Hepatocellular Cancer (Suspected)

Pathway

Images

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1		Hepatic Haemangioma Image 1 (Computed Tomography): Post-contrast images demonstrating initial peripheral enhancement, followed by delayed filling of the lesion with contrast. These features are typical of a haemangioma.
2a		Hepatic Haemangioma Image 2a, 2b and 2c (Triphasic Computed Tomography): Non-contrast scan (Image 2a) demonstrates a subtle low attenuation lesion in segment 6 of the liver (arrow). There is globular peripheral enhancement of the lesion in the post contrast arterial phase scan (Image 2b) with delayed filling in of the lesion in the portal venous phase (Image 2c).
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2d		Image 2d (Ultrasound): Ultrasound scan demonstrating the liver lesion in same patient.
3		Hepatic Haemangioma Image 3 (H&E, x2.5): Histological section of a hepatic haemangioma showing variously sized, dilated and congested blood vessels set in a fibrous stroma with residual islands of liver parenchyma.
4a		Hepatic Adenoma Image 4a and 4b (Computed Tomography): Coronal and axial views demonstrating several enhancing liver lesions.
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4c		Image 4c (Ultrasound): Ultrasound scan demonstrating the liver lesions in same patient.
5a		Hepatic Focal Nodular Hyperplasia Image 5a and 5b (Triphasic Computed Tomography): The arterial phase scan (Image 5a) shows a hyperattenuating nodular lesion (narrow arrow) with the typical central scar (broad arrow) in segment 4 of the liver. On the delayed portal venous phase (Image 5b), the lesion becomes isoattenuating (arrow).
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6a		Hepatic Focal Nodular Hyperplasia Image 6a, 6b, 6c and 6d (Magnetic Resonance Imaging): Gadolinium-enhanced T1-weighted MRI (Image 6a) demonstrates an ill-defined low-signal intensity mass in segment 4 of the liver with intense enhancement in the arterial phase (Image 6b). Minor enhancement persists in the portal venous phase (Image 6c) and the lesion becomes isointense with enhancement of the central scar (arrow) on the delayed image (Image 6d).
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7a		Hepatic Focal Nodular Hyperplasia Image 7a : Resection specimen showing the circumscribed, light brown to yellow nodular appearance withthe central stellate scar (arrow) characteristic of focal nodular hyperplasia.
7b		Image 7b (H&E, x10): Histological section showing hepatic nodules separated by fibrous septa with peripheral proliferation of bile ducts (arrow) associated with lymphocytic infiltration. The features are typical of focal nodular hyperplasia.
8		Simple Hepatic Cyst Image 8 (Ultrasound): Simple-appearing cyst in the left lobe of liver.
9a		Hepatocellular Carcinoma Image 9a and 9b (Ultrasound): Within segment 6 of the liver, there is an approximately 2cm subcapsular hypoechoic lesion (arrow) which does not demonstrate any increased vascularity.
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9c		Image 9c, 9d, 9e and 9f (Triphasic Computed Tomography): CT of the same patient shows a cirrhotic liver with patent hepatic and portal veins as well as ascites. Within segment 6, there is a nodular area which demonstrates slight enhancement corresponding to the lesion identified on ultrasound (arrow). This lesion could represent either a dysplastic cirrhotic nodule or an early hepatocellular carcinoma.
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9g		Image 9g, 9h, 9i and 9j (Magnetic Resonance Imaging): MRI of the same patient demonstrates a lesion measuring approximately 2.5 cm in diameter on the inferomedial aspect of segment 5 in a subcapsular location. This is bulging the capsule of the liver at the level of the upper pole of the right kidney. The lesion is essentially isointense to the rest of the liver on T1 weighted imaging (out of phase) but is slightly hyperintense on in-phase imaging suggesting that the rest of the liver has some fatty infiltration. The lesion is slightly hyperintense on first echo T2 but is not clearly visible on more heavily weighted T2 imaging. The lesion shows arterial enhancement but washes out in the portal venous phase, with the rim of the lesion remaining enhanced. The appearances are consistent with a hepatocellular carcinoma.
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10a		Hepatocellular Carcinoma Image 10a and 10b : Hepatectomy specimens showing a multifocal hepatocellular carcinoma with areas of necrosis and haemorrhage arising in a cirrhotic liver.
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10c		Image 10c (H&E, x2.5) and 10d (H&E, x10): Histological sections of a hepatocellular carcinoma arising on a background of cirrhosis. The usual lobular architecture is replaced by irregular and thickened trabeculae of malignant hepatocytes. There is mild nuclear pleomorphism.
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Teaching Points

