Journal of Liver Cancer

Review Articles

Imaging differentiation of hepatocellular carcinoma, combined hepatocellular-cholangiocarcinoma, and intrahepatic cholangiocarcinoma: pitfalls and advances: Jaeseung Shin, Taek Chung, Sang Yun Ha, Hyungjin Rhee; J Liver Cancer. 2026;26(1):9-18. Published online March 5, 2026; DOI: https://doi.org/10.17998/jlc.2026.03.05

7,409 Views
131 Downloads

Abstract PDF: Accurate non-invasive differentiation of primary liver cancers, such as hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCCA), and combined hepatocellular-cholangiocarcinoma (cHCC-CCA), is crucial for optimal management but challenging due to shared risk factors and overlapping imaging phenotypes. While the Liver Imaging Reporting and Data System category M effectively captures the classic targetoid appearance of large duct type iCCA, the small duct type frequently exhibits HCC-mimicking non-rim arterial phase hyperenhancement and non-peripheral washout, potentially compromising diagnostic specificity. Furthermore, cHCC-CCA presents a formidable diagnostic dilemma, existing on a continuous imaging spectrum that reflects its histologic dominance. This continuous imaging spectrum not only blurs radiologic distinctions but also complicates tissue sampling, limiting the diagnostic accuracy of core needle biopsies and highlighting the risk of misclassification. To enhance diagnostic clarity, this review highlights their key imaging hallmarks: while HCC typically shows non-rim arterial phase hyperenhancement (APHE) and non-peripheral washout, large duct iCCA displays a classic targetoid appearance with rim APHE and progressive central enhancement. Conversely, small duct iCCA often mimics HCC, and cHCC-CCA exhibits a variable spectrum depending on its predominant histologic component. Ultimately, overcoming these diagnostic pitfalls requires a rigorous, multidisciplinary approach that synthesizes imaging findings, serologic tumor markers, and clinical contexts.

Radiologic features of hepatocellular carcinoma related to prognosis: Shin Hye Hwang, Hyungjin Rhee; J Liver Cancer. 2023;23(1):143-156. Published online March 9, 2023; DOI: https://doi.org/10.17998/jlc.2023.02.16

16,761 Views
330 Downloads
30 Citations

The cross-sectional imaging findings play a crucial role in the diagnosis of hepatocellular carcinoma (HCC). Recent studies have shown that imaging findings of HCC are not only relevant for the diagnosis of HCC, but also for identifying genetic and pathologic characteristics and determining prognosis. Imaging findings such as rim arterial phase hyperenhancement, arterial phase peritumoral hyperenhancement, hepatobiliary phase peritumoral hypointensity, non-smooth tumor margin, low apparent diffusion coefficient, and the LR-M category of the Liver Imaging-Reporting and Data System have been reported to be associated with poor prognosis. In contrast, imaging findings such as enhancing capsule appearance, hepatobiliary phase hyperintensity, and fat in mass have been reported to be associated with a favorable prognosis. Most of these imaging findings were examined in retrospective, single-center studies that were not adequately validated. However, the imaging findings can be applied for deciding the treatment strategy for HCC, if their significance can be confirmed by a large multicenter study. In this literature, we would like to review imaging findings related to the prognosis of HCC as well as their associated clinicopathological characteristics.

