Hepatocellular carcinoma

Question: You are following a 42 year old Vietnamese male with HBV. Last month you discovered a 1.6 cm arterial enhancing lesion on contrast CT, but there was no washout on portal venous phase.  AFP was 96, above the upper limit of normal of 10.  You asked for a contrast MRI, and the results just came back: lesion is measured at 1.4 cm, has arterial enhancement but again no late-phase washout.  What do you recommend?

A. repeat AFP

B. repeat CT or MRI in 3 months

C. biopsy lesion

D. send for RFA (radiofrequency ablation)

Answer:  To answer this question, you should be familiar with the algorithm for investigating small nodules found on screening. In such a case, the most appropriate next step is biopsy.  If positive for hepatocellular carcinoma (HCC), treatment should be determined according to the BCLC staging/treatment allocation system.

Alpha fetoprotein is normal in roughly two-thirds of HCC cases; it is still used as part of the six month screening protocol (with imaging), and can be helpful in diagnosis when >400.  In this case, although it is elevated, it does not cinch the diagnosis.  Remember, germ cell tumors, cirrhosis, metastatic colon cancer and intrahepatic cholangiocarcinoma can all increase AFP to varying degrees.

Waiting three months is not the best idea for this patient.  Imagine that three months from now, this lesion measures 3.1 cm and a new, 7 mm lesion is discovered (and turns out to be HCC).  Suddenly, this patient is outside Milan criteria for transplant exception points- bad news.  Sending this patient directly for ablation without confirming a diagnosis is also not the best option; you would not know whether to begin a transplant evaluation.

For all the details on the 2010 AASLD Practice Guidelines: Management of Hepatocellular Carcinoma, click on the link below.  The multiple choice question above comes from Figure 1.

http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdf

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