Teaching Points

• In patients at risk of HCC
  • Liver lesions
  • Lesions >1cm should undergo further imaging, preferably with MRI with a liver-specific contrast agent
  • Lesions in patients at high risk for HCC showing typical features of HCC on imaging (arterial enhancement and then wash-out) can be treated as HCC without biopsy
  • Biopsy should be reserved for lesions with non-diagnostic appearances on imaging

References

References

Date of literature search: August 2015

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

1. Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020-2. (Review article). View the reference
2. European Association for the Study of the Liver, European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012;56(4):908-43. (Guidelines). View the reference
3. Omata M, Lesmana LA, Tateishi R, Chen PJ, Lin SM, Yoshida H, et al. Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma. Hepatol Int. 2010;4(2):439-74. (Guidelines). View the reference
4. Kudo M, Izumi N, Kokudo N, Matsui O, Sakamoto M, Nakashima O, et al. Management of hepatocellular carcinoma in Japan: Consensus-Based Clinical Practice Guidelines proposed by the Japan Society of Hepatology (JSH) 2010 updated version. Dig Dis. 2011;29(3):339-64. (Guidelines). View the reference
5. Giannini EG, Cucchetti A, Erroi V, Garuti F, Odaldi F, Trevisani F. Surveillance for early diagnosis of hepatocellular carcinoma: how best to do it? World J Gastroenterol. 2013;19(47):8808-21. (Guidelines). View the reference
6. Ronot M, Vilgrain V. Hepatocellular carcinoma: diagnostic criteria by imaging techniques. Best Pract Res Clin Gastroenterol. 2014;28(5):795-812. (Review article). View the reference
7. Chou R, Cuevas C, Fu R, Devine B, Wasson N, Ginsburg A, et al. Imaging techniques for the diagnosis of hepatocellular carcinoma: a systematic review and meta-analysis. Ann Intern Med. 2015;162(10):697-711. (Level I evidence). View the reference
8. Lee YJ, Lee JM, Lee JS, Lee HY, Park BH, Kim YH, et al. Hepatocellular carcinoma: diagnostic performance of multidetector CT and MR imaging-a systematic review and meta-analysis. Radiology. 2015;275(1):97-109. (Level I/II evidence). View the reference
9. Bruix J, Sherman M. Management of hepatocellular carcinoma. Hepatology. 2005;42(5):1208-36. (Guidelines). View the reference
10. Bolondi L, Cillo U, Colombo M, Craxi A, Farinati F, Giannini EG, et al. Position paper of the Italian Association for the Study of the Liver (AISF): the multidisciplinary clinical approach to hepatocellular carcinoma. Dig Liver Dis. 2013;45(9):712-23. (Guidelines). View the reference
11. Claudon M, Dietrich CF, Choi BI, Cosgrove DO, Kudo M, Nolsoe CP, et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultrasound Med Biol. 2013;39(2):187-210. (Guidelines). View the reference
12. Barreiros AP, Piscaglia F, Dietrich CF. Contrast enhanced ultrasound for the diagnosis of hepatocellular carcinoma (HCC): comments on AASLD guidelines. J Hepatol. 2012;57(4):930-2. (Level IV/V evidence). View the reference
13. Sangiovanni A, Manini MA, Iavarone M, Romeo R, Forzenigo LV, Fraquelli M, et al. The diagnostic and economic impact of contrast imaging techniques in the diagnosis of small hepatocellular carcinoma in cirrhosis. Gut. 2010;59(5):638-44. (Level III evidence). View the reference
14. Numata K, Fukuda H, Nihonmatsu H, Kondo M, Nozaki A, Chuma M, et al. Use of vessel patterns on contrast-enhanced ultrasonography using a perflubutane-based contrast agent for the differential diagnosis of regenerative nodules from early hepatocellular carcinoma or high-grade dysplastic nodules in patients with chronic liver disease. Abdom Imaging. 2015. [Epub ahead of print]. (Level III evidence). View the reference
15. Serste T, Barrau V, Ozenne V, Vullierme MP, Bedossa P, Farges O, et al. Accuracy and disagreement of computed tomography and magnetic resonance imaging for the diagnosis of small hepatocellular carcinoma and dysplastic nodules: role of biopsy. Hepatology. 2012;55(3):800-6. (Level III evidence). View the reference
