What to do once a nodule is detected in the liver?
If a nodule of size <1 cm is detected in the liver, a three monthly follow-up is recommended using the same technique which detected the nodule, for two successive follow-ups, to monitor for any enlargement in size.
Nodules <1 cm may also be evaluated for HCC with gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) scan and/or a Sonazoid contrast enhanced ultrasound if available.
If a nodule of size>1 cm is detected in the liver a dynamic (tri-phasic or four-phasic) computed tomography (CT) scan or MRI scan should be done at centers equipped with appropriate equipment and expertise.
On dynamic (tri-phasic or four-phasic) CT or MRI scan, features typical of HCC are characterized by hypervascularity of the nodule in arterial phase and washout in porto-venous phase.
If on these scans the features are typical of HCC in the setting of chronic liver disease then biopsy is not necessary for confirmation of diagnosis.
Nodular lesions that show an imaging pattern atypical for HCC on one of the dynamic scans (CT or MRI) should undergo the other dynamic scan (CT or MRI).
Any liver nodule of size >1 cm showing atypical imaging pattern on both dynamic scans (CT and MRI) requires histological confirmation for diagnosis of HCC.
If histological confirmation is required, image guided biopsy is recommended rather than fine needle aspiration cytology (FNAC).
Positron emission tomography (PET) scan has limited role in diagnosis of HCC.