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Review

Hepatocellular carcinoma surveillance: a health economic evaluation
Qi-Feng Chen, Xiong-Ying Jiang, Song Chen, Jiongliang Wang, Ming Zhao
Clin Mol Hepatol 2026;32(2):536-564.
Published online January 9, 2026
DOI: https://doi.org/10.3350/cmh.2025.1060
Hepatocellular carcinoma (HCC) imposes a major health and economic burden worldwide, with disproportionate effects in low- and middle-income countries (LMICs). Surveillance in high-risk populations, typically using semiannual ultrasound and alpha-fetoprotein testing, has been shown to be cost-effective by enabling earlier detection and improving survival. Yet, its overall value is reduced by poor adherence and the limited sensitivity of ultrasound, particularly in patients with metabolic-associated steatotic liver disease. Emerging approaches—including abbreviated magnetic resonance imaging, multi-biomarker models (e.g., gender, age, AFP, AFP-L3, and DCP), and liquid biopsy assays such as methylated DNA markers—demonstrate greater diagnostic accuracy and potential economic advantages compared with conventional methods. Integration of artificial intelligence into imaging may further enhance efficiency and reduce downstream costs. Moving toward precision surveillance, guided by individualized risk stratification that incorporates etiology, fibrosis stage, and molecular profiles, can optimize allocation of resources and maximize cost-effectiveness at the population level. Interventions to improve adherence, including mailed outreach and behavioral economic incentives, have shown both clinical benefit and cost savings, underscoring the role of implementation science. Because socioeconomic disparities influence both access and outcomes, economic models must explicitly address equity to achieve sustainable impact. Future research should prioritize prospective trials that evaluate not only clinical performance but also the real-world cost-effectiveness of novel technologies and stratified surveillance strategies. For LMICs, adapting proven models into affordable, context-appropriate programs is essential. By combining prevention, precision risk assessment, innovative technologies, and equitable implementation, HCC surveillance can deliver both clinical and economic value, reducing the global burden of disease.
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Editorial

Original Article

Hepatic neoplasm

Classification of microvascular invasion of hepatocellular carcinoma: correlation with prognosis and magnetic resonance imaging
Yoon Jung Hwang, Jae Seok Bae, Youngeun Lee, Bo Yun Hur, Dong Ho Lee, Haeryoung Kim
Clin Mol Hepatol 2023;29(3):733-746.
Published online May 8, 2023
DOI: https://doi.org/10.3350/cmh.2023.0034
Background/Aims
The microvascular invasion (MVI) of hepatocellular carcinoma (HCC) involves a wide histological spectrum, and it is unclear whether the degree of MVI correlates with patient prognosis or imaging findings. Here, we evaluate the prognostic value of MVI classification and analyze the radiologic features predictive of MVI.
Methods
Using a retrospective cohort of 506 patients with resected solitary HCCs, the histological and imaging features of MVI were reviewed and correlated with clinical data.
Results
MVI-positive HCCs invading ≥5 vessels or those with ≥50 invaded tumor cells were significantly associated with decreased overall survival (OS). The 5-year OS, recurrence-free survival (RFS), and beyond Milan criteria RFS rates were significantly poorer in patients with severe MVI compared with those with mild or no MVI. Severe MVI was a significant independent predictive factor for OS (odds ratio [OR], 2.962; p<0.001), RFS (OR, 1.638; p=0.002), and beyond Milan criteria RFS (OR, 2.797; p<0.001) on multivariable analysis. On MRI, non-smooth tumor margins (OR, 2.224; p=0.023) and satellite nodules (OR, 3.264; p<0.001) were independently associated with the severe-MVI group on multivariable analysis. Both non-smooth tumor margins and satellite nodules were associated with worse 5-year OS, RFS, and beyond Milan criteria RFS.
Conclusions
Histologic risk classification of MVI according to the number of invaded microvessels and invading carcinoma cells was a valuable predictor of prognosis in HCC patients. Non-smooth tumor margin and satellite nodules were significantly associated with severe MVI and poor prognosis.

