First Steps When a Liver Mass Is Found

First step: history and risk factors

When a liver mass is found, the first question is the background against which it arose. Chronic hepatitis B/C, cirrhosis, alcohol-related liver disease, fatty liver disease, a known prior cancer (particularly colon, breast or lung cancers that commonly metastasise to the liver), and oral contraceptive use are all important clues about the likely nature of the lesion.

Imaging: dynamic contrast-enhanced CT/MRI

The mainstay of liver mass characterisation is multiphase (arterial, portal venous, delayed) contrast-enhanced CT or MRI. The lesion's enhancement and washout pattern is highly useful in distinguishing among hemangioma, focal nodular hyperplasia, hepatic adenoma, hepatocellular carcinoma and metastasis. MRI, particularly with hepatobiliary contrast agents, can provide additional information for small or difficult-to-characterise lesions.

When are tumour markers needed?

In lesions found on a background of cirrhosis or with suspicious imaging features, alpha-fetoprotein (AFP) contributes to the evaluation for hepatocellular carcinoma. If there is a known history of colorectal cancer, markers such as CEA may be requested. However, tumour markers alone are not diagnostic — a normal level does not rule out malignancy, and an elevated level alone does not confirm cancer.

Benign or malignant? Key considerations

• The lesion's enhancement pattern on imaging (a 'classic' appearance for hemangioma or FNH)
• The condition of the underlying liver (cirrhosis raises risk)
• A known history of a primary cancer (raises the possibility of metastasis)
• Lesion size and how it changes over time (comparison with prior imaging if available)
• Accompanying symptoms (weight loss, abdominal pain, jaundice)

Is biopsy always necessary?

No. When imaging findings are typical for a benign lesion (a classic hemangioma or simple cyst, for example), biopsy is usually unnecessary and may add unwarranted procedural risk. On the other hand, biopsy may be considered for lesions whose diagnosis remains unclear on imaging, that carry a possibility of malignancy, or where the result would directly change the treatment plan. In some cases of suspected hepatocellular carcinoma, a diagnosis can be reached without biopsy when typical imaging features and risk factors are present — this decision is individualised.

Why multidisciplinary evaluation matters

Evaluating liver masses is a process that ideally involves general surgery, gastroenterology/hepatology, radiology, interventional radiology, oncology and, when needed, pathology working together. Especially for lesions of uncertain diagnosis or with malignant potential, the treatment plan (observation, surgical resection, interventional radiological techniques or systemic therapy) is shaped by this multidisciplinary evaluation rather than by a single physician's opinion. This approach helps avoid unnecessary procedures and supports the right treatment decision.