Magnetic resonance imaging of the cirrhotic liver: An update

Abstract

Noninvasive imaging has become the standard for hepatocellular carcinoma (HCC) diagnosis in cirrhotic livers. In this review paper, we go over the basics of MR imaging in cirrhotic livers and describe the imaging appearance of a spectrum of hepatic nodules marking the progression from regenerative nodules to low- and high-grade dysplastic nodules, and ultimately to HCCs. We detail and illustrate the typical imaging appearances of different types of HCC including focal, multi-focal, massive, diffuse/infiltrative, and intra-hepatic metastases; with emphasis on the diagnostic value of MR in imaging these lesions. We also shed some light on liver imaging reporting and data system, and the role of different magnetic resonance imaging (MRI) contrast agents and future MRI techniques including the use of advanced MR pulse sequences and utilization of hepatocyte-specific MRI contrast agents, and how they might contribute to improving the diagnostic performance of MRI in early stage HCC diagnosis.

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“…4 Diffuse HCCs (Figure 3) are usually large and have ill-defined boundaries. They usually present with high alpha-fetoprotein levels and are almost always associated with portal venous thrombus, which can be bland or, most of the time, tumoral in nature.…”

“…Because they can blend with the background cirrhotic parenchyma, they can prevent early diagnosis and lead to advanced disease at presentation with often distant metastases. 4 Large HCCs may exhibit a broad spectrum of morphologic features, including a mosaic pattern, a tumor capsule, an intratumoral nodule ("nodule-innodule" appearance), and extracapsular extension with the formation of satellite nodules. 3 …”

“…However, reported sensitivity and specificity are variable, and studies have shown that US detects HCC at a significantly lower rate than CT and MRI. 4 In 225 patients with HCC confirmed by pathologic analysis at liver explantation, the lesionbased sensitivity of US was only 46%. 6 Currently, all major clinical practice guidelines endorse multiphasic CT and MRI with extracellular contrast agents as first-line modalities for diagnosing and staging HCC.…”

“…Thus, the greatest benefit can be obtained from the combined use of DWI with conventional dynamic MRI; this combination provides higher sensitivities than dynamic MRI alone for detecting small HCC lesions in patients with chronic liver disease. 4 At present, DWI is typically used in conjunction with contrast enhancement. Here, it has been shown to improve detection rates, especially of small lesions (< 2 cm).…”

Utility of diffusion-weighted magnetic resonance imaging in diagnosing hepatocellular carcinoma in cirrhotic liver

“…Liver nodules that displayed a marked uptake of contrast agent on DCE-MRI in the arterial phase and displayed wash-out in the later phases were evaluated for the presence HCC [2][3][4][5]10 . If the liver nodule size was between 10-19 mm and displayed peripheral thin capsular enhancement in portal venous or delayed phases, and/or increased in size in a six-month interval follow-up imaging, then it was accepted as HCC (LI-RADS 5).…”