Download PDF
Semin Liver Dis 2001; 21(2): 213-224
DOI: 10.1055/s-2001-15497
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Imaging Evaluation of the Cirrhotic Liver

Takamichi Murakami1 , Kiyoshi Mochizuki2 , Hironobu Nakamura1
  • 1Department of Diagnostic Medicine (Radiology), Osaka University Graduate School of Medicine, Osaka, Japan
  • 2Internal Medicine and Therapeutics, Osaka University Graduate School of Medicine, Osaka, Japan
Further Information

Publication History

Publication Date:
31 December 2001 (online)

    Permissions and Reprints

ABSTRACT

Because recent advances in medical care decrease the mortality rate due to liver cirrhosis itself, many cirrhotic patients die due to hepatocellular carcinoma. Accordingly, the role of radiology in the evaluation of the patient with cirrhosis is primarily to characterize the morphologic manifestations of the disease, evaluate the hepatic and extrahepatic vasculature, assess the effects of portal hypertension, and detect hepatic tumors. When the latter are identified, a critical role of imaging technology is to differentiate hepatocellular carcinoma from other nodular lesions, such as dysplastic nodules and regenerating nodules.

Screening strategies for patients with cirrhosis have been proposed to facilitate the detection of small, asymptomatic hepatocellular carcinomas. Dynamic studies using computed tomography (CT) and magnetic resonance imaging (MRI) are very useful for the diagnosis of hepatic tumors previously detected by ultrasound, as well as for screening. In Japan, patients with documented cirrhosis typically undergo serum alpha-fetoprotein testing and/or PIVKA-II (protein induced by vitamin K absence or antagonist II) measurements every 2 months, ultrasound every 3 months, and CT or MRI every 6 months. This has resulted in great success in detecting small hepatocellular carcinomas (less than 2 cm in diameter) and early-stage well-differentiated hepatocellular carcinomas.

KEYWORD

Dysplastic nodule - hepatocellular carcinoma - liver cirrhosis - regenerating nodules - screening

