Hepatocellular carcinoma

Disquieting

Step 1: View clinicals

A 59-year-old man presents with dull cramping pain in the right upper abdomen for 3 days. No other symptoms are present. He was diagnosed with type 2 diabetes five years ago, which is well controlled on Metformin alone. His surgical and family histories are unremarkable. He smokes heavily, with a total of 15 pack years to date. He also drinks significantly, having consumed 2 to 3 units of alcohol almost every day for the last 10 years. A complete blood count, renal profile, electrolyte assay, and random capillary glucose level are all within normal parameters.


Step 2: Order all relevant investigations

Liver profile

ALT: 56 IU/L (8 - 48) AST: 65 IU/L (7 - 55) GGT: 71 IU/L (9 - 48) Albumin: 2.9 g/dL (3.5 - 5.9).

Ultrasound abdomen

There is a heterogeneously hyperechoic solitary lesion in the left lobe of the liver, ~6cm x 8cm in diameter. The remainder of the liver parenchyma appears normal. The pancreas, spleen and kidneys appear normal. There is no evidence of pre- or para-aortic lymphadenopathy.

Four-phase CT liver

The CT is consistent with the ultrasound findings of the focal liver lesion, and shows arterial phase enhancement and rapid contrast washout during the venous phase. There is no evidence of locoregional spread.

Liver Biopsy

You realize that a liver biopsy can probably be avoided for now.


Step 3: Select appropriate management

Sorafenib
Surgical resection
Transarterial chemoembolization
Radiofrequency ablation


Score: ★★☆