New Paradigm for Management of Hepatocellular Carcinoma by Imaging

Abstract

Based on recent clinical practice guidelines, imaging is largely replacing pathology as the preferred diagnostic method for determination of hepatocellular carcinoma (HCC). A variety of imaging modalities, including ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, and angiography, are currently used to examine patients with chronic liver disease and suspected HCC. Advancements in imaging techniques such as perfusion imaging, diffusion imaging, and elastography along with the development of new contrast media will further improve the ability to detect and characterize HCC. Early diagnosis of HCC is essential for prompt treatment, which may in turn improve prognosis. Considering the process of hepatocarcinogenesis, it is important to evaluate sequential changes via imaging which would help to differentiate HCC from premalignant or benign lesions. Recent innovations including multiphasic examinations, high-resolution imaging, and the increased functional capabilities available with contrast-enhanced US, multidetector row CT, and MRI have raised the standards for HCC diagnosis. Although hemodynamic features of nodules in the cirrhotic liver remain the main diagnostic criterion, newly developed cell-specific contrast agents have shown great possibilities for improved HCC diagnosis and may overcome the diagnostic dilemma associated with small or borderline hepatocellular lesions. In the 20th century paradigm of medical imaging, radiological diagnosis was based on morphological characteristics, but in the 21st century, a paradigm shift to include biomedical, physiological, functional, and genetic imaging is needed. A multidisciplinary team approach is necessary to foster an integrated approach to HCC imaging. By developing and combining new imaging modalities, all phases of HCC patient care, including screening, diagnosis, treatment, and therapy, can be dramatically improved.

Hepatocellular carcinoma: A comprehensive review

“…It can help characterize cirrhotic nodules from HCC using microbubble contrast agents [31,32] . In general, HCC does not have Kupffer cells (reticuloendothelial cells).…”

Focal liver lesions detection and characterization: The advantages of gadoxetic acid-enhanced liver MRI

“…This vascular change is a crucial step in the carcinogenesis. In view of this consideration, HCC diagnosis with imaging techniques is based on a "vascular analysis" of enhancing pattern, with an increased signal intensity or "wash-in" during the arterial phase and a "wash-out" pattern in the portal or equilibrium phase [35] ( Table 1). The lesion is located in the fourth liver segment, between medium and left sovrahepatic vein.…”

Hepatocellular Carcinoma: Current Concepts in Diagnosis, Staging and Treatment

“…In advanced HCC the blood supply is maintained by the abnormal hepatic artery branches. Tumor cells progressively replace normal bile canaliculi and normally functioning hepatocytes [10]. In the cirrhotic liver, the diagnosis of HCC can therefore be based on non-invasive criteria applying dynamic contrast-enhanced imaging modalities searching for the unique dynamic radiological features of HCC, with early contrast uptake in the arterial phase (hypervascularization) and washout in the portal venous or delayed phases.…”

“…However, the use of liver-specific contrast media in MRI imaging is not part of the current recommendations in the EASL and AASLD guidelines either. Gadoxetic acid, Gd-EOB-DTPA, is a hepatocyte-specific contrast agent for MRI that is taken up into the hepatocytes and secreted into the biliary system via distinct transporter proteins [10]. Assessment of the hepatobiliary phase in MRI after application of gadoxetic acid further enhances the sensitivity of MRI in the detection of HCC [15].…”