Hepatocelluar nodules in liver cirrhosis: hemodynamic evaluation (angiography-assisted CT) with special reference to multi-step hepatocarcinogenesis

Abdominal Imaging, Jun 2011

To understand the hemodynamics of hepatocellular carcinoma (HCC) is important for the precise imaging diagnosis and treatment, because there is an intense correlation between their hemodynamics and pathophysiology. Angiogenesis such as sinusoidal capillarization and unpaired arteries shows gradual increase during multi-step hepatocarcinogenesis from high-grade dysplastic nodule to classic hypervascular HCC. In accordance with this angiogenesis, the intranodular portal supply is decreased, whereas the intranodular arterial supply is first decreased during the early stage of hepatocarcinogenesis and then increased in parallel with increasing grade of malignancy of the nodules. On the other hand, the main drainage vessels of hepatocellular nodules change from hepatic veins to hepatic sinusoids and then to portal veins during multi-step hepatocarcinogenesis, mainly due to disappearance of the hepatic veins from the nodules. Therefore, in early HCC, no perinodular corona enhancement is seen on portal to equilibrium phase CT, but it is definite in hypervascular classical HCC. Corona enhancement is thicker in encapsulated HCC and thin in HCC without pseudocapsule. To understand these hemodynamic changes during multi-step hepatocarcinogenesis is important, especially for early diagnosis and treatment of HCCs.

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Hepatocelluar nodules in liver cirrhosis: hemodynamic evaluation (angiography-assisted CT) with special reference to multi-step hepatocarcinogenesis

Osamu Matsui [email protected] 0 Satoshi Kobayashi 0 Junichiro Sanada 0 Wataru Kouda 0 Yasuji Ryu 0 Kazuto Kozaka 0 Azusa Kitao 0 Koichi Nakamura 0 Toshifumi Gabata 0 0 Department of Radiology, Graduate School of Medical Science, Kanazawa University , Kanazawa, Japan To understand the hemodynamics of hepatocellular carcinoma (HCC) is important for the precise imaging diagnosis and treatment, because there is an intense correlation between their hemodynamics and pathophysiology. Angiogenesis such as sinusoidal capillarization and unpaired arteries shows gradual increase during multi-step hepatocarcinogenesis from high-grade dysplastic nodule to classic hypervascular HCC. In accordance with this angiogenesis, the intranodular portal supply is decreased, whereas the intranodular arterial supply is first decreased during the early stage of hepatocarcinogenesis and then increased in parallel with increasing grade of malignancy of the nodules. On the other hand, the main drainage vessels of hepatocellular nodules change from hepatic veins to hepatic sinusoids and then to portal veins during multi-step hepatocarcinogenesis, mainly due to disappearance of the hepatic veins from the nodules. Therefore, in early HCC, no perinodular corona enhancement is seen on portal to equilibrium phase CT, but it is definite in hypervascular classical HCC. Corona enhancement is thicker in encapsulated HCC and thin in HCC without pseudocapsule. To understand these hemodynamic changes during multi-step hepatocarcinogenesis is important, especially for early diagnosis and treatment of HCCs. - Hepatocellular carcinoma (HCC) is the most common primary liver cancer worldwide. Approximately 80% of Japanese HCC cases are derived from HCV-associated liver cirrhosis and chronic hepatitis, and the remaining less than 20% of the patients are HBV positive. The patients with hepatitis B or C cirrhosis are especially classified as a very high-risk group. Ultrasonography is performed every 34 months for the very high-risk group. Because of the introduction of this surveillance system, the size of HCCs firstly detected during 2002 2003 (n = 33731) was less than 2 cm in 32.5% of all cases, 2.15.0 cm 47.0%, respectively [1]. However, various types of hepatocellular nodules such as dysplastic nodule (DN) are also detected during screening procedures. Ultrasound and CT features of DNs and early HCCs are similar, and a precise differential diagnosis is impossible. Pathologically, human HCC develops in a multistep fashion from DN to classic hypervascular HCC. Therefore, for the early diagnosis of HCC, understanding of the concept of multi-step hepatocarcinogenesis and the sequential changes of imaging findings in accordance with multi-step hepatocarcinogenesis is important. To understand the hemodynamics of HCC is important for the precise imaging diagnosis and treatment, because there is an intense correlation between its hemodynamic and pathophysiology. For this purpose, dynamic MDCT is most valuable because of its high spatial and contrast resolution. However, because of the dual blood supply of the liver and intravenous injection of the contrast medium, the precise analysis of hemodynamics by conventional MDCT is often difficult. By the introduction of dynamic CT during selective arteriography, including CT during arterial portography (CTAP) [2, 3] and CT during hepatic arteriography (CTHA) [4], it has become possible to visualize the distribution of the intra-hepatic portal and arterial blood flow separately with extremely high contrast resolution, and as a result, to analyze precisely the correlation between blood supply and pathophysiology. In this article, blood flow imaging features of HCC will be discussed based on the CTAP and CTHA imaging and pathophysiologic correlations with special reference to multistep hepatocarcinogenesis. Classification of hepatocellular nodules and multi-step hepatocarcinogenesis The concept of multi-step hepatocarcinogenesis and related small hepatocellular nodules in the patients with chronic liver diseases, particularly those with cirrhosis or chronic hepatitis caused by hepatitis B or C viruses, was developed mainly in Japan. However, it had not been widely accepted throughout the world and the diagnostic criteria of these nodules different even among the world specialists. However, in 2009, the International Consensus Group for Hepatocellular Neoplasia organized by the worlds leading liver pathologists finally reached agreement [5]. According to this report, these nodules are divided into large regenerative nodule, low grade DN (L-DN), high-grade DN (H-DN), and HCC. In addition, small HCC (less than 2 cm) is divided into early HCC and progressed HCC. Early HCC has a vaguely nodular appearance and is well differentiated. Progressed HCC has a distinctly nodular pattern and is mostly moderately differentiated, often with evidence of microvascular invasion. L-DNs are vaguely or distinct nodular with mild i (...truncated)


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Osamu Matsui, Satoshi Kobayashi, Junichiro Sanada, Wataru Kouda. Hepatocelluar nodules in liver cirrhosis: hemodynamic evaluation (angiography-assisted CT) with special reference to multi-step hepatocarcinogenesis, Abdominal Imaging, 2011, pp. 264-272, Volume 36, Issue 3, DOI: 10.1007/s00261-011-9685-1