Citations

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  • 250 Download
  • 41 Web of Science
  • Crossref

Review

Imaging diagnosis of hepatocellular carcinoma: Future directions with special emphasis on hepatobiliary magnetic resonance imaging and contrast-enhanced ultrasound
Junghoan Park, Jeong Min Lee, Tae-Hyung Kim, Jeong Hee Yoon
Clin Mol Hepatol 2022;28(3):362-379.
Published online December 27, 2021
DOI: https://doi.org/10.3350/cmh.2021.0361
Hepatocellular carcinoma (HCC) is a unique cancer entity that can be noninvasively diagnosed using imaging modalities without pathologic confirmation. In 2018, several major guidelines for HCC were updated to include hepatobiliary contrast agent magnetic resonance imaging (HBA-MRI) and contrast-enhanced ultrasound (CEUS) as major imaging modalities for HCC diagnosis. HBA-MRI enables the achievement of high sensitivity in HCC detection using the hepatobiliary phase (HBP). CEUS is another imaging modality with real-time imaging capability, and it is reported to be useful as a second-line modality to increase sensitivity without losing specificity for HCC diagnosis. However, until now, there is an unsolved discrepancy among guidelines on whether to accept “HBP hypointensity” as a definite diagnostic criterion for HCC or include CEUS in the diagnostic algorithm for HCC diagnosis. Furthermore, there is variability in terminology and inconsistencies in the definition of imaging findings among guidelines; therefore, there is an unmet need for the development of a standardized lexicon. In this article, we review the performance and limitations of HBA-MRI and CEUS after guideline updates in 2018 and briefly introduce some future aspects of imaging-based HCC diagnosis.

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  • 280 Download
  • 32 Web of Science
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Editorial

Hepatic neoplasm

Diagnosis of hepatocellular carcinoma: Which MRI contrast agent? Which diagnostic criteria?
So Yeon Kim
Clin Mol Hepatol 2020;26(3):309-311.
Published online June 15, 2020
DOI: https://doi.org/10.3350/cmh.2020.0061

Citations

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Original Article

Hepatic neoplasm

Comparison of LI-RADS 2018 and KLCA-NCC 2018 for noninvasive diagnosis of hepatocellular carcinoma using magnetic resonance imaging
Sunyoung Lee, Seung-seob Kim, Dong ryul Chang, Hyerim Kim, Myeong-Jin Kim
Clin Mol Hepatol 2020;26(3):340-351.
Published online June 4, 2020
DOI: https://doi.org/10.3350/cmh.2020.0004
Background/Aims
This study aimed to compare the diagnostic performances of Liver Imaging Reporting and Data System (LI-RADS) 2018 and Korean Liver Cancer Association-National Cancer Center (KLCA-NCC) 2018 criteria on magnetic resonance imaging (MRI) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients.
Methods
This retrospective study included 273 treatment-naïve patients (71 patients with extracellular contrast agent [ECA]-MRI and 202 patients with hepatobiliary agent [HBA]-MRI; 352 lesions including 263 HCCs) with high risk of HCC who underwent contrast-enhanced MRI between 2016 and 2017. Two readers evaluated all lesions according to the criteria of LI-RADS 2018 and KLCA-NCC 2018. The per-lesion diagnostic performances were compared using the generalized estimating equation method.
Results
On ECA-MRI, the sensitivity and specificity of LI-RADS 2018 and KLCA-NCC 2018 were not significantly different (LR-5 vs. definite HCC: 75.8% vs. 69.4%, P=0.095 and 95.8% vs. 95.8%, P>0.999; LR-5/4 vs. definite/probable HCC: 87.1% vs.83.9%, P=0.313 and 87.5% vs. 91.7%, P=0.307). On HBA-MRI, definite HCC of KLCA-NCC 2018 showed significantly higher sensitivity (79.1% vs. 68.2%, P<0.001) than LR-5 of LI-RADS 2018 without a significant difference in specificity (93.9% vs. 95.4%, P=0.314). Definite/probable HCC of KLCA-NCC 2018 had higher specificity (92.3% vs. 80.0%, P=0.003) than LR-5/4 of LI-RADS 2018. The sensitivity was lower for definite/probable HCC than for LR-5/4 without statistical significance (85.6% vs. 88.1%, P=0.057).
Conclusions
On ECA-MRI, LI-RADS 2018 and KLCA-NCC 2018 showed comparable diagnostic performances. On HBA-MRI, definite HCC of KLCA-NCC 2018 provided better sensitivity than LR-5 category of LI-RADS 2018 without compromising the specificity, while definite/probable HCC of KLCA-NCC 2018 revealed higher specificity than LR-5/4 of LI-RADS 2018 for diagnosing HCC.

