Hepatic Neoplasms

SCORE 10/1
Sophia Liu PGY-2

By Sophia Liu

​Hepatic Neoplasms

​Case Presentation

60 yo M presents to clinic for an incidentally found hepatic lesion on CT. It is 3cm in segment 6 of the liver.

It was found following panscans from an MVC with no traumatic injuries.

Multiple Choice

Which segment of the liver is the lesion in?

• Green superior

• Yellow superior

• Orange inferior

• Purple anterior

-Cantlie line divides the liver into right and left, and lies along the middle hepatic vein (NOT falciform!)
-Horizontal plan divided by the portal vein
-Functionally independent segments

​

Couinard Classification of Hepatic Segments

Open Ended

What is the differential diagnosis for this hepatic neoplasm?

Open Ended

What questions about his history would you ask?

He denies any current symptoms.
His PMH only includes HTN, well controlled with one medication.
His last colonoscopy was 8 years ago, normal, and was told to follow up in 10 years. He has no known hx of hepatitis or cancer.
Denies any family history of cancer.
He denies smoking, drinking, IVDU, or any other drug use.

Open Ended

What are you looking for on physical exam?

On physical exam, he is obese with a BMI of 35.
It is otherwise unremarkable; he is in no acute distress, no abdominal distension, no ascites, no palpable masses, no blood on DRE, no caput medusae, etc.

Open Ended

What labs would you like to get?

Calculates 3-month mortality from liver disease, traditionally used for liver transplants
Has variations to include other important factors like sodium levels (MELD-Na, MELD combined)

MELD score

Used to predict morality from cirrhosis, and grade severity of liver disease. Often used to predict outcomes from other major surgeries.

Child-Pugh score

CLIP scoring
0 = 42.5 months 1 = 32.0 months
2 = 16.5 months 3 = 4.5 months
4 = 2.5 months 5-6 = 1 month

All the labs are within normal limits, except AFP, which is 100.

Open Ended

What is your leading differential diagnosis now?

Multiple Select

What is the next appropriate diagnostic imaging?

• MRI Abd/pel

• Triple phase CT

• CT PET

• No further imaging needed

Li-Rads scoring is used for liver lesions in patients with cirrhosis, to predict likelihood that lesion is HCC given the features seen on CT

Arterial phase

Venous phase

Capsule enhancement

Multiple Choice

Our patient has the classic triad of HCC features on CT scan, with early cirrhosis and fatty liver. No nodularity or portal hypertension. What is his Li-Rads score?

• LR 2

• LR 3

• LR 4

• LR 5

Poll

How would you manage this patient's HCC?

• Resection

• Transplant

• Biopsy

• Observation

Barcelona Clinic Liver Cancer (BCLC) staging

Multiple Choice

What margins are needed for resection?

• 4 cm

• 3 cm

• 1 cm

• 0.5 cm

Multiple Select

If this patient was a poor surgical candidate, what other treatment options are available?

• Ablation

• TACE

• Radioembo with yttrium-90

• Systemic chemotherapy

Poll

How would you manage the patient moving forward post-operatively?

• AFP and CT every 3-6 months for 2-3 years, then every 6 months afterwards

• AFP and MRI every 3-6 months for 2-3 years, then every 6 months afterwards

• AFP and CT every 6 months for 2 years, then fu PRN

• AFP and CT every 6 months indefinitely