In chronic liver disease, differentiating hepatocellular carcinoma (HCC) from other primary liver cancers, such as intrahepatic cholangiocarcinoma (IHCC) and combined hepatocellular-cholangiocarcinoma (cHCC-CC), is essential for treatment and patient prognosis1. Although significant advancements have been made, including the use of hepatospecific agents aimed at differentiating HCC from other primary liver cancers, this differentiation remains a diagnostic challenge. To enhance the interpretation of liver images in patients at risk for developing HCC, the Liver Imaging Reporting and Data System (LI-RADS) integrated the LI-RADS M category, with the aim of preserving the high specificity of LI-RADS 5 without compromising its sensitivity for malignancy diagnosis. Consequently, lesions that are definitively or probably malignant but not specific for HCC, including atypical HCCs, are included in this category [FIG.1].2
Imaging plays a crucial role in diagnosing HCC in high-risk patients3,4. This diagnosis can be particularly challenging in the context of chronic liver disease due to overlapping risk factors, clinical features, and imaging characteristics.