What is the role of MRI 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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Hepatocellular carcinoma (HCC) appearance varies on MRI depending on multiple factors, such as hemorrhage, degree of fibrosis, histologic pattern, degree of necrosis, and the amount of fatty change. HCC on T1-weighted images may be isointense, hypointense, or hyperintense relative to the liver. On T2-weighted images, HCC is usually hyperintense. Precontrast and postcontrast MRI has a 70-85% chance of detecting a solitary mass of HCC. [5, 8, 10, 16, 17, 18, 22]

MRI can help differentiate cirrhotic nodules from HCC as follows:

  • If the mass is bright on T2-weighted images, it is HCC until proven otherwise. 
  • If the mass is dark on T1- and T2-weighted images, it is a siderotic regenerative nodule or siderotic dysplastic nodule.
  • If the mass is bright on T1-weighted images and dark or isointense on T2-weighted images, it is a dysplastic nodule or low-grade HCC.

On T2-weighted images, HCC generally demonstrates high signal intensity. [23]

Gadolinium-enhanced MRI typically demonstrates that HCCs densely enhance, usually in the arterial phase, particularly if they are small. A lesion showing arterial enhancement is most likely HCC; however, dysplastic nodules and, less likely, regenerative nodules can show similar enhancement. The degree of enhancement varies, particularly with the degree of necrosis in larger tumors. Look carefully for enhancement in small portions of tumor. (In addition, a "flash filling" hemangioma can have rapid arterial enhancement but could be differentiated by lack of washout on delayed images.)

Administration of superparamagnetic iron oxide may demonstrate HCC, because most HCCs contain fewer or no Kupffer cells.

The contrast agent mangafodipir trisodium can evaluate questionable lesions in the liver. Mangafodipir trisodium is taken up by normal hepatocytes and masses that contain hepatocytes, causing increased signal intensity on T1-weighted images. This agent may help differentiate a tumor of hepatocellular origin, such as HCC, from secondary hepatic masses.

Complications (eg, vascular invasion) are evaluated well by MRI.

Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Some well-differentiated HCCs can mimic cirrhotic nodules on MRI.

Some HCCs can contain Kupffer cells, thus having signal characteristics similar to those of normal liver tissue on images contrasted with superparamagnetic iron oxide.

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