European Radiology

, Volume 29, Issue 12, pp 6539–6549 | Cite as

Analysis of Lipiodol uptake in angiography and computed tomography for the diagnosis of malignant versus benign hepatocellular nodules in cirrhotic liver

  • Marcel C. LangenbachEmail author
  • Thomas J. Vogl
  • Isabelle von den Driesch
  • Benjamin Kaltenbach
  • Jan-Erik Scholtz
  • Renate M. Hammerstingl
  • Tatjana Gruber-Rouh
Contrast Media



To evaluate the diagnostic value of Lipiodol distribution in angiography and CT to differentiate between hepatocellular carcinoma (HCC) and benign nodules of LI-RADS 3 and 4 lesions observed in MRI of liver cirrhosis.


This retrospective study included all patients with liver cirrhosis who had diagnosis of LI-RADS 3 or 4 lesions by MRI who underwent a Lipiodol-based angiography and post-interventional unenhanced CT- and liver biopsy. Two independent radiologists evaluated appearance, contrast enhancement, Lipiodol uptake in angiography, and morphological parameters (size, form, and density) of the lesions in unenhanced post-angiography CT. α-Fetoprotein (AFP) levels and pre-existing liver conditions were additionally taken into consideration. Differences between HCC lesions and benign nodules were analyzed. Sensitivity and specificity were calculated. P < 0.05 was considered as statistically significant.


Of 60 patients (men, n = 42 [70.0%]; women, 18 [30.0%]; mean age, 61 ± 9.1 years) 36 (60.0%) had HCC and 24 (40.0%) benign nodules. Clear visibility in angiography (sensitivity [se], 100%; specificity [sp], 87.5%) with homogeneous or lacunar Lipiodol enhancement (se, 86.1%; sp, 100%) in consecutive CT can be diagnosed as HCC lesions in cirrhotic liver. Lesion form (p < 0.001), round or oval, and intense contrast (p < 0.001) are minor features which can facilitate the findings. Furthermore, patients with HCC showed a larger lesion size in CT (p = 0.026).


Clearly detectable lesions in Lipiodol-based angiography and a homogeneous or lacunar enhancement in post-angiographic non-contrast CT allow for differentiation of intrahepatic lesions classified as LI-RADS 3 or 4 into benign vs. malign liver lesions with high sensitivity and specificity in patients with liver cirrhosis. Definite diagnosis may not require an additional biopsy.

Key Points

Combination of clear visibility in Lipiodol-based angiography and homogeneous or lacunar enhancement in following native CT scan is HCC-defining.

In lesions classified with MRI as LI-RADS 3 or 4, evaluation based on Lipiodol angiography and following plain CT performed is highly sensitive and specific for the differentiation between HCC and benign nodules in a cirrhotic liver.

The results lead to an alternative pathway in the diagnosis of HCC in cirrhotic liver without the need of an additional liver biopsy.


Ethiodized oil Carcinoma, hepatocellular Angiography Tomography, X-ray computed Liver cirrhosis 



Apparent diffusion coefficient




Barcelona Clinic Liver Cancer


Computed tomography


Conventional transarterial chemoembolization


Hepatocellular carcinoma


Inter-reader variability


Liver Imaging Reporting and Data System


Magnetic resonance imaging


Transarterial embolization



This study has received funding by Guerbet GmbH.

Compliance with ethical standards


The scientific guarantor of this publication is Marcel C. Langenbach.

Conflict of interest

All authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• Retrospective

• Diagnostic or prognostic study

• Performed at one institution


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Institute for Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurtGermany

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