Citations

Citations to this article as recorded by

Association of Signal Heterogeneity in the Hepatobiliary Phase of Gd‐EOB‐DTPA‐Enhanced MRI With Survival Outcomes and Tumor Microenvironment in Hepatocellular Carcinoma
Munetoshi Akaoka, Koichiro Haruki, Jun Woo, Kazuyoshi Ohki, Kenei Furukawa, Shinji Onda, Masashi Tsunematsu, Michinori Matsumoto, Yoshihiro Shirai, Toru Ikegami
Journal of Hepato-Biliary-Pancreatic Sciences.2026; 33(5): 352. CrossRef
Focal lesions in the cirrhotic liver: an update on LI-RADS classification and clinical implications
Antonino Andrea Blandino, Federica Vernuccio, Roberto Cannella, Aoife Kilcoyne, Leo L. Tsai, Giuseppe Brancatelli
Digestive and Liver Disease.2026; 58(6): 713. CrossRef
Arterial phase CT improves detection of colorectal liver metastases: evaluation of the downslope injection method
Hiroaki Takayama, Tomoaki Ichikawa, Takayuki Yokota, Yasuhiro Fukushima, Junya Fukuda, Yoshiyuki Sakai, Tomokazu Takeuchi, Koji Muroga, Yoshito Tsushima
European Radiology.2026; 36(7): 5392. CrossRef
Prognostic Significance of Intraindividual CT and MRI LI-RADS Agreement and Discordance in Hepatocellular Carcinoma
Yong Jun Jung, Seokhwi Kim, In Hye Song, Ju Hyun Shim, Seung Soo Lee, Subin Heo, Sang Hyun Choi
Radiology: Imaging Cancer.2026;[Epub] CrossRef
Imaging differentiation of hepatocellular carcinoma, combined hepatocellular-cholangiocarcinoma, and intrahepatic cholangiocarcinoma: pitfalls and advances
Jaeseung Shin, Taek Chung, Sang Yun Ha, Hyungjin Rhee
Journal of Liver Cancer.2026; 26(1): 9. CrossRef
Gd-EOB-DTPA-Enhanced Magnetic Resonance Imaging for Predicting Immunotherapy Response in Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis
Wenbo Xie, Linmao Sun, Yumin Fu, Shuhang Liang, Yao Liu, Jiabei Wang, Lianxin Liu
Liver Cancer.2026; : 1. CrossRef
A modified Rim APHE criterion to improve LI-RADS diagnostic performance for primary liver malignancies
Chunying Feng, Jun Liu, Dawei Yang, Lixue Xu, Min Li, Yan Bao, Jinghui Dong, Jiawen Luo, Qingqing Chen, Rufang Liao, Chenxia Li, Rongpin Wang, Hui Xu, Zhenghan Yang
Abdominal Radiology.2026;[Epub] CrossRef
Habitat and peritumoral CT radiomics accurately predict early treatment response to hepatic arterial infusion chemotherapy combined with tyrosine kinase inhibitors and programmed death−1 inhibitors in unresectable hepatocellular carcinoma
Wenyi Bao, Minghang Shen, Kaidi Long, Bo Huang, Zhiqiang Zhang, Peizhi Li
Frontiers in Oncology.2026;[Epub] CrossRef
Arterial-Phase Enhancement Patterns of Hepatocellular Carcinoma: From Pathologic Background to Prognostication and Treatment Response
Jun Gu Kang, Ja Kyung Yoon, Hyungjin Rhee
Korean Journal of Abdominal Radiology.2026; 9(1): 14. CrossRef
Clinical and LI-RADS features on gadoxetic acid‑enhanced MRI for predicting complete response after transarterial chemoembolization in hepatocellular carcinoma > 2 cm
Chuhang Liu, Shuya Tan, Xinpei Hu, Yaoning Chen, Cen Hu, Hanqi Liu, Tong Zhao, Yujia Chen, Yangyang Liu
Abdominal Radiology.2026;[Epub] CrossRef
Prognostic factors in first-line atezolizumab-bevacizumab treatment of intermediate or advanced hepatocellular carcinoma
Kyowon Gu, Tae Wook Kang, Jaeseung Shin, Dong Hyun Sinn, Myung Ji Goh, Jung Yong Hong, Sangah Chi, Po-Yao Hsu
PLOS One.2026; 21(7): e0354176. CrossRef
Beyond Diagnosis: Magnetic Resonance Imaging-Based Imaging Biomarkers for Tumor Biology, Prognosis, and Clinical Decision-Making in Hepatocellular Carcinoma
Ja Kyung Yoon, Jin-Young Choi
Korean Journal of Radiology.2026; 27(9): 868. CrossRef
Evolution of Research on Cell-Specific Magnetic Resonance Imaging Contrast Agents in Hepatocellular Carcinoma: A Bibliometric Study
ChenWei Zhang, TianAi Zhang, ShaoZhong Ni
Hepatitis Monthly.2026;[Epub] CrossRef
Integrating multimodality CT-MRI deep learning with clinical-radiological features for preoperative hepatocellular carcinoma grading: a multicenter study
