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CLINICAL IMAGE
Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 78-79

Radiological imaging in infiltrative hepatocellular carcinoma


1 Department of Radiology, Sir Gangaram Hospital, New Delhi, India
2 Department of CT and MRI, Sir Gangaram Hospital, New Delhi, India

Date of Submission09-Mar-2022
Date of Decision21-Mar-2022
Date of Acceptance21-Mar-2022
Date of Web Publication28-Apr-2022

Correspondence Address:
Dr. Rosaiah Komirisetti
Department of Radiology, Sir Gangaram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_17_22

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How to cite this article:
Komirisetti R, S. Buxi TB, Goyal M, Ghuman SS. Radiological imaging in infiltrative hepatocellular carcinoma. J Med Evid 2022;3:78-9

How to cite this URL:
Komirisetti R, S. Buxi TB, Goyal M, Ghuman SS. Radiological imaging in infiltrative hepatocellular carcinoma. J Med Evid [serial online] 2022 [cited 2022 Aug 12];3:78-9. Available from: http://www.journaljme.org/text.asp?2022/3/1/78/344284



The imaging diagnosis of hepatocellular carcinoma (HCC) is well known now with multiple societies adopting arterial phase enhancement and venous washout in a patient with cirrhosis as diagnostic of HCC. Diagnosis of infiltrative HCC on imaging is a challenge because it does not always follow the expected imaging characteristics of HCC and is often difficult to distinguish it from background changes of cirrhosis at imaging. Radiologists and treating clinicians must be aware of unusual appearances of infiltrative HCC, otherwise it can be missed/misdiagnosed on imaging. Infiltrative HCC usually occupies an entire hepatic lobe or more of the liver.


  Contrast-Enhanced Computed Tomography and Magnetic Resonance Imaging Top


The enhancement of infiltrative HCC on the post-contrast hepatic arterial phase is minimal, patchy or punctate.[1] Even though enhancement on arterial phase is a characteristic finding for nodular/massive HCC, infiltrative HCC most often appears as iso or hypodense to the liver parenchyma on the arterial phase [Figure 1].[2] Washout during the venous phase remains the valid feature for infiltrative HCC, even its appearance is irregular and heterogeneous compared with the washout of nodular HCCs.[3] It is frequently associated with thrombosis of the portal vein [Figure 2]. Involvement of the portal vein alters the perfusion of the tumour which results in minimal, inconsistent arterial enhancement with heterogeneous washout on contrast-enhanced computed tomography (CT) and magnetic resonance (MR) imaging. Because of subtle and inconsistent enhancement of the infiltrating HCC and cirrhotic background of the liver, the tumour itself can be completely missed and portal vein thrombosis and intraluminal arterioportal shunting appear as the primary imaging finding.
Figure 1: Triphasic computed tomography scan of upper abdomen represents a large hypodense lesion in the right lobe of liver on plain scan (A) (asterisk) which shows subtle enhancement on arterial phase (arrows) with no apparent washout on delayed phases

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Figure 2: Portal vein thrombosis (arrows)

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As altered enhancement characteristics due to the involvement of the portal vein obscure the tumour, therefore, the tumour may be more apparent on T1-, T2- and diffusion-weighted MR images than post-contrast dynamic images [Figure 3] and [Figure 4].[4] In case of patients with cirrhosis with strong clinical suspicion for HCC and/or portal vein thrombosis with arterioportal shunting, MR may be performed even if no obvious tumour is seen on CT
Figure 3: Magnetic resonance imaging of upper abdomen showing hyperintense lesion in the right lobe of the liver on T2-weighted sequence and somewhat hypointense on T1-weighted sequence. It shows mild restricted diffusion

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Figure 4: Magnetic resonance imaging of upper abdomen dynamic contrast using hepatobiliary contrast showing patchy enhancing lesion in the right lobe of the liver on arterial phase with delayed washout and well seen on hepatobiliary phase

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  Case Top


An 81 years male patient presented with abdominal pain and distension associated with decreased appetite. No history of fever, malena and jaundice was present. On investigation, he has found to have Hb 9.7 mg/dl, TLC 6.25/cumm, T/D bilirubin 1.07/0.66mg/dl, SGOT/PT 69/43IU/L. AFP(alpha-fetoprotein)level was raised(1014ng/ml). USG whole abdomen showed chronic liver disease with portal vein thrombosis and mild to moderate ascites. Triple phase CT and then dynamic contrast-enhanced MRI was done to rule out HCC on a background of cirrhosis , imaging appearances as shown below.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kneuertz PJ, Demirjian A, Firoozmand A, Corona-Villalobos C, Bhagat N, Herman J, et al. Diffuse infiltrative hepatocellular carcinoma: Assessment of presentation, treatment, and outcomes. Ann Surg Oncol 2012;19:2897-907.  Back to cited text no. 1
    
2.
Rosenkrantz AB, Lee L, Matza BW, Kim S. Infiltrative hepatocellular carcinoma: Comparison of MRI sequences for lesion conspicuity. Clin Radiol 2012;67:e105-11.  Back to cited text no. 2
    
3.
Kanematsu M, Semelka RC, Leonardou P, Mastropasqua M, Lee JK. Hepatocellular carcinoma of diffuse type: MR imaging findings and clinical manifestations. J Magn Reson Imaging 2003;18:189-95.  Back to cited text no. 3
    
4.
Reynolds AR, Furlan A, Fetzer DT, Sasatomi E, Borhani AA, Heller MT, et al. Infiltrative hepatocellular carcinoma: What radiologists need to know. Radiographics 2015;35:371-86.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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