Small Hepatocellular Carcinoma

Rationale and Objectives

Current clinical practice favors imaging rather than biopsy to diagnose hepatocellular carcinoma (HCC). There is a need to better understand tumor biology and aggressiveness of HCC. Our goal is to investigate magnetic resonance imaging (MRI) features of HCC that are associated with faster growth rates (GRs).

Materials and Methods

After approval from institutional review board, a retrospective evaluation was performed of pre–liver transplant patients. Fifty-two patients who developed a >2 cm HCC on serial imaging were included in the study group, with a total of 60 HCCs seen. Precursor foci were identified on serial MRIs before the specific diagnostic features of >2 cm HCC could be made, and GRs and MRI features, including signal on T1- and T2-weighted images (WI), the presence of intralesional steatosis on chemical shift imaging, and enhancement pattern were analyzed. GRs were correlated with imaging features.

Results

The average GR of precursor lesions to >2 cm HCC was determined to be 0.23 cm/mo (standard deviation [SD], 0.32), with a doubling time of 5.26 months (SD, 5.44). The presence of increased signal intensity (SI) on T2-WI was associated with significantly higher growth ( P = .0002), whereas increased intensity on T1-WI at the initial study was associated with a significantly lower GR ( P = .0162). Furthermore, lesions with hypervascular enhancement with washout pattern had significantly higher GR ( P = .0164). There is no evidence of differences in GRs seen in lesions with steatosis.

Conclusions

Small precursor lesions with increased SI on T2-WI and a washout pattern of enhancement are associated with faster GRs, which may suggest more aggressive tumor biology. These features may be helpful in patient management and surveillance for HCC.

Currently, in the United States, liver transplant is offered to patients with hepatocellular carcinoma (HCC) as the best method of improving long-term survival. Cirrhotic patients with small HCC (one lesion that measures 2–5 cm or up to three lesions that measure <3 cm each) are candidates for transplant. Patients with HCCs that meet these size and number criteria and have no evidence of extrahepatic disease or tumor macrovascular invasion are awarded a higher position on transplant lists . Most transplant centers in North America use imaging as a method of establishing the diagnosis of HCC and forgo biopsy because of concerns of tumor seeding, complications related to the procedure, and the concern for sampling error. However, there is growing evidence that size-based criteria do not adequately predict tumor aggressiveness and prognosis in individual patients .

Evidence accumulated in the past two decades strongly favors the existence of a sequence in hepatocarcinogenesis from dysplastic nodules to small HCC (<2 cm) to large HCC . Prior researchers have found an association between the size, differentiation, and intratumoral arterial density in HCC and the presence of fat . These pathologic features have imaging correlates that may be useful in making a diagnosis of HCC.

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Materials and methods

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Image Analysis

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Statistical Analyses

GR and DT Calculated for Follow-up Data Only

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DT=log(2)×tlog(Volumelast−Volumefirst) DT

log

(

)

log

(

Volumelast

−

Volumefirst

)

and t is time in months between the first and the last visit.

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Descriptive Statistics

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Results

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Table 1

Demographics

Race Percent Diagnosis Percent African-American 23.08 Biliary 5.77 Asian 19.23 Alcoholism 3.85 Caucasian 42.31 Hepatitis B 17.31 Hispanic 1.92 Hepatitis C 63.46 Other 13.46 Other 3.85 Unknown 5.77

Table 2

Tumor Growth Rates (GR) and Doubling Times (DT)

Growth rates in centimeter per month and doubling time in months.

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Kappa Values

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Table 3

Kappa Values to Assess Agreement Among Readers: Assessment of All HCC and Precursor Lesions

Variable Kappa Standard Error_z__P_ Value T1 0.55344 0.030946 17.8840 <.0001 T2 0.57725 0.034807 16.5841 <.0001 Fat on DGRE 0.63716 0.042914 14.8473 <.0001

HCC, hepatocellular carcinoma; DGRE, Dual gradient-echo.

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Discussion

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Conclusions

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References

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Small Hepatocellular Carcinoma

Rationale and Objectives

Materials and Methods

Results

Conclusions

Materials and methods

Image Analysis

Statistical Analyses

GR and DT Calculated for Follow-up Data Only

Descriptive Statistics

Results

Kappa Values

Discussion

Conclusions

References

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