## Diagnosis of HCC: Imaging vs. Serology **Key Point:** The diagnosis of HCC in a cirrhotic patient with a nodule >1 cm relies on imaging hallmarks, not histology or biomarkers alone. ### Diagnostic Criteria for HCC (AASLD/EASL Guidelines) For nodules **1–2 cm**: Two imaging modalities (CT, MRI, or ultrasound with contrast) showing arterial phase enhancement (APHE) with washout in portal venous or delayed phase. For nodules **>2 cm**: One imaging modality (CT or MRI) showing the characteristic pattern is sufficient for diagnosis. **High-Yield:** In this case, the 4 cm lesion with APHE and washout on contrast-enhanced CT or MRI is **diagnostic of HCC** without need for biopsy. ### Why Imaging is Superior to Biopsy | Feature | Imaging (CT/MRI) | Liver Biopsy | |---------|------------------|---------------| | Sensitivity for HCC | >90% | 60–70% (sampling error) | | Invasiveness | Non-invasive | Invasive; risk of bleeding, peritonitis | | Spatial information | Entire liver; detects satellites | Single lesion only | | Cirrhosis assessment | Yes | Limited | | Recommended | First-line | Only if imaging inconclusive | **Clinical Pearl:** Biopsy is reserved for: - Nodules with indeterminate imaging findings - Non-cirrhotic patients with small nodules - Lesions that do not meet imaging criteria ### Role of AFP **Warning:** AFP is a **prognostic marker**, not a diagnostic marker. Elevated AFP (even >1000 ng/mL) cannot diagnose HCC alone because: - Seen in benign cirrhosis, chronic hepatitis B, and hepatic regeneration - ~30% of HCCs are AFP-negative - Used for surveillance, not confirmation **Mnemonic: APHE-WO** — **A**rterial **P**hase **H**yper**E**nhancement with **W**ash**O**ut = HCC hallmark on imaging. [cite:Harrison 21e Ch 297] 
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