Noninvasive Diagnosis of Hepatocellular Carcinoma in Cirrhotic Liver: Current Guidelines and Future Prospects for Radiological Imaging

Abstract

Noninvasive imaging has become the standard for hepatocellular carcinoma (HCC) diagnosis in cirrhotic patients. Typical imaging features of HCC such as arterial wash-in and venous wash-out deliver very high specificity and acceptable sensitivity even in nodules from 1 to 2 cm in diameter. However, limitations apply specifically in hypovascular HCC, for which the addition of new techniques such as diffusion-weighted magnetic resonance imaging (DW-MRI) or hepatobiliary MRI is helpful. Whereas DW-MRI adds to both the sensitivity and specificity, hepatobiliary MRI additionally contributes valuable information in cirrhotic patients on the histopathology of small lesions, including early HCC and high-grade dysplastic nodules. Biopsy of small, atypical lesions is associated with a high rate of false-negative findings and should be used only after careful consideration in selected patients. Here, we review the current international guidelines on HCC diagnosis as well as the latest developments in imaging that may contribute to safe detection and accurate characterization of suspicious nodules in patients with liver cirrhosis.

Delayed Diagnosis of HCC with Chronic Alcoholic Liver Disease

“…For patients with HBV and HCV infection, surveillance is recommended by international guidelines [13,14,15] based on the lifetime risk of developing HCC for infected patients under certain conditions.…”

Pyogenic Liver Abscess Mimicking Liver Neoplasm on Computed Tomography Scan in a Patient With Elevated CA 19-9

“…Application of dynamic imaging criteria to diagnose HCC was suggested only in cirrhotic patients regardless of etiology and patients with chronic hepatopathy [3]. Imaging diagnosis of HCC is a worldwide accepted guideline for HCC diagnosis in cirrhotic patients [4].…”

“…Contrast enhanced ultrasounds were dropped from AASLD recommendations to diagnose PLC due to the potential risk of misdiagnosis of ICC as HCC [3]. Additionally, biopsies were also excluded from HCC diagnosis guidelines by the AASLD and APASL for small, atypical lesions in view of high false-negative rate and should be used after careful evaluation in selected cases only without wash-in or wash-out findings on two imaging modalities [4].…”

“…Although inflammation-mediated carcinogenesis can be carried out over a considerable time, certain cancers can masquerade as liver abscesses either through spontaneous tumor necrosis or biliary obstruction superimposed by bacterial infection caused by tumor thrombi [1,2]. As previously published in the American Association for the Study of Liver Diseases (AASLD) and the Asian Pacific Association for the Study of the Liver (APASL) guidelines, computed tomography (CT) imaging is sufficient to confirm the diagnosis of hepatocellular carcinoma (HCC) without the need for histopathologic confirmation [3,4]. We present a rare case of PLAs caused by Streptococcus constellatus with similar radiological features to liver neoplasm on contrast enhanced CT scan in a patient found to have elevated tumor marker carbohydrate antigen (CA) 19-9.…”

Emerging Strategies for the Management of Hepatocellular Carcinoma

“…During session II entitled ‘Diagnosis of Pathological Early HCC', the pathology in early HCC was discussed [3], with presenters from various countries explaining the clear usefulness of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid magnetic resonance imaging for the diagnosis of early HCC [4,5,6,7]. During session III entitled ‘Diagnostic Algorithm of HCC' [8,9], the topic for discussion was whether the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL) guidelines should include contrast-enhanced ultrasonography. The Japanese diagnostic algorithm pertaining to hypervascular and hypovascular tumors in particular was then introduced.…”