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Hepatocellular Carcinoma with Indeterminate or False-Negative Findings at Initial MR Imaging: Effect on Eligibility for Curative Treatment—Initial Observations¹

¹ From the Departments of Radiology (D.C., D.G.M., S.K.V., D.B.) and Medicine (V.J.N., A.B.M., C.M., H.L.H., S.K.H.), Thomas Jefferson University Hospital, 132 S 10th St, 1094 Main Bldg, Philadelphia, PA 19107. From the 2006 RSNA Annual Meeting. Received August 4, 2006; revision requested October 10; final revision received October 31; accepted December 6; final version accepted January 16, 2007. Address correspondence to D.G.M. (e-mail: donald.mitchell{at}jefferson.edu).

View larger version (166K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: MR images in a 46-year-old woman with subcentimeter indeterminate nodule. Fat suppression was not used to reduce artifact from metallic transjugular intrahepatic portosystemic shunt. Prospective radiology report suggested dysplastic nodule and recommended follow-up. (a–c) Transverse T1-weighted 3D gradient-echo MR images (3/0.9). (a) Unenhanced image shows 0.9-cm indeterminate hyperintense nodule (arrow). (b) Image obtained in arterial phase shows minimal perilesional enhancement of nodule (arrow). (c) Image obtained in delayed phase shows no nodule. (d) Transverse fast spin-echo MR image (2000/78.9 [effective]) reveals hypointense indeterminate nodule (arrow). (e–g) MR images obtained at 7-month follow-up. Edmondson-Steiner grade II HCC was found at explantation for liver transplantation. (e) Transverse T1-weighted 3D gradient-echo MR image (3/0.9) obtained during hepatic arterial phase shows considerable growth of enhancing nodule (arrow), which now measures 1.7 cm. (f) T1-weighted transverse gradient-echo MR image (19/1.5) obtained during delayed phase reveals hypointense HCC (arrow) with washout enhancement pattern. (g) T2-weighted transverse fast spin-echo MR image (2000/71.6 [effective]) shows slightly hypointense HCC (arrow).

View larger version (167K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: MR images in a 46-year-old woman with subcentimeter indeterminate nodule. Fat suppression was not used to reduce artifact from metallic transjugular intrahepatic portosystemic shunt. Prospective radiology report suggested dysplastic nodule and recommended follow-up. (a–c) Transverse T1-weighted 3D gradient-echo MR images (3/0.9). (a) Unenhanced image shows 0.9-cm indeterminate hyperintense nodule (arrow). (b) Image obtained in arterial phase shows minimal perilesional enhancement of nodule (arrow). (c) Image obtained in delayed phase shows no nodule. (d) Transverse fast spin-echo MR image (2000/78.9 [effective]) reveals hypointense indeterminate nodule (arrow). (e–g) MR images obtained at 7-month follow-up. Edmondson-Steiner grade II HCC was found at explantation for liver transplantation. (e) Transverse T1-weighted 3D gradient-echo MR image (3/0.9) obtained during hepatic arterial phase shows considerable growth of enhancing nodule (arrow), which now measures 1.7 cm. (f) T1-weighted transverse gradient-echo MR image (19/1.5) obtained during delayed phase reveals hypointense HCC (arrow) with washout enhancement pattern. (g) T2-weighted transverse fast spin-echo MR image (2000/71.6 [effective]) shows slightly hypointense HCC (arrow).

View larger version (180K): [in this window] [in a new window] [Download PPT slide]   Figure 1c: MR images in a 46-year-old woman with subcentimeter indeterminate nodule. Fat suppression was not used to reduce artifact from metallic transjugular intrahepatic portosystemic shunt. Prospective radiology report suggested dysplastic nodule and recommended follow-up. (a–c) Transverse T1-weighted 3D gradient-echo MR images (3/0.9). (a) Unenhanced image shows 0.9-cm indeterminate hyperintense nodule (arrow). (b) Image obtained in arterial phase shows minimal perilesional enhancement of nodule (arrow). (c) Image obtained in delayed phase shows no nodule. (d) Transverse fast spin-echo MR image (2000/78.9 [effective]) reveals hypointense indeterminate nodule (arrow). (e–g) MR images obtained at 7-month follow-up. Edmondson-Steiner grade II HCC was found at explantation for liver transplantation. (e) Transverse T1-weighted 3D gradient-echo MR image (3/0.9) obtained during hepatic arterial phase shows considerable growth of enhancing nodule (arrow), which now measures 1.7 cm. (f) T1-weighted transverse gradient-echo MR image (19/1.5) obtained during delayed phase reveals hypointense HCC (arrow) with washout enhancement pattern. (g) T2-weighted transverse fast spin-echo MR image (2000/71.6 [effective]) shows slightly hypointense HCC (arrow).

