ESR Essentials: diagnosis of hepatocellular carcinoma—practice recommendations by ESGAR

Category	Detail
Condition	Hepatocellular carcinoma (HCC)
Key Mechanisms	Noninvasive diagnosis via imaging criteria in high-risk patients using contrast-enhanced CT, MRI, or ultrasound
Target Population	Patients at high risk including those with cirrhosis, chronic viral hepatitis B, and current or prior HCC history
Care Setting	Radiology and hepatology clinical settings with access to advanced imaging modalities

Noninvasive diagnosis of HCC is applicable only in high-risk patients to maintain high specificity.
Contrast-enhanced CT or MRI are recommended imaging modalities; MRI offers higher sensitivity for small lesions.
Key imaging criteria include lesion size, non-rim arterial phase hyperenhancement, non-peripheral washout, enhancing capsule, and threshold growth.

Apply noninvasive diagnostic criteria only in patients with defined high-risk factors (cirrhosis, chronic hepatitis B, prior HCC).
Use contrast-enhanced CT or MRI as primary diagnostic imaging; consider contrast-enhanced ultrasound as a problem-solving tool in experienced centers.
Confirm diagnosis by histopathology in patients not meeting high-risk criteria or with inconclusive imaging.

Select imaging modality and contrast agent based on availability, expertise, and patient-specific factors including contraindications.
Use ultrasound for surveillance in high-risk patients due to cost-effectiveness and repeatability.

Perform surveillance with ultrasound regularly in high-risk populations to detect early lesions.
Use multiphasic imaging techniques with appropriate timing of contrast phases for accurate lesion characterization.

Noninvasive criteria have limited specificity in non-high-risk patients; misdiagnosis possible without histopathology.
Limitations of ultrasound include operator dependency and reduced sensitivity in obese patients or those with ascites.
MRI contraindications include incompatible devices and claustrophobia; CT involves radiation exposure.

High-risk patients with cirrhosis, chronic hepatitis B, or prior HCC history undergoing diagnostic imaging

Imaging modality choice should consider patient-specific contraindications and local resource availability to optimize diagnostic accuracy.

Restrict noninvasive HCC diagnosis to patients with established high-risk factors to maintain diagnostic specificity.
Prefer MRI with extracellular contrast agents for higher sensitivity in detecting small HCC lesions.
Use contrast-enhanced ultrasound selectively as a problem-solving tool in centers with appropriate expertise.
Confirm diagnosis histologically in patients outside high-risk groups or with atypical imaging features.
Ensure multiphasic imaging protocols with appropriate arterial and venous phase timing for accurate lesion assessment.

Clinical Scorecard: Key Insights on Diagnosing Hepatocellular Carcinoma: ESGAR's Practice Guidelines