VA Morning Report: Solid liver lesion without cirrhosis

Case summary: Rockstar MS3 Axel Adams did a fantastic job presenting the case of a 70M with PMH schizophrenia and HCV without cirrhosis, who presented with LE edema and was found to have an IVC thrombus and multifocal hepatic mass.

Top pearls:
1. Recall that 80-90% of hepatocellular carcinomas are associated with cirrhosis. HCC can develop without cirrhosis in patients with HBV, NASH, alpha-1-antitrypsin, and transformation from hepatic adenoma.
2. Work-up of a solid liver lesion without HBV, cirrhosis or extrahepatic malignancy should include checking tumor markers, getting CT or MRI, and considering biopsy versus resection if the preceding tests are non-diagnostic.
3. The three cancers that classically can be diagnosed without a biopsy are: hepatocellular carcinoma, renal cell carcinoma, and testicular cancer.

Solid liver lesion WITHOUT HBV, cirrhosis or extrahepatic malignancy
Thanks to Chief of Medicine/Gastroenterologist Ken McQuaid for joining us today and giving us this great framework
 
Conditions leading to HCC without cirrhosis: NASH, alpha 1 antitrypsin, conversion from adenoma
 
Work-up:
– Lesions <1cm: get MRI with contrast, resect if confirmed HCC, or follow serial imaging if not.
– Lesions >1cm:
1. Check AFP and obtain triple-phase CT or MRI with contrast.
2. If imaging non-diagnostic for HCC, check CA 19-9 for cholangiocarcinoma (can be falsely elevated in biliary obstruction).
3. If work-up remains non-diagnostic, consider biopsy versus resection.
 
Differential diagnosis:
Benign
– hepatic hemangioma
– focal nodular hyperplasia
– hepatic adenoma
– idiopathic noncirrhotic portal hypertension
– regenerative nodules
Malignant
– HCC (including fibrolamellar variant)
– cholangiocarcinoma
– non-Hodgkins lymphoma
– mucinous cystic neoplasms
– mesenchymal tumors (rare soft tissue/vascular sarcomas)
– hepatoblastoma
– metastases

Cancers where tissue is not the issue

1. Renal cell carcinoma- tissue diagnosis obtained via nephrectomy or partial nephrectomy
2. Testicular cancer- tissue diagnosis obtained via orchiectomy
3. Hepatocellular carcinoma- diagnosed radiographically on triple-phase CT or MRI with contrast
Mittal S, El-Serag HB. Epidemiology of hepatocellular carcinoma: consider the population. J Clin Gastroenterol. 2013;47(Suppl):S2–S6.
El-Serag HB. Hepatocellular carcinoma. N Engl J Med. 2011;365:1118-1127.

Gupta S, Bent S, Kohlwes J. Test characteristics of alpha-fetoprotein for detecting hepatocellular carcinoma in patients with hepatitis C. A systematic review and critical analysis. Ann Intern Med. 2003 Jul 1; 139(1):46-50.

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