patient with no history of pain is highly suggestive of the development of a malignancy such as cholangiocarcinoma or pancreatic adenocarcinoma. Advanced malignant infiltration and some benign masses may be associated with palpable hepatomegaly, which may be nodular in the presence of cirrhosis or focal masses. History and physical examination findings are complemented by the results of laboratory tests which can indicate or reveal whether the patient has active hepatitis, chronic liver disease with cirrhosis, portal hypertension and hypersplenism resulting in a low platelet count, or hyperbilirubinemia. The use of the serum alpha fetoprotein (AFP) test as a surveillance test for hepatocellular carcinoma is controversial due to its low sensitivity for the detection of early stage disease. The AFP test is well-established as a predictor of risk of development of HCC in individuals with cirrhosis and can be extremely useful for diagnosis of HCC in those individuals with diffuse HCCs who do not have focal liver lesions on imaging studies. While one-time determinations of the AFP have a high false positive rate, particularly in patients with chronic hepatitis C virus infection, careful attention to trends in AFP levels can prove invaluable in the early diagnosis of HCC. The AFPL3 isoform and des-gamma carboxyprothrombin (DCP) are also predictors of risk of HCC. The CA19-9 test is helpful in the diagnosis and prognostic prediction of patients with cholangiocarcinoma. In the absence of acute cholangitis, a CA19-9 value greater than a 1000 units/mL is almost always associated with the presence of extrahepatic disease. The CEA is valuable in assessing colorectal cancer metastatic to the liver and the chromogranin A and 24-hour urine 5-HIAA are useful for assessing neuroendocrine carcinomas metastatic to the liver.