Synopsis
Several
studies reveal a large number of MRI phenotypes related to the biologic
behavior of hepatocellular carcinoma (HCC). Hemodynamic change-related, peri-tumoral
change-related, hepatocyte-related, and diffusion-related phenotypes. In this
talk, I will touch on various MRI features of HCC and their implications for
the diagnosis and prognosis as imaging biomarkers.Introduction:
Until now it is widely accepted that tumor
size, multifocality, and vascular invasion are the most important prognostic
factors of HCC. These variables are incorporated into various staging systems,
and imaging plays a major role in the assessment of these variables. Therefore,
the established roles of imaging include not only screening and surveillance of
at-risk patients, but also diagnosis, staging, and prognostication of HCC. For
these purposes, MRI is advantageous because of its high soft tissue contrast,
capacity for multiple parameters, and use of various contrast agents.
Furthermore, in addition to the severity of liver disease and tumor
characteristics, several other features related to survival have emerged from a
large number of studies. Therefore, some MR imaging features may have
prognostic, as well as the diagnostic values.
Hemodynamic change-related phenotypes:
Angiogenesis in HCC is characterized by the
presence of unpaired arteries and sinusoidal capillarization. In parallel with
these changes, the portal tracts progressively diminish. Physiologically, the
diminution in portal tracts causes a gradual reduction in arterial and portal
venous flow to the nodule, while the formation of unpaired neo-arteries
increases arterial flow. The balance is such that in the early phases of
hepatocarcinogenesis, there is a net decrease in intranodular arterial flow and
preservation of portal venous flow, while in the later phases, portal flow declines
and eventually becomes absent while net arterial flow increases. Thus, the overt
HCC usually have elevated arterial flow with reduced or absent portal flow,
which makes the diagnostic hallmark of HCC, “arterial enhancement and washout”.
Some HCCs showing peripheral, progressive/persistent enhancement patterns express
progenitor cell markers and have tendency of early recurrence rate.
Peri-tumoral change-related phenotypes:
Tumor capsule is one of the characteristics
of nodular progressed HCC, either true fibrous capsule or pseudocapsule. Some
studies suggest that host mesenchymal cells, not tumor cells elaborate
extracellular matrix component of these structures, possibly in response to
compression of liver parenchyma by expansile tumor as well as host-tumor
interactions. It has been reported that HCCs with intact capsules are
associated with a better prognosis, probably due to the barrier effect which
inhibit HCC dissemination. Corona enhancement, a transient rim enhancement
around a hypervascular HCC in the late arterial phase or early portal venous phase,
is another characteristic feature of HCC. It can be differentiated from
capsular enhancement, which is usually seen in the equilibrium phase not in the
arterial phase. The area of corona enhancement is considered as the initial drainage
pathway of the tumor, because local recurrence is usually observed in this
area. Distortion of corona enhancement is one of the findings predicting
microvessel invasion.
Hepatocyte-specific contrast agent-related phenotypes:
Hepatocyte-specific contrast agents are
taken up by functioning hepatocytes and excreted into the biliary system. OATP8
is known to be responsible for it. The expression of OATP is gradually
decreases beginning from DN to progressed HCC. Because the reduction of OATP
occurs prior to the increase of arterial flow, early HCC, which is usually
hypovascular, is frequently found on hepatobiliary phase of gadoxetic
acid-enhanced MRI. In addition to the early detection, the signal intensity of
the tumor in the hepatocyte phase inversely correlates with histologic grades.
Therefore, the signal intensity of the tumor in the hepatocyte phase could be a
prognostic factor5 to 12% of HCCs show hyperintensity on hepatocyte phase, and
most of them are well- or moderately differentiated HCCs, indicating favorable
prognosis.
Diffusion-related phenotypes
There are several studies that suggests ADC
values are correlated with the histologic grade of HCC, since high-grade tumor
usually have densely-packed cells and a high N/C ratio, resulting in restricted
diffusion. DWI has been used to monitor response assessment after treatment.
Conclusion:
MRI can be used for predicting tumor
biology as an imaging biomarker in patients with HCC.
Acknowledgements
Jin-Young Choi, MDReferences
No reference found.