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Reviews

Hepatic neoplasm

Gadoxetic acid-enhanced magnetic resonance imaging: Hepatocellular carcinoma and mimickers
Yeun-Yoon Kim, Mi-Suk Park, Khalid Suliman Aljoqiman, Jin-Young Choi, Myeong-Jin Kim
Clin Mol Hepatol 2019;25(3):223-233.
Published online January 21, 2019
DOI: https://doi.org/10.3350/cmh.2018.0107
Gadoxetic acid, a hepatocyte-specific magnetic resonance imaging (MRI) contrast agent, has emerged as an important tool for hepatocellular carcinoma (HCC) diagnosis. Gadoxetic acid-enhanced MRI is useful for the evaluation of earlystage HCC, diagnosis of HCC precursor lesions, and highly sensitive diagnosis of HCC. Furthermore, functional information provided by gadoxetic acid-enhanced MRI can aid in the characterization of focal liver lesions. For example, whereas lesions lack functioning hepatocytes appear hypointense in the hepatobiliary phase, preserved or enhanced expression of organic anion transporting polypeptides in some HCCs as well as focal nodular hyperplasia lead to hyperintensity in the hepatobiliary phase; and a targetoid appearance on transitional phase or hepatobiliary phase imaging can be helpful for identifying the histopathological composition of tumors. While gadoxetic acid-enhanced MRI may improve the sensitivity of HCC diagnosis and provide new insights into the characterization of focal liver lesions, there are many challenges associated with its use. This article reviews the pros and cons of HCC diagnosis with gadoxetic acid-enhanced MRI and discuss some clues in the radiological differentiation of HCC from HCC mimickers.

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Steatotic liver disease

Imaging evaluation of non-alcoholic fatty liver disease: focused on quantification
Dong Ho Lee
Clin Mol Hepatol 2017;23(4):290-301.
Published online October 10, 2017
DOI: https://doi.org/10.3350/cmh.2017.0042
Non-alcoholic fatty liver disease (NAFLD) has been an emerging major health problem, and the most common cause of chronic liver disease in Western countries. Traditionally, liver biopsy has been gold standard method for quantification of hepatic steatosis. However, its invasive nature with potential complication as well as measurement variability are major problem. Thus, various imaging studies have been used for evaluation of hepatic steatosis. Ultrasonography provides fairly good accuracy to detect moderate-to-severe degree hepatic steatosis, but limited accuracy for mild steatosis. Operator-dependency and subjective/qualitative nature of examination are another major drawbacks of ultrasonography. Computed tomography can be considered as an unsuitable imaging modality for evaluation of NAFLD due to potential risk of radiation exposure and limited accuracy in detecting mild steatosis. Both magnetic resonance spectroscopy and magnetic resonance imaging using chemical shift technique provide highly accurate and reproducible diagnostic performance for evaluating NAFLD, and therefore, have been used in many clinical trials as a non-invasive reference of standard method.

