Non-measurable infiltrative HCC: is post-contrast attenuation on CT a sign of tumor response?



To evaluate the value of CT attenuation to assess the response to sorafenib in infiltrative/endovascular non-measurable advanced hepatocellular carcinoma (HCC).


From 2007 to 2014, patients with infiltrative HCC ± tumor-in-vein (TIV) were retrospectively included. Attenuation of tumors and TIV were measured at baseline and follow-up on arterial and portal venous phase CT by two independent radiologists. Attenuation changes (overall and as per Choi criteria) and Child-Pugh score were correlated to overall survival.


Forty patients were included (38 men, 95%). Attenuation of both the tumors and TIV was significantly lower in follow-up CT than on baseline CT (p = 0.002 (arterial), and p = 0.001 (portal) for tumor, and p = 0.004 (arterial) and p < 0.001 (porta) for TIV). Median attenuation of TIV was significantly lower than that of the tumor in follow-up images (p = 0.010). Median OS for the entire cohort was 4 ± 1 months (95% CI: 2.1–5.9), with estimated OS rates at 6, 12, and 24 months of 43%, 29 and 12%, respectively. Baseline and follow-up CT attenuation in tumors and TVI were not correlated with survival. Survival was not significantly increased in patients with Choi criteria >15% CT HU decrease in the tumor and/or TIV during follow-up. Only Child-Pugh A (HR 4.9 (95%CI 2.3–10.7), p < 0.001) was identified as an independent factor of improved survival on multivariate analysis.


Despite significant changes under sorafenib, tumor attenuation of infiltrative/endovascular non-measurable HCC may be of limited value to assess survival in this subgroup of patients with very poor prognosis.

Key Points

• Attenuation of both tumors and tumor-in-vein decreases after sorafenib.

• Attenuation decrease is more marked in the tumor-in-vein than in the tumor.

• Attenuation decrease is not associated with longer overall survival.

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Barcelona Clinic Liver Cancer


Computed tomography


European Association for the Study of the Liver


Hepatocellular carcinoma


Intraclass correlation coefficient


(modified) Response Criteria In Solid Tumors


Region of interest




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Correspondence to Maxime Ronot.

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The scientific guarantor of this publication is Maxime Ronot.

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The 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

No complex statistical methods were necessary for this paper.

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• retrospective

• diagnostic or prognostic study

• single-center study

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Koulakian, H., Allaham, W., Vilgrain, V. et al. Non-measurable infiltrative HCC: is post-contrast attenuation on CT a sign of tumor response?. Eur Radiol 29, 4389–4399 (2019).

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  • Sorafenib
  • Carcinoma, hepatocellular
  • Portal vein
  • Follow-up studies