1) Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, strongly associated with cirrhosis and hepatitis B virus infection. 2) LI-RADS is a classification system used to evaluate liver lesions seen on CT and MRI scans, assigning a probability of HCC based on features such as arterial phase hyperenhancement, washout, and size. 3) Major LI-RADS features of HCC include arterial phase hyperenhancement, lack of washout in portal venous phase, presence of a capsule, size over 2cm, and threshold growth; these features are used to categorize lesions as definitely benign (LR-1), probably benign (LR-2),

1. IMAGING FEATURES OF
HEPATOCELLULAR
CARCINOMA
PRESENTER: DR ABHISHEK GOHIL(RADIOLOGY PG)

2. HCC(HEPATOMA)
• Most common primary malignancy of the liver
• Strongly associated with cirrhosis and HBV.
• Risk factors:
• hepatitis B (HBV) /hepatitis C (HCV) infection
• alcoholism
• biliary cholangitis
• food toxins, e.g. aflatoxins
• congenital biliary atresia
• obesity and diabetes mellitus

3. Clinical presentation:
• jaundice
• portal hypertension from the invasion of the portal vein
• hepatomegaly/mass

4. Pathology:

5. • Features of HCC:
• Arterial phase enhancement
• Isodose or hypodense to liver in the portal venous phase due to fast wash-
out.
• Delayed images the capsule demonstrate prolonged enhancement.
• Tumoral capsule
• Internal mosaic pattern
• Uncommon ca+

6. HCC and Portal Vein thrombosis:
• Many patients with cirrhosis have portal venous thrombosis and many patients
with HCC have thrombosis.
It is very important to make the distinction between just thrombus and tumor
thrombus.
• Malignant thrombus :
• Enhance best in arterial phase.
• it will increase the diameter of the vessel.
• neovascularity within the thrombus

7. LI-RADS
• Liver Imaging Reporting and Data System
• classification system for liver lesions which is used in patients with liver
cirrhosis and chronic HBV without cirrhosis
• probability of HCC and is based on the typical CT and MR-findings in HCC.
• LI-RADS is not meant to be used in patients <18 years or patients with cirrhosis
due to congenital hepatic fibrosis or due to vascular disorders, because
these patients have a lower chance of developing HCC.

8. WHEN TO USE LI-RADS
• USE LIRADS
• cirrhosis
• hep b virus
• current or prior HCC
• DO NOT USE LIRADS:
• <18YEARS
• cirrhosis due to congenital hepatic fibrosis and vascular disorders

9. LI-RADS MAJOR FEATURES
• Five major features which are typically seen in HCC
1)Arterial phase hyperenhancement (APHE)
• Non-rim arterial hyperenhancement of a lesion which is greater than the
enhancement of the surrounding liver.
• Rim enhancement is not a feature of HCC.
2)Non-peripheral washout
• Decrease in attenuation or intensity from earlier to later phase, resulting in
hypoenhancement in the portal venous or delayed phase.

10. 3.Capsule
• Smooth, uniform border surrounding
4.Size
• A large lesion(>2CM) has a greater chance of
being a HCC than a small lesion.
5.Threshold growth
• Threshold growth is increase in size of 50% or
more within 6 months time during follow-up
imaging.

11. ADDITIONAL CATEGORIES ARE:
• LR-TIV - tumor in vein.
• LR-M - malignant but not HCC.
• LR-TR - treated HCC.
• LR-NC - non-categorizable for lesions in which the technical quality of the
imaging does not allow evaluation of the major features

13. USE LI-RADS AS FOLLOWS:
First determine whether there is
enhancement.
Then look at the type of enhancement
Then look at the size of the lesion
Finally look for additional typical features of
HCC like enhancing capsule, non-peripheral
washout and growth of the lesion. LR-3- intermediate probability
LR-4-probable
LR-5- which is definitely HCC

14. • Lesion in a patient with liver
cirrhosis.
• There is arterial phase non-rim
hyperenhancement and the size
is 15mm.
• There is a capsule and washout
in a later phase.
This means that there are 2
additional features.

15. MAJOR FEATURES
• Arterial Phase non-rim
Hyperenhancement (APHE)
• non-rim hyperenhancement
• washout
• Washout - Capsule
Size - Threshold growth

16. LI-RADS CATEGORIES
• LI-RADS 1 - definitely benign
• Examples of LR-1 lesions are definite:
• Cyst
• Hemangioma
• Perfusion alteration (e.g., arterioportal shunt)
• Hepatic fat deposition/sparing
• Confluent fibrosis or focal scar

17. Non enhancing lesions in a cirrhotic liver, compatible with cysts, LR-1

18. • LI-RADS 2 - probably benign
• Atypical appearance of benign entities may be categorized as LR2
• LR2 cirrhosis-associated nodule is also included
• LI-RADS 3 - intermediate probability
• Nodules with features of focal nodular hyperplasia or hepatic
• Nodules of < 20mm without major features but with one or more
such as intralesional fat, T2 hyperintensity, diffusion restriction and HB
• Nodules above 20 mm and without major or ancillary features.

