Image-Guided Biopsy Liver Biopsy plays a minor role in establishing the diagnosis of HCC because the imaging criteria of LI-RADS category 5 (definite HCC) can establish such diagnosis with nearly 100% specificity and PPV [6,74]. Biopsy may be necessary if the imaging features of the lesion do not meet the criteria for LI-RADS 5 (definite HCC) category or for molecular analysis to determine clinical trial eligibility or to guide treatment [74]. Overall risk of bleeding for image-guided biopsy can be as high as 12% [27]. An additional risk in biopsy of HCC is a risk of needle-tract seeding, with track seeding incidence being 2.7% overall and 0.1% to 0.9% per year [52-54,75]. RBC Scan Abdomen and Pelvis There is no relevant literature to support the use of a Tc-99m RBC scan in this clinical scenario. Liver Spleen Scan There is no relevant literature to support the use of a Tc-99m sulfur colloid scan in this clinical scenario. Liver Lesion-Initial Characterization US Abdomen with Contrast For indeterminate liver lesions detected on US, CEUS can provide definitive diagnosis in 77% to 93% of cases and can distinguish between benign and malignant lesions in 89% to 96% of cases [31,32]. The sensitivity of CEUS for diagnosing a small HCC (<2 cm) is 68% compared with 53% for contrast-enhanced CT and 77% for gadolinium- ethoxybenzyl-diethylenetriamine pentaacetic acid MRI in the same study [56]. Diagnostic accuracy of CEUS for HCC is 79% [35]. On CEUS, HCC typically shows a global arterial hyperenhancement and a delayed contrast wash-out, whereas intrahepatic cholangiocarcinoma shows an initial contrast enhancement primarily at the tumor periphery followed by an early portal-venous contrast wash-out in the tumor center [78]. CEUS can accurately differentiate between intrahepatic cholangiocarcinoma and HCC [79]. CT of the abdomen with and without IV contrast is not recommended for this clinical scenario because there is no added value for unenhanced images.
Liver Lesion Initial Characterization. Image-Guided Biopsy Liver Biopsy plays a minor role in establishing the diagnosis of HCC because the imaging criteria of LI-RADS category 5 (definite HCC) can establish such diagnosis with nearly 100% specificity and PPV [6,74]. Biopsy may be necessary if the imaging features of the lesion do not meet the criteria for LI-RADS 5 (definite HCC) category or for molecular analysis to determine clinical trial eligibility or to guide treatment [74]. Overall risk of bleeding for image-guided biopsy can be as high as 12% [27]. An additional risk in biopsy of HCC is a risk of needle-tract seeding, with track seeding incidence being 2.7% overall and 0.1% to 0.9% per year [52-54,75]. RBC Scan Abdomen and Pelvis There is no relevant literature to support the use of a Tc-99m RBC scan in this clinical scenario. Liver Spleen Scan There is no relevant literature to support the use of a Tc-99m sulfur colloid scan in this clinical scenario. Liver Lesion-Initial Characterization US Abdomen with Contrast For indeterminate liver lesions detected on US, CEUS can provide definitive diagnosis in 77% to 93% of cases and can distinguish between benign and malignant lesions in 89% to 96% of cases [31,32]. The sensitivity of CEUS for diagnosing a small HCC (<2 cm) is 68% compared with 53% for contrast-enhanced CT and 77% for gadolinium- ethoxybenzyl-diethylenetriamine pentaacetic acid MRI in the same study [56]. Diagnostic accuracy of CEUS for HCC is 79% [35]. On CEUS, HCC typically shows a global arterial hyperenhancement and a delayed contrast wash-out, whereas intrahepatic cholangiocarcinoma shows an initial contrast enhancement primarily at the tumor periphery followed by an early portal-venous contrast wash-out in the tumor center [78]. CEUS can accurately differentiate between intrahepatic cholangiocarcinoma and HCC [79]. CT of the abdomen with and without IV contrast is not recommended for this clinical scenario because there is no added value for unenhanced images.