16. Xu HX, Lu MD, Liu LN, Zhang YF, Guo LH, Xu JM, et al. Discrimination between neoplastic and non-neoplastic lesions in cirrhotic liver using contrast-enhanced ultrasound. Br J Radiol. 2012;85(1018):1376-84. (Level III evidence). View the reference
17. Dumitrescu CI, Gheonea IA, Sandulescu L, Surlin V, Saftoiu A, Dumitrescu D. Contrast enhanced ultrasound and magnetic resonance imaging in hepatocellular carcinoma diagnosis. Med Ultrason. 2013;15(4):261-7. (Level IV evidence). View the reference
18. D'Onofrio M, Crosara S, De Robertis R, Canestrini S, Mucelli RP. Contrast-enhanced ultrasound of focal liver lesions. AJR Am J Roentgenol. 2015;205(1):W56-66. (Review article). View the reference
19. Sirlin CB, Hussain HK, Jonas E, Kanematsu M, Min Lee J, Merkle EM, et al. Consensus report from the 6th International forum for liver MRI using gadoxetic acid. J Magn Reson Imaging. 2014;40(3):516-29. (Guidelines). View the reference
20. Junqiang L, Yinzhong W, Li Z, Shunlin G, Xiaohui W, Yanan Z, et al. Gadoxetic acid disodium (Gd-EOBDTPA)-enhanced magnetic resonance imaging for the detection of hepatocellular carcinoma: a meta-analysis. J Magn Reson Imaging. 2014;39(5):1079-87. (Level I/II evidence). View the reference
21. Zech CJ, Bartolozzi C, Bioulac-Sage P, Chow PK, Forner A, Grazioli L, et al. Consensus report of the Fifth International Forum for Liver MRI. AJR Am J Roentgenol. 2013;201(1):97-107. (Guidelines). View the reference
22. Kwon HJ, Byun JH, Kim JY, Hong GS, Won HJ, Shin YM, et al. Differentiation of small (≤2 cm) hepatocellular carcinomas from small benign nodules in cirrhotic liver on gadoxetic acid-enhanced and diffusion-weighted magnetic resonance images. Abdom Imaging. 2015;40(1):64-75. (Level III evidence). View the reference
23. Tsurusaki M, Sofue K, Isoda H, Okada M, Kitajima K, Murakami T. Comparison of gadoxetic acid-enhanced magnetic resonance imaging and contrast-enhanced computed tomography with histopathological examinations for the identification of hepatocellular carcinoma: a multicenter phase III study. J Gastroenterol. 2015. [Epub ahead of print]. (Level II/III evidence). View the reference
24. Inchingolo R, De Gaetano AM, Curione D, Ciresa M, Miele L, Pompili M, et al. Role of diffusion-weighted imaging, apparent diffusion coefficient and correlation with hepatobiliary phase findings in the differentiation of hepatocellular carcinoma from dysplastic nodules in cirrhotic liver. Eur Radiol. 2015;25(4):1087-96. (Level III evidence). View the reference
25. Sutherland T, Steele E, van Tonder F, Yap K. Solid focal liver lesion characterisation with apparent diffusion coefficient ratios. J Med Imaging Radiat Oncol. 2014;58(1):32-7. (Level III evidence). View the reference
26. Wu LM, Xu JR, Lu Q, Hua J, Chen J, Hu J. A pooled analysis of diffusion-weighted imaging in the diagnosis of hepatocellular carcinoma in chronic liver diseases. J Gastroenterol Hepatol. 2013;28(2):227-34. (Level II/III evidence). View the reference
27. Li Y, Chen Z, Wang J. Differential diagnosis between malignant and benign hepatic tumors using apparent diffusion coefficient on 1.5-T MR imaging: a meta analysis. Eur J Radiol. 2012;81(3):484-90. (Level II evidence). View the reference
28. Sherman M, Bruix J. Biopsy for liver cancer: how to balance research needs with evidence-based clinical practice. Hepatology. 2015;61(2):433-6. (Level IV/V evidence). View the reference
29. Caturelli E, Solmi L, Anti M, Fusilli S, Roselli P, Andriulli A, et al. Ultrasound guided fine needle biopsy of early hepatocellular carcinoma complicating liver cirrhosis: a multicentre study.Gut. 2004;53(9):1356-62. (Level II evidence). View the reference
30. Chhieng DC. Fine needle aspiration biopsy of liver - an update. World J Surg Oncol. 2004;2:5. (Review article). View the reference
31. Silva MA, Hegab B, Hyde C, Guo B, Buckels JA, Mirza DF. Needle track seeding following biopsy of liver lesions in the diagnosis of hepatocellular cancer: a systematic review and meta-analysis. Gut. 2008;57(11):1592-6. (Level II/III evidence). View the reference

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