A large liver mass in a child under 3 with very high alpha-fetoprotein: PRETEXT counts the involved sections and the annotation factors (vessels, extrahepatic disease, multifocality, rupture) that decide resectability or transplant.
Orient first
- PRETEXT I–IV by the number of liver sections involved; annotation factors V, P, E, M, C, F, R, N (verify the 2017 version).
- Differential: infantile haemangioma (< 6 months, normal AFP for age), mesenchymal hamartoma (cystic), HCC in older children.
- Lung metastases are staged with a chest CT.
Acquire the study
- Curvilinear probe; colour Doppler of the hepatic and portal veins.
The manoeuvre
- Mass size in cm in two orthogonal planes; heterogeneity and calcification.
- Portal and hepatic veins: invasion or thrombus on colour Doppler.
- Number of lesions on a sweep in the transverse and longitudinal planes.
What confirms it
- A liver mass in a young child with markedly raised AFP; histology confirms.
What licenses you to exclude it
- Normal AFP for age and typical vascular pattern favour haemangioma.
The classic misread
- Measuring AFP-normal infantile haemangioma as a malignant mass — check age and AFP.