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Progression to Hypervascular Hepatocellular Carcinoma: Correlation with Intranodular Blood Supply Evaluated with CT during Intraarterial Injection of Contrast Material¹

¹ From the Department of Radiology, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-8641, Japan (M.H., O.M., T.G.); Department of Radiology, Kouritsu Kaga Chuo Hospital, Kaga, Japan (K.U.); Department of Radiology, Kouseiren Takaoka Hospital, Takaoka, Japan (Y.K.); and Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan (M.K.). Received July 30, 2001; revision requested September 25; revision received December 19; accepted March 12, 2002. Supported in part by a grant-in-aid for cancer research (10-16) from the Ministry of Health and Welfare of Japan. Address correspondence to M.H.

View larger version (180K): [in a new window]   Figure 1a. Transverse CTAP images illustrate the groups of findings seen in hepatocellular nodules with this modality. (a) Group B nodule appears as a slightly hypoattenuating nodule (arrow). (b) Group C nodule appears as a slightly hypoattenuating nodule with a partial internal focus (arrow) of definite hypoattenuation. (c) Group D nodule appears as a markedly hypoattenuating nodule (arrow).

View larger version (178K): [in a new window]   Figure 1b. Transverse CTAP images illustrate the groups of findings seen in hepatocellular nodules with this modality. (a) Group B nodule appears as a slightly hypoattenuating nodule (arrow). (b) Group C nodule appears as a slightly hypoattenuating nodule with a partial internal focus (arrow) of definite hypoattenuation. (c) Group D nodule appears as a markedly hypoattenuating nodule (arrow).

View larger version (165K): [in a new window]   Figure 1c. Transverse CTAP images illustrate the groups of findings seen in hepatocellular nodules with this modality. (a) Group B nodule appears as a slightly hypoattenuating nodule (arrow). (b) Group C nodule appears as a slightly hypoattenuating nodule with a partial internal focus (arrow) of definite hypoattenuation. (c) Group D nodule appears as a markedly hypoattenuating nodule (arrow).

View larger version (162K): [in a new window]   Figure 2a. Transverse CTHA images illustrate groups of findings seen in hepatocellular nodules with this modality. (a) Group II nodule appears as a hypoattenuating nodule (arrow). (b) Group III nodule appears as a hypoattenuating nodule (arrow) with an internal partially hyperattenuating focus. (c) Group IV nodule appears as a hyperattenuating nodule (arrow).

View larger version (182K): [in a new window]   Figure 2b. Transverse CTHA images illustrate groups of findings seen in hepatocellular nodules with this modality. (a) Group II nodule appears as a hypoattenuating nodule (arrow). (b) Group III nodule appears as a hypoattenuating nodule (arrow) with an internal partially hyperattenuating focus. (c) Group IV nodule appears as a hyperattenuating nodule (arrow).

View larger version (158K): [in a new window]   Figure 2c. Transverse CTHA images illustrate groups of findings seen in hepatocellular nodules with this modality. (a) Group II nodule appears as a hypoattenuating nodule (arrow). (b) Group III nodule appears as a hypoattenuating nodule (arrow) with an internal partially hyperattenuating focus. (c) Group IV nodule appears as a hyperattenuating nodule (arrow).

View larger version (33K): [in a new window]   Figure 3. Graph shows non-malignant transformation curves (calculated with the Kaplan-Meier method) for nodules categorized at CTAP as group A, B, and C.

View larger version (202K): [in a new window]   Figure 4a. Transverse images in a nodule show its multistep malignant transformation during 27 months of follow-up. (a) CTHA image shows a hypoattenuating (group II) nodule (arrow). (b) CTAP image reveals a slightly hypoattenuating (group B) nodule (arrow). (c) CTHA image obtained 15 months after a shows internal hyperattenuating foci (arrow) in the nodule, which is now classified as a group III nodule. (d) CTAP image obtained at the same time as c demonstrates internal hypoattenuating foci in the nodule (arrow), which is now classified as a group C nodule. (e) CTHA image obtained 12 months after c reveals definite hyperattenuation in the entire nodule (arrow), which is now classified as a group IV nodule. (f) CTAP image obtained at the same time as e demonstrates definite hypoattenuation in the entire nodule (arrow), which is now classified as a group D nodule. This nodule was followed up because it was not detected with US and coexisted with classic hypervascular HCC.

