Are these small hepatocellular carcinomas in this at-risk patient?
The small (8 mm) nodules demonstrate hypervascularity, but no other worrisome findings such as "washout" or a capsule. Although they were not present on the prior exam 3 months earlier, a new lesion <10 mm does not count as interval growth.
What is your recommendation for follow up or intervention?
The recommendations change based on what level of certainty one has that the lesion is hepatocellular carcinoma. For this patient, these are LR3 nodules ("indeterminate"). Close interval follow up per local protocol would be appropriate.
What is an LR2 cirrhosis-associated nodule?
Cirrhotic livers frequently contain a large number of regenerative nodules, and likely some dysplastic nodules as well. Current models of hepatocellular carcinoma suggest that the tumour arises from cirrhotic nodules through ever-increasing amounts of dysplasia. That said, however, not every cirrhotic nodule seen on MRI has to be reported as "potential cancer". A nodule that seems slightly atypical relative to its neighbors, either with slight size or signal alteration still may fall under the category of a benign finding. When a nodule develops abnormal enhancement, or if it starts becoming very large (>2 cm), it should be regarded with a suspicious eye.
Multiple new small (8 mm) nodular hypervascular lesions are present in the right hepatic lobe on the arterial phase (red arrows). On the portal venous phase, these lesions fade to background liver enhancement. There is no capsule around any lesion.
On the T2W sequence (not shown), these lesions cannot be discretely identified in the setting of diffuse fibrotic change from cirrhosis. There is no restricted diffusion.
Nodular liver surface is compatible with cirrhosis. No evidence of portal hypertension.
The left hepatic lobe lesion treated with TACE (not shown) is similar in size and appearance to 3 months ago.