Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-7b9c58cd5d-dlb68 Total loading time: 0 Render date: 2025-03-14T18:29:57.307Z Has data issue: false hasContentIssue false

4 - Radiological diagnosis of hepatocellular carcinoma

Published online by Cambridge University Press:  04 August 2010

By
Jonathon M. Willatt ,
Hero K. Hussain  and
Isaac R. Francis
Edited by
Hero K. Hussain  and
Isaac R. Francis
Hero K. Hussain
Affiliation:
University of Michigan Medical School, Ann Arbor
Isaac R. Francis
Affiliation:
University of Michigan Medical School, Ann Arbor
Get access

Summary

Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) perform the major roles in the diagnosis of hepatocellular carcinoma (HCC) alongside alpha-fetoprotein (AFP) serology and biopsy. There is also increasing use of contrast-enhanced ultrasound (CEUS) for the diagnosis of HCC. Accessibility to each modality and expertise determine which is used as the major imaging tool for the diagnosis of HCC. In the context of the rapid increase in the incidence of HCC, it is important to recognize that there will be increasing reliance on imaging tools to diagnose and stage tumors.

Two sets of clinical practice guidelines published in the western literature form the basis of radiologic diagnosis of HCC in both Europe and the United States. These are the European Association for the Study of the Liver (EASL) guidelines formed at the single-topic conference on HCC in 2000 and the American Association for the Study of Liver Diseases (AASLD) practice guideline published in 2005.

Ultrasound

The role of ultrasound is primarily in the surveillance of at-risk patients. The introduction of contrast agents has presented new opportunities for ultrasound specialists in the diagnosis of HCC. HCC shows strong intratumoral enhancement in the arterial phase followed by rapid washout with an isoechoic or hypoechoic appearance in the portal and delayed phases (Figure 4.1). Regenerative and dysplastic nodules do not show early contrast enhancement. Selective arterial enhancement has been shown in 91–96% of lesions confirming a high sensitivity in identifying the arterial neoangiogenesis of HCC.