REFERENCES

  • 1 Podolsky D K, Isselbacher K J. Alcohol-related liver disease and cirrhosis. In: Isselbacher KJ, Braunwald E, Wilson JD, et al., eds. Harrison's Principles of Internal Medicine, 13th ed New York: McGraw-Hill, 1994: 1483-1495
    Google Scholar
  • 2 Conn H O, Atterbury C E. Cirrhosis. In: Schiff L, Schiff ER, eds. Diseases of the Liver, 7th ed Philadelphia: Lippincott; 1993 ;875-934
    Google Scholar
  • 3 Genesca J, Esteban J I, Alter H J. Blood-borne non-A, non-B hepatitis: hepatitis C.  Semin Liver Dis . 1991;  11 147-164
    PubMedGoogle Scholar
  • 4 Ince N, Wands J R. The increasing incidence of hepatocellular carcinoma.  N Engl J Med . 1999;  340 798-799
    CrossrefPubMedGoogle Scholar
  • 5 Kobayashi K, Sugimoto T, Makino H. Screening methods for early detection of hepatocellular carcinoma.  Hepatology . 1985;  5 1100-1105
    PubMedGoogle Scholar
  • 6 Oka H, Kurioka N, Kim K. Prospective study of early detection of hepatocellular carcinoma in patients with cirrhosis.  Hepatology . 1990;  12 680-687
    PubMedGoogle Scholar
  • 7 Popper H. Pathologic aspects of cirrhosis: a review.  Am J Pathol . 1977;  87 228-264
    PubMedGoogle Scholar
  • 8 Brown J J, Naylor M J, Yagan N. Imaging of hepatic cirrhosis.  Radiology . 1997;  202 1-16
    CrossrefPubMedGoogle Scholar
  • 9 Laennec R TH. Traite de l'auscultation medicale. Paris, France:Chaude, 1826: 196
    Google Scholar
  • 10 Harbin W P, Robert N J, Ferrucci Jr T J. Diagnosis of cirrhosis based on regional changes in hepatic morphology: a radiological and pathological analysis.  Radiology . 1980;  135 273-283
    PubMedGoogle Scholar
  • 11 Freeman M P, Vick C W, Taylor K JW. Regenerating nodules in cirrhosis: sonographic appearance with anatomic correlation.  AJR . 1986;  146 533-536
    PubMedGoogle Scholar
  • 12 Murakami T, Nakamura H, Hori S. CT and MRI of siderotic regenerating nodules in cirrhotic liver.  J Comput Assist Tomogr . 1992;  16 578-582
    PubMedGoogle Scholar
  • 13 Itai Y, Ohnishi S, Ohtomo K. Regenerating nodules of liver cirrhosis: MR imaging with pathologic correlation.  AJR . 1987;  165 419-423
    PubMedGoogle Scholar
  • 14 Ohtomo K, Itai Y, Ohtomo Y, Shiga J, Ito M. Regeneration nodules of liver cirrhosis: MR imaging with pathologic correlation.  AJR . 1990;  154 505-507
    PubMedGoogle Scholar
  • 15 Murakami T, Kuroda C, Marukawa T. Regenerating nodules of hepatic cirrhosis: MR findings with pathologic correlation.  AJR . 1990;  155 1227-1231
    PubMedGoogle Scholar
  • 16 Ohtomo K, Baron R L, Dodd III D G. Confluent hepatic fibrosis in advanced cirrhosis: appearance at CT.  Radiology . 1993;  188 31-35
    PubMedGoogle Scholar
  • 17 Ralls P W. Color Doppler sonography of the hepatic artery and portal venous system.  AJR . 1990;  155 522-526
    PubMedGoogle Scholar
  • 18 Middleton W D. The liver. In: Kurtz AB, Middleton, eds. Ultrasound: the requisites St. Louis: Mosby-Year Book, 1996: 3-34
    Google Scholar
  • 19 Bolondi L, Li Bassi S, Gaiani S. Liver cirrhosis: changes of Doppler waveform of hepatic veins.  Radiology . 1991;  178 513-516
    CrossrefPubMedGoogle Scholar
  • 20 Edelman R R, Zhao B, Liu C. MR angiography and dynamic flow evaluation of the portal venous system.  AJR . 1989;  153 755-760
    PubMedGoogle Scholar
  • 21 Finn J P, Kane R A, Edelman R R. Imaging of the portal venous system in patients with cirrhosis: MR angiography versus duplex Doppler sonography.  AJR . 1993;  161 989-994
    PubMedGoogle Scholar
  • 22 Minami M, Itai Y, Ohtomo K. Siderotic nodules in the spleen: MR imaging of portal hypertension.  Radiology . 1989;  172 681-684
    PubMedGoogle Scholar
  • 23 Kondo F, Ebara M, Sugiura N. Histological features and clinical course of large regenerative nodules: evaluation of their precancerous potentiality.  Hepatology . 1990;  12 592-598
    PubMedGoogle Scholar
  • 24 Liver cancer study group of Japan. General rules for the clinical and pathological study of primary liver cancer Tokyo: Kanehara, 1992: 14-17
  • 25 Craig J R, Klatt E C, Yu M. Role of cirrhosis and the development of HCC: evidence from histologic studies and large population studies. In: Tabor E, Di Bisceglie AM, Purcell RH, eds. Etiology, Pathology and Treatment of Hepatocellular Carcinoma in North America The Woodlands, TX: Portfolio 1991: 177-190
