## Diagnosis of Hepatocellular Carcinoma — Imaging Criteria and Confirmation **Key Point:** A nodule 1–2 cm in size requires confirmation by a second imaging modality (ultrasound, CT, or MRI) before diagnosis of HCC can be established, even in a cirrhotic liver. ### Diagnostic Criteria for HCC (AASLD/EASL Guidelines) | Nodule Size | Imaging Criteria for HCC Diagnosis | |--------------|-------------------------------------| | **≥ 2 cm** | Arterial enhancement + washout on one imaging modality | | **1–2 cm** | Arterial enhancement + washout on **two imaging modalities** OR biopsy | | **< 1 cm** | Follow-up imaging at 3–4 months | **High-Yield:** The 2.5 cm lesion in this case shows arterial enhancement but **lacks portal venous phase washout** on CT. This is incomplete imaging criteria for HCC diagnosis on a single modality. ### Why a Second Imaging Study Is Needed The lesion described: - Is 2.5 cm (borderline) - Shows arterial enhancement ✓ - **Lacks washout on portal venous phase** ✗ - Requires confirmation by MRI or ultrasound to establish HCC diagnosis If the second imaging (e.g., MRI) confirms arterial enhancement + washout, HCC diagnosis is established and treatment (resection, ablation, or systemic therapy) can proceed. **Clinical Pearl:** Segment 7 is a posterosuperior segment of the right lobe. Resection feasibility depends on liver function (Child-Pugh score, MELD score) and remnant liver volume — not just lesion characteristics. ### Why Sorafenib Is Premature Sorafenib is indicated for advanced HCC (BCLC stage C: extrahepatic spread or macrovascular invasion). This patient: - Has no evidence of extrahepatic disease - Has no vascular invasion described - May be a candidate for curative therapy (resection or ablation) if HCC is confirmed [cite:Robbins 10e Ch 18; Harrison 21e Ch 297] 
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