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September 2012 Liver Newsletter >>
Clinical Scenario: Liver Mass Following “Mild” Cirrhosis
Routine follow up leads to discovery of a liver mass in patient with previous diagnosis of “mild” cirrhosis.
A 54-year-old male patient with a remote history of alcohol abuse and previous diagnosis of “mild” cirrhosis presented for a primary care appointment after having been lost to follow-up for 5 years. He has not drunk alcohol in the last 3 years. A CT scan for screening identified a 3.5 cm mass in the left lobe of his liver that was hyperenhancing on arterial phase with washout in the portal venous phase. Alpha fetoprotein was elevated at 180. On exam he looked well, with no findings directly attributable to liver failure or the mass. Labs were notable for a platelet count of 150, normal creatinine, bilirubin of 0.8, INR of 1.1, AST of 35 and ALT of 55.
The patient was discussed at the UW Health Primary Liver Tumor Clinic. His history and imaging were considered. The options for management of this patient would include loco-regional therapy (LRT) which includes tumor ablation with radiofrequency ablation (RFA), microwave ablation, transarterial chemoembolization (TACE), radioactive bead ablation (Theraspheres), liver resection (non-anatomic or anatomic), and/or liver transplant (deceased donor or living donor). After discussion, the recommendation was made for non-anatomic liver resection as his best chance to enjoy minimal change in quality of life with a good long-term survival.
While seemingly straightforward, the decision-making for patients with liver disease in the setting of cirrhosis has become complicated, with many different options that span a multi-disciplinary array of expertise. Each patient needs to be considered in a longitudinal way, with different options to be considered in the future management of the patient.
There remains controversy on which patients should be treated with LRT, liver transplant, or resection.
The key factors include liver functional status, presence of portal hypertension, presence of hepatitis C (and whether this has been responsive to treatment), presence of hepatitis B (and whether this has been treated), size and rate of growth of the tumor, other radiologic characteristics, tumor markers, social factors (concerning whether a patient may or may not be a transplant candidate), and patient desires.
It is crucial that radiologists that specialize in reading CT, MRI and ultrasound of the liver in cirrhotics are involved, and that the input of hepatology, surgical oncology, transplant surgery, oncology, and interventional radiology is considered on every patient. Additionally there may be regional variables that play a role, which can affect organ availability/transplant waiting times. This will dictate decisions about whether a patient is best suited getting LRT as a bridge to transplant, or alternatively for consideration of living donor liver transplantation.
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For More Information
Learn more about UW Health’s Primary Liver Tumor Clinic here