Current staging of hepatocellular carcinoma: imaging implications

Abstract

The incidence of hepatocellular carcinoma has been rising in the USA in the past two decades. Hepatocellular carcinoma primarily affects older people and reaches its highest prevalence among those aged between 50 and 70 years. Chronic infection by the hepatitis B virus is the most common cause of this disease. Since hepatocellular carcinoma is an indolent tumor, it has a low life expectancy. In patients with suspected hepatocellular carcinoma, CT, MRI, and ultrasound techniques are useful for formulating the diagnosis based on vascularity and specific enhancement features. In this paper we will discuss the multimodal approach for diagnosis and surveillance of hepatocellular carcinoma. We will also furnish the latest staging and treatment, epidemiology, clinical presentation, pathology and laboratory findings in hepatocellular carcinoma.

Figure 1

(a) A 64-year-old man with hepatocellular carcinoma and chronic transfusion-related hepatitis C. Transverse sonogram shows a small, 3 cm, hypoechoic mass in the right lobe of the liver. (b) A 51-year-old man with a history of hemochromatosis and hepatocellular carcinoma. Transverse sonogram shows a heterogeneous large mass in the right lobe of the liver.

Figure 2

A 51-year-old man with a history of hemochromatosis and hepatocellular carcinoma. (a) Transverse sonogram shows portal vein thrombus. (b) Transverse color Doppler sonogram of the right upper quadrant shows heterogeneous flow within the tumor thrombus.

Figure 3

A 70-year-old man with hepatocellular carcinoma. (a) Unenhanced CT of the liver shows a heterogeneous mass in segment VIII. (b) Contrast-enhanced CT of the liver during the early arterial phase shows an enhancing mass in segment VIII. (c) Contrast-enhanced CT of the liver during the late arterial phase shows a progressively enhancing mass in segment VIII. (d) Contrast-enhanced CT in the delayed phase of contrast enhancement shows an increase in contrast between low-attenuation hepatocellular carcinoma and liver parenchyma.

Figure 4

(a) A 51-year-old man with a history of cirrhosis, hemochromatosis, and hepatocellular carcinoma. Arterial phase contrast-enhanced CT of the abdomen at the level of the main portal vein shows heterogeneous enhancement of the portal vein and nodularity of the hepatic contour. (b) In the same patient, late-phase contrast-enhanced CT of the abdomen at the same level as (a) shows washout of enhancement in the portal vein. There is a hypodense lesion within segment IV consistent with hepatocellular carcinoma. (c) A 54-year-old man with hepatocellular carcinoma and non-A/non-B hepatitis. Late-phase contrast-enhanced CT of the abdomen shows cavernous transformation of the portal vein.

Figure 5

A 65-year-old man with history of partial left hepatic lobectomy. (a) Early arterial contrast-enhanced CT of the abdomen shows enhancing recurrent tumor adjacent to the surgical margin. (b) Delayed contrast-enhanced CT of the abdomen shows contrast between the low-attenuation recurrent tumor and the hepatic parenchyma adjacent to the surgical margin.

Figure 6

An 85-year-old woman with hepatocellular carcinoma. Axial three-dimensional spoiled gradient-echo unenhanced MR image (TR/TE, 5/2) shows a hypointense mass in segment II/III of the left lobe of the liver.

Figure 7

An 85-year-old woman with hepatocellular carcinoma. Axial fast spin-echo T2-weighted MR image (381/75; echo-train length, 12) shows hyperintense hepatocellular carcinoma in segment II/III of the left lobe of the liver.

Figure 8

An 85-year-old woman with hepatocellular carcinoma. (a) Axial three-dimensional spoiled gradient-echo in the early arterial phase MR image (TR/TE, 5/2) shows a hyperintense mass in segment II/III of the left lobe of the liver. (b) Axial three-dimensional spoiled gradient-echo in the early arterial phase MR image (TR/TE, 5/2) shows a progressive enhancement of the hepatic parenchyma and the mass in segment II/III of the left lobe of the liver. (c) Axial three-dimensional spoiled gradient-echo in the early arterial phase MR image (TR/TE, 5/2) shows washout of contrast from the mass in segment II/III of the left lobe of the liver. Note the hyperintense capsule.

Figure 9

An 86-year-old man with melanoma. (a) Axial fast spin-echo T2 axial 2D fast spin echo (TR/TE 4000/85) weighted MR image of the liver shows a hyperintense mass in segment VIII, consistent with a well-differentiated hepatocellular carcinoma. (b) Axial 2D gradient echo T2 ^* (TR/TE 180/15) weighted MR image of the liver shows a hyperintense mass in segment VIII. (c) Axial 2D gradient echo T2 ^* (TR/TE 180/15) post Feridex gradient echo T2 weighted MR image of the liver shows a hyperintense mass in segment VIII, due to lack of Feridex uptake. Note the normal liver parenchyma is hypointense. In this case the clinical history is misleading as to the correct diagnosis.

Figure 10

A 60-year-old woman with hepatocellular carcinoma and underlying Crohn’s disease. (a) Axial three-dimensional precontrast gradient-echo MR image (TR/TE, 220/4) shows a hypointense recurrent tumor in segment IV of the liver, at the site of wedge resection. Note another HCC in segment III. (b) Axial three-dimensional gradient-echo early arterial phase MR image (TR/TE, 220/4) shows a hyperintense recurrent tumor in segment IV of the liver, at the site of wedge resection. (c) Axial three-dimensional gradient-echo portal venous phase MR image (TR/TE, 220/4) shows a hypointense mass relative to the hepatic parenchyma segment IV of the liver, at the site of wedge resection. Note delayed capsular enhancement.

Figure 11

A 55-year-old man with hepatocellular carcinoma, in the setting of hepatitis C, following PVE. (a) Axial CT of the abdomen shows portal vein thrombus following portal vein embolization. (b) Axial CT of the abdomen shows superior mesenteric vein thrombus following portal vein embolization.