Body Imaging| Volume 97, P34-43, May 2023

Download started.


Multimodality imaging approach in identifying invasive hepatocellular carcinoma


      • HCC has high propensity for vascular and locoregional invasion.
      • Patients with invasive disease may not be eligible for curative treatment.
      • Radiologists should be familiar with findings of invasive HCCs.


      Hepatocellular carcinoma (HCC) is the 5th most common neoplasm and the 3rd leading cause of cancer related mortality worldwide. Early stages of the neoplasm may be treated curatively with liver resection or orthotopic liver transplant. However, HCC has a high propensity for vascular and locoregional invasion, which can preclude these treatment options. The portal vein is the most invaded structure, while other regional structures affected include the hepatic vein, inferior vena cava, gallbladder, peritoneum, diaphragm, and the gastrointestinal tract. Management of invasive and advanced stages of HCC includes modalities such as transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and systemic chemotherapy, which are non-curative and focus on relieving tumor burden and slowing progression. A multimodality imaging approach is effective in identifying areas of tumor invasion and distinguishing between bland and tumor thrombi. Due to implications in prognosis and management, it is imperative for radiologists to accurately identify imaging patterns of regional invasion by HCC and to distinguish between bland and tumor thrombus in cases of potential vascular invasion.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Imaging
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • An J.
        • et al.
        Clinical features and outcomes of patients with hepatocellular carcinoma complicated with bile duct invasion.
        Clin Mol Hepatol. 2017; 23: 160-169
        • Marrero J.A.
        • et al.
        Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases.
        Hepatology. 2018; 68: 723-750
        • Llovet J.M.
        Updated treatment approach to hepatocellular carcinoma.
        J Gastroenterol. 2005; 40: 225-235
        • Sneag D.B.
        • et al.
        Extrahepatic spread of hepatocellular carcinoma: spectrum of imaging findings.
        Am J Roentgenol. 2011; 197: W658-W664
        • Suresh D.
        • Srinivas A.N.
        • Kumar D.P.
        Etiology of hepatocellular carcinoma: special focus on fatty liver disease.
        Front Oncol. 2020; 10601710
        • Chernyak V.
        • et al.
        Liver imaging reporting and data system (LI-RADS) version 2018: imaging of hepatocellular carcinoma in at-risk patients.
        Radiology. 2018; 289: 816-830
        • Choi J.-Y.
        • Lee J.-M.
        • Sirlin C.B.
        CT and MR imaging diagnosis and staging of hepatocellular carcinoma: part II. Extracellular agents, hepatobiliary agents, and ancillary imaging features.
        Radiology. 2014; 273: 30-50
        • Chan S.L.
        • et al.
        Management of hepatocellular carcinoma with portal vein tumor thrombosis: review and update at 2016.
        World J Gastroenterol. 2016; 22: 7289-7300
        • Chou C.T.
        • et al.
        Prediction of microvascular invasion of hepatocellular carcinoma: preoperative CT and histopathologic correlation.
        AJR Am J Roentgenol. 2014; 203: W253-W259
        • Xu P.
        • et al.
        Microvascular invasion in small hepatocellular carcinoma: is it predictable with preoperative diffusion-weighted imaging?.
        J Gastroenterol Hepatol. 2014; 29: 330-336
        • Hong S.B.
        • et al.
        MRI features for predicting microvascular invasion of hepatocellular carcinoma: a systematic review and meta-analysis.
        Liver Cancer. 2021; 10: 94-106
        • Dong Y.
        • et al.
        Potential application of dynamic contrast enhanced ultrasound in predicting microvascular invasion of hepatocellular carcinoma.
        Clin Hemorheol Microcirc. 2021; 77: 461-469
        • Catalano O.A.
