Which imaging modalities are used in the workup of hepatocellular carcinoma (HCC)?

Updated: Jul 31, 2019
  • Author: Daniel R Jacobson, MD, MS; Chief Editor: John Karani, MBBS, FRCR  more...
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Cross-sectional imaging with computed tomography (CT) scanning and magnetic resonance imaging (MRI) is most commonly used to detect hepatocellular carcinoma (HCC). CT scanning is frequently the first examination; however, MRI has superior contrast resolution and may better detect lesions less than 1 cm in diameter. Ultrasonography (US) can be sensitive in detecting HCC and, depending on the operator, can detect small lesions. US can evaluate for vascular invasion of the portal and hepatic veins through color Doppler imaging. Nuclear medicine imaging, angiography, and plain films are less useful. [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]

CT scanning should be performed in hepatic arterial, portal venous, and delayed phases. Similarly, if MRI is used, precontrast, arterial, venous, and delayed phases are essential. Enhancement patterns of regenerative, dysplastic, and HCC nodules overlap; therefore, nodules of cirrhosis may not be differentiated from small HCCs. 

Nonspecific findings on plain film are standard. An abdominal mass may be visible. Plain films amay show a mass in the upper abdomen if the HCC is large. Calcification is rare in HCC but is more frequent in other hepatic masses, such as fibrolamellar HCC. Patients with hemochromatosis as a predisposing factor in the development of HCC may show deposition of calcium pyrophosphate in the cartilage of joints. Many other causes of chondrocalcinosis exist, such as gout, hyperparathyroidism, Wilson disease, and degenerative joint disease.

Nuclear imaging provides relatively nonspecific findings. The HCC may present as a "cold" defect on a sulfur-colloid study or may demonstrate uptake of radiopharmaceuticals if the mass produces bile. Gallium uptake is seen in 90% of HCCs. The US appearance of HCC varies; it may be hyperechoic or hypoechoic. A small hyperechoic HCC may be confused with hemangioma.

Angiography may show increased vascularity of other hepatic tumors, including benign masses.

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