Surveillance imaging in adults at risk for hepatocellular carcinoma

AFP: alpha-fetoprotein; CT: computed tomography; MRI: magnetic resonance imaging; LI-RADS: Liver Imaging Reporting and Data System.
* Abdominal ultrasound is recommended in most patients. However, surveillance modalities (eg, addition of serum alpha fetal protein, abdominal CT, or MRI with intravenous contrast rather than ultrasound) are sometimes individualized as described elsewhere in UpToDate.
¶ If there are multiple lesions, this algorithm can be applied to each lesion. However, management choice is driven by the lesion that is the most suspicious (eg, largest and not definitely benign, growing).
Δ Examples of definitely benign lesions include simple cysts or those previously characterized on contrast-enhanced liver imaging or biopsy as definitely benign (eg, hemangioma).
◊ Size is defined as the maximum cross-section diameter measured on the image where the lesion is most clearly seen.
§ Same imaging modality should be used for initial follow-up, but subsequent imaging may involve a change in modality. While the two-year follow-up represents our practice, stability over that time does not confirm that a lesion is benign. For these patients, we resume routine surveillance imaging every six months.
¥ Practice varies on whether serum AFP is measured in this setting.
‡ Imaging technology and performance should adhere to standards required for liver lesion characterization which are more stringent than those for routine abdominal imaging and requires multiphase post-contrast imaging¹. Modality choice depends on available scanner technology, imaging expertise, and patient contraindications. Contrast-enhanced CT and MRI demonstrate comparable accuracy. Contrast-enhanced ultrasound is more limited in availability and its diagnostic performance is not as well characterized.
† Liver Imaging Reporting and Data System (LI-RADS) system to categorize, further evaluate, and diagnose liver lesions is described elsewhere in UpToDate. LI-RADS evaluation can involve biopsy or follow-up imaging with contrast-enhanced CT, MRI, or ultrasound.