CT diagnosis of early hepatocellular carcinoma: sensitivity, findings, and CT-pathologic correlation.

OBJECTIVE: The purpose of this study was to determine the sensitivity of CT in detecting early hepatocellular carcinoma and to evaluate its CT appearance. An early hepatocellular carcinoma is a nodular lesion with no fibrous capsule composed of well-differentiated tumor histologically. It differs from a small hepatocellular carcinoma, which is an overt tumor that is moderately to poorly differentiated and has a fibrous capsule. Size is not a criterion for distinguishing between early and small hepatocellular carcinomas.

MATERIALS AND METHODS: Thirty-one patients with 39 histopathologically proved early hepatocellular carcinomas (mean diameter, 1.7 cm) found by sonography, MR imaging, and/or intraoperative sonography were included in a retrospective study. We reviewed unenhanced CT scans of the entire liver in 30 patients (37 lesions) and early and late (35 sec and 5 min after the beginning of injection of contrast material) contrast-enhanced CT scans of the entire liver in all 31 patients (table incremental CT in 21; helical CT in 10; 39 lesions). Eighteen histologically proved small hepatocellular carcinomas (< or = 3 cm; mean diameter, 2.3 cm), present in the same patients, served for comparison. Histopathologically, nine patients had chronic hepatitis, and 22 had cirrhosis.

RESULTS: The overall sensitivity of CT in detecting early hepatocellular carcinoma was 56%. These tumors were usually isodense with respect to surrounding liver on unenhanced, early enhanced, and late enhanced CT scans (iso-iso-iso). This pattern was seen in 17 (46%) of 37 lesions; thus, these 17 histologically proved early hepatocellular carcinomas were not detected with CT. An iso-iso-low density pattern was recognized in eight (22%), a low-low-low pattern in seven (19%), and several different patterns in five (13%) of the 37 lesions. Only two (5%) of 39 early hepatocellular carcinomas had a high-density appearance on early enhanced CT scans. In comparison, the most common pattern of small overt hepatocellular carcinomas on CT scans was low-high-low, seen in 17 lesions (94%) detected with CT. When the density of lesions on unenhanced CT scans was compared with the histopathologic appearance of the masses, low-density lesions showed mild to moderate fatty change and isodense lesions showed no or minimal fatty change (p = .006).

CONCLUSION: The sensitivity of CT in detecting early hepatocellular carcinoma is poor (56%). However, the diagnosis of early hepatocellular carcinoma should be considered if CT scans show a small lesion with an iso-low or low-low density enhancement pattern on early and late contrast-enhanced CT scans, respectively, in patients with chronic liver disease.