    Google Scholar
  • 26 Calvet X, Bruix J, Bru C. Natural history of hepatocellular carcinoma in Spain.  J Hepatol . 1990;  10 311-317
    CrossrefPubMedGoogle Scholar
  • 27 Zaman S N, Johnson P J, Williams R. Silent cirrhosis in patients with hepatocellular carcinoma: implications for screening in high-incidence and low-incidence areas.  Cancer . 1990;  65 1607-1610
    PubMedGoogle Scholar
  • 28 Tribelli C, Melato M, Croce L S. Prevalence of hepatocellular carcinoma and relation to cirrhosis: comparison of two different cities of the world-Trieste, Italy, and Chiba, Japan.  Hepatology . 1989;  10 998-1002
    PubMedGoogle Scholar
  • 29 El-Serag H B, Mason A C. Rising incidence of hepatocellular carcinoma in the United States.  N Engl J Med . 1999;  340 745-750
    CrossrefPubMedGoogle Scholar
  • 30 Nzeako V C, Goodman Z D, Ishak K G. Hepatocellular carcinoma in cirrhotic and noncirrhotic livers: a clinico- histopatholgoic study of 804 North American patients.  Am J Clin Pathol . 1996;  105 65-75
    PubMedGoogle Scholar
  • 31 Okuda K. Hepatocellular carcinoma in cirrhotics.  Semin Liver Dis . 1993;  13 374-383
    PubMedGoogle Scholar
  • 32 Alpert E, Hershberg R, Schur P H. Alpha fetoprotein in human hepatoma: improved detection in serum and quantitative studies using a new sensitive technique.  Gastroenterology . 1971;  61 137-143
    PubMedGoogle Scholar
  • 33 Tanaka S, Kitamura T, Imaoka S. Hepatocellular carcinoma: sonographic and histologic correlation.  AJR . 1983;  140 701-707
    PubMedGoogle Scholar
  • 34 Dodd III D G, Miller W J, Baron R L, Kolnick M L, Campbell W L. Detection of malignant tumors in end-stage cirrhotic livers: efficacy of sonography as a screening tool.  AJR . 1992;  159 727-733
    PubMedGoogle Scholar
  • 35 Tanaka S, Kitamura T, Fujita M, Nakanishi K, Okuda S. Color Doppler flow imaging of liver tumors.  AJR . 1990;  154 509-514
    PubMedGoogle Scholar
  • 36 Tanaka S, Kitamura T, Fujita M. Small hepatocellular carcinoma: differentiation from adenomatous hyperplastic nodule with color Doppler flow imaging.  Radiology . 1992;  182 161-165
    CrossrefPubMedGoogle Scholar
  • 37 Tochio H, Minowa K, Tomita S. Differential diagnosis of hepatic tumors using color Doppler flow imaging: value of the Doppler spectral analysis.  Jpn J Med Ultrasonics . 1992;  19 277-287
    PubMedGoogle Scholar
  • 38 Nanda N C, Schlief R. Advances in Echo Imaging Using Contrast Enhancement.  Dordrecht, the Netherlands: Kluwer Academic Publishers; 1993
    Google Scholar
  • 39 Fujimoto M, Moriyasu F, Nishikawa K. Color Doppler sonography of hepatic tumors with a galactose-based contrast agent: Correlation with angiographic findings.  AJR . 1994;  163 1099-1104
    PubMedGoogle Scholar
  • 40 Yamashita Y, Takahashi M, Baba Y. Hepatocellular carcinoma with or without cirrhosis: a comparison of CT and angiographic presentations in the United States and Japan.  Abdom Imaging . 1993;  18 168-175
    PubMedGoogle Scholar
  • 41 Kim T, Murakami T, Oi H. Detection of hypervascular hepatocellular carcinoma by dynamic MRI and dynamic spiral CT.  J Comput Assist Tomogr . 1995;  19 948-954
    PubMedGoogle Scholar
  • 42 Mitsuzaki K, Yamashita Y, Ogata I, Nishiharu T, Urata J, Takahashi M. Multiple-phase helical CT of the liver for detecting small hepatomas in patients with liver cirrhosis: contrast-injection protocol and optimal timing.  AJR . 1996;  167 753-757
    PubMedGoogle Scholar
  • 43 Earls J, Rofsky N R, DeCorato D. Arterial-phase dynamic gadolinium-enhanced MR imaging: optimizing with a test examination and a power injector.  Radiology . 1997;  202 268-273
    PubMedGoogle Scholar
  • 44 Kelekis N L, Semelka R C, Worawattanakul S. Hepatocellular carcinoma in North America: a multiinstitutional study of appearance on T1-weighted, T2-weighted, and serial gadolinium-enhanced gradient-echo images.  AJR . 1998;  170 1005-1013
    PubMedGoogle Scholar
  • 45 Itai Y, Matsui O. Blood flow and liver imaging.  Radiology . 1997;  202 306-314
    PubMedGoogle Scholar
