PET Imaging of Hepatocellular Carcinoma

  • Eric C. EhmanEmail author
  • Scott M. Thompson
  • Brian T. Welch
  • Derek R. Johnson
  • Hugh C. J. McGregor
Part of the following topical collections:
  1. Nuclear Medicine & PET/CT Imaging


Purpose of Review

Positron emission tomography has not traditionally played a major role in the evaluation of hepatocellular carcinoma (HCC). Owing to high background liver uptake and molecular mechanisms within HCC lesions, uptake of 18F-fluorodeoxyglucose (FDG) is variable and prior studies have shown only modest overall detection of intrahepatic disease.

Recent Findings

Tracers such as 18F- and 11C-choline as well as 11C-acetate have been explored either in isolation or together with 18F-FDG have shown greater promise in detection of intrahepatic lesions, but yet are not in widespread clinical use. 68 Ga-Prostate specific membrane antigen is a tracer developed for use in prostate cancer but a pilot study and several case reports have indicated that there may be the potential for use in the evaluation of HCC.


Increased rates of lesion detection using 18F-FDG may be seen in poorly differentiated tumors and in the setting of metastatic disease or within recurrent tumor following loco-regional therapies and FDG uptake may indicate a greater risk of recurrence following transplantation. Further work will be required to elucidate the precise role of other non FDG tracers in the evaluation of patients at risk for or with HCC.


