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Background  To compare the apparent diffusion coefficient (ADC) on diffusion-weighted imaging (DWI) with the standardized uptake values (SUV) measured by 18 F-FDG-PET/CT in naïve hepatocellular carcinoma (HCC) nodules, and to determine whether these markers are associated with tumours at high-risk of aggressiveness.    Methods  From 2007 to 2010, all patients with HCC on the waiting list for liver transplantation and who underwent both FDG-PET/CT and 1.5-T DWI-MRI (b values: 0, 200, 400, and 800 s/mm 2 ) were included in this institutional review board-approved retrospective study. Tumour size, tumour ADC, tumour-to-liver ADC ratio (ADC T/L ), maximal tumour SUV and tumour-to-liver SUV ratio (SUV T/L ) were measured and compared to serum alpha-fetoprotein (AFP) levels, tumour size and differentiation grade on explanted specimens.    Results  A total of 37 HCC nodules in 28 patients were available for correlation between MRI and PET/CT, 7 of which (in 7 patients) showed a SUV T/L  > 1.15. We did not find any correlation between tumour ADC or ADC T/L  and tumour SUV or SUV T/L . To note, SUV T/L  was positively correlated with AFP levels ( R  = 0.95, P ≤ 0.0001), while ADC T/L  was not ( P  = 0.73). Twenty-four patients (with 32 nodules) underwent liver transplantation. In this subgroup, an increased SUV T/L  ratio was associated with larger tumours (average size, 32 ± 14 mm; range, 18–60 mm;  P  < 0.0001) and with poor differentiation on pathology (grades 3 and 4;  P  = 0.04), while ADC T/L  was neither associated with tumour size or differentiation grade.    Conclusions  ADC and SUV measures in HCC nodules are not correlated. SUV T/L  ratio correlates with AFP levels, tumour size and poor differentiation, and should probably be integrated as a co-variable in a predictive outcome model of patients on the waiting-list for liver transplantation.

Functional imaging of hepatocellular carcinoma using diffusion-weighted MRI and 18F-FDG PET/CT in patients on waiting-list for liver transplantation