In a patient with cirrhosis and a solitary liver nodule ≥2 cm that shows arterial phase hyperenhancement and portal‑venous wash‑out on contrast‑enhanced CT or MRI, should a biopsy be performed to diagnose hepatocellular carcinoma?

Biopsy for HCC in Cirrhotic Patients with Typical Imaging Features

In a cirrhotic patient with a solitary liver nodule ≥2 cm showing arterial phase hyperenhancement and portal-venous washout on contrast-enhanced CT or MRI, biopsy is NOT necessary for diagnosis—the lesion can be confidently diagnosed as HCC based on imaging alone. 1

Diagnostic Approach Based on Nodule Size and Imaging Features

Nodules ≥2 cm with Typical Features

• A single imaging modality (multiphasic CT or MRI) showing characteristic HCC features is sufficient for definitive diagnosis without biopsy 1
• The typical radiological hallmark consists of arterial phase hyperenhancement (APHE) followed by washout in the portal venous or delayed phases 1
• This approach achieves specificities of 91-100%, providing high diagnostic confidence 1
• Biopsy should be reserved only for cases where imaging features are atypical or the vascular profile is not characteristic 1

Nodules 1-2 cm

• These require a more conservative approach due to lower diagnostic accuracy of imaging 1
• Two concordant imaging studies showing typical HCC features are recommended before making a definitive diagnosis 1
• If findings are not characteristic or discordant between techniques, biopsy should be performed 1
• The sensitivity of imaging for this size range is only 41-62%, compared to 65-89% for larger lesions 1

Nodules <1 cm

• Follow-up with ultrasound at 3-6 month intervals is recommended rather than immediate biopsy 1
• If stable for 12 months, can return to routine 6-month surveillance 1
• If growth occurs, re-evaluate using the algorithm appropriate for the new size 1

When Biopsy IS Indicated

Biopsy should be performed in the following specific scenarios:

• Atypical imaging features: Lesions lacking the characteristic APHE with washout pattern 1
• Non-cirrhotic patients: Imaging criteria only apply to high-risk patients with cirrhosis, chronic hepatitis B, or chronic hepatitis C 1
• Lesions with targetoid appearance or marked T2 hyperintensity: These features suggest non-HCC malignancy 1
• Discordant imaging findings: When multiple imaging modalities show conflicting results 1
• Need for higher diagnostic certainty: When treatment decisions require absolute confirmation, considering the 5-10% uncertainty rate with imaging alone 1

Important Caveats and Pitfalls

Safety of Biopsy

• Needle tract seeding occurs in only 1-3% of cases and does not affect overall survival 1
• Bleeding risk is low and manageable 1
• These risks should not deter biopsy when clinically indicated 1

False-Positive Imaging Diagnoses

• Benign lesions can mimic HCC, including focal nodular hyperplasia-like nodules, serum amyloid A-positive nodules, and dysplastic nodules 2
• Non-HCC malignancies such as cholangiocarcinoma, combined hepatocellular-cholangiocarcinoma, and metastatic adenocarcinoma can show similar enhancement patterns 2
• This 5-10% false-positive rate supports considering biopsy when absolute diagnostic certainty is required for treatment planning 1, 2

Negative Biopsy Results

• If biopsy is negative but imaging remains suspicious, close follow-up at 3-6 month intervals is mandatory 1
• Repeat biopsy is recommended if the lesion enlarges or changes enhancement pattern during follow-up 1
• False-negative biopsies can occur, particularly in small lesions 1

Optimal Biopsy Technique When Indicated

• Both fine-needle aspiration and core biopsy should be obtained to maximize diagnostic yield 3
• Core biopsy is preferred over cytology alone as it allows differentiation between dysplastic nodules and early HCC 4
• Image guidance (ultrasound or CT) should be used 3