Jin Cui, Chao Ye, Zhixin Luo, Yunxuan Xie, Yan Lei, Changyi Ma, Junqi Sun, Yu Liu, Meiqi Wan, Jinran Chen, Bao Feng, Yaqin Zhang, Enming Cui
Magnetic Resonance Imaging.2026; 134: 110773. CrossRef
A Nomogram Based on MRI Visual Decision Tree to Evaluate Vascular Endothelial Growth Factor in Hepatocellular Carcinoma
Hanting Dai, Chuan Yan, Wanrong Huang, Yifan Pan, Feng Pan, Yamei Liu, Shunli Wang, Huifang Wang, Rongping Ye, Yueming Li
Journal of Magnetic Resonance Imaging.2025; 61(2): 970. CrossRef
Prediction early recurrence of hepatocellular carcinoma after hepatectomy using gadoxetic acid-enhanced MRI and IVIM
Da Guo, Liping Liu, Yu Jin
European Journal of Radiology Open.2025; 14: 100643. CrossRef
MRI Imaging Biomarkers for Prognostication of Hepatocellular Carcinoma
Ja Kyung Yoon, Jin-Young Choi
Journal of the Korean Society of Radiology.2025; 86(3): 364. CrossRef
Radiologic and Pathologic Discordance in Hepatocellular Carcinoma: More Than a Mismatch, with Prognostic Significance
Ijin Joo
Gut and Liver.2025; 19(4): 477. CrossRef
Contrast-enhanced MRI for identifying the steatohepatitic hepatocellular carcinoma from small hepatocellular carcinoma
Jiachen Liu, Xiurong Ding, Yanyan Zhang, Hongjun Li
Abdominal Radiology.2025; 51(6): 2831. CrossRef
Proposal of a Mathematical Model for Motion Blur in MRI Images
Tatsuya Kondo, Hiroaki Saito, Tsutomu Kanazawa
Japanese Journal of Radiological Technology.2025; 81(11): n/a. CrossRef
Prognostic prediction of primary liver cancer following transcatheter arterial chemoembolization (TACE) combined with targeted immunotherapy based on CT morphological characteristics
Disi Liu
American Journal of Cancer Research.2025; 15(11): 5014. CrossRef
Radiomics and machine learning based on preoperative MRI for predicting extrahepatic metastasis in hepatocellular carcinoma patients treated with transarterial chemoembolization
Gang Peng, Xiaojing Cao, Xiaoyu Huang, Xiang Zhou
European Journal of Radiology Open.2024; 12: 100551. CrossRef
Clinical Parameters Work Well as Predictive Factors for Atezolizumab and Bevacizumab Treatment in Hepatocellular Carcinoma
Ji Yeon Lee, Pil Soo Sung
Gut and Liver.2024; 18(4): 558. CrossRef
Advances in Understanding Hepatocellular Carcinoma Vasculature: Implications for Diagnosis, Prognostication, and Treatment
Hyungjin Rhee, Young Nyun Park, Jin-Young Choi
Korean Journal of Radiology.2024; 25(10): 887. CrossRef
Inter-reader agreement for CT/MRI LI-RADS category M imaging features: a systematic review and meta-analysis
Dong Hwan Kim, Sang Hyun Choi
Journal of Liver Cancer.2024; 24(2): 192. CrossRef
Gd-EOB-DTPA-enhanced MR imaging features of hepatocellular carcinoma in non-cirrhotic liver
Mingyue Song, Yuhao Tao, Hanjun Zhang, Mingzhan Du, Lingchuan Guo, Chunhong Hu, Weiguo Zhang
Magnetic Resonance Imaging.2024; 114: 110241. CrossRef
Prediction of PD-L1 expression in unresectable hepatocellular carcinoma with gadoxetic acid-enhanced MRI
Jun Gu Kang, Kyunghwa Han, Taek Chung, Hyungjin Rhee
European Journal of Radiology.2024; 181: 111772. CrossRef
The histopathological and molecular heterogeneity of hepatocellular carcinoma: a narrative review
Wonju Chung, Haeryoung Kim
The Ewha Medical Journal.2024;[Epub] CrossRef
Gadoxetic Acid-Enhanced Magnetic Resonance Imaging Features Can Predict Immune-Excluded Phenotype of Hepatocellular Carcinoma
Eisuke Ueshima, Keitaro Sofue, Takahiro Kodama, Shuhei Yamamoto, Masato Komatsu, Shohei Komatsu, Nobuaki Ishihara, Akihiro Umeno, Takeru Yamaguchi, Masatoshi Hori, Takumi Fukumoto, Tetsuo Takehara, Takamichi Murakami
Liver Cancer.2024; 14(3): 271. CrossRef
Imaging prognostication and tumor biology in hepatocellular carcinoma
Diana Kadi, Marilyn F. Yamamoto, Emily C. Lerner, Hanyu Jiang, Kathryn J. Fowler, Mustafa R. Bashir
Journal of Liver Cancer.2023; 23(2): 284. CrossRef