Type
Chapter
Information
Primary Carcinomas of the Liver , pp. 33 - 50
Publisher: Cambridge University Press
Print publication year: 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Bruix, J, Sherman, M, Llovet, JM, et al. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol 2001; 35(3): 421–30.CrossRefGoogle ScholarPubMed
Bruix, J and Sherman, M. Management of hepatocellular carcinoma. Hepatology 2005; 42(5): 1208–36.CrossRefGoogle ScholarPubMed
Zhang, BH, Yang, BH, and Tang, ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol 2004; 130(7): 417–22.CrossRefGoogle ScholarPubMed
Fracanzani, AL, Burdick, L, Borzio, M, et al. Contrast-enhanced Doppler ultrasonography in the diagnosis of hepatocellular carcinoma and premalignant lesions in patients with cirrhosis. Hepatology 2001; 34(6): 1109–12.CrossRefGoogle Scholar
Albrecht, T, Blomley, M, Bolondi, L, et al. Guidelines for the use of contrast agents in ultrasound. Ultraschall Med 2004; 25(4): 249–56.CrossRefGoogle ScholarPubMed
Nicolau, C, Vilana, R, and Bru, C. The use of contrast-enhanced ultrasound in the management of the cirrhotic patient and for detection of HCC. Eur Radiol 2004; 14(Suppl 8): P63–71.Google ScholarPubMed
Gaiani, S, Celli, N, Piscaglia, F, et al. Usefulness of contrast-enhanced perfusional sonography in the assessment of hepatocellular carcinoma hypervascular at spiral computed tomography. J Hepatol 2004; 41(3): 421–6.CrossRefGoogle ScholarPubMed
Quaia, E, Calliada, F, Bertolotto, M, et al. Characterization of focal liver lesions with contrast-specific US modes and a sulfur hexafluoride-filled microbubble contrast agent: Diagnostic performance and confidence. Radiology 2004; 232(2): 420–30.CrossRefGoogle Scholar
Levy, I, Greig, PD, Gallinger, S, Langer, B, and Sherman, M. Resection of hepatocellular carcinoma without preoperative tumor biopsy. Ann Surg 2001; 234(2): 206–9.CrossRefGoogle ScholarPubMed
Torzilli, G, Minagawa, M, Takayama, T, et al. Accurate preoperative evaluation of liver mass lesions without fine-needle biopsy. Hepatology 1999; 30(4): 889–93.CrossRefGoogle ScholarPubMed
Marrero, JA, Hussain, HK, Nghiem, HV, Umar, R, Fontana, RJ, and Lok, AS. Improving the prediction of hepatocellular carcinoma in cirrhotic patients with an arterially-enhancing liver mass. Liver Transpl 2005; 11(3): 281–9.CrossRefGoogle ScholarPubMed
,Sharing UNfO. The Organ Placement Process: Resources and policies – policy 3.6. 2005 [cited July 30, 2006]. Available from: http://www.unos.org/policiesandbylaws/policies.asp?resources=true
Yamashita, Y, Mitsuzaki, K, Yi, T, et al. Small hepatocellular carcinoma in patients with chronic liver damage: Prospective comparison of detection with dynamic MR imaging and helical CT of the whole liver. Radiology 1996; 200(1): 79–84.CrossRefGoogle ScholarPubMed
Krinsky, GA and Lee, VS. MR imaging of cirrhotic nodules. Abdom Imaging 2000; 25(5): 471–82.CrossRefGoogle ScholarPubMed
Earls, JP, Theise, ND, Weinreb, JC, et al. Dysplastic nodules and hepatocellular carcinoma: Thin-section MR imaging of explanted cirrhotic livers with pathologic correlation. Radiology 1996; 201(1): 207–14.CrossRefGoogle ScholarPubMed
Kelekis, NL, Semelka, RC, Worawattanakul, S, et al. Hepatocellular carcinoma in North America: A multiinstitutional study of appearance on T1-weighted, T2-weighted, and serial gadolinium-enhanced gradient-echo images. AJR Am J Roentgenol 1998; 170(4): 1005–13.CrossRefGoogle ScholarPubMed
Kelekis, NL, Semelka, RC, and Woosley, JT. Malignant lesions of the liver with high signal intensity on T1-weighted MR images. J Magn Reson Imaging 1996; 6(2): 291–4.CrossRefGoogle ScholarPubMed
Mitchell, DG, Palazzo, J, Hann, HW, Rifkin, MD, Burk, DL, and Rubin R. Hepatocellular tumors with high signal on T1-weighted MR images: Chemical shift MR imaging and histologic correlation. J Comput Assist Tomogr 1991; 15(5): 762–9.CrossRefGoogle ScholarPubMed
