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Hepatocellular Carcinoma in the Cirrhotic Liver with Helical CT and MRI: Imaging Spectrum and Pitfalls of Cirrhosis-Related Nodules

¹ Department of Diagnostic Radiology, Chonnam National University Medical School, 8 Hack-Dong, Dong-Ku, Gwang-Ju 501-757, South Korea.

View larger version (20K): [in a new window]   Fig. 1 —Drawing shows stepwise development of hepatocellular carcinoma from regenerative nodule in cirrhotic liver using new terminology for nodular lesions. Brown cells indicate malignant transformation. There is gradually increasing size from regenerative nodule to hepatocellular carcinoma. (Adapted with permission from [1])

View larger version (15K): [in a new window]   Fig. 2 —Drawing shows intranodular hemodynamic change during hepatocarcinogenesis in cirrhotic liver. Light red and blue areas indicate variation of blood supply in cirrhotic nodules. As grade of malignancy increases, hepatic arterial flow to nodular lesions tends to increase, and portal venous supply tends to decrease. (Adapted with permission from [2])

View larger version (111K): [in a new window]   Fig. 3A —Regenerative nodules in cirrhotic liver in 47-year-old woman. Arterial phase CT shows nodular hepatic surface and paraumbilical varix (arrow). There are no enhancing lesions within liver.

View larger version (112K): [in a new window]   Fig. 3B —Regenerative nodules in cirrhotic liver in 47-year-old woman. Delayed-phase CT scan shows isoattenuated regenerative nodule and gastric varix (arrow).

View larger version (122K): [in a new window]   Fig. 3C —Regenerative nodules in cirrhotic liver in 47-year-old woman. T1-weighted gradient-echo MR image shows irregularity of the hepatic surface and multiple isointense nodules.

View larger version (127K): [in a new window]   Fig. 3D —Regenerative nodules in cirrhotic liver in 47-year-old woman. T2-weighted fat-saturated fast spin-echo MR image shows multiple small hypointense nodules and splenomegaly.

View larger version (130K): [in a new window]   Fig. 3E —Regenerative nodules in cirrhotic liver in 47-year-old woman. Delayed-phase T1-weighted gradient-echo MR image shows enhancement of fibrous septa of multiple, small regenerative nodules within hepatic parenchyma.

View larger version (152K): [in a new window]   Fig. 4A —Siderotic nodules on T1- and T2-weighted MR images in 43-year-old man. T1-weighted gradient-echo MR image shows multiple hypointense nodules in liver.

View larger version (151K): [in a new window]   Fig. 4B —Siderotic nodules on T1- and T2-weighted MR images in 43-year-old man. T2-weighted fat-saturated fast spin-echo MR image reveals multiple subcentimeter hypointense nodules.

View larger version (125K): [in a new window]   Fig. 5A —Dysplastic nodule in 60-year-old man with cirrhosis. T1-weighted gradient-echo MR image shows small hyperintense nodule (arrow) in inferior segment of right hepatic lobe in comparison with adjacent liver parenchyma.

View larger version (132K): [in a new window]   Fig. 5B —Dysplastic nodule in 60-year-old man with cirrhosis. T2-weighted fat-saturated fast spin-echo MR image shows lesion (arrow) has lower signal intensity than surrounding liver parenchyma.

View larger version (124K): [in a new window]   Fig. 5C —Dysplastic nodule in 60-year-old man with cirrhosis. Arterial phase T1-weighted gradient-echo MR image shows no enhancement of lesion. Biopsy confirmed dysplastic nodule.

View larger version (123K): [in a new window]   Fig. 6 —Dysplastic nodule with subfocus of hepatocellular carcinoma in 58-year-old man. T1-weighted in-phase gradient-echo MR image shows hyperintense areas (thin arrow) in background hypointense nodules (thick arrows) suggestive of nodule-within-nodule appearance. Microscopic examination of surgical specimen revealed dysplastic nodule with subfocus of hepatocellular carcinoma.

