Hepatocellular carcinoma (HCC)

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  Primary malignancy of liver arising from hepatocytes

Synonyms: Hepatoma, primary liver cancer

Ultrasound: Primary test for screening/surveillance for HCC

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  Solid, intrahepatic mass may be hypoechoic (most common), hyperechoic, or isoechoic

  
  
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  May see hypoechoic halo, mild posterior acoustic enhancement, or internal vascularity on color Doppler

  
  
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  Infiltrative tumors often difficult to visualize margins; look for refractive edge shadows, parenchymal distortion, or loss of normal echogenic portal triads, which are helpful secondary findings

  
  
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  Portal vein or hepatic vein tumor invasion highly suggestive of HCC

Contrast-enhanced CT, MR, or CEUS: For characterization

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  Arterial hyperenhancement and portal/delayed washout

Intrahepatic cholangiocarcinoma

Regenerative or dysplastic nodule

Hepatic hemangioma (especially hyalinized subtype)

Focal nodular hyperplasia

Hepatic adenoma

Metastases

Screening/surveillance ultrasound every 6 months recommended for the following populations in USA

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  Cirrhosis (60-90%) from any cause

  
  
  
  
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    Most commonly due to chronic viral hepatitis (HBV, HCV), alcoholic cirrhosis

  
  
  
  
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  Noncirrhotic chronic Hepatitis B in certain populations

  
  
  
  
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    Asian male > 40, Asian female > 50, African/North American black, family history HCC

  
  
  
  
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  Surveillance benefit uncertain in following populations: Noncirrhotic chronic HCV with stage 3 fibrosis, noncirrhotic nonalcoholic fatty liver disease, and noncirrhotic HBV carriers with active hepatitis who do not meet above criteria

Careful inspection of portal veins and hepatic veins for thrombus critical; infiltrative HCC often invades veins

Liver dome lesions are often missed; angle transducer to image above HV to completely visualize liver dome

RT and LT inferior tip of liver lesions are easily missed; carefully scan through very inferior portions of liver

Anterior lesions often poorly visualized with curvilinear or vector transducers; diligent use of 9-MHz linear probe helps visualization of superficial portions of liver

Trying multiple probes, positions, and windows are key to improve detection; some liver lesions may only be seen on left lateral decubitus position (vs. supine) or intercostal approach (vs. subcostal)