What are the imaging guidelines for hepatocellular carcinoma (HCC)?

Updated: Jul 31, 2019
  • Author: Daniel R Jacobson, MD, MS; Chief Editor: John Karani, MBBS, FRCR  more...
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According to the National Comprehensive Cancer Network (NCCN), screening and surveillance for HCC is considered cost-effective in patients with cirrhosis or chronic hepatitis B. The NCCN recommended ultrasonography with or without α-fetoprotein (AFP). If ultrasonography-detected nodules are negative, testing should be repeated in 6 months. If the nodules are small (< 10 mm), repeat in 3 to 6 months. For patients who have a positive AFP test result or have large nodules (≥10 mm) or have capsular retraction or vascular invasion, further imaging with computed tomography (CT) or MRI allows for a definitive diagnosis. [16]

The American Association for the Study of Liver Diseases (AASLD) guidelines, like NCCN, recommend routine screening for HCC in adults with cirrhosis. The initial screening is performed with ultrasound with or without alpha- fetoprotein (AFP) every 6 months. Unlike NCCN, there are no recommendations for screening and surveillance of HCC in noncirrhotic patients. [17]  

In adults with cirrhosis and suspected HCC, the AASLD recommends diagnostic evaluation with either multiphasic CT or multiphasic MRI. The selection of the optimal modality and contrast agent for a particular patient depends on multiple factors beyond diagnostic accuracy. These include modality availability, scan time, throughput, scheduling backlog, institutional technical capability, examination costs and charges, radiologist expertise, patient preference, and safety considerations. [17]

The American College of Radiology (ACR) imaging guidelines acknowledge that all international organizations recommend ultrasonography to screen for HCC, however, the ACR notes that this modality is particularly limited for identifying HCC in patients with obesity, nonalcoholic fatty liver disease (NAFLD), and nodular cirrhotic livers. According to the ACR, in these patient groups, as well as in patients who are on the liver transplant wait list, ultrasonography is so limited that consideration should be made for screening for HCC with either MRI or multiphase CT. [18, 19]

The ACR guidelines also state that if a suspicious liver lesion greater than 1 cm is identified on ultrasound, the diagnosis must be confirmed by MRI or multiphase CT. MRI is preferable because of its slightly increased accuracy over CT and because MRI can detect premalignant nodules. However, multiphase CT can accurately diagnose HCC as well. [18]  The guidelines also note that patients who have been previously diagnosed with and treated for HCC require continued surveillance for recurrent HCC. Multiphase CT or MRI is recommended to assess response 1 month after resection or therapy, followed by imaging every 3 months for at least 2 years. [18]

The Liver Image Reporting Data System (LIRADS) was created to standardize the acquisition, interpretation, reporting, and data collection of HCC cases. LIRADS advocates using multiphase CT or MRI, as well as US. [3]

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