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Editorial

Hepatic neoplasm

Surveillance of hepatocellular carcinoma: is only ultrasound enough?
Woo Kyoung Jeong
Clin Mol Hepatol 2017;23(3):222-223.
Published online September 19, 2017
DOI: https://doi.org/10.3350/cmh.2017.0046

Citations

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Original Articles

Hepatic neoplasm

Comparison of hepatic MDCT, MRI, and DSA to explant pathology for the detection and treatment planning of hepatocellular carcinoma
Lauren M. Ladd, Temel Tirkes, Mark Tann, David M. Agarwal, Matthew S. Johnson, Bilal Tahir, Kumaresan Sandrasegaran
Clin Mol Hepatol 2016;22(4):450-457.
Published online December 14, 2016
DOI: https://doi.org/10.3350/cmh.2016.0036
Background/Aims
The diagnosis and treatment plan for hepatocellular carcinoma (HCC) can be made from radiologic imaging. However, lesion detection may vary depending on the imaging modality. This study aims to evaluate the sensitivities of hepatic multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) in the detection of HCC and the consequent management impact on potential liver transplant patients.
Methods
One hundred and sixteen HCC lesions were analyzed in 41 patients who received an orthotopic liver transplant (OLT). All of the patients underwent pretransplantation hepatic DSA, MDCT, and/or MRI. The imaging results were independently reviewed retrospectively in a blinded fashion by two interventional and two abdominal radiologists. The liver explant pathology was used as the gold standard for assessing each imaging modality.
Results
The sensitivity for overall HCC detection was higher for cross-sectional imaging using MRI (51.5%, 95% confidence interval [CI]=36.2-58.4%) and MDCT (49.8%, 95% CI=43.7-55.9%) than for DSA (41.7%, 95% CI=36.2-47.3%) (P=0.05). The difference in false-positive rate was not statistically significant between MRI (22%), MDCT (29%), and DSA (29%) (P=0.67). The sensitivity was significantly higher for detecting right lobe lesions than left lobe lesions for all modalities (MRI: 56.1% vs. 43.1%, MDCT: 55.0% vs. 42.0%, and DSA: 46.9% vs. 33.9%; all P<0.01). The sensitivities of the three imaging modalities were also higher for lesions ≥2 cm vs. <2 cm (MRI: 73.4% vs. 32.7%, MDCT: 66.9% vs. 33.8%, and DSA: 62.2% vs. 24.1%; all P<0.01). The interobserver correlation was rated as very good to excellent.
Conclusions
The sensitivity for detecting HCC is higher for MRI and MDCT than for DSA, and so cross-sectional imaging modalities should be used to evaluate OLT candidacy.

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Liver fibrosis, cirrhosis, and portal hypertension

Magnetization-tagged MRI is a simple method for predicting liver fibrosis
Kyung-Eun Kim, Mi-Suk Park, Sohae Chung, Chansik An, Leon Axel, Rakhmonova Gulbahor Ergashovna
Clin Mol Hepatol 2016;22(1):140-145.
Published online March 28, 2016
DOI: https://doi.org/10.3350/cmh.2016.22.1.140
Background/Aims
To assess the usefulness of magnetization-tagged magnetic resonance imaging (MRI) in quantifying cardiac-induced liver motion and deformation in order to predict liver fibrosis.
Methods
This retrospective study included 85 patients who underwent liver MRI including magnetization-tagged sequences from April 2010 to August 2010. Tagged images were acquired in three coronal and three sagittal planes encompassing both the liver and heart. A Gabor filter bank was used to measure the maximum value of displacement (MaxDisp) and the maximum and minimum values of principal strains (MaxP1 and MinP2, respectively). Patients were divided into three groups (no fibrosis, mild-to-moderate fibrosis, and significant fibrosis) based on their aspartate-aminotransferase-to-platelet ratio index (APRI) score. Group comparisons were made using ANOVA tests.
Results
The patients were divided into three groups according to APRI scores: no fibrosis (≤0.5; n=41), moderate fibrosis (0.5–1.5; n=23), and significant fibrosis (>1.5; n=21). The values of MaxDisp were 2.9±0.9 (mean±SD), 2.3±0.7, and 2.1±0.6 in the no fibrosis, moderate fibrosis, and significant fibrosis groups, respectively (P<0.001); the corresponding values of MaxP1 were 0.05±0.2, 0.04±0.02, and 0.03±0.01, respectively (P=0.002), while those of MinP2 were –0.07±0.02, –0.05±0.02, and –0.04±0.01, respectively (P<0.001).
Conclusions
Tagged MRI to quantify cardiac-induced liver motion can be easily incorporated in routine liver MRI and may represent a helpful complementary tool in the diagnosis of early liver fibrosis.

