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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]
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Satoshi Kobayashi
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Junichiro Sanada
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Wataru Kouda
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Yasuji Ryu
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Kazuto Kozaka
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Azusa Kitao
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Koichi Nakamura
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Toshifumi Gabata
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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.
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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)