View larger version (187K): [in a new window]   Figure 4b. Transverse images in a nodule show its multistep malignant transformation during 27 months of follow-up. (a) CTHA image shows a hypoattenuating (group II) nodule (arrow). (b) CTAP image reveals a slightly hypoattenuating (group B) nodule (arrow). (c) CTHA image obtained 15 months after a shows internal hyperattenuating foci (arrow) in the nodule, which is now classified as a group III nodule. (d) CTAP image obtained at the same time as c demonstrates internal hypoattenuating foci in the nodule (arrow), which is now classified as a group C nodule. (e) CTHA image obtained 12 months after c reveals definite hyperattenuation in the entire nodule (arrow), which is now classified as a group IV nodule. (f) CTAP image obtained at the same time as e demonstrates definite hypoattenuation in the entire nodule (arrow), which is now classified as a group D nodule. This nodule was followed up because it was not detected with US and coexisted with classic hypervascular HCC.

View larger version (197K): [in a new window]   Figure 4c. Transverse images in a nodule show its multistep malignant transformation during 27 months of follow-up. (a) CTHA image shows a hypoattenuating (group II) nodule (arrow). (b) CTAP image reveals a slightly hypoattenuating (group B) nodule (arrow). (c) CTHA image obtained 15 months after a shows internal hyperattenuating foci (arrow) in the nodule, which is now classified as a group III nodule. (d) CTAP image obtained at the same time as c demonstrates internal hypoattenuating foci in the nodule (arrow), which is now classified as a group C nodule. (e) CTHA image obtained 12 months after c reveals definite hyperattenuation in the entire nodule (arrow), which is now classified as a group IV nodule. (f) CTAP image obtained at the same time as e demonstrates definite hypoattenuation in the entire nodule (arrow), which is now classified as a group D nodule. This nodule was followed up because it was not detected with US and coexisted with classic hypervascular HCC.

View larger version (195K): [in a new window]   Figure 4d. Transverse images in a nodule show its multistep malignant transformation during 27 months of follow-up. (a) CTHA image shows a hypoattenuating (group II) nodule (arrow). (b) CTAP image reveals a slightly hypoattenuating (group B) nodule (arrow). (c) CTHA image obtained 15 months after a shows internal hyperattenuating foci (arrow) in the nodule, which is now classified as a group III nodule. (d) CTAP image obtained at the same time as c demonstrates internal hypoattenuating foci in the nodule (arrow), which is now classified as a group C nodule. (e) CTHA image obtained 12 months after c reveals definite hyperattenuation in the entire nodule (arrow), which is now classified as a group IV nodule. (f) CTAP image obtained at the same time as e demonstrates definite hypoattenuation in the entire nodule (arrow), which is now classified as a group D nodule. This nodule was followed up because it was not detected with US and coexisted with classic hypervascular HCC.

View larger version (177K): [in a new window]   Figure 4e. Transverse images in a nodule show its multistep malignant transformation during 27 months of follow-up. (a) CTHA image shows a hypoattenuating (group II) nodule (arrow). (b) CTAP image reveals a slightly hypoattenuating (group B) nodule (arrow). (c) CTHA image obtained 15 months after a shows internal hyperattenuating foci (arrow) in the nodule, which is now classified as a group III nodule. (d) CTAP image obtained at the same time as c demonstrates internal hypoattenuating foci in the nodule (arrow), which is now classified as a group C nodule. (e) CTHA image obtained 12 months after c reveals definite hyperattenuation in the entire nodule (arrow), which is now classified as a group IV nodule. (f) CTAP image obtained at the same time as e demonstrates definite hypoattenuation in the entire nodule (arrow), which is now classified as a group D nodule. This nodule was followed up because it was not detected with US and coexisted with classic hypervascular HCC.

View larger version (192K): [in a new window]   Figure 4f. Transverse images in a nodule show its multistep malignant transformation during 27 months of follow-up. (a) CTHA image shows a hypoattenuating (group II) nodule (arrow). (b) CTAP image reveals a slightly hypoattenuating (group B) nodule (arrow). (c) CTHA image obtained 15 months after a shows internal hyperattenuating foci (arrow) in the nodule, which is now classified as a group III nodule. (d) CTAP image obtained at the same time as c demonstrates internal hypoattenuating foci in the nodule (arrow), which is now classified as a group C nodule. (e) CTHA image obtained 12 months after c reveals definite hyperattenuation in the entire nodule (arrow), which is now classified as a group IV nodule. (f) CTAP image obtained at the same time as e demonstrates definite hypoattenuation in the entire nodule (arrow), which is now classified as a group D nodule. This nodule was followed up because it was not detected with US and coexisted with classic hypervascular HCC.