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 1d: MR images in a 46-year-old woman with subcentimeter indeterminate nodule. Fat suppression was not used to reduce artifact from metallic transjugular intrahepatic portosystemic shunt. Prospective radiology report suggested dysplastic nodule and recommended follow-up. (a–c) Transverse T1-weighted 3D gradient-echo MR images (3/0.9). (a) Unenhanced image shows 0.9-cm indeterminate hyperintense nodule (arrow). (b) Image obtained in arterial phase shows minimal perilesional enhancement of nodule (arrow). (c) Image obtained in delayed phase shows no nodule. (d) Transverse fast spin-echo MR image (2000/78.9 [effective]) reveals hypointense indeterminate nodule (arrow). (e–g) MR images obtained at 7-month follow-up. Edmondson-Steiner grade II HCC was found at explantation for liver transplantation. (e) Transverse T1-weighted 3D gradient-echo MR image (3/0.9) obtained during hepatic arterial phase shows considerable growth of enhancing nodule (arrow), which now measures 1.7 cm. (f) T1-weighted transverse gradient-echo MR image (19/1.5) obtained during delayed phase reveals hypointense HCC (arrow) with washout enhancement pattern. (g) T2-weighted transverse fast spin-echo MR image (2000/71.6 [effective]) shows slightly hypointense HCC (arrow).

View larger version (173K): [in this window] [in a new window] [Download PPT slide]   Figure 1e: MR images in a 46-year-old woman with subcentimeter indeterminate nodule. Fat suppression was not used to reduce artifact from metallic transjugular intrahepatic portosystemic shunt. Prospective radiology report suggested dysplastic nodule and recommended follow-up. (a–c) Transverse T1-weighted 3D gradient-echo MR images (3/0.9). (a) Unenhanced image shows 0.9-cm indeterminate hyperintense nodule (arrow). (b) Image obtained in arterial phase shows minimal perilesional enhancement of nodule (arrow). (c) Image obtained in delayed phase shows no nodule. (d) Transverse fast spin-echo MR image (2000/78.9 [effective]) reveals hypointense indeterminate nodule (arrow). (e–g) MR images obtained at 7-month follow-up. Edmondson-Steiner grade II HCC was found at explantation for liver transplantation. (e) Transverse T1-weighted 3D gradient-echo MR image (3/0.9) obtained during hepatic arterial phase shows considerable growth of enhancing nodule (arrow), which now measures 1.7 cm. (f) T1-weighted transverse gradient-echo MR image (19/1.5) obtained during delayed phase reveals hypointense HCC (arrow) with washout enhancement pattern. (g) T2-weighted transverse fast spin-echo MR image (2000/71.6 [effective]) shows slightly hypointense HCC (arrow).

View larger version (178K): [in this window] [in a new window] [Download PPT slide]   Figure 1f: MR images in a 46-year-old woman with subcentimeter indeterminate nodule. Fat suppression was not used to reduce artifact from metallic transjugular intrahepatic portosystemic shunt. Prospective radiology report suggested dysplastic nodule and recommended follow-up. (a–c) Transverse T1-weighted 3D gradient-echo MR images (3/0.9). (a) Unenhanced image shows 0.9-cm indeterminate hyperintense nodule (arrow). (b) Image obtained in arterial phase shows minimal perilesional enhancement of nodule (arrow). (c) Image obtained in delayed phase shows no nodule. (d) Transverse fast spin-echo MR image (2000/78.9 [effective]) reveals hypointense indeterminate nodule (arrow). (e–g) MR images obtained at 7-month follow-up. Edmondson-Steiner grade II HCC was found at explantation for liver transplantation. (e) Transverse T1-weighted 3D gradient-echo MR image (3/0.9) obtained during hepatic arterial phase shows considerable growth of enhancing nodule (arrow), which now measures 1.7 cm. (f) T1-weighted transverse gradient-echo MR image (19/1.5) obtained during delayed phase reveals hypointense HCC (arrow) with washout enhancement pattern. (g) T2-weighted transverse fast spin-echo MR image (2000/71.6 [effective]) shows slightly hypointense HCC (arrow).