Hepatocellular carcinoma PET FDG Choline PSMA Acetate 



Recently published papers of particular interest have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Global Cancer Observatory. (2018). Accessed 25 Jan 2019.
  2. 2.
    Makarova-Rusher OV, et al. Population attributable fractions of risk factors for hepatocellular carcinoma in the United States. Cancer. 2016;122(11):1757–65.CrossRefGoogle Scholar
  3. 3.
    Heimbach JK, et al. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology. 2018;67(1):358–80.CrossRefGoogle Scholar
  4. 4.
    Galle PR, et al. EASL clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2018;69:182–236.CrossRefGoogle Scholar
  5. 5.
    Kokudo N, et al. Evidence-based clinical practice guidelines for hepatocellular carcinoma: the Japan Society of Hepatology 2013 update (3rd JSH-HCC guidelines). Hepatol Res. 2015. Scholar
  6. 6.
    Chernyak V, et al. Liver Imaging Reporting and Data System (LI-RADS) version 2018: imaging of hepatocellular carcinoma in at-risk patients. Radiology. 2018;289(3):816–30.CrossRefGoogle Scholar
  7. 7.
    Wald C, et al. New OPTN/UNOS policy for liver transplant allocation: standardization of liver imaging, diagnosis, classification, and reporting of hepatocellular carcinoma. Oak Brook: Radiological Society of North America Inc.; 2013.Google Scholar
  8. 8.
    Trojan J, et al. Fluorine-18 FDG positron emission tomography for imaging of hepatocellular carcinoma. Am J Gastroenterol. 1999;94(11):3314–9.CrossRefGoogle Scholar
  9. 9.
    Khan MA, et al. Positron emission tomography scanning in the evaluation of hepatocellular carcinoma. J Hepatol. 2000;32(5):792–7.CrossRefGoogle Scholar
  10. 10.
    Wudel LJ Jr, et al. The role of [18F] fluorodeoxyglucose positron emission tomography imaging in the evaluation of hepatocellular carcinoma/discussion. Am Surg. 2003;69(2):117.PubMedGoogle Scholar
  11. 11.
    Lin W-Y, Tsai S-C, Hung G-U. Value of delayed 18F-FDG-PET imaging in the detection of hepatocellular carcinoma. Nucl Med Commun. 2005;26(4):315–21.CrossRefGoogle Scholar
  12. 12.
    Torizuka T, et al. In vivo assessment of glucose metabolism in hepatocellular carcinoma with FDG-PET. J Nucl Med. 1995;36(10):1811.PubMedGoogle Scholar
  13. 13.
    Salem N, et al. Quantitative evaluation of 2-deoxy-2[F-18]fluoro-d-glucose-positron emission tomography imaging on the woodchuck model of hepatocellular carcinoma with histological correlation. Mol Imaging Biol. 2007;9(3):135–43.CrossRefGoogle Scholar
  14. 14.
    Podo F. Tumour phospholipid metabolism. NMR Biomed. 1999;12(7):413–39.CrossRefGoogle Scholar
  15. 15.
    Yamamoto Y, et al. Detection of hepatocellular carcinoma using 11C-choline PET: comparison with 18F-FDG PET. J Nucl Med. 2008;49(8):1245–8.CrossRefGoogle Scholar
  16. 16.
    Talbot J-N, et al. Detection of hepatocellular carcinoma with PET/CT: a prospective comparison of 18F-fluorocholine and 18F-FDG in patients with cirrhosis or chronic liver disease. J Nucl Med. 2010;51(11):1699–706.CrossRefGoogle Scholar
  17. 17.
    Kolthammer JA, et al. PET imaging of hepatocellular carcinoma with 18F-fluoroethylcholine and 11C-choline. Eur J Nucl Med Mol Imaging. 2011;38(7):1248–56.CrossRefGoogle Scholar
  18. 18.
    Grassi I, et al. The clinical use of PET with 11C-acetate. Am J Nucl Med Mol Imaging. 2012;2(1):33.PubMedGoogle Scholar
  19. 19.
    Ho CL, Yu SC, Yeung DW. 11C-acetate PET imaging in hepatocellular carcinoma and other liver masses. J Nucl Med. 2003;44(2):213–21.PubMedGoogle Scholar
  20. 20.
    Park JW, et al. A prospective evaluation of 18F-FDG and 11C-acetate PET/CT for detection of primary and metastatic hepatocellular carcinoma. J Nucl Med. 2008;49(12):1912–21.CrossRefGoogle Scholar
  21. 21.
    Rauscher I, et al. (68)Ga-PSMA ligand PET/CT in patients with prostate cancer: how we review and report. Cancer Imaging. 2016;16(1):14.CrossRefGoogle Scholar
  22. 22.
    • Huang HL, Zhen Loh TJ, Hoe Chow PK. A case of well-differentiated hepatocellular carcinoma identified on gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography. World J Nucl Med. 2018;17(2):102–05. Case reports demonstrating focal 68 Ga-PSMA uptake in HCC.Google Scholar
  23. 23.
    • Sasikumar A, et al. 68 Ga-PSMA PET/CT imaging in primary hepatocellular carcinoma. Eur J Nucl Med Mol Imaging. 2016;43(4):795–96. Case reports demonstrating focal 68 Ga-PSMA uptake in HCC.Google Scholar
  24. 24.
    •• Kesler M, et al. (68)Ga-PSMA is a novel PET-CT tracer for imaging of hepatocellular carcinoma: a prospective pilot study. J Nucl Med 2018. Pilot study demonstrating high sensitivity for HCC using 68 Ga-PSMA.Google Scholar
  25. 25.
    Katyal S, et al. Extrahepatic metastases of hepatocellular carcinoma. Radiology. 2000;216(3):698–703.CrossRefGoogle Scholar
  26. 26.
    Sugiyama M, et al. 18 F-FDG PET in the detection of extrahepatic metastases from hepatocellular carcinoma. J Gastroenterol. 2004;39(10):961–8.CrossRefGoogle Scholar
  27. 27.
    Wu H-B, et al. F-18 FDG in conjunction with 11C-choline PET/CT in the diagnosis of hepatocellular carcinoma. Clin Nucl Med. 2011;36(12):1092–7.CrossRefGoogle Scholar
  28. 28.
    Ho C-L, et al. Dual-tracer PET/CT imaging in evaluation of metastatic hepatocellular carcinoma. J Nucl Med. 2007;48(6):902.CrossRefGoogle Scholar
  29. 29.
    Lopci E, et al. Diagnostic accuracy of 11 C-choline PET/CT in comparison with CT and/or MRI in patients with hepatocellular carcinoma. Eur J Nucl Med Mol Imaging. 2015;42(9):1399–407.CrossRefGoogle Scholar
  30. 30.
    Paudyal B, et al. Early diagnosis of recurrent hepatocellular carcinoma with 18F-FDG PET after radiofrequency ablation therapy. Oncol Rep. 2007;18(6):1469–73.PubMedGoogle Scholar
  31. 31.
    Han A-R, et al. The clinical value of 18F-FDG PET/CT for investigating unexplained serum AFP elevation following interventional therapy for hepatocellular carcinom. Hepatogastroenterology. 2009;56(93):1111–6.PubMedGoogle Scholar
  32. 32.
    Lee JW, et al. Prediction of tumor recurrence by 18F-FDG PET in liver transplantation for hepatocellular carcinoma. J Nucl Med. 2009;50(5):682–7.CrossRefGoogle Scholar
  33. 33.
    Yang SH, et al. The role of 18F-FDG-PET imaging for the selection of liver transplantation candidates among hepatocellular carcinoma patients. Liver Transpl. 2006;12(11):1655–60.CrossRefGoogle Scholar
  34. 34.
    Lee SD, et al. 18F-FDG-PET/CT predicts early tumor recurrence in living donor liver transplantation for hepatocellular carcinoma. Transpl Int. 2013;26(1):50–60.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Eric C. Ehman
    • 1
    Email author
  • Scott M. Thompson
    • 1
  • Brian T. Welch
    • 1
  • Derek R. Johnson
    • 1
  • Hugh C. J. McGregor
    • 2
  1. 1.Deparment of RadiologyMayo ClinicRochesterUSA
  2. 2.Department of Medical ImagingUniversity of ArizonaTucsonUSA

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