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Diagnostic algorithm
New nodule
Ø < 1cm
Ø ≥ 1cm
US/3 months
RM/TC/CEUS
Growing Ø
Typical feature
(wash in/wash out)
NO
Sì
NO
US/3 months
(for 12 months)
Growing Ø
Sì
Other contrast enhanced
technique
Sì
NO
Atypical feature
US/6 months
Biopsy
Not diagnostic
Typical feature
Other diagnosis
HCC
Raccomandazioni AISF per la gestione integrata del paziente con Epatocarcinoma; published on www.webaisf.org
Available on: http://www.webaisf.org/media/16110/raccomandazioni-aisf-per-hcc.pdf
US, Ultrasound
Hypovascular HCC represent about 17% of malignant nodules
between 1-2 cm
Bolondi L et al. Characterization of small nodules in liver
cirrhosis by assessment of vascularity. The problem of
hypovascular HCC.
Hepatology 2005;42 (1): 27-34
Hypovascular HCC are described in nodules > 2cm
Bolondi L et al. Characterization of small nodules in liver
cirrhosis by assessment of vascularity. The problem of
hypovascular HCC.
Hepatology 2005;42 (1): 27-34
The grey area
Intratumoral blood flow 
Neovascularization
EOB o Gd-Bopta uptake
Sum of
arterial
flow
SPIO uptake
Hypervascular
Portal flow
Preexisting arterial flow
Histological grading 
RN / low-grade
DN
High-grade
DN
Early HCC
Well-differentiated HCC
Moderatelydifferentiated HCC
Kudo M. International Workshop and SORAMIC Study Meeting, Freyburg, 2009.
Conclusioni
Diagnostic algorithm
Mass/nodule on US
<1cm
1-2cm
>2cm
Repeat US at 4 mo
4-phase CT/Dynamic
Contrast enhanced MRI
4-phase CT or Dynamic
Contrast enhanced MRI
1 or 2 positive techniques*:
HCC radiological Hallmarks**
1 positive technique:
HCC radiological Hallmarks**
Growing/Changing
Character
Stable
Investigate
according to size
Yes
HCC
No
Biopsy
Yes
HCC
No
Biopsy
Inconclusive
Diagnostic algorithm and recall policy.*One imaging technique only recommended in centers of excellence with high-end radiological equipment.**HCC radiological hallmark: arterial
hypervascularity and venous/late phase washout
EASL–EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma Journal of Hepatology 2012 vol. 56 j 908–943
Available on: http://www.easl.eu/assets/application/files/d38c7689f123edf_file.pdf
Conclusioni
Diagnostic algorithm and recall policy.
*One imaging technique only recommended in centers
of excellence with high-end radiological
equipment.**HCC radiological hallmark: arterial
hypervascularity and venous/late phase washout
EASL–EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma
Journal of Hepatology 2012 vol. 56 j 908–943