Newly Developed Hepatocellular Carcinoma (HCC) in Chronic Liver Disease

Multimodality imaging of hepatocellular carcinoma and intrahepatic cholangiocarcinoma

Hepatocellular carcinoma and intrahepatic cholangiocarcinoma are the two most common primary malignant tumors of the liver. The similarities and variations in imaging characteristics that may aid in distinguishing between these two primary tumors will be discussed and outlined in this review. Knowledge of imaging techniques that are currently available would assist in the differentiation between these primary malignancies.

Evidence Supporting LI-RADS Major Features for CT- and MR Imaging-based Diagnosis of Hepatocellular Carcinoma: A Systematic Review

The Liver Imaging Reporting and Data System (LI-RADS) standardizes the interpretation, reporting, and data collection for imaging examinations in patients at risk for hepatocellular carcinoma (HCC). It assigns category codes reflecting relative probability of HCC to imaging-detected liver observations based on major and ancillary imaging features. LI-RADS also includes imaging features suggesting malignancy other than HCC. Supported and endorsed by the American College of Radiology (ACR), the system has been developed by a committee of radiologists, hepatologists, pathologists, surgeons, lexicon experts, and ACR staff, with input from the American Association for the Study of Liver Diseases and the Organ Procurement Transplantation Network/United Network for Organ Sharing. Development of LI-RADS has been based on literature review, expert opinion, rounds of testing and iteration, and feedback from users. This article summarizes and assesses the quality of evidence supporting each LI-RADS major feature for diagnosis of HCC, as well as of the LI-RADS imaging features suggesting malignancy other than HCC. Based on the evidence, recommendations are provided for or against their continued inclusion in LI-RADS. © RSNA, 2017 Online supplemental material is available for this article.

Magnetic resonance imaging in cirrhosis: what's new?

Cirrhosis is the main risk factor for the development of hepatocellular carcinoma (HCC). The major causative factors of cirrhosis in the United States and Europe are chronic hepatitis C infection and excessive alcohol consumption with nonalcoholic steatohepatitis emerging as another important risk factor. Magnetic resonance imaging is the most sensitive imaging technique for the diagnosis of HCC, and the sensitivity can be further improved with the use of diffusion-weighted imaging and hepatocyte-specific contrast agents. The combination of arterial phase hyperenhancement, venous or delayed phase hypointensity "washout feature," and capsular enhancement are features highly specific for HCC with reported specificities of 96% and higher. When these features are present in a mass in the cirrhotic liver, confirmatory biopsy to establish the diagnosis of HCC is not necessary. Other tumors, such as cholangiocarcinoma, sometimes occur in the cirrhotic at a much lower rate than HCC and can mimic HCC, as do other benign lesions such as perfusion abnormalities. In this article, we discuss the imaging features of cirrhosis and HCC, the role of magnetic resonance imaging in the diagnosis of HCC and other benign and malignant lesions that occur in the cirrhotic liver, and the issue of nonspecific arterially hyperenhancing nodules often seen in cirrhosis.

Detection of small intrahepatic metastases of hepatocellular carcinomas using diffusion-weighted imaging: comparison with conventional dynamic MRI

PURPOSE

The purpose of our study was to compare diffusion-weighted MR imaging (DWI) with conventional dynamic MRI in terms of the assessment of small intrahepatic metastases from hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

In 24 patients with multifocal, small (≤2 cm) intrahepatic metastatic foci of advanced HCC, a total of 134 lesions (≤1 cm, n=81; >1 cm, n=53) were subjected to a comparative analysis of hepatic MRI including static and gadopentetate dimeglumine-enhanced dynamic imaging, and DWI using a single-shot spin-echo echo-planar MRI (b values=50, 400 and 800 s/mm(2)), by two independent reviewers.

RESULTS

A larger number of the lesions were detected and diagnosed as intrahepatic metastases on DWI [Reviewer 1, 121 (90%); Reviewer 2, 117 (87%)] than on dynamic imaging [Reviewer 1, 107 (80%); Reviewer 2, 105 (78%)] (P<.05). For the 81 smaller lesions (≤1 cm), DWI was able to detect more lesions than dynamic imaging [Reviewer 1, 68 (84%) vs. 56 (69%), P=.008; Reviewer 2, 65 (80%) vs. 55 (68%), P=.031], but there was no statistically significant difference between the two image sets for larger (>1 cm) lesions.

CONCLUSION

Due to its higher detection rate of subcentimeter lesions, DWI could be considered complementary to dynamic MRI in the diagnosis of intrahepatic metastases of HCCs.

MR imaging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common malignancy typically associated with chronic liver disease and is a leading cause of mortality among these patients. Prognosis is improved when detected early. MRI is the best imaging examination for accurate diagnosis. Although arterial enhancement with delayed washout, increased T2-weighted signal intensity, delayed capsular enhancement, restricted diffusion, and tumor thrombus are typical features, not all lesions demonstrate these findings. The radiologist must be familiar with these typical imaging characteristics, and less common appearances and associated findings of HCC, and must be able to differentiate them from those of lesions that mimic HCC. Knowledge of therapeutic options and how those are related to imaging findings is imperative to assist clinicians in managing these patients.

Optimization of imaging diagnosis of 1-2 cm hepatocellular carcinoma: an analysis of diagnostic performance and resource utilization

BACKGROUND & AIMS

To determine the optimal imaging scan or combinations in terms of diagnostic performance and resource utilization for 1-2 cm nodules found on surveillance for hepatocellular carcinoma.

