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      Atypical Appearance of Hepatocellular Carcinoma and Its Mimickers: How to Solve Challenging Cases Using Gadoxetic Acid-Enhanced Liver Magnetic Resonance Imaging

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          Abstract

          Hepatocellular carcinoma (HCC) can be diagnosed noninvasively with contrast-enhanced dynamic computed tomography, magnetic resonance imaging, or ultrasonography on the basis of its hallmark imaging features of arterial phase hyperenhancement and washout on portal or delayed phase images. However, approximately 40% of HCCs show atypical imaging features, posing a significant diagnostic challenge for radiologists. Another challenge for radiologists in clinical practice is the presentation of many HCC mimickers such as intrahepatic cholangiocarcinoma, combined HCC-cholangiocarcinoma, arterioportal shunt, and hemangioma in the cirrhotic liver. The differentiation of HCCs from these mimickers on preoperative imaging studies is of critical importance. Hence, we will review the typical and atypical imaging features of HCCs and the imaging features of its common mimickers. In addition, we will discuss how to solve these challenges in practice.

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          JSH Consensus-Based Clinical Practice Guidelines for the Management of Hepatocellular Carcinoma: 2014 Update by the Liver Cancer Study Group of Japan

          Masatoshi Kudo, Osamu Matsui, Namiki Izumi … (2014)
          The Clinical Practice Guidelines for the Management of Hepatocellular Carcinoma proposed by the Japan Society of Hepatology was updated in June 2014 at a consensus meeting of the Liver Cancer Study Group of Japan. Three important items have been updated: the surveillance and diagnostic algorithm, the treatment algorithm, and the definition of transarterial chemoembolization (TACE) failure/refractoriness. The most important update to the diagnostic algorithm is the inclusion of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging as a first line surveillance/diagnostic tool. Another significant update concerns removal of the term “lipiodol” from the definition of TACE failure/refractoriness.
          Article 0 comments Cited 248 times – based on 0 reviews     Review now
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            Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: Prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma.

            Alejandro Forner, Ramón Vilana, Carmen Ayuso … (2008)
            This study prospectively evaluates the accuracy of contrast-enhanced ultrasound (CEUS) and dynamic magnetic resonance imaging (MRI) for the diagnosis of nodules 20 mm or smaller detected during ultrasound (US) surveillance. We included 89 patients with cirrhosis [median age, 65 years; male 53, hepatitis C virus 68, Child-Pugh A 80] without prior hepatocellular carcinoma (HCC) in whom US detected a small solitary nodule (mean diameter, 14 mm). Hepatic MRI, CEUS, and fine-needle biopsy (gold standard) (FNB) were performed at baseline. Non-HCC cases were followed (median 23 months) by CEUS/3 months and MRI/6 months. FNB was repeated up to 3 times and on detection of change in aspect/size. Intense arterial contrast uptake followed by washout in the delayed/venous phase was registered as conclusive for HCC. Final diagnoses were: HCC (n = 60), cholangiocarcinoma (n = 1), and benign lesions (regenerative/dysplastic nodule, hemangioma, focal nodular hyperplasia) (n = 28). Sex, cirrhosis cause, liver function, and alpha-fetoprotein (AFP) levels were similar between HCC and non-HCC groups. HCC patients were older and their nodules significantly larger (P < 0.0001). First biopsy was positive in 42 of 60 HCC patients. Sensitivity, specificity, and positive and negative predictive values of conclusive profile were 61.7%, 96.6%, 97.4%, and 54.9%, for MRI, 51.7%, 93.1%, 93.9%, and 50.9%, for CEUS. Values for coincidental conclusive findings in both techniques were 33.3%, 100%, 100%, and 42%. Thus, diagnosis of HCC 20 mm or smaller can be established without a positive biopsy if both CEUS and MRI are conclusive. However, sensitivity of these noninvasive criteria is 33% and, as occurs with biopsy, absence of a conclusive pattern does not rule out malignancy. These results validate the American Association for the Study of Liver Disease (AASLD) guidelines.
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              Pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia.

              (2009)
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                Author and article information

                Journal
                Journal ID (nlm-ta): Korean J Radiol
                Journal ID (iso-abbrev): Korean J Radiol
                Journal ID (publisher-id): KJR
                Title: Korean Journal of Radiology
                Publisher: The Korean Society of Radiology
                ISSN (Print): 1229-6929
                ISSN (Electronic): 2005-8330
                Publication date (Print): July 2019
                Publication date (Electronic): 03 June 2019
                Volume: 20
                Issue: 7
                Pages: 1019-1041
                Affiliations
                [1 ]Department of Radiology, Seoul National University Hospital, Seoul, Korea.
                [2 ]Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
                [3 ]Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.
                Author notes
                Corresponding author: Jeong Min Lee, MD, Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: (822) 2072-3154, Fax: (822) 743-6385, jmsh@ 123456snu.ac.kr
                Author information
                https://orcid.org/0000-0002-6691-3932
                https://orcid.org/0000-0002-1341-4072
                https://orcid.org/0000-0003-0561-8777
                Article
                DOI: 10.3348/kjr.2018.0636
                PMC ID: 6609440
                PubMed ID: 31270973
                SO-VID: 65c53abc-2b54-44ea-b1b2-af9168618821
                Copyright © Copyright © 2019 The Korean Society of Radiology
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 11 September 2018
                Date accepted : 17 March 2019
                Categories
                Subject: Gastrointestinal Imaging
                Subject: Review Article

                ScienceOpen disciplines: Radiology & Imaging
                Keywords: atypical hepatocellular carcinoma,hepatocellular carcinoma mimickers,intrahepatic mass-forming cholangiocarcinoma,combined hepatocellular-cholangiocarcinoma,liver imaging reporting and data system
                Data availability:
                ScienceOpen disciplines: Radiology & Imaging
                Keywords: atypical hepatocellular carcinoma, hepatocellular carcinoma mimickers, intrahepatic mass-forming cholangiocarcinoma, combined hepatocellular-cholangiocarcinoma, liver imaging reporting and data system

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