Update on Pathologic and Radiologic Diagnosis of Combined Hepatocellular-Cholangiocarcinoma: Hyungjin Rhee, Jae Hyon Park, Young Nyun Park; J Liver Cancer. 2021;21(1):12-24. Published online March 31, 2021; DOI: https://doi.org/10.17998/jlc.21.1.12

14,535 Views
395 Downloads
14 Citations

Abstract PDF

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a malignant primary liver carcinoma characterized by the unequivocal presence of both hepatocytic and cholangiocytic differentiation within the same tumor. Recent research has highlighted that cHCC-CCAs are more heterogeneous than previously expected. In the updated consensus terminology and WHO 2019 classification, “classical type” and “subtypes with stem-cell features” of the WHO 2010 classification are no longer recommended. Instead, it is recommended that the presence and percentages of various histopathologic components and stem-cell features be mentioned in the pathologic report. The new terminology and classification enable the exchange of clearer and more objective information about cHCC-CCAs, facilitating multi-center and multinational research. However, there are limitations to the diagnosis of cHCC-CCA by imaging and biopsy. cHCC-CCAs showing typical imaging findings of HCC could be misdiagnosed as HCC and subjected to inappropriate treatment, if other clinical findings are not sufficiently considered. cHCC-CCAs showing at least one of the CCA-like imaging features or unusual clinical features should be subjected to biopsy. There may be a sampling error for the biopsy diagnosis of cHCC-CCA. An optimized diagnostic algorithm integrating clinical, radiological, and histopathologic information of biopsy is required to resolve these diagnostic pitfalls.

