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Hepatocellular carcinoma
Diagnosis
Updated: October 29, 2005
Imaging
Ultrasound
The initial diagnostic test in the symptomatic patient may be
ultrasonography, as it is noninvasive and can detect lesions as
small as 1 cm. Ultrasound findings should be followed up with more
specific imaging. Ultrasound guided biopsies may be used to
establish the diagnosis.
CT and MRI
Triple-phase, high-resolution CT and contrast-enhanced MRI are the
primary imaging modalities used to diagnose and stage hepatocellular
carcinoma. CT scan predicts resectability in only 40%-50% of cases
and does not accurately determine the functional extent of
cirrhosis. Major difficulties arise when the liver parenchyma is not
homogeneous and the lesions are smaller than 1 cm.
Grossly, metastatic tumors are
often peripheral and multiple and cause umbilication of the surface
of the liver, whereas primary liver tumors are more often central
and can be solitary, but are usually hypervascular on the arterial
phase of a helical CT scan.
Invasion of the portal vein and to a lesser extent the hepatic vein is
typically seen on dynamic CT as an obstruction of portal flow with
venous expansion, which thus distinguishes malignant from benign
thrombosis. Malignant thrombi are often hypervascular on the
arterial phase of the CT, whereas bland thrombi are not
hypervascular.
Biopsy
Some authors believe that percutaneous liver biopsy carries a high
risk and has little diagnostic value. Nevertheless, a biopsy is
imperative to establish the diagnosis either by percutaneous
technique or by surgery.
Laparoscopy
Laparoscopy is useful for the evaluation of small tumors, the extent
of cirrhosis, peritoneal seeding, and the volume of noninvolved
liver and therefore may be used prior to open laparotomy for
resection. Laparoscopic or intraoperative ultrasonography should be
used to confirm preoperative imaging tests. The laparoscopic results
may change surgical management in up to one third of selected
patients.
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Labs
α-Fetoprotein is produced by 70% of hepatocellular carcinomas. The
normal range for this serum marker is 0-20 ng/mL, and a level > 200
ng/mL is essentially diagnostic for hepatocellular cancer in the
absence of chronic, active hepatitis B infection. In the presence of
active hepatitis B infection, the diagnostic cutoff is considered to
be at least 1,000 ng/mL. In the setting of hepatitis C
infection, the cutoff for diagnosis of hepatocellular carcinoma has
not been well studied. False-positive results may be due to acute or
chronic hepatitis, germ-cell tumors, or pregnancy.
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