METHODS

Eighty-four cirrhotic patients with 101, 1-2 cm nodules (34 malignant, 67 non-malignant) prospectively underwent standardized contrast-enhanced ultrasound, CT, and MRI scans. Sensitivity/specificity and potential imaging/biopsy utilization of individual imaging modalities and two-modality combinations performed at the same time (coincidental) or in sequence were measured. Final diagnosis was determined by biopsy (23), growth (10), recurrence (1), or stability in size for ≥ 18 months (67).

RESULTS

For single imaging scans, sensitivities/specificities ranged between 53-62% and 91-100%. When two scans were combined requiring both to be positive, sensitivities/specificities ranged between 29-41% and 99-100%. When two scans were combined sequentially, requiring only one to be positive, sensitivities/specificities ranged between 74-89% and 91-99%. When comparing combination of two positive tests (MRI and CT) to MRI alone, there was a significant drop in sensitivity (41% vs. 62%, p=0.02), no change in specificity (both 100%), with twice as many scans performed, and 9% rise in potential biopsies or 7% rise in follow-up scans. When comparing the combination of MRI then CT (if MRI negative) to MRI alone, there was an insignificant rise in sensitivity (74% vs. 62%, p=0.13), drop in specificity (97% vs. 100%), with 77% more scans performed, and 6% drop in potential biopsies or 7% drop in potential follow-up scans.

CONCLUSIONS

Single imaging scans have similar specificity to two coincidental positive scans with much less resource utilization. Sequential imaging provides the best sensitivity but with diminished specificity.

The management of hepatocellular carcinoma. Current expert opinion and recommendations derived from the 10th World Congress on Gastrointestinal Cancer, Barcelona, 2008

This article summarizes the expert discussion on the management of hepatocellular carcinoma (HCC), which took place during the 10th World Gastrointestinal Cancer Congress (WGICC) in Barcelona, June 2008. A multidisciplinary approach to a patient with HCC is essential, to guarantee optimal diagnosis and staging, planning of surgical options and selection of embolisation strategies or systemic therapies. In many patients, the underlying cirrhosis represents a challenge and determines therapeutic options. There is now robust evidence in favour of systemic therapy with sorafenib in patients with advanced HCC with preserved liver function. Those involved in the care for patients with HCC should be encouraged to participate in well-designed clinical trials, to increase evidence-based knowledge and to make further progress.

The multidisciplinary management of gastrointestinal cancer. The diagnostic and therapeutic approach for primary solid liver tumours in adults

The finding of a focal solid liver lesion represents a challenge for the clinician in terms of the most optimal diagnostic and therapeutic algorithm. Tumours may arise from hepatocytes (hepatocellular adenoma, dysplastic nodules and carcinoma), bile ducts (cholangiocarcinoma) or mesenchymal tissue (hemangioma, epithelioid haemangioendothelioma), or are metastases from primary tumours outside the liver. Focal nodular hyperplasia is the most frequent tumour-like lesion. Imaging techniques are able to detect and characterise most lesions. However, small hypervascular lesions in a cirrhotic liver may be difficult to characterise. More insight has been gathered recently in the histological classification of hepatocellular adenomas, but the differential diagnosis by imaging of adenoma versus FNH or well-differentiated hepatocellular carcinoma remains often difficult. The therapy of a focal liver lesion is determined by its natural history and the functional status of the surrounding liver parenchyma. Selected patients with primary liver cancer are candidates for liver transplantation, while patients with advanced malignant tumours have a poor outcome.

Hepatocellular carcinoma with indeterminate or false-negative findings at initial MR imaging: effect on eligibility for curative treatment initial observations

PURPOSE

To retrospectively evaluate the effect of indeterminate or false-negative findings at magnetic resonance (MR) imaging on eligibility for curative treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This HIPAA-compliant retrospective study was approved by the institutional review board; the need for informed consent was waived. Of 166 patients with cirrhosis in whom HCC was detected with MR imaging, 21 (13 men, eight women; mean age, 60 years) had 33 proved HCCs that were not detected on previous MR images obtained 6-24 months earlier. MR imaging included T1-weighted, T2-weighted, and dynamic contrast material-enhanced T1-weighted imaging. Serial MR images and treatment records were reviewed to evaluate nodule growth and the effect of delayed diagnosis on treatment eligibility.

RESULTS

Of 33 HCCs in 21 patients, 24 corresponding nodules (73%) were described on previous MR images as benign or indeterminate. Five additional nodules were visible at retrospective evaluation, but only on arterial phase images. The diameters of these 29 visible but indeterminate nodules were initially 0.6-1.9 cm (mean, 1.1 cm) and increased to 0.9-4.5 cm (mean, 1.9 cm) at HCC diagnosis (mean follow-up, 378 days). The mean doubling time was 856 days for diameter and 285 days for volume. All nine HCCs with a delayed diagnosis of less than 1 year were smaller than 3 cm at diagnosis, and the patients had undergone liver transplantation (n=3) or technically successful ablation or embolization (n=6). All 10 subcentimeter indeterminate nodules were smaller than 2 cm at HCC diagnosis, and none progressed to untreatable HCC.

CONCLUSION

Indeterminate nodules smaller than 2 cm did not become untreatable HCC with delayed HCC diagnosis of 6-12 months.