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DOI:10.2214/AJR.06.0317
AJR 2006; 186:S431-S433
© American Roentgen Ray Society

Imaging of Hepatocellular Carcinoma: Self-Assessment Module

Michelle M. Bittle1 and Felix S. Chew1

1 Both authors: Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA 98105-6008.

Received March 2, 2006; accepted after revision March 2, 2006.

 
Address correspondence to F. S. Chew.


Abstract
Top
 Abstract
INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
 References
 
The educational objectives for this self-assessment module on imaging of hepatocellular carcinoma are for the participant to exercise, self-assess, and improve his or her understanding of imaging of incidentally discovered liver masses and to gain familiarity with the clinical entity of hepatocellular carcinoma and its radiologic appearance.

Keywords: gastrointestinal imaging • hepatocellular carcinoma • liver


INTRODUCTION
Top
 Abstract
 INTRODUCTION
EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
 References
 
This self-assessment module on hepatocellular carcinoma has an educational component and a self-assessment component. The educational component consists of three required articles that the participant should read, and two recommended articles that may provide the participant with additional information and perspective. The self-assessment component consists of five multiple-choice questions with solutions. All of these materials are available on the ARRS web site (www.arrs.org). To claim CME and SAM credit, each participant must enter his or her responses to the questions online.


EDUCATIONAL OBJECTIVES
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
 References
 
By completing this educational activity, the participant will:

  1. Exercise, self-assess, and improve his or her understanding of the evaluation and management of an incidentally discovered liver mass.
  2. Gain familiarity with the imaging features of hepatocellular carcinoma.
  3. Improve his or her understanding of the use of current imaging technologies in the evaluation of hepatocellular carcinoma.


REQUIRED READING
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
RECOMMENDED READING
 INSTRUCTIONS
 References
 
(available at www.arrs.org)

  1. Bittle MM, Chew FS. Radiological reasoning: incidentally discovered liver mass. AJR 2006;186 [suppl]:S434-S441[Abstract/Free Full Text]
  2. Szklaruk J, Silverman PM, Charnsangavej C. Imaging in the diagnosis, staging, treatment, and surveillance of hepatocellular carcinoma. AJR 2003;180 :441-454[Free Full Text]
  3. Kim HJ, Kim AY, Kim TK, et al. Transient hepatic attenuation differences in focal hepatic lesions: dynamic CT features. AJR 2005;184 :83-90[Free Full Text]


RECOMMENDED READING
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
INSTRUCTIONS
 References
 
(available at www.arrs.org)

  1. Lee KH, O'Malley ME, Haider MA, Hanbidge A. Triple-phase MDCT of hepatocellular carcinoma. AJR2004 ;182 :643-649[Abstract/Free Full Text]
  2. Mok TSK, Yu SCH, Lee C, et al. False-negative rate of abdominal sonography for detecting hepatocellular carcinoma in patients with hepatitis B and elevated serum {alpha}-fetoprotein levels. AJR 2004;183 :453-458[Abstract/Free Full Text]


INSTRUCTIONS
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
References
 

  1. Complete the required reading.
  2. Visit www.arrs.org and select the Journals/Integrative Imaging link on the left-hand side of the home page.
  3. Using your member login, order the online SAM as directed.
  4. Follow the online instructions for entering your responses to the self-assessment questions and complete the test by answering the questions online.


QUESTION 1

Which liver lesion is most likely to appear as hyperdense or perhaps even calcified on unenhanced CT?

  1. Hepatocellular carcinoma.
  2. Intrahepatic cholangiocarcinoma.
  3. Metastasis from mucinous gastrointestinal primary tumor.
  4. Hemangioma.

QUESTION 2

Which of the following is a risk factor for the development of hepatocellular carcinoma?

  1. Hepatitis A.
  2. Alcoholic hepatitis.
  3. Hormone replacement therapy.
  4. Low {alpha}-fetoprotein level.

QUESTION 3

Which CT feature is characteristic of hepatocellular carcinoma?

  1. Delayed peripheral enhancement.
  2. Central scar, sometimes with calcification.
  3. Fibrosis with capsular retraction.
  4. Hypodensity on unenhanced CT.

QUESTION 4

Which benign lesion has an appearance on CT that is the most similar to that of hepatocellular carcinoma?

  1. Hepatic adenoma.
  2. Focal nodular hyperplasia.
  3. Regenerative nodule.
  4. Hemangioma.

QUESTION 5

What are the typical MRI signal characteristics of hepatocellular carcinoma?