View larger version (159K): [in a new window]   Figure 5a. Transverse images in a nodule initially classified as group III and group C show malignant transformation during 12 months of follow-up. (a) Initial CTHA image shows a hypoattenuating nodule (arrow) with internal hyperattenuating foci (group III nodule). (b) Initial CTAP image reveals a slightly hypoattenuating nodule (arrow) with internal foci of definite hypoattenuation (group C nodule). (c) CTHA and (d) CTAP images obtained 12 months after a and b reveal a group IV nodule (arrow), indicating malignant transformation.

View larger version (151K): [in a new window]   Figure 5b. Transverse images in a nodule initially classified as group III and group C show malignant transformation during 12 months of follow-up. (a) Initial CTHA image shows a hypoattenuating nodule (arrow) with internal hyperattenuating foci (group III nodule). (b) Initial CTAP image reveals a slightly hypoattenuating nodule (arrow) with internal foci of definite hypoattenuation (group C nodule). (c) CTHA and (d) CTAP images obtained 12 months after a and b reveal a group IV nodule (arrow), indicating malignant transformation.

View larger version (173K): [in a new window]   Figure 5c. Transverse images in a nodule initially classified as group III and group C show malignant transformation during 12 months of follow-up. (a) Initial CTHA image shows a hypoattenuating nodule (arrow) with internal hyperattenuating foci (group III nodule). (b) Initial CTAP image reveals a slightly hypoattenuating nodule (arrow) with internal foci of definite hypoattenuation (group C nodule). (c) CTHA and (d) CTAP images obtained 12 months after a and b reveal a group IV nodule (arrow), indicating malignant transformation.

View larger version (173K): [in a new window]   Figure 5d. Transverse images in a nodule initially classified as group III and group C show malignant transformation during 12 months of follow-up. (a) Initial CTHA image shows a hypoattenuating nodule (arrow) with internal hyperattenuating foci (group III nodule). (b) Initial CTAP image reveals a slightly hypoattenuating nodule (arrow) with internal foci of definite hypoattenuation (group C nodule). (c) CTHA and (d) CTAP images obtained 12 months after a and b reveal a group IV nodule (arrow), indicating malignant transformation.

View larger version (30K): [in a new window]   Figure 6. Graph shows non-malignant transformation curves (calculated with the Kaplan-Meier method) for nodules categorized at CTHA (CTA) as group I, II, and III.

View larger version (140K): [in a new window]   Figure 7a. Transverse images in a nodule that demonstrated no malignant transformation during 25 months of follow-up. (a) Initial CTHA image reveals a hypoattenuating nodule (arrow) of about 1.0 cm in diameter (group II nodule). (b) CTAP image obtained at the same time as a shows an isoattenuating area (arrow) that is not visible as an actual nodule (group A nodule). (c) CTHA image obtained 25 months after a reveals that the nodule still appears as a hypoattenuating nodule (arrow). The diameter of the nodule was slightly increased.

View larger version (151K): [in a new window]   Figure 7b. Transverse images in a nodule that demonstrated no malignant transformation during 25 months of follow-up. (a) Initial CTHA image reveals a hypoattenuating nodule (arrow) of about 1.0 cm in diameter (group II nodule). (b) CTAP image obtained at the same time as a shows an isoattenuating area (arrow) that is not visible as an actual nodule (group A nodule). (c) CTHA image obtained 25 months after a reveals that the nodule still appears as a hypoattenuating nodule (arrow). The diameter of the nodule was slightly increased.

View larger version (134K): [in a new window]   Figure 7c. Transverse images in a nodule that demonstrated no malignant transformation during 25 months of follow-up. (a) Initial CTHA image reveals a hypoattenuating nodule (arrow) of about 1.0 cm in diameter (group II nodule). (b) CTAP image obtained at the same time as a shows an isoattenuating area (arrow) that is not visible as an actual nodule (group A nodule). (c) CTHA image obtained 25 months after a reveals that the nodule still appears as a hypoattenuating nodule (arrow). The diameter of the nodule was slightly increased.

View larger version (29K): [in a new window]   Figure 8. Graph shows non-malignant transformation curves (calculated with the Kaplan-Meier method) for each group of nodules categorized according to combined CTAP and CTHA findings.