Benign and malignant mimickers of infiltrative hepatocellular carcinoma: tips and tricks for differential diagnosis on CT and MRI

  • Federica Vernuccio
    Corresponding author at: University of Palermo, Via del Vespro, 129, 90127 Palermo, Italy.
    Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy

    University Paris Diderot, Sorbonne Paris Cité, Paris, France

    I.R.C.C.S. Centro Neurolesi Bonino Pulejo, Contrada Casazza, SS113, 98124 Messina, Italy

    Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127 Palermo, Italy
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  • Giorgia Porrello
    Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127 Palermo, Italy
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  • Roberto Cannella
    Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy

    Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127 Palermo, Italy
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  • Laura Vernuccio
    U.O.C. Geriatria e Lungodegenza, AOUP University Hospital Palermo, CDCD Geriatria, Palermo, Italy
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  • Massimo Midiri
    Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127 Palermo, Italy
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  • Lydia Giannitrapani
    Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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  • Maurizio Soresi
    Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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  • Giuseppe Brancatelli
    Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127 Palermo, Italy
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      • Infiltrative HCC appears as an ill-defined large mass with variable enhancement.
      • Portal vein tumor thrombosis appears as enhancing thrombus close to the main tumor.
      • Diagnosis of infiltrative HCC and neoplastic thrombosis may be challenging.
      • Many benign and malignant lesions may mimic infiltrative HCC and tumor thrombosis.


      Hepatocellular carcinoma (HCC) may have an infiltrative appearance in about 8–20% of cases. Infiltrative HCC can be a challenging diagnosis and it is associated with the worst overall survival among HCC patients. Infiltrative HCC is characterized by the spread of multiple minute nodules throughout the liver, without a dominant one, ultimately resulting into macrovascular invasion. On CT and MRI, infiltrative HCC appears as an ill-defined, large mass, with variable degree of enhancement, and satellite neoplastic nodules in up to 52% of patients. On MRI, it may show restriction on diffusion weighted imaging, hyperintensity on T2- and hypointensity on T1-weighted images, and, if hepatobiliary agent is used, hypointensity on hepatobiliary phase. Infiltrative HCC must be differentiated from other liver diseases, such as focal confluent fibrosis, steatosis, amyloidosis, vascular disorders of the liver, cholangiocarcinoma, and diffuse metastatic disease. In cirrhotic patients, the identification of vascular tumor invasion of the portal vein and its differentiation from bland thrombosis is of utmost importance for patient management. On contrast enhanced CT and MRI, portal vein tumor thrombosis appears as an enhancing thrombus within the portal vein, close to the main tumor and results into vein enlargement. The aim of this pictorial review is to show CT and MRI features that allow the diagnosis of infiltrative HCC and portal vein tumor thrombosis. A particular point of interest includes the tips and tricks for differential diagnosis with potential mimickers of infiltrative HCC.


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