Guideline Recommendations for Evaluation and Management of Suspected Liver Neoplasm

Initial Imaging Assessment

Dynamic contrast‑enhanced CT or MRI of the liver together with chest CT should be obtained immediately to characterize hepatic lesions and detect metastatic disease, guiding subsequent multidisciplinary treatment planning (National Comprehensive Cancer Network [NCCN] guidelines) [1][2].
Multiphasic contrast‑enhanced CT or MRI of the abdomen is required to assess enhancement patterns, lesion number, size, vascular invasion, and underlying liver function (guideline consensus) [1][3]4.
The classic imaging phenotype of hepatocellular carcinoma (HCC) is intense arterial phase enhancement followed by delayed wash‑out; this pattern is diagnostic in appropriate clinical contexts (NCCN) 2.
Viable tumor tissue is defined by arterial‑phase contrast uptake on imaging (guideline consensus) [1][3].
Chest CT is recommended to evaluate for extra‑hepatic metastatic disease (guideline consensus) [4][2].

Serum alpha‑fetoprotein (AFP), a complete liver function panel, and assessment of hepatitis B/C infection or cirrhosis should be performed in all patients with suspected liver neoplasm (guideline consensus) [1][3].
An AFP level > 400 ng/mL in the presence of typical HCC imaging strongly supports the diagnosis, although approximately 46 % of HCC patients have normal AFP levels (NCCN) 2.
AFP must not be used as the sole criterion for treatment decisions; clinical and imaging data are required for definitive management (guideline consensus) [1][3].

Biopsy of potentially resectable lesions should be avoided when possible because of a 1–3 % risk of needle‑tract tumor seeding (guideline consensus) 4.
Indications for biopsy include inconclusive imaging, absence of cirrhosis (where imaging specificity is lower), or when histologic confirmation would change management (guideline consensus) [4][5].

Patients should be referred promptly to a multidisciplinary team comprising hepatologists, surgical oncologists, transplant surgeons, and interventional radiologists (NCCN) 2.
Multidisciplinary management is associated with higher rates of curative treatment and improved overall survival (NCCN) 2.

Liver function (Child‑Pugh classification): Only Child‑Pugh A and selected B patients are candidates for curative or locoregional therapies; Child‑Pugh C patients receive supportive care only (guideline consensus) [6][4].
Very early/early stage (single tumor or ≤ 3 nodules ≤ 3 cm): Consider surgical resection, liver transplantation, or radiofrequency ablation (RFA) (guideline consensus) [1][7].
Intermediate stage (multinodular disease without vascular invasion or extra‑hepatic spread): Transarterial chemoembolization (TACE) is the preferred locoregional therapy (guideline consensus) [8][7].
Advanced stage (vascular invasion or extra‑hepatic disease with preserved liver function): Sorafenib is the standard first‑line systemic therapy (guideline consensus) [1][3]8.

Liver transplantation is indicated for patients meeting Milan criteria (solitary lesion < 5 cm or up to three lesions < 3 cm) in the setting of cirrhosis (guideline consensus) [7][4]; these patients achieve > 75 % five‑year survival (guideline consensus) 6.
Surgical resection is appropriate for non‑cirrhotic HCC (including fibrolamellar variant) and for highly selected Child‑Pugh A cirrhotic patients who are not transplant candidates (guideline consensus) [6][4].
RFA is recommended for tumors ≤ 5 cm and ≤ 5 lesions; it provides superior efficacy to percutaneous ethanol injection for larger lesions (guideline consensus) [7][6].

After curative treatment (resection or RFA), dynamic CT or MRI should be performed every 3 months for the first 2 years, then every 6 months thereafter, with clinical assessment for liver decompensation at each visit (guideline consensus) [1][3]9.
Patients who develop recurrence may still be eligible for curative therapies such as repeat resection, transplantation, or ablative techniques (guideline consensus) [1][10].