  • 46 Matsui O, Kadoya M, Yoshikawa J. Aberrant gastric venous drainage in cirrhotic livers: imaging findings in focal areas of liver parenchyma.  Radiology . 1995;  197 345-349
    PubMedGoogle Scholar
  • 47 Mitani T, Nakamura H, Murakami T. Dynamic MR studies of hepatocellular carcinoma with portal vein tumor thrombosis.  Radiation Medicine . 1992;  10 232-234
    PubMedGoogle Scholar
  • 48 Kadoya M, Matsui O, Takashima T, Nonomura A. Hepatocellular carcinoma: correlation of MR imaging and histologic findings.  Radiology . 1992;  183 819-825
    CrossrefPubMedGoogle Scholar
  • 49 Itai Y, Ohtomo K, Furui S, Minami M, Yoshikawa K, Yashiro N. Lobar intensity differences of the liver on MR imaging.  J Comput Assist Tomogr . 1986;  10 236-241
    PubMedGoogle Scholar
  • 50 Weissleder R. Liver MR imaging with iron oxides: toward consensus and clinical practice.  Radiology . 1994;  193 593-595
    PubMedGoogle Scholar
  • 51 Murakami T, Baron R L, Federle M P. Cirrhosis of the liver: MR imaging with mangafodipir trisodium (Mn-DPDP).  Radiology . 1996;  200 69-77
    PubMedGoogle Scholar
  • 52 Imai Y, Murakami T, Yoshida S. Superparamagnetic iron oxide-enhanced MR images of hepatocellular carcinoma: correlation with histological grading.  Hepatology . 2000;  32 205-212
    CrossrefPubMedGoogle Scholar
  • 53 International working party. Terminology of nodular hepatocellular lesions.  Hepatology . 1995;  22 983-993
    CrossrefPubMedGoogle Scholar
  • 54 Hytiroglou P, Theis N D. Differential diagnosis of hepatocellular nodular lesions.  Semin Diagn Pathol . 1998;  15 285-299
    PubMedGoogle Scholar
  • 55 Mitchell D G. Focal manifestations of diffuse liver disease at MR imaging.  Radiology . 1992;  185 1-11
    PubMedGoogle Scholar
  • 56 Sakamoto M, Hirohashi S, Shimosato Y. Early stages of multistep hepatocarcinogenesis: adenomatous hyperplasia and early hepatocellular carcinoma.  Hum Pathol . 1991;  22 172-178
    CrossrefPubMedGoogle Scholar
  • 57 Lim J H, Kim C K, Lee W J. Detection of hepatocellular carcinoma and dysplastic nodules in cirrhotic livers: accuracy of helical CT in transplant patients.  AJR . 2000;  175 693-698
    PubMedGoogle Scholar
  • 58 Matsui O, Kadoya M, Kameyama T. Benign and malignant nodules in cirrhotic livers: distinction based on blood supply.  Radiology . 1991;  178 493-497
    PubMedGoogle Scholar
  • 59 Lim J H, Kim E Y, Lee W J. Regenerating nodules in liver cirrhosis: findings at CT during arterial portography and CT hepatic arteriography with histopathologic correlation.  Radiology . 1999;  210 451-458
    PubMedGoogle Scholar
  • 60 Ebara M, Ohto M, Waranabe Y. Diagnosis of small hepatocellular carcinoma: correlation of MR imaging and tumor histologic studies.  Radiology . 1986;  159 371-377
    PubMedGoogle Scholar
  • 61 Ebara M, Fukuda H, Kojima Y. Small hepatocellular carcinoma: relationship of signal intensity to histopathologic findings and metal content of the tumor and surrounding hepatic parenchyma.  Radiology . 1999;  210 81-88
    CrossrefPubMedGoogle Scholar
  • 62 Sedek A G, Mitchell D G, Siegelman E S. Early hepatocellular carcinoma that develops within macroregenerative nodules: growth rate depicted at serial MR imaging.  Radiology . 1995;  195 753-756
    PubMedGoogle Scholar
  • 63 Oka H, Kurioka N, Kanno T. Prospective study of early detection of hepatocellular carcinoma in patient with cirrhosis.  Hepatology . 1990;  12 680-687
    PubMedGoogle Scholar
  • 64 Arii S, Tobe T. Results of surgical treatment. Follow-up study by liver cancer study group of Japan In: Tobe T, et al, eds. Primary Liver Cancer in Japan Tokyo: Springer-Verlag 1992: 243-255
    Google Scholar
  • 65 Tanaka S, Kitamura T, Nakanishi K. Recent advances in ultrasonographic diagnosis of hepatocellular carcinoma.  Cancer . 1989;  63 1313-1317
    PubMedGoogle Scholar
  • 66 Ebara M, Ohto M, Shinagawa T. Natural history of minute hepatocellular carcinoma smaller than three centimeters complicating cirrhosis: a study in 22 patients.  Gastroenterology . 1986;  90 289-298
    PubMedGoogle Scholar
  • 67 Kaneko S, Unoura M, Kobayashi K. Early detection of hepatocellular carcinoma. In: Okuda K, Tabor E, eds. Liver Cancer New York: Churchill Livingstone 1997: 393-406
    Google Scholar