Research article
Diagnosis and staging of hepatocellular carcinoma (HCC): current guidelines

https://doi.org/10.1016/j.ejrad.2018.01.025Get rights and content

Highlights

  • Surveillance based on biannual ultrasonography allows early detection of Hepatocellular Carcinoma (HCC) in patients at risk.

  • Only patients at risk that could be treated if diagnosed of HCC should be included in surveillance programs.

  • Diagnosis of HCC in early stages is key to apply effective therapy and expand life expectancy.

  • Typical vascular profile of HCC on imaging allows non-invasive diagnosis of HCC in patients at risk with sensitivity and specificity rates of 60% and 96–100% respectively.

  • The added benefit of new diagnostic tools for HCC based on MRI and PET in the decision making process is pending on robust data on specificity rates.

  • Treatment should be indicated only when the diagnosis of HCC is secure to avoid overtreatment of suspicious lesions.

Abstract

One of the key strategies to improve the prognosis of HCC, beside prevention, is to diagnose the tumor in early stages, when the patient is asymptomatic and the liver function is preserved, because in this clinical situation effective therapies with survival benefit can be applied. Imaging techniques are a key tool in the surveillance and diagnosis of HCC. Screening should be based in US every 6 months and non-invasive diagnostic criteria of HCC based on imaging findings on dynamic-MR and/or dynamic-CT have been validated and thus, accepted in clinical guidelines. The typical vascular pattern depicted by HCC on CT and or MRI consists on arterial enhancement, stronger than the surrounding liver (wash-in), and hypodensity or hyposignal intensity compared to the surrounding liver (wash-out) in the venous phase. This has a sensitivity of around 60% with a 96–100% specificity. Major improvements on liver imaging have been introduced in the latest years, adding functional information that can be quantified: the use of hepatobiliary contrast media for liver MRI, the inclusion of diffusion-weighted sequences in the standard protocols for liver MRI studies and new radiotracers for positron-emission tomography (PET). However, all them are still a matter of research prior to be incorporated in evidence based clinical decision making. This review summarizes the current knowledge about imaging techniques for the early diagnosis and staging of HCC, and it discusses the most relevant open questions.

Section snippets

Surveillance of HCC

Hepatocellular carcinoma (HCC) is the third leading cause of cancer mortality, and it is a major cause of death in patients with cirrhosis [1]. The incidence of HCC has been increasing in the last 40 years, and the associated mortality is still increasing in the United States and Canada [2], mainly due to the high prevalence of chronic hepatitis C, and the current epidemic of nonalcoholic steatohepatitis (NASH) that may overlap with excessive alcohol intake. HCC has all the requirements needed

Diagnosis of HCC

The recognition of a nodule > 10 mm by US in livers of patients at high risk for HCC should be followed by diagnostic dynamic CT or MR (Fig. 1). Neoangiogenesis develops actively in small lesions (10–20 mm), resulting in stronger lesion arterial vascularization compared to the surrounding liver parenchyma (wash-in). Simultaneously, a progressive decrease of the portal supply takes place and leads to a decrease of portal blood within the lesion compared to the surrounding liver parenchyma in

Clinical staging and treatment

The Barcelona Clinic Liver Cancer (BCLC) staging system links prognosis of HCC with the best treatment option based on strong clinical evidence [63]. It has been endorsed by scientific associations and many other research groups. It takes into account the most relevant independent prognostic factors influencing survival in patients with HCC: the performance status, the liver function, and the tumor burden (Fig. 9). It has been validated and provides a first allocation of an individual patient

Conflict of interest

The authors report no conflict of interest.

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