Top

04-01-2025 | Hepatocellular Carcinoma | Review

Magnetic resonance imaging of hepatocellular carcinoma: a spectrum of uncommon morphologic subtypes, unusual imaging patterns and mimics

Authors: Mindy X. Wang, M. Azfar Siddiqui, Alexandra Roudenko, Amita Kamath, Humaira Chaudhry, Roopa Ram, Amir A. Borhani, Venkateswar Surabhi, Khaled M. Elsayes, Robert M. Marks, Maxime Ronot

Published in: Abdominal Radiology

Abstract

Advances in imaging techniques have evolved, allowing for early noninvasive diagnosis and improved management of high-risk patients with hepatocellular carcinoma (HCC). The hallmark imaging features of HCC on multiphasic cross-sectional imaging can be explained by the multistep process of hepatocarcinogenesis and is seen in 60% of cases. However, approximately 40% of cases do not abide by the classic imaging appearance and may pose a diagnostic challenge for radiologists. These may be accounted by their morphologic subtypes with differing molecular and/or genetic features. Additionally, various malignant and benign lesions and pseudolesions may mimic HCC. This article aims to highlight the unusual cross-sectional imaging manifestations of HCC and describe its pitfalls and mimics.

Minami Y, Nishida N, Kudo M (2023) Imaging Diagnosis of Various Hepatocellular Carcinoma Subtypes and Its Hypervascular Mimics: Differential Diagnosis Based on Conventional Interpretation and Artificial Intelligence. Liver Cancer 12:103–115. https://doi.org/10.1159/000528538CrossRefPubMed

Chernyak V, Fowler KJ, Kamaya A, et al (2018) Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients. Radiology 289:816–830. https://doi.org/10.1148/radiol.2018181494

Liver Imaging Reporting & Data System (LI-RADS^®)

Shriki JE, Seyal AR, Dighe MK, et al (2015) CT of Atypical and Uncommon Presentations of Hepatocellular Carcinoma. American Journal of Roentgenology 205:W411–W423. https://doi.org/10.2214/AJR.14.14000CrossRefPubMed

Loy LM, Low HM, Choi J-Y, et al (2022) Variant Hepatocellular Carcinoma Subtypes According to the 2019 WHO Classification: An Imaging-Focused Review. American Journal of Roentgenology 219:212–223. https://doi.org/10.2214/AJR.21.26982CrossRefPubMed

Lee JH, Lee JM, Kim SJ, et al (2012) Enhancement patterns of hepatocellular carcinomas on multiphasic multidetector row CT: comparison with pathological differentiation. Br J Radiol 85:e573–e583. https://doi.org/10.1259/bjr/86767895CrossRefPubMedPubMedCentral

Fowler KJ, Burgoyne A, Fraum TJ, et al (2021) Pathologic, Molecular, and Prognostic Radiologic Features of Hepatocellular Carcinoma. RadioGraphics 41:1611–1631. https://doi.org/10.1148/rg.2021210009CrossRefPubMed

Torbenson M, Ng I, Park Y, et al (2019) WHO classification of tumours: digestive system tumours, 5th ed

Olofson AM, Gonzalo DH, Chang M, Liu X (2018) Steatohepatitic Variant of Hepatocellular Carcinoma: A Focused Review. Gastroenterology Res 11:391–396. https://doi.org/10.14740/gr1110CrossRefPubMedPubMedCentral

10.

Cannella R, Dioguardi Burgio M, Beaufrère A, et al (2021) Imaging features of histological subtypes of hepatocellular carcinoma: Implication for LI-RADS. JHEP Reports 3:100380. https://doi.org/10.1016/j.jhepr.2021.100380CrossRefPubMedPubMedCentral

11.

Campos-Correia D, Cruz J, Matos AP, et al (2018) Magnetic resonance imaging ancillary features used in Liver Imaging Reporting and Data System: An illustrative review. World J Radiol 10:9–23. https://doi.org/10.4329/wjr.v10.i2.9CrossRefPubMedPubMedCentral

12.

Faure A, Dioguardi Burgio M, Cannella R, et al (2024) Imaging and prognostic characterization of fat-containing hepatocellular carcinoma subtypes. Radiol Med 129:687–701. https://doi.org/10.1007/s11547-024-01807-wCrossRefPubMed

13.