Kim, T, Baron, RL, and Nalesnik, MA. Infarcted regenerative nodules in cirrhosis: CT and MR imaging findings with pathologic correlation. AJR Am J Roentgenol 2000; 175(4): 1121–5.CrossRefGoogle Scholar
Hussain, HK, Syed, I, Nghiem, HV, et al. T2-weighted MR imaging in the assessment of cirrhotic liver. Radiology 2004; 230(3): 637–44.CrossRefGoogle ScholarPubMed
Efremidis, SC, Hytiroglou, P, and Matsui, O. Enhancement patterns and signal-intensity characteristics of small hepatocellular carcinoma in cirrhosis: Pathologic basis and diagnostic challenges. Eur Radiol 2007; 17: 2969–82.CrossRefGoogle ScholarPubMed
Yu, JS, Kim, KW, Sung, KB, Lee, JT, and Yoo, HS. Small arterial-portal venous shunts: A cause of pseudolesions at hepatic imaging. Radiology 1997; 203(3): 737–42.CrossRefGoogle ScholarPubMed
Yu, JS, Lee, JH, Chung, JJ, Kim, JH, and Kim, KW. Small hypervascular hepatocellular carcinoma: Limited value of portal and delayed phases on dynamic magnetic resonance imaging. Acta Radiol 2008; 16: 1–9.Google Scholar
Dodd, GD, Baron, RL, Oliver, JH, and Federle, MP. Spectrum of imaging findings of the liver in end-stage cirrhosis: Part II, focal abnormalities. AJR Am J Roentgenol 1999; 173(5): 1185–92.CrossRefGoogle ScholarPubMed
Brancatelli, G, Federle, MP, Blachar, A, and Grazioli, L. Hemangioma in the cirrhotic liver: Diagnosis and natural history. Radiology 2001; 219(1): 69–74.CrossRefGoogle ScholarPubMed
Ito, K. Hepatocellular carcinoma: Conventional MRI findings including gadolinium-enhanced dynamic imaging. Eur J Radiol 2006; 58(2): 186–99.CrossRefGoogle ScholarPubMed
Bos, IC, Hussain, SM, Dwarkasing, RS, et al. MR imaging of hepatocellular carcinoma: Relationship between lesion size and imaging findings, including signal intensity and dynamic enhancement patterns. J Magn Reson Imaging 2007; 26: 1548–55.Google ScholarPubMed
Kanematsu, M, Semelka, RC, Leonardou, P, Mastropasqua, M, and Lee, JK. Hepatocellular carcinoma of diffuse type: MR imaging findings and clinical manifestations. J Magn Reson Imaging 2003; 18(2): 189–95.CrossRefGoogle ScholarPubMed
Krinsky, GA, Lee, VS, Theise, ND, et al. Hepatocellular carcinoma and dysplastic nodules in patients with cirrhosis: Prospective diagnosis with MR imaging and explantation correlation. Radiology 2001; 219(2): 445–54.CrossRefGoogle ScholarPubMed
Taouli, B, Losada, M, Holland, A, and Krinsky, G. Magnetic resonance imaging of hepatocellular carcinoma. Gastroenterology 2004; 127(5 Suppl 1): S144–52.CrossRefGoogle ScholarPubMed
Freeny, PC, Grossholz, M, Kaakaji, K, and Schmiedl, UP. Significance of hyperattenuating and contrast-enhancing hepatic nodules detected in the cirrhotic liver during arterial phase helical CT in pre-liver transplant patients: Radiologic-histopathologic correlation of explanted livers. Abdom Imaging 2003; 28(3): 333–46.Google ScholarPubMed
Llovet, JM, Burroughs, A, and Bruix, J. Hepatocellular carcinoma. Lancet 2003; 362(9399): 1907–17.Google ScholarPubMed
Arii, S, Yamaoka, Y, Futagawa, S, et al. Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: A retrospective and nationwide survey in Japan. The Liver Cancer Study Group of Japan. Hepatology 2000; 32: 1224–9.CrossRefGoogle ScholarPubMed
Martin, J, Puig, J, Darnell, A, and Donoso, L. Magnetic resonance of focal liver lesions in hepatic cirrhosis and chronic hepatitis. Semin Ultrasound CT MR. 2002; 23(1): 62–78.CrossRefGoogle ScholarPubMed
Mueller, GC, Hussain, HK, Carlos, RC, Nghiem, HV, and Francis, IR. Effectiveness of MR imaging in characterizing small hepatic lesions: Routine versus expert interpretation. AJR Am J Roentgenol 2003; 180(3): 673–80.CrossRefGoogle ScholarPubMed
Shimizu, A, Ito, K, Koike, S, Fujita, T, Shimizu, K, and Matsunaga, N. Cirrhosis or chronic hepatitis: Evaluation of small (< or = 2-cm) early-enhancing hepatic lesions with serial contrast-enhanced dynamic MR imaging. Radiology 2003; 226(2): 550–5.Google ScholarPubMed