View larger version (137K): [in a new window]   Fig. 7A —Multifocal hepatocellular carcinoma on dual-phase CT in 74-year-old man. Arterial phase CT scan shows heterogeneous enhancement of three hepatocellular carcinomas (arrows).

View larger version (142K): [in a new window]   Fig. 7B —Multifocal hepatocellular carcinoma on dual-phase CT in 74-year-old man. On portal venous phase CT scan, lesions have capsular enhancement.

View larger version (139K): [in a new window]   Fig. 8A —Hypervascular hepatocellular carcinoma on dynamic contrast-enhanced MRI in 62-year-old man. Arterial phase T1-weighted gradient-echo MR image shows heterogeneous enhancing mass (arrows) in medial segment of left hepatic liver.

View larger version (166K): [in a new window]   Fig. 8B —Hypervascular hepatocellular carcinoma on dynamic contrast-enhanced MRI in 62-year-old man. Delayed-phase T1-weighted gradient-echo MR image reveals hypointensity of mass with capsular enhancement. Hepatocellular carcinoma was found in surgical specimen.

View larger version (75K): [in a new window]   Fig. 9A —Small hepatocellular carcinoma on dynamic contrast-enhanced CT in 49-year-old man. Arterial phase CT scan shows small enhancing nodule (arrow) in lateral segment of left hepatic lobe.

View larger version (70K): [in a new window]   Fig. 9B —Small hepatocellular carcinoma on dynamic contrast-enhanced CT in 49-year-old man. Portal venous phase CT scan shows lesion has capsular enhancement (arrow). Patient underwent surgical resection.

View larger version (144K): [in a new window]   Fig. 10A —Well-differentiated hepatocellular carcinoma with fat in 61-year-old man. T1-weighted in-phase gradient-echo MR image (TR/TE = 120/4.2 msec) shows hyperintense mass (arrows) with hypointense capsule in lateral segment of liver.

View larger version (170K): [in a new window]   Fig. 10B —Well-differentiated hepatocellular carcinoma with fat in 61-year-old man. T1-weighted opposed-phase gradient-echo MR image (TR/TE = 120/2.1 msec) shows reduced signal intensity of mass (arrow). Chemical shift imaging is useful to detect fat-containing hepatocellular carcinoma.

View larger version (160K): [in a new window]   Fig. 10C —Well-differentiated hepatocellular carcinoma with fat in 61-year-old man. T2-weighted fat-saturated fast spin-echo MR image shows intermediate hyperintense lesion. Surgical specimen showed hepatocellular carcinoma with fatty metamorphosis.

View larger version (170K): [in a new window]   Fig. 11 —Hepatocellular carcinoma with mosaic appearance in 64-year-old man. Portal venous phase contrast-enhanced T1-weighted gradient-echo MR image reveals large hepatocellular carcinoma (arrows) and enhancement of fibrous capsule. Patient underwent segmental resection.

View larger version (86K): [in a new window]   Fig. 12A —Hepatocellular carcinoma with portal vein thrombosis in 69-year-old man. Arterial phase CT scan shows low-attenuating mass (white arrows) in lateral segment of left hepatic lobe. There is heterogeneous enhancing lesion (black arrows) within left portal vein. Cirrhosis and ascites are seen.

View larger version (103K): [in a new window]   Fig. 12B —Hepatocellular carcinoma with portal vein thrombosis in 69-year-old man. Delayed-phase CT scan reveals hypoattenuating thrombi in left portal vein. Hypoattenuating hepatocellular carcinoma (arrows) with capsular enhancement is noted.

View larger version (152K): [in a new window]   Fig. 13A —Dysplastic nodule with enhancement in 52-year-old man. An 8-mm dysplastic nodule is seen as slightly hyperintense on T1-weighted gradient-echo MR image (A) and hypointense (arrow) on T2-weighted fast spin-echo MR image (B) compared with hepatic parenchyma.

