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[67]
As other tumor factors related to MVI, tumor markers [65,66] and FDG-PET uptake have been reported. As
FDG-PET is not used as common imaging modality for the diagnosis of HCC, the papers about the predict-
ability of FDG-PET for MVI were omitted from this review. Although tumor markers such as alpha-fetopro-
tein and des-γ-carboxy prothrombin (DCP) are closely related to the presence of MVI, they are also highly
[68]
expressed in patients with benign diseases such as chronic hepatitis and liver cirrhosis . Furthermore, as
several cut-off values according to studies were suggested, the best cut-off value has not been unknown.
[69]
However, Shirabe et al. reported that a scoring system for predicting MVI using tumor size, serum DCP
levels, and FDG-PET uptake can provide a precise prediction of MVI, and the sensitivity and specificity were
100% and 90.9%, respectively. Probably, tumor marker levels would be helpful for predicting MVI.

There are some limitations in this research field. Firstly, although some highly specific or sensitive imag-
ing findings for predicting poorly differentiated HCC or MVI have been reported, there are no highly ac-
curate diagnostic findings. This may be due to limited accuracy of identifying histologic differentiation or
MVI from resected specimens. MVI would often be missed if thorough microscopic examination is not
performed, and histologic differentiation would be judged as non-poorly differentiated HCC if poorly dif-
ferentiated components are not dominant. It is difficult to search for MVI throughout the whole tumor us-
ing a microscope, and MVI detection depends on the serial slice width of the tumor specimen. The thinner
the specimen, the more accurate the MVI detection. Secondly, since most of previous reports are small-
cohort, single-center, and retrospective, and diagnostic ability also depends on the performance of imaging
equipment, their conclusions might be unreliable and biased. To validate their results, large scale prospective
studies are needed. Lastly, adequate treatment strategy based on MVI prediction or histologic differentiation
has not been established. At this time, if a HCC patient is predicted to have high risk of MVI as assessed by
imaging, it should be treated as advanced HCC even after resection or local ablation.

In conclusion, HCCs with high grade malignant potential can be diagnosed with commonly used imaging
modalities. For accurate prediction of MVI in HCC, the diagnosis of poor histologic differentiation or non-
SN type is needed, and the combination of MRI with other imaging modalities should be used.

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Copyright
© The Author(s) 2018.