Citations

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  • Harnessing intrinsic cardiac motion vs. external mechanical vibrations: a comparison of MRI cine-tagging and MR elastography for liver fibrosis assessment
    Thierry L Lefebvre, Anton Volniansky, Léonie Petitclerc, Emmanuel Montagnon, Giada Sebastiani, Jeanne-Marie Giard, Marie-Pierre Sylvestre, Bich Ngoc Nguyen, Guillaume Gilbert, Guy Cloutier, An Tang
    British Journal of Radiology.2025; 98(1176): 2066.     CrossRef
  • MRI cine‐tagging of cardiac‐induced motion for noninvasive staging of liver fibrosis
    Thierry Lefebvre, Léonie Petitclerc, Mélanie Hébert, Laurent Bilodeau, Giada Sebastiani, Damien Olivié, Zu‐Hua Gao, Marie‐Pierre Sylvestre, Guy Cloutier, Bich N. Nguyen, Guillaume Gilbert, An Tang
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Hepatic neoplasm

The usefulness of contrast-enhanced ultrasonography in the early detection of hepatocellular carcinoma viability after transarterial chemoembolization: pilot study
Youn Zoo Cho, So Yeon Park, Eun Hee Choi, Soon Koo Baik, Sang Ok Kwon, Young Ju Kim, Seung Hwan Cha, Moon Young Kim
Clin Mol Hepatol 2015;21(2):165-174.
Published online June 26, 2015
DOI: https://doi.org/10.3350/cmh.2015.21.2.165
Background/Aims

The therapeutic effect of transarterial chemoembolization (TACE) against hepatocellular carcinoma (HCC) is usually assessed using multidetector computed tomography (MDCT). However, dense lipiodol depositions can mask the enhancement of viable HCC tissue in MDCT. Contrast-enhanced ultrasonography (CEUS) could be effective in detecting small areas of viability and patency in vessels. We investigated whether arterial enhancement in CEUS after treatment with TACE can be used to detect HCC viability earlier than when using MDCT.

Methods

Twelve patients received CEUS, MDCT, and gadoxetic-acid-enhanced dynamic magnetic resonance imaging (MRI) at baseline and 4 and 12 weeks after TACE. The definition of viable HCC was defined as MRI positivity after 4 or 12 weeks.

Results

Eight of the 12 patients showed MRI positivity at 4 or 12 weeks. All patients with positive CEUS findings at 4 weeks (n=8) showed MRI positivity and residual viable HCC at 4 or 12 weeks. Five of the eight patients with positive CEUS findings at 4 weeks had negative results on the 4-week MDCT scan. Four (50%) of these eight patients did not have MRI positivity at 4 weeks and were ultimately confirmed as having residual HCC tissue at the 12-week MRI. Kappa statistics revealed near-perfect agreement between CEUS and MRI (κ=1.00) and substantial agreement between MDCT and MRI (κ=0.67).

Conclusions

In the assessment of the response to TACE, CEUS at 4 weeks showed excellent results for detecting residual viable HCC, which suggests that CEUS can be used as an early additive diagnosis tool when deciding early additional treatment with TACE.

Citations

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    Chao Zhang, Xin Chen, Jukun Wang, Tao Luo
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Liver Imagings

Hepatic neoplasm

Recent advances in the imaging of hepatocellular carcinoma
Myung-Won You, So Yeon Kim, Kyoung Won Kim, So Jung Lee, Yong Moon Shin, Jin Hee Kim, Moon-Gyu Lee
Clin Mol Hepatol 2015;21(1):95-103.
Published online March 25, 2015
DOI: https://doi.org/10.3350/cmh.2015.21.1.95

The role of imaging is crucial for the surveillance, diagnosis, staging and treatment monitoring of hepatocellular carcinoma (HCC). Over the past few years, considerable technical advances were made in imaging of HCCs. New imaging technology, however, has introduced new challenges in our clinical practice. In this article, the current status of clinical imaging techniques for HCC is addressed. The diagnostic performance of imaging techniques in the context of recent clinical guidelines is also presented.

