European Society Diagnostic Criteria for HCC
For nodules ≥1 cm in cirrhotic patients, the EASL diagnostic criteria require arterial phase hyperenhancement (APHE) combined with washout on the portal venous phase or delayed phase on multiphasic CT or MRI. 1
Target Population for Non-Invasive Diagnosis
EASL restricts non-invasive diagnostic criteria exclusively to cirrhotic patients, recognizing the high pre-test probability of HCC in this population. 1 Non-cirrhotic patients—even those at risk for HCC—must have pathological confirmation regardless of imaging findings. 2, 3
Imaging Modalities
First-line diagnostic imaging includes:
- Multiphasic contrast-enhanced CT with extracellular contrast agents 1
- Multiphasic MRI with extracellular contrast agents (ECA) or gadobenate dimeglumine 1
- Multiphasic MRI with hepatobiliary agents (HBA) such as gadoxetic acid 1
EASL 2018 newly permits contrast-enhanced ultrasound (CEUS) as a secondary imaging modality for diagnosing hypervascular HCC when first-line imaging is inconclusive. 1 However, CT or MRI should be used first due to higher sensitivity and whole-liver analysis capability. 1
Size-Based Diagnostic Algorithm
Nodules <1 cm
- Repeat ultrasound at 4-month intervals 1
- If stable for 12 months (three controls after four months), return to regular 6-month surveillance 1
- No definite HCC diagnosis is permitted for nodules <1 cm 1
Nodules ≥1 cm
- Perform multiphasic contrast-enhanced CT or MRI 1
- Diagnosis requires BOTH imaging hallmarks:
Specific Washout Definitions by Contrast Agent
EASL employs a narrow definition of washout compared to other guidelines: 1
- CT or MRI with extracellular agents: Washout on portal venous phase OR delayed phase 1
- MRI with hepatobiliary agents (gadoxetic acid): Washout on portal venous phase ONLY 1
- CEUS: Late-onset washout (>60 seconds) of mild intensity 1
This narrow definition distinguishes EASL from other systems and reflects prioritization of specificity over sensitivity. 1
What EASL Does NOT Permit
EASL provides the narrowest diagnostic scope among international guidelines: 1
- No diagnosis of arterial phase iso- or hypoenhancing HCC 1
- No "probable HCC" category 1
- No use of ancillary features (capsule, mosaic pattern, threshold growth) to modulate diagnosis 1
- No role for AFP in diagnosis (though AFP may provide prognostic information post-diagnosis) 2
When Biopsy is Required
Biopsy is mandatory when: 1
- Imaging does not show both diagnostic hallmarks (APHE + washout) 1
- Patient is non-cirrhotic 2, 3
- Nodule shows atypical features suggesting non-HCC malignancy 2
- After using alternative imaging modality, findings remain inconclusive 1
Performance Characteristics
The EASL criteria intentionally prioritize specificity over sensitivity: 1
- Specificity: 85-100% across studies 1
- Sensitivity varies by nodule size:
This design reflects European/North American treatment priorities where high specificity prevents false-positive diagnoses that could lead to inappropriate liver transplantation. 1 The trade-off is lower sensitivity compared to Asian guidelines (APASL, KLCA-NCC), which favor early detection. 1, 4
Common Pitfalls
Critical limitation: Requiring two coincidental imaging techniques (as in older EASL-EORTC 2012 guidelines) dramatically reduces sensitivity to 30% for 1-2 cm nodules, though maintaining 100% specificity. 1 The 2018 EASL guidelines addressed this by accepting one conclusive imaging study in centers with high-end equipment. 1
Contrast agent matters: Recent evidence shows extracellular contrast agents provide higher sensitivity than hepatobiliary agents for EASL criteria (76.2% vs 63.0%), though specificities remain comparable. 5 This finding supports EASL's inclusion of both agent types. 1