Kim H, Jang M, Park YN (2020) Histopathological Variants of Hepatocellular Carcinomas: an Update According to the 5th Edition of the WHO Classification of Digestive System Tumors. Journal of Liver Cancer 20:17–24. https://doi.org/10.17998/jlc.20.1.17CrossRefPubMedPubMedCentral

14.

Liu Q-Y (2011) Primary clear cell carcinoma in the liver: CT and MRI findings. World J Gastroenterol 17:946. https://doi.org/10.3748/wjg.v17.i7.946CrossRefPubMedPubMedCentral

15.

Park B V., Gaba RC, Huang Y-H, et al (2019) Histology of Hepatocellular Carcinoma: Association with Clinical Features, Radiological Findings, and Locoregional Therapy Outcomes. J Clin Imaging Sci 9:52. https://doi.org/10.25259/JCIS_111_2019CrossRefPubMedPubMedCentral

16.

Kokubo R, Saito K, Shirota N, et al (2019) A case of primary clear cell hepatocellular carcinoma comprised mostly of clear cells. Radiol Case Rep 14:1377–1381. https://doi.org/10.1016/j.radcr.2019.08.021CrossRefPubMedPubMedCentral

17.

Rhee H, Cho E-S, Nahm JH, et al (2021) Gadoxetic acid-enhanced MRI of macrotrabecular-massive hepatocellular carcinoma and its prognostic implications. J Hepatol 74:109–121. https://doi.org/10.1016/j.jhep.2020.08.013CrossRefPubMed

18.

Chen J, Xia C, Duan T, et al (2021) Macrotrabecular-massive hepatocellular carcinoma: imaging identification and prediction based on gadoxetic acid–enhanced magnetic resonance imaging. Eur Radiol 31:7696–7704. https://doi.org/10.1007/s00330-021-07898-7CrossRefPubMed

19.

Park MJ, Kim YK, Park HJ, et al (2013) Scirrhous Hepatocellular Carcinoma on Gadoxetic Acid–Enhanced Magnetic Resonance Imaging and Diffusion-Weighted Imaging. J Comput Assist Tomogr 37:872–881. https://doi.org/10.1097/RCT.0b013e31829d44c1CrossRefPubMed

20.

Choi S-Y, Kim YK, Min JH, et al (2018) Added value of ancillary imaging features for differentiating scirrhous hepatocellular carcinoma from intrahepatic cholangiocarcinoma on gadoxetic acid-enhanced MR imaging. Eur Radiol 28:2549–2560. https://doi.org/10.1007/s00330-017-5196-yCrossRefPubMed

21.

Ganeshan D, Szklaruk J, Kundra V, et al (2014) Imaging Features of Fibrolamellar Hepatocellular Carcinoma. American Journal of Roentgenology 202:544–552. https://doi.org/10.2214/AJR.13.11117CrossRefPubMed

22.

Chen L, Ruan S, Wang P, et al (2023) Imaging features of primary hepatic sarcomatoid carcinoma: Differentiation from hepatocellular carcinoma and intrahepatic cholangiocarcinoma on CT: A preliminary study. Heliyon 9:e14123. https://doi.org/10.1016/j.heliyon.2023.e14123CrossRefPubMedPubMedCentral

23.

Vernuccio F, Porrello G, Cannella R, et al (2021) Benign and malignant mimickers of infiltrative hepatocellular carcinoma: tips and tricks for differential diagnosis on CT and MRI. Clin Imaging 70:33–45. https://doi.org/10.1016/j.clinimag.2020.10.011CrossRefPubMed

24.

Kneuertz PJ, Demirjian A, Firoozmand A, et al (2012) Diffuse Infiltrative Hepatocellular Carcinoma: Assessment of Presentation, Treatment, and Outcomes. Ann Surg Oncol 19:2897–2907. https://doi.org/10.1245/s10434-012-2336-0CrossRefPubMedPubMedCentral

25.

Rosenkrantz AB, Lee L, Matza BW, Kim S (2012) Infiltrative hepatocellular carcinoma: Comparison of MRI sequences for lesion conspicuity. Clin Radiol 67:e105–e111. https://doi.org/10.1016/j.crad.2012.08.019CrossRefPubMed

26.