Forner, A, Vilana, R, Ayuso, C, et al. Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: Prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma. Hepatology 2008; 47(1): 97–104.CrossRefGoogle ScholarPubMed
Bolondi, L, Gaiani, S, Celli, N, et al. Characterization of small nodules in cirrhosis by assessment of vascularity: The problem of hypovascular hepatocellular carcinoma. Hepatology 2005; 42(1): 27–34.CrossRefGoogle ScholarPubMed
Matsui, O. Imaging of multistep human hepatocarcinogenesis by CT during intra-arterial contrast injection. Intervirology 2004; 47(3–5): 271–6.CrossRefGoogle ScholarPubMed
Kojiro, M. Focus on dysplastic nodules and early hepatocellular carcinoma: An Eastern point of view. Liver Transpl 2004; 10(2 Suppl 1): S3–8.CrossRefGoogle ScholarPubMed
Byrnes, V, Shi, H, Kiryu, S, Rofsky, NM, and Afdhal, NH. The clinical outcome of small (<20 mm) arterially enhancing nodules on MRI in the cirrhotic liver. Am J Gastroenterol 2007; 102(8): 1654–9.CrossRefGoogle ScholarPubMed
Jeong, YY, Mitchell, DG, and Kamishima, T. Small (<20 mm) enhancing hepatic nodules seen on arterial phase MR imaging of the cirrhotic liver: Clinical implications. AJR Am J Roentgenol 2002; 178(6): 1327–34.CrossRefGoogle ScholarPubMed
Rode, A, Bancel, B, Douek, P, et al. Small nodule detection in cirrhotic livers: Evaluation with US, spiral CT, and MRI and correlation with pathologic examination of explanted liver. J Comput Assist Tomogr 2001; 25(3): 327–36.CrossRefGoogle ScholarPubMed
Libbrecht, L, Bielen, D, Verslype, C, et al. Focal lesions in cirrhotic explant livers: Pathological evaluation and accuracy of pretransplantation imaging examinations. Liver Transpl 2002; 8(9): 749–61.CrossRefGoogle ScholarPubMed
Colli, A, Fraquelli, M, Casazza, G, et al. Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: A systematic review. Am J Gastroenterol 2006; 101(3): 513–23.CrossRefGoogle ScholarPubMed
Bizollon, T, Rode, A, Bancel, B, et al. Diagnostic value and tolerance of lipiodol-computed tomography for the detection of small hepatocellular carcinoma: Correlation with pathologic examination of explanted livers. J Hepatol 1998; 28(3): 491–6.CrossRefGoogle ScholarPubMed
Hanna, RF, Kased, N, Kwan, SW, et al. Double-contrast MRI for accurate staging of hepatocellular carcinoma in patients with cirrhosis. AJR Am J Roentgenol 2008; 190: 47–57.CrossRefGoogle ScholarPubMed
Kim, YK, Kwak, HS, Han, YM, and Kim, CS. Usefulness of combining sequentially acquired gadobenate dimeglumine-enhanced magnetic resonance imaging and resovist-enhanced magnetic resonance imaging for the detection of hepatocellular carcinoma: Comparison with computed tomography hepatic arteriography and computed tomography arterioportography using 16-slice multidetector computed tomography. J Comput Assist Tomogr 2007; 31: 702–11.CrossRefGoogle ScholarPubMed
Kim, SH, Choi, BI, Lee, JY, et al. Diagnostic accuracy of multi-/single-detector row CT and contrast-enhanced MRI in the detection of hepatocellular carcinomas meeting the Milan criteria before liver transplantation. Intervirology 2008; 51(Suppl 1): 52–60.CrossRefGoogle ScholarPubMed
Choi, SH, Lee, JM, Yu, NC, et al. Hepatocellular carcinoma in liver transplantation candidates: Detection with gadobenate dimeglumine-enhanced MRI. AJR Am J Roentgenol 2008; 191: 529–36.CrossRefGoogle ScholarPubMed
Bruegel, M, Holzapfel, K, Gaa, J, et al. Characterization of focal liver lesions by ADC measurements using a respiratory triggered diffusion-weighted single-shot echo-planar MR imaging technique. Eur J Radiol 2008; 18: 477–85.CrossRefGoogle ScholarPubMed
Parikh, T, Drew, SJ, Lee, VS, et al. Focal liver lesion detection and characterization with diffusion-weighted MR imaging: Comparison with standard breath-hold T2-weighted imaging. Radiology 2008; 246: 812–22.CrossRefGoogle ScholarPubMed

Save book to Kindle

To save this book to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×