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Hepatic neoplasm

Composite liver tumors: A radiologic-pathologic correlation
Megha Nayyar, David K. Imagawa, Temel Tirkes, Aram N. Demirjian, Roozbeh Houshyar, Kumar Sandrasegaran, Chaitali S. Nangia, Tara Seery, P Bhargava, Joon II Choi, Chandana Lall
Clin Mol Hepatol 2014;20(4):406-410.
Published online December 24, 2014
DOI: https://doi.org/10.3350/cmh.2014.20.4.406

Bi-phenotypic neoplasm refers to tumors derived from a common cancer stem cell with unique capability to differentiate histologically into two distinct tumor types. Bi-phenotypic hepatocellular carcinoma-cholangiocarcinoma (HCC-CC), although a rare tumor, is important for clinicians to recognize, since treatment options targeting both elements of the tumor are crucial. Imaging findings of bi-phenotypic HCC-CC are not specific and include features of both HCC and CC. A combination of imaging and immuno-histochemical analysis is usually needed to make the diagnosis.

Citations

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  • Overexpression of lncRNA MT1JP Mediates Apoptosis and Migration of Hepatocellular Carcinoma Cells by Regulating miR-24-3p


    Qiu-Li Shan, Ning-Ning Chen, Gui-Zhi Meng, Fan Qu
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    Agnieszka Anysz-Grodzicka, Joanna Podgorska, Andrzej Cieszanowski
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    Calvin T. Sung, Anup Shetty, Christine O. Menias, Roozbeh Houshyar, Shreya Chatterjee, Thomas K. Lee, Paul Tung, Mohammed Helmy, Chandana Lall
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Case Report

Viral hepatitis

Reversible splenial lesion on the corpus callosum in nonfulminant hepatitis A presenting as encephalopathy
Soon Young Ko, Byung Kook Kim, Dong Wook Kim, Jeong Han Kim, Won Hyeok Choe, Hee Yeon Seo, So Young Kwon
Clin Mol Hepatol 2014;20(4):398-401.
Published online December 24, 2014
DOI: https://doi.org/10.3350/cmh.2014.20.4.398

Reversible focal lesions on the splenium of the corpus callosum (SCC) have been reported in patients with mild encephalitis/encephalopathy caused by various infectious agents, such as influenza, mumps, adenovirus, Varicella zoster, Escherichia coli, Legionella pneumophila, and Staphylococcus aureus. We report a case of a reversible SCC lesion causing reversible encephalopathy in nonfulminant hepatitis A. A 30-year-old healthy male with dysarthria and fever was admitted to our hospital. After admission his mental status became confused, and so we performed electroencephalography (EEG) and magnetic resonance imaging (MRI) of the brain, which revealed an intensified signal on diffusion-weighted imaging (DWI) at the SCC. His mental status improved 5 days after admission, and the SCC lesion had completely disappeared 15 days after admission.

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Review

Hepatic neoplasm

The MR imaging diagnosis of liver diseases using gadoxetic acid: Emphasis on hepatobiliary phase
Woo Kyoung Jeong, Young Kon Kim, Kyoung Doo Song, Dongil Choi, Hyo Keun Lim
Clin Mol Hepatol 2013;19(4):360-366.
Published online December 28, 2013
DOI: https://doi.org/10.3350/cmh.2013.19.4.360

Hepatocyte specific contrast agents including gadoxetic acid and gadobenate dimeglumine are very useful to diagnose various benign and malignant focal hepatic lesions and even helpful to estimate hepatic functional reservoir. The far delayed phase image referred to as the hepatobiliary phase makes the sensitivity of detection for malignant focal hepatic lesions increased, but specificity of malignant diseases, including hepatocellular carcinoma, metastasis and cholangiocarcinoma, characterization remained to be undetermined.

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Liver Imagings

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Review

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Liver Imagings
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