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Question 13#

A 52-year-old man with cirrhosis resulting from chronic hepatitis C presents with increasing right upper quadrant pain, anorexia, and 15-lb weight loss. The patient is mildly icteric and has moderate ascites. A friction rub is heard over the liver. Abdominal paracentesis reveals blood-tinged fluid, and CT scan shows a 4-cm solid mass in the right lobe of the liver.

Which of the following is the most important initial diagnostic study? 

A. Serum α-fetoprotein level
B. Colonoscopy to search for a primary neoplasm
C. Measurement of hepatitis C viral RNA
D. Upper GI endoscopy
E. Positron emission tomography scan

Correct Answer is A

Comment:

This patient has probably developed hepatocellular carcinoma (HCC) as a complication of his macronodular cirrhosis. HCC is a feared complication of patients with cirrhosis resulting from hepatitis B, hepatitis C, and hemochromatosis (although it occurs with modestly increased frequency in patients with alcoholic cirrhosis as well). The incidence in high-risk patients is 3% per year. An α-fetoprotein (AFP) level greater than 500 µg/L is suggestive, and greater than 1000 μg/L virtually diagnostic, of this tumor. In patients with cirrhosis, elevated AFP, and tumors that are greater than 2 cm in size with typical CT appearance, diagnosis can be made without biopsy. Most patients will die within 6 months if untreated; resection of the tumor is often difficult due to the underlying liver disease. Liver transplantation can be curative in selected patients. If the α-fetoprotein is unexpectedly normal, CT-guided biopsy of the lesion would be more productive than a blind search (EGD, colonoscopy) for a primary tumor. PET scans are very expensive and would be unlikely to provide information that would change his management.