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Optimum imaging for small suspected hepatocellular carcinoma
  1. Morris Sherman
  1. Correspondence to Dr Morris Sherman, Toronto General Hospital, Rm# NCSB 11C 1252, 585 University Avenue, Toronto, ON M5G 2N2, Canada; morris.sherman{at}uhn.on.ca

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Hepatocellular carcinoma (HCC) has progressed within the last 10–15 years from being a cancer that was almost universally fatal to one that is potentially curable in the majority of cases. However, for this to happen it is essential that the HCC is found early. Patients at risk for HCC have to undergo regular surveillance with ultrasound. Lesions detected during surveillance have to be aggressively investigated and aggressively treated. If HCC can be diagnosed when the lesion is <2 cm in diameter the likelihood of cure by resection or local ablation is >90%.1 2 Treated patients remain at risk for the development of a second primary, but the treated HCC can be completely cured.

Ultrasound surveillance identifies many small lesions in the liver that may or may not be HCC. These include dysplastic nodules, cirrhotic nodules and haemangioma. Making the distinction between HCC and haemangioma is usually not difficult, but distinguishing between cirrhotic nodules, dysplastic nodules and HCC can be difficult. The tools available include contrast-enhanced radiological imaging, or biopsy. It is possible to diagnose HCC without biopsy. Indeed, if the typical radiological features are present, the diagnostic accuracy is almost 100%. The highly characteristic features are that in the arterial phase of a dynamic contrast-enhanced study the HCC shows hypervascularity—that is, it gives a brighter signal that the surrounding liver. In the portal venous phase of the study and in the delayed phase ∼3 min …

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