Hepatocellular carcinoma differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [2]

Overview

Hepatocellular carcinoma must be differentiated from other diseases that cause abdominal pain, jaundice, and weight loss, such as hepatitis B, hepatitis C, liver cirrhosis, and pancreatitis.

Differentiating Hepatocellular Carcinoma from other Diseases

Hepatocellular carcinoma must be differentiated from the following diseases:[1][2][3][4][5][6][7][8][9]

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Hepatocellular carcinoma/Metastasis RUQ + − − + − − + − − − −
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Chronic pancreatitis Epigastric − − ± ± − + + − − − − N
  • Increased amylase / lipase
  • Increased stool fat content
  • Pancreatic function test
 CT scan
  • Calcification
  • Pseudocyst
  • Dilation of main pancreatic duct
  • Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric − − + + − + + − − − − N

Skin manifestations may include:

Inflammatory bowel disease Diffuse ± − − ± − + + + − − − Normal or hyperactive

Extra intestinal findings:

Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Whipple's disease Diffuse ± − − ± − + + − ± − − N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Viral hepatitis RUQ + − + + − Positive in Hep A and E + − Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + − ± + − + + ± Normal or hypoactive
  • US
  • CT
Cirrhosis RUQ − − − + − − + + + − − N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur

References

  1. ↑ Kim TK, Lee E, Jang HJ (2015). "Imaging findings of mimickers of hepatocellular carcinoma". Clin Mol Hepatol. 21 (4): 326–43. doi:10.3350/cmh.2015.21.4.326. PMC 4712159. PMID 26770920.
  2. ↑ Ferrell, Linda (2000). "Liver Pathology: Cirrhosis, Hepatitis and Primary Liver Tumors. Update and Diagnostic Problems". Modern Pathology. 13 (6): 679–704. doi:10.1038/modpathol.3880119. ISSN 0893-3952.
  3. ↑ Kim, Tae Kyoung; Lee, Eunchae; Jang, Hyun-Jung (2015). "Imaging findings of mimickers of hepatocellular carcinoma". Clinical and Molecular Hepatology. 21 (4): 326. doi:10.3350/cmh.2015.21.4.326. ISSN 2287-2728.
  4. ↑ Doo, Kyung Won; Lee, Chang Hee; Choi, Jae Woong; Lee, Jongmee; Kim, Kyeong Ah; Park, Cheol Min (2009). ""Pseudo Washout" Sign in High-Flow Hepatic Hemangioma on Gadoxetic Acid Contrast-Enhanced MRI Mimicking Hypervascular Tumor". American Journal of Roentgenology. 193 (6): W490–W496. doi:10.2214/AJR.08.1732. ISSN 0361-803X.
  5. ↑ Zech CJ, Herrmann KA, Reiser MF, Schoenberg SO (2007). "MR imaging in patients with suspected liver metastases: value of liver-specific contrast agent Gd-EOB-DTPA". Magn Reson Med Sci. 6 (1): 43–52. PMID 17510541.
  6. ↑ Cheng, H C; Tsai, S H; Chiang, J H; Chang, C Y (1995). "Hyalinized liver hemangioma mimicking malignant tumor at MR imaging". American Journal of Roentgenology. 165 (4): 1016–1017. doi:10.2214/ajr.165.4.7676959. ISSN 0361-803X.
  7. ↑ Haratake J, Horie A, Nagafuchi Y (1992). "Hyalinized hemangioma of the liver". Am. J. Gastroenterol. 87 (2): 234–6. PMID 1370873.
