Abstract
ObjectiveTo evaluate the accuracy of CT for small, hypervascular hepatocellular carcinomas (HCCs) and assess the enhancement patterns on CT.Materials and methodsNinety-nine patients who underwent cone-beam CT hepatic arteriography (CBCT-HA) during initial chemoembolization for HCC suspected on CT were enrolled in this study. A total of 297 hypervascular HCCs (142 ≥ 1 cm, 155 < 1 cm) were confirmed as HCCs based on two-year follow-up CT and CBCT-HA images. During the two-year follow-up, pre-existing hypervascular foci on CBCT-HA were regarded as HCCs at the initial presentation. Two radiologists categorized HCCs according to the following enhancement patterns on CT: type I, arterial enhancement and washout; type II, arterial enhancement without washout; and type III, no arterial enhancement. Two blinded reviewers rated the possibility of HCC.ResultsFor the 297 HCCs, the enhancement patterns according to size were as follows: type I ≥1 cm in 114 HCCs; type I <1 cm in 40 HCCs; type II ≥1 cm in 16 HCCs; type II <1 cm in 37 HCCs; type III ≥1 cm in 12 HCCs; and type III <1 cm in 10 HCCs. The remaining 68 HCCs (22.9%) were not detected on CT. The detection rates of HCCs ≥ 1 cm were 83.1%, 76.8%, and 83.1% in the formal report for reviewer 1 and reviewer 2. In comparison, the detection rates of HCCs < 1 cm were 20.6%, 17.4%, and 17.4% in the formal report for reviewer 1 and reviewer 2.ConclusionMany subcentimeter sized hypervascular HCCs were frequently missed or not evident on CT at the initial diagnostic workup. CT has limitations for diagnosing HCCs that are <1 cm in size or have atypical enhancement patterns.
Highlights
With an enhanced understanding of the pathophysiology of hepatocellular carcinoma (HCC) and advances in imaging techniques, the diagnosis of hepatocellular carcinomas (HCCs) is increasing based on imaging criteria
For the 297 HCCs, the enhancement patterns according to size were as follows: type I !1 cm in 114 HCCs; type I
The lesions ! 1 cm and with the typical enhancement patterns of HCC such as arterial enhancement and portal/delayed washout seen on dynamic computed tomography (CT) images, were diagnosed as HCC according to the Association for the Study of Liver Diseases (AASLD) guidelines [1]
Summary
With an enhanced understanding of the pathophysiology of hepatocellular carcinoma (HCC) and advances in imaging techniques, the diagnosis of HCC is increasing based on imaging criteria. Recent advances in the use of tissue-specific MRI contrast agents have been determined to be more sensitive for the detection of HCCs less than 2 cm in size [3, 4], the use of MRI rather than CT is limited by its relatively high cost and technical demand. Studies have evaluated the performance of contrast-enhanced, dynamic CT for diagnosing HCC as a standard of reference rather than using histological examinations [5,6,7,8,9,10,11,12]. Contrastenhanced, dynamic CT is a useful imaging modality for the diagnosis of HCCs larger than 1 cm, and the reported sensitivity is as high as 94% [7]; previous studies have reported various ranges with low sensitivity values for contrast-enhanced, dynamic CT for diagnosing HCCs less than 1 cm. Even pathologic correlation in whole-liver explants is limited for detecting small HCCs less than 1 cm in diameter
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