View larger version (163K): [in this window] [in a new window] [Download PPT slide]   Figure 1g: MR images in a 46-year-old woman with subcentimeter indeterminate nodule. Fat suppression was not used to reduce artifact from metallic transjugular intrahepatic portosystemic shunt. Prospective radiology report suggested dysplastic nodule and recommended follow-up. (a–c) Transverse T1-weighted 3D gradient-echo MR images (3/0.9). (a) Unenhanced image shows 0.9-cm indeterminate hyperintense nodule (arrow). (b) Image obtained in arterial phase shows minimal perilesional enhancement of nodule (arrow). (c) Image obtained in delayed phase shows no nodule. (d) Transverse fast spin-echo MR image (2000/78.9 [effective]) reveals hypointense indeterminate nodule (arrow). (e–g) MR images obtained at 7-month follow-up. Edmondson-Steiner grade II HCC was found at explantation for liver transplantation. (e) Transverse T1-weighted 3D gradient-echo MR image (3/0.9) obtained during hepatic arterial phase shows considerable growth of enhancing nodule (arrow), which now measures 1.7 cm. (f) T1-weighted transverse gradient-echo MR image (19/1.5) obtained during delayed phase reveals hypointense HCC (arrow) with washout enhancement pattern. (g) T2-weighted transverse fast spin-echo MR image (2000/71.6 [effective]) shows slightly hypointense HCC (arrow).

View larger version (172K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: MR images with image degradation from patient motion in a 53-year-old woman show subcentimeter indeterminate nodule. HCC was noted at MR imaging performed 17 months later. (a) Transverse T1-weighted 3D gadolinium-enhanced gradient-echo dynamic MR image (5/1.4) obtained during hepatic arterial phase shows subtle enhancement of 0.8-cm nodule (arrow). Prospective radiology report did not note this nodule, and it was not visible on any other image. (b) Transverse T1-weighted 3D gradient-echo MR image (4/1.4) obtained 17 months later during hepatic arterial phase shows interval growth of enhancing nodule (arrow), which now measures 1.3 cm. Nodule was slightly hyperintense on T2-weighted images (not shown).

View larger version (176K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: MR images with image degradation from patient motion in a 53-year-old woman show subcentimeter indeterminate nodule. HCC was noted at MR imaging performed 17 months later. (a) Transverse T1-weighted 3D gadolinium-enhanced gradient-echo dynamic MR image (5/1.4) obtained during hepatic arterial phase shows subtle enhancement of 0.8-cm nodule (arrow). Prospective radiology report did not note this nodule, and it was not visible on any other image. (b) Transverse T1-weighted 3D gradient-echo MR image (4/1.4) obtained 17 months later during hepatic arterial phase shows interval growth of enhancing nodule (arrow), which now measures 1.3 cm. Nodule was slightly hyperintense on T2-weighted images (not shown).

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: MR images in a 61-year-old woman with HCC who had no visible nodule at MR imaging performed 14 months earlier. (a) Transverse T1-weighted 3D gadolinium-enhanced gradient-echo dynamic MR image (5/1.6) obtained during hepatic arterial phase shows early homogeneous enhancement of 1.6-cm nodule (arrow). (b) Transverse T1-weighted 3D gadolinium-enhanced gradient-echo dynamic MR image (5/1.6) obtained during venous phase reveals hypointense HCC (arrow) with washout enhancement pattern. (c) Transverse fast spin-echo MR image (2500/80.0 [effective]) shows slightly hyperintense HCC (arrow).

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: MR images in a 61-year-old woman with HCC who had no visible nodule at MR imaging performed 14 months earlier. (a) Transverse T1-weighted 3D gadolinium-enhanced gradient-echo dynamic MR image (5/1.6) obtained during hepatic arterial phase shows early homogeneous enhancement of 1.6-cm nodule (arrow). (b) Transverse T1-weighted 3D gadolinium-enhanced gradient-echo dynamic MR image (5/1.6) obtained during venous phase reveals hypointense HCC (arrow) with washout enhancement pattern. (c) Transverse fast spin-echo MR image (2500/80.0 [effective]) shows slightly hyperintense HCC (arrow).

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 3c: MR images in a 61-year-old woman with HCC who had no visible nodule at MR imaging performed 14 months earlier. (a) Transverse T1-weighted 3D gadolinium-enhanced gradient-echo dynamic MR image (5/1.6) obtained during hepatic arterial phase shows early homogeneous enhancement of 1.6-cm nodule (arrow). (b) Transverse T1-weighted 3D gadolinium-enhanced gradient-echo dynamic MR image (5/1.6) obtained during venous phase reveals hypointense HCC (arrow) with washout enhancement pattern. (c) Transverse fast spin-echo MR image (2500/80.0 [effective]) shows slightly hyperintense HCC (arrow).