Primary liver cancer is the fifth most prevalent malignant tumor and is highly valued by the medical community because of its high malignancy and short survival period. Therefore, it is especially important to closely monitor patients with hepatitis and cirrhosis, and try to achieve early detection, early diagnosis and early treatment of hepatocellular carcinoma.
At the same time, we should also see that many benign intrahepatic occupying lesions are misdiagnosed as primary hepatocellular carcinoma and incorrectly treated with intervention, chemotherapy, surgery or even liver transplantation, which cause certain damage to the patient’s body, mental stress and economic loss. Some of the misdiagnosis cases are introduced as follows.
(1) Cirrhotic nodules: cirrhotic nodules are one of the most common cases misdiagnosed as hepatocellular carcinoma. Since most primary hepatocellular carcinoma occurs in the stage of cirrhosis, and patients with more severe cirrhosis will have a large number of hyperplastic nodules in the liver parenchyma, and such nodules are difficult to distinguish from early hepatocellular carcinoma in terms of imaging, while both can be accompanied by elevated methemoglobin. Ultrasound or CT-guided puncture biopsy is a more accurate diagnostic method. Histologically, cirrhotic nodules are divided into general hyperplasia, atypical hyperplasia and undifferentiated nodules. Only undifferentiated nodules are precancerous in the pathological sense, and it takes months to years for undifferentiated nodules to develop into hepatocellular carcinoma. It can also be observed regularly and followed up for 2-3 months whether there are abnormal changes in imaging and clinical biochemical indexes, which are usually obvious in primary hepatocellular carcinoma.
(2) Hepatic hemangioma: Both hepatic hemangioma and hepatocellular carcinoma are occupying lesions with rich blood vessels, and both have rich blood flow signals under ultrasonic multispectral and CT-enhanced conditions. The hepatic hemangioma will not have obvious changes when it can be traced.
(3) Uneven fatty liver: With the improvement of living standard, the incidence of fatty liver and metabolic syndrome increases year by year. Most patients with fatty liver show the phenomenon of bright liver with anterior strength and posterior failure under ultrasound imaging, but some patients show inhomogeneous accumulation of fat in liver parenchyma with low CT value, which is sometimes difficult to distinguish from liver cancer. However, clinically it will not have the systemic manifestations of liver cancer patients (such as abdominal distension, diarrhea, discomfort in the right hepatic area, wasting, etc.), while it is not accompanied by increased AFP and GGT.
(4) Sarcoidosis: Some female patients had an isolated smooth and complete nodule in the liver in the past due to oral contraceptive pill, or parasitic infection, or autoimmune dysfunction, which is sometimes difficult to distinguish from hepatocellular carcinoma on imaging. The best method is ultrasound or CT-guided histological examination to clarify the diagnosis.
(5) Liver abscess: liver abscess is a manifestation of hematogenous dissemination in the liver after infection in a certain part of the body. Patients have clinical manifestations such as malaise, poor performance, low fever, emaciation and discomfort in the liver area.
(6) Calcified foci: patients with previous infections of tuberculosis, parasites and atopic microorganisms form calcified foci in the liver after healing, and the imaging examination shows strong echogenic dots, while some patients with hepatocellular carcinoma also show strong echogenicity on imaging examination.
(7) Drug-related liver injury: drug-related liver injury is a manifestation of adverse drug reactions, and some patients may have hepatic mass-like inhomogeneous echogenicity, accompanied by elevation of various biochemical enzymes of liver function and significant rise of AFP, which are difficult to identify in some imaging. There are also many other diseases that can be easily confused with liver cancer, such as mismatched sulcus tumor, heterogeneous hyperplastic nodules, adenoma, etc., which are not listed here.
To avoid unnecessary misdiagnosis, the following points can be referred to.
I. Detailed medical history.
The occurrence of liver cancer is closely related to the following risk factors: whether there is a history of chronic hepatitis B and C, whether there is a history of eating or exposure to aflatoxin, whether there is a history of long-term alcohol abuse, whether there is a family history of liver cancer.
2. Carefully inquire about the clinical manifestations of liver cancer, which is a malignant tumor, often accompanied by weakness, poor performance, discomfort in liver area, low fever, wasting and weight loss, etc.
3. Pay attention to the dynamic situation of imaging examination, because there is no significant difference before and after imaging examination of hepatic hemangioma, calcified foci and sclerotic nodules.
2. Pay attention to the detection of positive signs.
Some patients with hepatocellular carcinoma occurring on the basis of cirrhosis may have mild yellow sclera, appearance of liver palm and spider nevus, enlarged lymph nodes in middle and late stage patients, enlarged liver can be found under the ribs and the subserous process of abdominal examination, some patients have positive mobile turbid sounds and mild edema of both lower limbs, while patients with benign lesions lack the above signs.
III. Pay attention to imaging examination.
Ultrasound and CT are important means to diagnose hepatocellular carcinoma, especially enhanced CT and enhanced ultrasound. The principle of enhancement is to make use of the rich local blood vessels of hepatocellular carcinoma, and the arterial phase of hepatocellular carcinoma tissue is enhanced and the venous phase disappears, forming a stronger contrast. For some patients who are difficult to be diagnosed, they can be tracked regularly to further clarify the size and signal strength before and after comparison.
IV. Pay attention to pathological biopsy of liver tissues.
Histological biopsy under ultrasound or CT guidance is the gold standard for definite diagnosis of liver cancer. Many patients have certain fear of liver histological biopsy, in fact, the safety of puncture under CT or B ultrasound guidance is better, and at the same time, it can reduce patients’ psychological pressure and do various treatments in advance to avoid the delay of the disease. In conclusion, it is clinically significant to clarify the diagnosis of liver occupancy and avoid misdiagnosis and mistreatment of hepatocellular carcinoma.