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MR Imaging of Hepatocellular Carcinoma in the Cirrhotic Liver: Challenges and Controversies¹

¹ From the Departments of Radiology/MRI (J.M.W., H.K.H., S.A.) and Internal Medicine/Hepatology (J.A.M.), University of Michigan Health System, UH-B2A209K, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0030. Received August 2, 2006; revision requested October 3; revision received January 10, 2007; accepted February 22; final version accepted June 8; final review and update by H.K.H. November 16. Address correspondence to H.K.H. (e-mail: hhussain{at}umich.edu).

The incidence of hepatocellular carcinoma (HCC) is expected to increase in the next 2 decades, largely due to hepatitis C infection and secondary cirrhosis. HCC is being detected at an earlier stage owing to the implementation of screening programs. Biopsy is no longer required prior to treatment, and diagnosis of HCC is heavily dependent on imaging characteristics. The most recent recommendations by the American Association for the Study of Liver Diseases (AASLD) state that a diagnosis of HCC can be made if a mass larger than 2 cm shows typical features of HCC (hypervascularity in the arterial phase and washout in the venous phase) at contrast material–enhanced computed tomography or magnetic resonance (MR) imaging or if a mass measuring 1–2 cm shows these features at both modalities. There is an ever-increasing demand on radiologists to detect smaller tumors, when curative therapies are most effective. However, the major difficulty in imaging cirrhosis is the characterization of hypervascular nodules smaller than 2 cm, which often have nonspecific imaging characteristics. The authors present a review of the MR imaging and pathologic features of regenerative nodules and dysplastic nodules and focus on HCC in the cirrhotic liver, with particular reference to small tumors and lesions that may mimic HCC. The authors also review the sensitivity of MR imaging for the detection of these tumors and discuss the staging of HCC and the treatment options in the context of the guidelines of the AASLD and the imaging criteria required by the United Network for Organ Sharing for transplantation. MR findings following ablation and chemoembolization are also reviewed.

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