Citations

Citations to this article as recorded by

Combined hepatocellular-cholangiocarcinoma: a contemporary pathologic and molecular perspective
Taek Chung
Journal of Liver Cancer.2026; 26(1): 1. CrossRef
Imaging differentiation of hepatocellular carcinoma, combined hepatocellular-cholangiocarcinoma, and intrahepatic cholangiocarcinoma: pitfalls and advances
Jaeseung Shin, Taek Chung, Sang Yun Ha, Hyungjin Rhee
Journal of Liver Cancer.2026; 26(1): 9. CrossRef
Radiological Assessment of Liver and Biliary Neoplasms
Rayane El Rahi, Murat Yüce, Bachir Taouli
Hematology/Oncology Clinics of North America.2026; 40(4): 451. CrossRef
Advances in the imaging of liver cancer
Ijin Joo, Jeong Min Lee, Maxime Ronot
Journal of Hepatology.2026;[Epub] CrossRef
Preoperative Assessment of Bile Duct Cancer: The Role of Magnetic Resonance Imaging and Magnetic Resonance Cholangiopancreatography
Bohyun Kim
Investigative Magnetic Resonance Imaging.2026; 30(2): 75. CrossRef
Classification and early diagnostic markers of Primary hepatic carcinoma: a comprehensive review
Xinyao Liu, Lin Gong, Weiran Kong, Jie Kong, Yang Zhang, Chuantao Yuan, Shuai Chen
Biomarkers in Medicine.2026; 20(10): 649. CrossRef
Combined hepatocellular-cholangiocarcinoma shows distinct recurrence patterns and poorer postoperative outcomes compared to hepatocellular carcinoma
Yeongseok Hwang, Subin Heo, Young-in Yoon, Sung Won Chung, Jonggi Choi, Danbi Lee, Ju Hyun Shim, Kang Mo Kim, Young-Suk Lim, Han Chu Lee, in Hye Song, Won-Mook Choi
International Journal of Surgery.2026;[Epub] CrossRef
Management of rare primary liver cancers: combined hepato-cholangiocarcinoma and fibrolamellar hepatocellular carcinoma
Matteo Gallant, Marie Decraecker, Marianne Ziol, Julien Calderaro, Maxime Ronot, Jessica Zucman-Rossi, Jean-Charles Nault
JHEP Reports.2026; : 101991. CrossRef
Combined Hepatocellular-Cholangiocarcinoma: A Clinical and Molecular Review
Shaodian Xu, Julien Calderaro
Seminars in Liver Disease.2025; 45(04): 476. CrossRef
Enhancing liver cirrhosis varices and CSPH risk prediction with spleen stiffness measurement using 100-Hz probe
Jeong-Ju Yoo, Sun Ah Maeng, Young Chang, Sae Hwan Lee, Soung Won Jeong, Jae Young Jang, Gab Jin Cheon, Young Seok Kim, Hong Soo Kim, Sang Gyune Kim
Scientific Reports.2024;[Epub] CrossRef
MRI features of combined hepatocellular-cholangiocarcinoma
Noor Fatima Majeed, Mathew Macey, Marta Braschi Amirfarzan, Sheida Sharifi, Jeremy R Wortman
Abdominal Radiology.2024; 50(1): 169. CrossRef
Imaging findings of intrahepatic cholangiocarcinoma for prognosis prediction and treatment decision-making: a narrative review
Jun Gu Kang, Taek Chung, Dong Kyu Kim, Hyungjin Rhee
The Ewha Medical Journal.2024;[Epub] CrossRef
Differentiation between hepatic angiomyolipoma and hepatocellular carcinoma in individuals who are not at-risk for hepatocellular carcinoma
Sungtae Park, Myeong-Jin Kim, Kyunghwa Han, Jae Hyon Park, Dai Hoon Han, Young Nyun Park, Jaehyo Kim, Hyungjin Rhee
European Journal of Radiology.2023; 166: 110957. CrossRef
The Human TOR Signaling Regulator Is the Key Indicator of Liver Cancer Patients’ Overall Survival: TIPRL/LC3/CD133/CD44 as Potential Biomarkers for Early Liver Cancers
Soo Young Jun, Hyang Ran Yoon, Ji-Yong Yoon, Su-Jin Jeon, Jeong-Ju Lee, Debasish Halder, Jin-Man Kim, Nam-Soon Kim
Cancers.2021; 13(12): 2925. CrossRef

First
Prev
Page of 1
Next
Last

Search