  1. High T2 signal and variable (high or low) T1 signal.
  2. Low T2 signal and low T1 signal.
  3. Variable (high or low) T2 signal and high T1 signal.
  4. Variable (high or low) T2 signal and variable (high or low) T1 signal.

 

Solution to Question 1
Hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma, hemangioma, and most metastases appear on unenhanced CT images as hypodense lesions [1]. Metastases to the liver from mucinous primary tumors may calcify and are best seen on unenhanced CT images; metastases from ovarian, thyroid, renal, lung, and breast primary tumors may also calcify [1]. Option C is the best response.

Solution to Question 2
Hepatitis B and hepatitis C are implicated in the development of HCC, but hepatitis A is not. Oral contraceptive use is a risk factor for HCC, but hormone replacement therapy is not. Other risk factors include {alpha}1-antitrypsin deficiency, excessive androgen use, hemochromatosis, and exposure to aflatoxin or vinyl chloride. Alpha-fetoprotein levels are typically elevated in HCC, not decreased. Alcoholic hepatitis is an important risk factor for HCC [2]. Option B is the best response.

Solution to Question 3
Delayed peripheral enhancement is characteristic of hemangioma. Central scar, sometimes with calcification, is found in focal nodular hyperplasia and in the less common fibrolamellar HCC. Fibrosis with capsular retraction is characteristic of focal confluent fibrosis. HCC is characteristically hypodense on unenhanced CT; however, so are many other benign and malignant focal liver lesions [3]. Option D is the best response.

Solution to Question 4
Focal nodular hyperplasia is usually peripherally located and may have a pedunculated morphology; characteristically, this lesion has a central scar that enhances on delayed images. Regenerative nodules, on unenhanced CT, are isodense to liver unless they are siderotic, in which case they are hyperdense. HCC is hypodense on unenhanced CT. On contrast-enhanced CT, hemangiomas of the liver generally have a characteristic discontinuous peripheral puddling during the arterial phase and centripetal filling during the portal venous phase that continue after blood pooling; HCC has a variable appearance during the arterial phase, but washes out during the portal venous phase. Hepatic adenomas have a variable CT appearance that overlaps with that of HCC on both unenhanced and contrast-enhanced CT; therefore, these two lesions usually cannot be differentiated reliably from each other on the basis of CT appearance [4]. Option A is the best response.

Solution to Question 5
The MRI appearance of HCC can be quite variable, often related to the degree of differentiation. The T1 appearance is variable, with 40% having low signal and 35% having high signal; 90% have increased T2 signal [5]. Option A is the best response.


References
Top
 Abstract
 INTRODUCTION
 EDUCATIONAL OBJECTIVES
 REQUIRED READING
 RECOMMENDED READING
 INSTRUCTIONS
 References
 

  1. Sica GT, Ji H, Ros PR. CT and MR imaging of hepatic metastases. AJR 2000; 174:691 -698[Free Full Text]
  2. Szklaruk J, Silverman PM, Charnsangavej C. Imaging in the diagnosis, staging, treatment, and surveillance of hepatocellular carcinoma. AJR 2003; 180:441 -454[Free Full Text]
  3. Lee KH, O'Malley ME, Haider MA, Hanbidge A. Triple-phase MDCT of hepatocellular carcinoma. AJR 2004;182 : 643-649[Abstract/Free Full Text]
  4. Grazioli L, Federle MP, Brancatelli G, Ichikawa T, Olivetti L, Blachar A. Hepatic adenomas: imaging and pathologic findings. RadioGraphics 2001;21 : 877-892[Abstract/Free Full Text]
  5. Murakami T, Hori M, Kim T, Kawata S, Abe H, Nakamura H. Multidetector row CT and MRI in diagnosing hepatocellular carcinoma. Intervirology 2004;47 : 209-226[Medline]

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Related articles in AJR:

Radiological Reasoning: Incidentally Discovered Liver Mass
Michelle M. Bittle and Felix S. Chew
AJR 2006 186: S434-S441. [Abstract] [Full Text]  




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow CME/SAM Credit
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Related articles in AJR
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Bittle, M. M.
Right arrow Articles by Chew, F. S.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Bittle, M. M.
Right arrow Articles by Chew, F. S.
Social Bookmarking
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Hotlight (NEW!)
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