Kanda M, Tateishi R, Yoshida H, et al (2008) Extrahepatic metastasis of hepatocellular carcinoma: incidence and risk factors. Liver International 28:1256–1263. https://doi.org/10.1111/j.1478-3231.2008.01864.xCrossRefPubMed

27.

Sneag DB, Krajewski K, Giardino A, et al (2011) Extrahepatic Spread of Hepatocellular Carcinoma: Spectrum of Imaging Findings. American Journal of Roentgenology 197:W658–W664. https://doi.org/10.2214/AJR.10.6402CrossRefPubMed

28.

Sotiropoulos GC, Malago M, Molmenti EP, et al (2005) Disease course after liver transplantation for hepatocellular carcinoma in patients with complete tumor necrosis in liver explants after performance of bridging treatments. Eur J Med Res 10:539–42PubMed

29.

Kim JH, Joo I, Lee JM (2019) Atypical Appearance of Hepatocellular Carcinoma and Its Mimickers: How to Solve Challenging Cases Using Gadoxetic Acid-Enhanced Liver Magnetic Resonance Imaging. Korean J Radiol 20:1019. https://doi.org/10.3348/kjr.2018.0636CrossRefPubMedPubMedCentral

30.

Choi J-Y, Lee J-M, Sirlin CB (2014) CT and MR Imaging Diagnosis and Staging of Hepatocellular Carcinoma: Part II. Extracellular Agents, Hepatobiliary Agents, and Ancillary Imaging Features. Radiology 273:30–50. https://doi.org/10.1148/radiol.14132362CrossRefPubMed

31.

Kim YK, Lee WJ, Park MJ, et al (2012) Hypovascular Hypointense Nodules on Hepatobiliary Phase Gadoxetic Acid–enhanced MR Images in Patients with Cirrhosis: Potential of DW Imaging in Predicting Progression to Hypervascular HCC. Radiology 265:104–114. https://doi.org/10.1148/radiol.12112649CrossRefPubMed

32.

Desai A, Sandhu S, Lai J-P, Sandhu DS (2019) Hepatocellular carcinoma in non-cirrhotic liver: A comprehensive review. World J Hepatol 11:1–18. https://doi.org/10.4254/wjh.v11.i1.1CrossRefPubMedPubMedCentral

33.

Kim TK, Lee E, Jang H-J (2015) Imaging findings of mimickers of hepatocellular carcinoma. Clin Mol Hepatol 21:326. https://doi.org/10.3350/cmh.2015.21.4.326CrossRefPubMedPubMedCentral

34.

Duran R, Ronot M, Di Renzo S, et al (2015) Is magnetic resonance imaging of hepatic hemangioma any different in liver fibrosis and cirrhosis compared to normal liver? Eur J Radiol 84:816–822. https://doi.org/10.1016/j.ejrad.2015.01.016CrossRefPubMed

35.

Costa AF, Clarke SE, Stueck AE, et al (2021) Benign Neoplasms, <scp > Mass-Like</scp > Infections, and Pseudotumors That Mimic Hepatic Malignancy at < scp > MRI</scp>. Journal of Magnetic Resonance Imaging 53:979–994. https://doi.org/10.1002/jmri.27251CrossRefPubMed

36.

Elsayes KM, Chernyak V, Morshid AI, et al (2018) Spectrum of Pitfalls, Pseudolesions, and Potential Misdiagnoses in Cirrhosis. American Journal of Roentgenology 211:87–96. https://doi.org/10.2214/AJR.18.19781CrossRefPubMed

37.

Kim T-H, Woo S, Ebrahimzadeh S, et al (2023) Hepatic Adenoma Subtypes on Hepatobiliary Phase of Gadoxetic Acid–Enhanced MRI: Systematic Review and Meta-Analysis. American Journal of Roentgenology 220:28–38. https://doi.org/10.2214/AJR.22.27989CrossRefPubMed

38.

Tse JR, Felker ER, Naini B V., et al (2023) Hepatocellular Adenomas: Molecular Basis and Multimodality Imaging Update. RadioGraphics 43:. https://doi.org/10.1148/rg.220134

39.