        • et al.
        Differentiation of malignant thrombus from bland thrombus of the portal vein in patients with hepatocellular carcinoma: application of diffusion-weighted MR imaging.
        Radiology. 2009; 254: 154-162
        • Sun J.-X.
        • et al.
        Portal vein tumor thrombus is a bottleneck in the treatment of hepatocellular carcinoma.
        Cancer Biol Med. 2016; 13: 452-458
        • Liava C.
        • et al.
        Liver imaging reporting and data system criteria for the diagnosis of hepatocellular carcinoma in clinical practice: a pictorial minireview.
        World J Gastroenterol. 2022; 28: 4540-4556
        • Quencer K.B.
        • et al.
        Tumor thrombus: incidence, imaging, prognosis and treatment.
        Cardiovasc Diagn Ther. 2017; 7: S165-S177
        • Gawande R.
        • et al.
        MRI in differentiating malignant versus benign portal vein thrombosis in patients with hepatocellular carcinoma: value of post contrast imaging with subtraction.
        Eur J Radiol. 2019; 118: 88-95
        • Luo X.
        • et al.
        Hepatocellular carcinoma with tumor thrombus occupying the right atrium and portal vein: a case report and literature review.
        Medicine. 2015; 94
        • Wang Y.
        • et al.
        Survival benefit of surgical treatment for hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: results of a retrospective cohort study.
        Ann Surg Oncol. 2013; 20: 914-922
        • Roayaie S.
        • et al.
        Resection of hepatocellular carcinoma with macroscopic vascular invasion.
        Ann Surg Oncol. 2013; 20: 3754-3760
        • Long X.-Y.
        • et al.
        Diagnosis of bile duct hepatocellular carcinoma thrombus without obvious intrahepatic mass.
        World J Gastroenterol. 2010; 16: 4998-5004
        • Zeng H.
        • et al.
        Hepatocellular carcinoma with bile duct tumor thrombus: a clinicopathological analysis of factors predictive of recurrence and outcome after surgery.
        Medicine. 2015; 94: e364
        • Park K.-K.
        • Yang S.-I.
        • Yoon M.-H.
        One stage resection of spontaneous rupture of hepatocellular carcinoma in the triangular ligament with diaphragm invasion: case report and review of the literature.
        World J Emerg Surg. 2012; 7: 30
        • Liu Y.-C.
        • et al.
        Hepatocellular carcinoma with en bloc diaphragmatic resection: a single-center experience over 14 years.
        Int J Surg. 2018; 53: 93-97
        • Yamashita Y.-I.
        • et al.
        Surgical impacts of an en bloc resection of the diaphragm for hepatocellular carcinoma with gross diaphragmatic involvement.
        Surg Today. 2011; 41: 101-106
        • Hirashita T.
        • et al.
        Direct invasion to the colon by hepatocellular carcinoma: report of two cases.
        World J Gastroenterol. 2008; 14: 4583-4585
      1. Korkolis, D.P., et al., Successful en bloc resection of primary hepatocellular carcinoma directly invading the stomach and pancreas. (2219-2840 (Electronic)).

      2. Spiliotis, J., et al., Hepatocellular Carcinoma Peritoneal Metastasis: Role of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). (2078-2101 (Print)).

        • Hung M.-C.
        • et al.
        Intraperitoneal metastasis of hepatocellular carcinoma after spontaneous rupture: a case report.
        World J Gastroenterol. 2008; 14: 3927-3931
        • Chen H.-W.
        • Yang C.-F.
        • Chao C.-C.
        Spontaneous rupture of peritoneal seeding hepatocellular carcinoma: report of two cases.
        JACME. 2016; 6: 64-66
        • Ishikawa T.
        • et al.
        Rupture of peritoneal metastatic tumor that developed due to needle-tract implantation of hepatocellular carcinoma.
        J Gastroenterol. 2005; 40: 547-548
        • Portolani N.
        • et al.
        Parietal and peritoneal localizations of hepatocellular carcinoma: is there a place for a curative surgery?.
        World J Surg Oncol. 2014; 12: 298