Q. My liver elastogram revealed a large mass with a fatty liver. Please help.

Answered by
Dr. Ajeet Kumar Lohana
and medically reviewed by Dr. Preetha J
This is a premium question & answer published on Oct 23, 2020 and last reviewed on: Oct 31, 2020

Hi doctor,

My liver elastogram has revealed a large mass of 19.8 to 10 cm, with increased reflectivity in the liver's right lobe, also confirmed in the CT scan. Though presently do not have any symptoms, but worried about feeling weak and having weight loss. I was diagnosed with fatty liver five years ago. I am also having high blood sugar and high blood pressure.

#

Hello,

Welcome to icliniq.com.

Well, I can completely understand your anxiety and worry. And to be very honest, I cannot tell the next best treatment approach to this liver mass unless we confirm it with the biopsy of the mass and fully understand what we are dealing with. The treatment can then be guided easily. I have seen all your reports which you have uploaded (attachment removed to protect patient identity).

The CT (Computed tomography) scan has confirmed a large mass in the liver, which suggests two possibilities.

  1. The one is metastatic liver disease (secondary liver tumor). It means there is a possible tumor somewhere else in the body, which has spread to involve the liver.
  2. The second high possibility is a primary liver tumor called hepatocellular carcinoma (HCC).

Some features in the CT scan suggest the former diagnosis, and some suggest the later diagnosis.

The best investigations would be a biopsy of this mass under ultrasound guidance to confirm what it is.

I acknowledge that you had the fatty liver disease in the past, but looking to your CT scan, it does not show any evidence of liver scarring (liver fibrosis or cirrhosis).

I must tell you the liver elastogram is the least helpful test in all of the difficulties you have done because it is usually performed to see the liver stiffness and rule out fibrosis/cirrhosis and never helped diagnose the mass lesion in the liver.

So the best next step is a biopsy of the mass with the help of ultrasound guidance. Once we have the biopsy report available, a further decision can then be taken.

Meanwhile, I want you to get some blood tests; they are tumor markers, which would give us a clue about whether there is any trace of the tumor in other body organs.

I also want you to tell me about the following things. This will help to establish the source of the tumor in other organs of the body.

  • Do you smoke or take alcohol?
  • Do you have any altered bowel habits or noticed changes in the color of stools? Do you have black or bloody stools?
  • Do you have shortness of breath or cough or chest pain?
  • Do you have any swelling anywhere?

Let me know the above things. And get the testing, which I suggest below.

Best regards.


The Probable causes:

Metastatic liver disease versus primary hepatocellular carcinoma (HCC).

Investigations to be done:

Serum Alpha-fetoprotein.
Carcinoembryonic antigen (CEA) levels.
CA19-9.
CA 125.
Serum Chromogranin A levels.
If you have any altered bowel habits, I suggest you discuss colonoscopy with your gastroenterologist there. Otherwise, it would help if you waited for the above testing to come, and then we will decide.

Regarding follow up:

Please update me about your other symptoms.

Hi doctor,

Thank you for your reply.

The patient does not smoke, is not experiencing a change in stool color, shortness of breath, cough, or any swelling elsewhere. As advised, have given samples for tests suggested by you. However, I have received some additional test reports, including AFP.

Antinuclear antibodies are positive and autoimmune hepatitis has markedly increased AFP is 579.

Please advise the best course of action. We will try to upload the other test results also.

#

Hello,

Welcome back to icliniq.com.

Thank you for providing further information about your case and the tests (attachment removed to protect patient identity).

So with raised AFP (Alpha-fetoprotein), it is highly likely that it is primary hepatocellular carcinoma (HCC).

But I must tell you that your case is a little tricky. Because the radiology report (CT scan) has not been helpful as it is in usual hepatocellular cancer cases, if the CT scan report has been conclusive, we probably would not have been in this discussion anymore. We would have labeled that this is HCC and would have now been discussing the further management plan. But this is not the case.

Note: AFP can rise in non-HCC cases. Such as in certain tumors of others can spread to the liver and start secreting AFP mimicking like HCC.

The best next option is to do a biopsy of this large mass in the liver with ultrasound guidance while awaiting the reports of tumor markers that I have suggested to you earlier. For a liver biopsy, do consult your hospital radiologist.

Other reports as advised, viz CEA, serum chromogranin A, CA 125, CA 19-9, have come. Please find attached. We have still not gone for Biopsy, due to fear that, the disease might spread. Again Ultrasound of Liver was done on 8th, Oct, report is also attached.
Please advise the best future course of action, which we may follow.
Chromagranin A and CA 19-9 is on a higher side.
# Hello Mr. Singh. I welcome you again on icliniq.
I have seen the current reports which you have uploaded, and kept on reviewing your previous reports as well.
Yes the chromogranin levels is little high and CA 19-9 which is also twice than normal. However with that little elevation of chromogranin I am not convinced that it is a neuroendocrine tumor.
Let me give you idea why I suggested all this.
AFP-for primary hepatocellular carcinoma
CA125 for male internal genitalia tumor. Which is normal
Chromogranin A CgA - for neuroendocrine tumor. Which is just above the limit of normal reference range. If there were a neuroendocrine tumor sitting in the abdomen and now spread to the liver, it should have been markedly elevated - like twice to thrice than normal.
CA19-9. A tumor marker for pancreatic and bile ( gall bladder ) cancer. This is elevated which raise a suspicion of the potential primary tumor is within gall bladder or pancreas. Since I do not see that pancreas ( a gland sit in the back of tummy) has shown any mass or tumor, however the CT scan report does show that the liver mass which is approx. 14 cm in size is somewhat adherent to the gall bladder.
So the conclusion is that you have two potential possibilities. The one is Hepatocellular carcinoma, and the other possibility is gall bladder cancer which has spread to the liver.
Now we stand again on the same point, that a biopsy is required to confirm among the two strong possibilities . Because the treatment is entirely different.

Unfortunately the prognosis is poor, meaning the survival is no more than 6 months in both of these conditions. But diagnosing them with the help of biopsy is crucial and essential in a sense that, the treatment is sorafenib in HCC, and it is systemic chemotherapy ( intravenous cycles of chemo agents) in case of gall bladder cancer.

But I also want to admit the guidelines for treatment of HCC is quite advanced. So in certain cases, we do go beyond what is recommended in guidelines and we do Transarterial chemoembolization ( TACE) which is a radiological guided procedure- of course after the radiologist gives consent to do it.

So we need biopsy, that is the plan.
Now the risk of sedimentation ( spread) is a real concern, but HCC do not really spread via this. However some gall bladder cancer can spread, but you see the tumor is already spread, and I do not think that the biopsy would more harm at all.
Your thoughts

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