Brancatelli G, Vilgrain V, Federle MP, et al (2007) Budd-Chiari Syndrome: Spectrum of Imaging Findings. American Journal of Roentgenology 188:W168–W176. https://doi.org/10.2214/AJR.05.0168CrossRefPubMed

40.

Chavhan GB, Yoo S-J, Lam CZ, Khanna G (2021) Abdominal Imaging of Children and Young Adults With Fontan Circulation: Pathophysiology and Surveillance. American Journal of Roentgenology 217:207–217. https://doi.org/10.2214/AJR.20.23404CrossRefPubMed

41.

Choi BI, Lee JM, Kim TK, et al (2015) Diagnosing Borderline Hepatic Nodules in Hepatocarcinogenesis: Imaging Performance. American Journal of Roentgenology 205:10–21. https://doi.org/10.2214/AJR.14.12655CrossRefPubMed

42.

Tanaka S, Sato K, Yamamoto R, et al (2023) Gallbladder fossa nodularity in the liver typically observed in patients with alcoholic liver disease; comparison with chronic hepatitis C patients. Abdominal Radiology 48:1965–1974. https://doi.org/10.1007/s00261-023-03874-5CrossRefPubMed

Title: Magnetic resonance imaging of hepatocellular carcinoma: a spectrum of uncommon morphologic subtypes, unusual imaging patterns and mimics
Authors: Mindy X. Wang
M. Azfar Siddiqui
Alexandra Roudenko
Amita Kamath
Humaira Chaudhry
Roopa Ram
Amir A. Borhani
Venkateswar Surabhi
Khaled M. Elsayes
Robert M. Marks
Maxime Ronot
Publication date: 04-01-2025
Publisher: Springer US
Keywords: Hepatocellular Carcinoma
Hepatocellular Carcinoma
Magnetic Resonance Imaging
Magnetic Resonance Imaging
Published in: Abdominal Radiology
Print ISSN: 2366-004X
Electronic ISSN: 2366-0058
DOI: https://doi.org/10.1007/s00261-024-04773-z

Keynote webinar | Spotlight on menopause

Menopause
Video Series

Menopause can have a significant impact on the body, with effects ranging beyond the endocrine and reproductive systems. Learn about the broader systemic effects of menopause, so you can help patients in your clinics through the transition.

Prof. Martha Hickey

Dr. Claudia Barth

Dr. Samar El Khoudary

Developed by: Springer Medicine

Watch now

Keynote webinar | Spotlight on adolescent vaping

Live
Webinar | 29-01-2025 | 18:00 (CET)

Growing numbers of young people are using e-cigarettes, despite warnings of respiratory effects and addiction. How can doctors tackle the epidemic, and what health effects should you prepare to manage in your clinics?

Watch it live: Wednesday 29th January, 18:00-19:30 CET

Prof. Ann McNeill

Dr. Debbie Robson

Benji Horwell

Developed by: Springer Medicine

Join the webinar

Keynote webinar | Spotlight on modern management of frailty

Frailty in Geriatric Patients
On-demand webinar

Frailty has a significant impact on health and wellbeing, especially in older adults. Our experts explain the factors that contribute to the development of frailty and how you can manage the condition and reduce the risk of disability, dependency, and mortality in your patients.

Prof. Alfonso Cruz-Jentoft

Prof. Barbara C. van Munster

Prof. Mirko Petrovic

Developed by: Springer Medicine

Watch now

A quick guide to ECGs

Electrocardiography
Training Course

Improve your ECG interpretation skills with this comprehensive, rapid, interactive course. Expert advice provides detailed feedback as you work through 50 ECGs covering the most common cardiac presentations to ensure your practice stays up to date.

PD Dr. Carsten W. Israel

Developed by: Springer Medizin

Start the cases

At a glance: The STEP trials

Obesity
Clinical Trial Summary

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Keynote webinar | Spotlight on adolescent vaping

Springer Medicine

Abstract

Please log in to get access to this content

Keynote webinar | Spotlight on menopause

Keynote webinar | Spotlight on adolescent vaping

Keynote webinar | Spotlight on modern management of frailty

A quick guide to ECGs

At a glance: The STEP trials