  8. ↑ Takayasu, K; Moriyama, N; Shima, Y; Muramatsu, Y; Yamada, T; Makuuchi, M; Yamasaki, S; Hirohashi, S (1986). "Atypical radiographic findings in hepatic cavernous hemangioma: correlation with histologic features". American Journal of Roentgenology. 146 (6): 1149–1153. doi:10.2214/ajr.146.6.1149. ISSN 0361-803X.
  9. ↑ Yamashita Y, Shimada M, Taguchi K, Gion T, Hasegawa H, Utsunomiya T, Hamatsu T, Matsumata T, Sugimachi K (2000). "Hepatic sclerosing hemangioma mimicking a metastatic liver tumor: report of a case". Surg. Today. 30 (9): 849–52. PMID 11039718.
  10. ↑ Kim TK, Choi BI, Han JK, Jang HJ, Cho SG, Han MC (1997). "Peripheral cholangiocarcinoma of the liver: two-phase spiral CT findings". Radiology. 204 (2): 539–43. doi:10.1148/radiology.204.2.9240550. PMID 9240550.
  11. ↑ Ohtomo K, Baron RL, Dodd GD, Federle MP, Miller WJ, Campbell WL, Confer SR, Weber KM (1993). "Confluent hepatic fibrosis in advanced cirrhosis: appearance at CT". Radiology. 188 (1): 31–5. doi:10.1148/radiology.188.1.8511316. PMID 8511316.
  12. ↑ Matsui, O; Kadoya, M; Takahashi, S; Yoshikawa, J; Gabata, T; Takashima, T; Kitagawa, K (1995). "Focal sparing of segment IV in fatty livers shown by sonography and CT: correlation with aberrant gastric venous drainage". American Journal of Roentgenology. 164 (5): 1137–1140. doi:10.2214/ajr.164.5.7717220. ISSN 0361-803X.
  13. ↑ Itai Y, Matsui O (1999). "'Nonportal' splanchnic venous supply to the liver: abnormal findings on CT, US and MRI". Eur Radiol. 9 (2): 237–43. doi:10.1007/s003300050661. PMID 10101644.
  14. [[#cite_ref-NicolauBr�2004_14-0|↑]] Nicolau, C.; Br�, C. (2004). "Focal liver lesions: evaluation with contrast-enhanced ultrasonography". Abdominal Imaging. 29 (3). doi:10.1007/s00261-003-0117-8. ISSN 0942-8925. replacement character in |last2= at position 3 (help)
  15. ↑ Hamer OW, Aguirre DA, Casola G, Lavine JE, Woenckhaus M, Sirlin CB (2006). "Fatty liver: imaging patterns and pitfalls". Radiographics. 26 (6): 1637–53. doi:10.1148/rg.266065004. PMID 17102041.
  16. ↑ Hamer OW, Aguirre DA, Casola G, Sirlin CB (2005). "Imaging features of perivascular fatty infiltration of the liver: initial observations". Radiology. 237 (1): 159–69. doi:10.1148/radiol.2371041580. PMID 16100085.
  17. ↑ Mathieu D, Vasile N, Dibie C, Grenier P (1985). "Portal cavernoma: dynamic CT features and transient differences in hepatic attenuation". Radiology. 154 (3): 743–8. doi:10.1148/radiology.154.3.3881794. PMID 3881794.
  18. ↑ Itai, Y; Matsui, O (1997). "Blood flow and liver imaging". Radiology. 202 (2): 306–314. doi:10.1148/radiology.202.2.9015047. ISSN 0033-8419.
  19. ↑ Kim JH, Kim TK, Kim BS, Eun HW, Kim PN, Lee MG, Ha HK (2002). "Enhancement of hepatic hemangiomas with levovist on coded harmonic angiographic ultrasonography". J Ultrasound Med. 21 (2): 141–8. PMID 11833870.
  20. ↑ Brannigan, Margot; Burns, Peter N.; Wilson, Stephanie R. (2004). "Blood Flow Patterns in Focal Liver Lesions at Microbubble-enhanced US". RadioGraphics. 24 (4): 921–935. doi:10.1148/rg.244035158. ISSN 0271-5333.
  21. ↑ 21.0 21.1 Kim TK, Jang HJ, Wilson SR (2006). "Benign liver masses: imaging with microbubble contrast agents". Ultrasound Q. 22 (1): 31–9. PMID 16641791.
