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Rationale Schnittbildgebung des hepatozellulären Karzinoms

Die Herausforderung multimodaler Diagnosekriterien

Rational imaging of hepatocellular carcinoma

The challenge of multimodal diagnostic criteria

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Zusammenfassung

Klinisches/methodisches Problem

CT und MRT bilden den Goldstandard in der bildgebenden Diagnostik des hepatozellulären Karzinoms (HCC). Beide Verfahren erlauben als alleinige Untersuchung bei entsprechendem Kontrastmittelverhalten die Diagnose eines HCC. Eine radiologische Herausforderung stellen immer noch die Detektion von HCC-Läsionen < 2 cm, die Abgrenzung prämaligner und maligner Läsionen von anderen benignen Vorstufen der Hepatokarzinogenese sowie die Dignitätseinschätzung hypovaskulärer Leberläsionen in der zirrhotischen Leber dar.

Leistungsfähigkeit

Beide Untersuchungsmodalitäten erreichen inzwischen für Läsionen > 2 cm sehr hohe Detektionsraten zwischen 90 und 100 %. Für Läsionen zwischen 1 und 2 cm bestehen Vorteile der MRT mit Sensitivitäten zwischen 80 und 90 % gegenüber 60–75 % der CT. Die MRT-Diagnostik profitiert neben den multimodalen Diagnosekriterien zusätzlich vom Einsatz leberspezifischer Kontrastmittel, insbesondere in Kombination mit der Diffusionsbildgebung, wobei sowohl eine Erhöhung der Sensitivät als auch der diagnostischen Genauigkeit für Läsionen < 2 cm nachgewiesen werden konnte. Bezüglich der Abgrenzung des HCC von anderen nodulären Herdläsionen der zirrhotischen Leber hat sich gezeigt, dass die gleichzeitig vorliegende arterielle Hypervaskularisation und Hypointensität in der hepatobiliären Phase als spezifisch für das Vorliegen eines HCC einzustufen ist. Zudem ist ein hypointenses Signal in der hepatobiliären Phase mit einem hohen Vorhersagewert von bis zu 100 % für das Vorliegen eines High-grade-dysplastischen Knotens oder HCC assoziiert.

Bewertung

Die MRT unter Berücksichtigung von hepatobiliärer und diffusionsgewichteter Bildgebung („diffusion-weighted imaging“, DWI) stellt heutzutage die beste nichtinvasive Bilddiagnostik für die Detektion des HCC sowie zur Charakterisierung von Knoten in der zirrhotischen Leber dar, mit deutlichen Vorteilen gegenüber der CT bei der Detektion kleiner Läsionen < 2 cm sowie der Dignitäts- und Prognoseeinschätzung hypovaskulärer Vorstufen im Rahmen der Hepatokarzinogenese.

Empfehlung für die Praxis

Sowohl die MRT als auch die CT ermöglichen einen hohen Standard zur Diagnostik des HCC in der zirrhotischen Leber, mit Vorteilen der MRT bzgl. Detektionsrate und Spezifität. Die CT bietet für den klinischen Alltag eine schnelle, robuste sowie gut verfügbare Modalität mit Vorteilen bei Patienten in reduziertem Allgemeinzustand sowie eingeschränkter Compliance.

Abstract

Clinical/methodical issue

Both computed tomography (CT) and magnetic resonance imaging (MRI) constitute the gold standard in radiological imaging of hepatocellular carcinoma (HCC). In cases of typical contrast behavior each modality as a single dynamic technique allows the diagnosis of HCC. There is still a challenge in detection of small HCCs < 2 cm, in differentiating HCC and high-grade dysplasia from other benign liver lesions as well as the evaluation of hypovascular liver lesions in the cirrhotic liver.

Performance

Nowadays, both modalities achieve high detection rates of 90–100 % for lesions > 2 cm. Regarding lesions between 1 and 2 cm there is a higher sensitivity for MRI ranging between 80 and 90 % compared to 60–75 % with CT. Besides the multimodal diagnostic criteria, MRI provides significant benefits with the use of hepatobiliary contrast. Especially in combination with diffusion- weighted imaging (DWI) increased sensitivity and diagnostic accuracy compared to CT has been described for lesions sized < 2 cm. Regarding the differentiation from other hepatic nodules in the cirrhotic liver there is strong evidence that the coexistence of arterial enhancement and hypointensity on hepatobiliary imaging is specific for HCC. Moreover, hypointensity on hepatobiliary imaging is associated with a high positive predictive value (PPV) of up to 100 % for the presence of high-grade dysplasia and HCC.

Achievements

The use of MRI including hepatobiliary imaging and DWI has to be regarded as the best non-invasive imaging modality for the detection of HCC and for the characterization of nodules in patients with liver cirrhosis. In comparison to CT there are benefits regarding detection of small lesions < 2 cm and evaluation of hypovascular liver lesions in the context of the hepatocarcinogenesis including prognostic values of premalignant lesions.

Practical recommendations

Both MRI and CT provide a high diagnostic performance in evaluation of HCC in liver cirrhosis. With MRI there are considerable advantages regarding the detection rate and specificity. For daily clinical routine, CT offers a fast, reliable and easy available modality with benefits for patients in reduced general state of health and restricted compliance.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. C.J. Zech und E.M. Merkle weisen auf folgende Beziehungen hin: C.J. Zech – Advisory Board und Vortragshonorare von Bayer Healthcare; E.M. Merkle – Advisory Board und Vortragshonorare von Bayer Healthcare und Bracco. A. Kircher und G. Bongartz geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel, Petersgraben 4, 4031, Basel, Schweiz

    A. Kircher, G. Bongartz, E.M. Merkle &  C.J. Zech

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  1. A. Kircher
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  2. G. Bongartz
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Kircher, A., Bongartz, G., Merkle, E. et al. Rationale Schnittbildgebung des hepatozellulären Karzinoms. Radiologe 54, 664–672 (2014). https://doi.org/10.1007/s00117-014-2652-4

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