View larger version (171K): [in a new window]   Fig. 13B —Dysplastic nodule with enhancement in 52-year-old man. An 8-mm dysplastic nodule is seen as slightly hyperintense on T1-weighted gradient-echo MR image (A) and hypointense (arrow) on T2-weighted fast spin-echo MR image (B) compared with hepatic parenchyma.

View larger version (172K): [in a new window]   Fig. 13C —Dysplastic nodule with enhancement in 52-year-old man. Arterial phase T1-weighted gradient-echo MR image shows enhancing nodule. Hypointensity on T2-weighted image is helpful finding for differentiating dysplastic nodule from hepatocellular carcinoma. Patient underwent segmental resection.

View larger version (123K): [in a new window]   Fig. 14A —Early enhancing hemangioma in 46-year-old man. Arterial (A), portal venous (B), and delayed-phase (C) CT scans show enhancing hemangioma (arrow, A) similar to that of appropriate vessels. Persistent enhancement on these images is important for differentiating early enhancing hemangioma from hepatocellular carcinoma.

View larger version (132K): [in a new window]   Fig. 14B —Early enhancing hemangioma in 46-year-old man. Arterial (A), portal venous (B), and delayed-phase (C) CT scans show enhancing hemangioma (arrow, A) similar to that of appropriate vessels. Persistent enhancement on these images is important for differentiating early enhancing hemangioma from hepatocellular carcinoma.

View larger version (138K): [in a new window]   Fig. 14C —Early enhancing hemangioma in 46-year-old man. Arterial (A), portal venous (B), and delayed-phase (C) CT scans show enhancing hemangioma (arrow, A) similar to that of appropriate vessels. Persistent enhancement on these images is important for differentiating early enhancing hemangioma from hepatocellular carcinoma.

View larger version (131K): [in a new window]   Fig. 15A —Nontumorous arterioportal shunt in 45-year-old man. T2-weighted fast spin-echo MR image shows multiple regenerating nodules in cirrhotic liver.

View larger version (142K): [in a new window]   Fig. 15B —Nontumorous arterioportal shunt in 45-year-old man. Arterial phase T1-weighted gradient-echo MR image shows wedge-shaped intensely enhancing lesion (short arrows) in subcapsular portion of right hepatic liver with markedly enhancing vein (long arrow).

View larger version (144K): [in a new window]   Fig. 15C —Nontumorous arterioportal shunt in 45-year-old man. On portal-venous phase T1-weighted gradient-echo MR image, enhancing lesion on arterial phase MR image changes to iso-signal intensity compared with adjacent hepatic parenchyma.

View larger version (115K): [in a new window]   Fig. 16A —Aberrant vessel in 61-year-old man. Arterial phase CT scan shows rectangular area of enhancement in dorsum of segment IV (arrows).

View larger version (108K): [in a new window]   Fig. 16B —Aberrant vessel in 61-year-old man. Delayed-phase CT scan shows no abnormalities. Perfusion disorder probably corresponds to third hepatic inflow tracts (aberrant right gastric veins or parabiliary venous system).

View larger version (10K): [in a new window]   Fig. 17A —Focal confluent fibrosis in 50-year-old man. Drawing shows wedge-shaped zone of fibrosis in right hepatic lobe. Lesion abnormality will appear round rather than wedge-shaped, simulating tumor.

View larger version (133K): [in a new window]   Fig. 17B —Focal confluent fibrosis in 50-year-old man. Axial T2-weighted single-shot fast spin-echo MR image shows irregular, round-shaped area of fibrosis (arrows) in right hepatic liver, simulating tumor. Confluent fibrosis associated with cirrhosis is always of hyperintensity on T2-weighted images.

View larger version (149K): [in a new window]   Fig. 17C —Focal confluent fibrosis in 50-year-old man. Arterial phase T1-weighted gradient-echo MR image shows wedge-shaped minimal enhancement of lesion (arrows) in right hepatic dome.

View larger version (148K): [in a new window]   Fig. 17D —Focal confluent fibrosis in 50-year-old man. Delayed-phase T1-weighted gradient-echo MR image reveals intense enhancement of lesion (arrows).

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