  22. ↑ Jang, Hyun-Jung; Kim, Tae Kyoung; Lim, Hyo Keun; Park, Sang Jae; Sim, Jung Suk; Kim, Hyae Young; Lee, Joo-Hyuk (2003). "Hepatic Hemangioma: Atypical Appearances on CT, MR Imaging, and Sonography". American Journal of Roentgenology. 180 (1): 135–141. doi:10.2214/ajr.180.1.1800135. ISSN 0361-803X.
  23. ↑ . doi:10.1102/1470-7330.2009.0015. Missing or empty |title= (help)
  24. ↑ 24.0 24.1 Jang, Hyun-Jung; Yu, Hojun; Kim, Tae Kyoung (2009). "Imaging of Focal Liver Lesions". Seminars in Roentgenology. 44 (4): 266–282. doi:10.1053/j.ro.2009.05.008. ISSN 0037-198X.
  25. ↑ Bhayana, Deepak; Kim, Tae Kyoung; Jang, Hyun-Jung; Burns, Peter N.; Wilson, Stephanie R. (2010). "Hypervascular Liver Masses on Contrast-Enhanced Ultrasound: The Importance of Washout". American Journal of Roentgenology. 194 (4): 977–983. doi:10.2214/AJR.09.3375. ISSN 0361-803X.
  26. ↑ Tamada T, Ito K, Yamamoto A, Sone T, Kanki A, Tanaka F, Higashi H (2011). "Hepatic hemangiomas: evaluation of enhancement patterns at dynamic MRI with gadoxetate disodium". AJR Am J Roentgenol. 196 (4): 824–30. doi:10.2214/AJR.10.5113. PMID 21427331.
  27. ↑ Heiken, Jay P. (2007). "Distinguishing benign from malignant liver tumours". Cancer Imaging. 7 (Special Issue A): S1–S14. doi:10.1102/1470-7330.2007.9084. ISSN 1470-7330.
  28. ↑ Alturkistany, Samira; Jang, Hyun-Jung; Yu, Hojun; Lee, Kyoung Ho; Kim, Tae Kyoung (2011). "Fading hepatic hemangiomas on multiphasic CT". Abdominal Radiology. 37 (5): 775–780. doi:10.1007/s00261-011-9826-6. ISSN 2366-004X.
  29. ↑ Liu GJ, Lu MD, Xie XY, Xu HX, Xu ZF, Zheng YL, Liang JY, Wang W (2008). "Real-time contrast-enhanced ultrasound imaging of infected focal liver lesions". J Ultrasound Med. 27 (4): 657–66. PMID 18359914.
  30. ↑ Kim, Kyoung Won; Choi, Byung Ihn; Park, Seong Ho; Kim, Ah Young; Koh, Young Hwan; Lee, Hyun Ju; Han, Joon Koo (2004). "Pyogenic hepatic abscesses: distinctive features from hypovascular hepatic malignancies on contrast-enhanced ultrasound with SH U 508A; early experience". Ultrasound in Medicine & Biology. 30 (6): 725–733. doi:10.1016/j.ultrasmedbio.2004.03.006. ISSN 0301-5629.
  31. ↑ Syed MA, Kim TK, Jang HJ (2007). "Portal and hepatic vein thrombosis in liver abscess: CT findings". Eur J Radiol. 61 (3): 513–9. doi:10.1016/j.ejrad.2006.11.022. PMID 17161932.
  32. ↑ Menias, Christine O.; Surabhi, Venkateswar R.; Prasad, Srinivasa R.; Wang, Hanlin L.; Narra, Vamsi R.; Chintapalli, Kedar N. (2008). "Mimics of Cholangiocarcinoma: Spectrum of Disease". RadioGraphics. 28 (4): 1115–1129. doi:10.1148/rg.284075148. ISSN 0271-5333.
  33. ↑ Gollapudi P, Chejfec G, Zarling EJ (1992). "Spontaneous regression of hepatic pseudotumor". Am. J. Gastroenterol. 87 (2): 214–7. PMID 1734701.
  34. ↑ Yoon KH, Ha HK, Lee JS, Suh JH, Kim MH, Kim PN, Lee MG, Yun KJ, Choi SC, Nah YH, Kim CG, Won JJ, Auh YH (1999). "Inflammatory pseudotumor of the liver in patients with recurrent pyogenic cholangitis: CT-histopathologic correlation". Radiology. 211 (2): 373–9. doi:10.1148/radiology.211.2.r99ma36373. PMID 10228516.


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