19. Hyper enhancing lesions without any additional feature like washout,
capsule or threshold growth.

20. • LI-RADS 4 - probably HCC
• Of all LR-4 observations about 74% are HCC and 81% are malignant
• LR-4 depends on the size of the lesion, the presence of APHE and the
major features
Small area of arterial enhancement
and washout

21. • LI-RADS 5 - definitely HCC
• Major features - which makes this a LR-5 lesion:
1.lesion > 20mm
2.non-rim APHE
3.Washout
• Diffusion restriction

22. FEATURES FAVORING HCC
• Non-enhancing capsule
• Nodule in nodule
• Mosaic structure
• Blood products in mass
• Fat in mass

23. • Nodule in nodule
• Fat containing lesion with arterial
• Within this lesion there is a nodule (arrow)
and a capsule.
• Fat in mass
• non-rim enhancement and macroscopic fat
• Mosaic architecture
• Hyperenhancement in the late arterial phase

24. • non-rim APHE in segment VI of the liver
• Washout on PV phase
• Enhancing capsule
• Microscopic fat on IP/OOP sequences, Diffusion restriction

25. LR-TIV - TUMOR IN VEIN
• Almost always the venous invasion by tumor is related
to a HCC.
• LR-TIV is a contraindication to liver transplantation.
• clues of possible venous invasion by tumor are:
• Presence of an occluded vein with ill-defined
margins
• Diffusion restriction
• Expansion of a vein

26. LR-M - MALIGNANT
• LR-M should be applied to malignant appearing lesions that do not have
the typical characteristics of HCC.
• Non-HCC malignant lesions either show:
• Targetoid appearance: rim-like APHE and peripheral washout and
delayed central enhancement.
• Non-targetoid with an infiltrative growth pattern.
• Marked diffusion restriction or necrosis.

27. rim enhancing mass in the late arterial phase in a patient with chronic hepatitis.
In the portal venous phase there is progressive peripheral enhancement.

28. LRTR-TREATED HCC
• LRTR non viable-
• without residual areas of
arterial enhancement or
washout
• LRTR viable-
• Area of arterial
enhancement and
washout adjacent to the
surgical clips

29. DIFFERENTIAL DIAGNOSIS
• Fibrolamellar carcinoma (FLC)
• Hyper vascular hepatic metastases
• Focal nodular hyperplasia (FNH)
• Hepatic adenoma
• Intrahepatic cholangiocarcinoma

30. FIBROLAMELLAR CARCINOMA (FLC)
• uncommon malignant hepatocellular tumor but less aggressive than
HCC
• 10-20 cm large hepatic mass
• adolescents or young adults.
• Unlike HCCs they do not have an association with cirrhosis, alcoholism,
or hepatitis B/C infection
• Lobulated heterogeneous mass with a central scar in an otherwise
normal liver.
• Calcifications 30-60%

31. Central calcification and heterogenous enhancement in a lamellar pattern.
venous phase with hypodense central scar.

32. FOCAL NODULAR HYPERPLASIA (FNH)
• second most common tumor of the liver.
• The origin of focal nodular hyperplasia is thought to be due to a hyperplastic
growth of normal hepatocytes with a malformed biliary drainage system,
possibly in response to a pre-existent arteriovenous malformation.
• CT will show FNH as a vascular tumor, that will be hyperdense in the arterial
phase, except for the central scar
• Typical FNH with a central scar that is hypodense in the portal venous phase
and hyperdense in the equilibrium phase.

35. HYPER VASCULAR HEPATIC METASTASES
• Hyper vascular metastases are sometimes difficult to differentiate from
HCC because of their similar arterial enhancement pattern
• Multiplicity and targetoid enhancement pattern
• Multiple heterogenous lesions with mild peripheral enhancement in the
arterial phase.
• Mildly hypodense compared to adjacent liver parenchyma on the portal
phase

37. HEPATIC ADENOMA
• Young woman using contraceptives
• Hepatocellular adenomas are large, well circumscribed encapsulated
tumors.
• Adenomas typically measure 8-15 cm and consist of sheets of well-
differentiated hepatocytes.
• Adenomas are prone to central necrosis and hemorrhage
• The pathogenesis is related to a generalized vascular ectasia that
develops due to exposure of the liver to oral contraceptives and related
synthetic steroids.
• CT will show most adenomas as a lesion with homogeneous enhancement
in the late arterial phase, that will stay isodense to the liver in later
phases.

40. CHOLANGIOCARCINOMA
• Cholangiocarcinoma usually presents as a mass of 5-20cm. In 65% there
are satellite nodules and in some cases punctate calcifications are seen
• peripheral location
• biliary obstruction
• delayed enhancement
• Infiltrating mass with capsular retraction and delayed persistent
enhancement is very typical for a cholangiocarcinoma.
• .

41. •Lesion is hypodens in the arterial and portal
venous phase with some peripheral enhancement.
•The lesion is hyperdense in the equilibrium phase
indicating dens fibrous tissue.
•The lesion causes retraction of the liver capsule