European Radiology

, Volume 29, Issue 4, pp 1724–1732 | Cite as

Retrospective validation of a new diagnostic criterion for hepatocellular carcinoma on gadoxetic acid-enhanced MRI: can hypointensity on the hepatobiliary phase be used as an alternative to washout with the aid of ancillary features?

  • Ijin Joo
  • Jeong Min LeeEmail author
  • Dong Ho Lee
  • Ju Hyeon Jeon
  • Joon Koo Han



To validate new diagnostic criteria for hepatocellular carcinoma (HCC) on gadoxetic acid-enhanced MR imaging (Gd-EOB-MRI) using hypointensity on the hepatobiliary phase (HBP) as an alternative to washout in combination with ancillary features.


This retrospective study included 288 patients at high risk for HCC with 387 nodules (HCCs, n=292; non-HCCs, n=95) showing arterial phase hyper-enhancement (APHE) ≥1 cm on Gd-EOB-MRI. Imaging diagnoses of HCCs were made using different criteria: APHE plus hypointensity on the portal venous phase (PVP) (criterion 1), APHE plus hypointensity on the PVP and/or transitional phase (TP) (criterion 2), APHE plus hypointensity on the PVP and/or TP and/or HBP (criterion 3), and criterion 3 plus non-LR-1/2/M according to the Liver Imaging Reporting and Data System (LI-RADS) v2017 considering ancillary features (criterion 4). Sensitivities and specificities of those criteria were compared using McNemar’s test.


Among diagnostic criteria for HCCs, criteria 3 and 4 showed significantly higher sensitivities (93.8% and 92.5%, respectively) than criteria 1 and 2 (70.9% and 86.6%, respectively) (p values <0.001). The specificity of criterion 4 (87.4%) was shown to be significantly higher than that of criterion 3 (48.4%, p<0.001), albeit comparable to criterion 2 (86.3%, p>0.999) and significantly lower than criterion 1 (97.9%, p=0.002).


In the non-invasive diagnosis of HCCs on Gd-EOB-MRI, HBP hypointensity may be used as an alternative to washout enabling a highly sensitive diagnosis with little loss in specificity if it is used after excluding nodules considered to be benignities or non-HCC malignancies based on characteristic imaging features.

Key Points

• Gd-EOB-MRI enhancement and ancillary features can be used to diagnose HCC.

• Exclusion of LR-1/2/M improves specificity when HBP hypointensity is used.


Carcinoma, hepatocellular Magnetic resonance imaging Liver Practice guideline 



Hepatic arterial phase


Gadoxetic acid-enhanced magnetic resonance imaging


Hepatobiliary phase


Hepatocellular carcinoma


Liver Imaging Reporting and Data System


Portal venous phase


Transitional phase



We thank Chris Woo, B.A. for editing the manuscript.


The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Jeong Min Lee.

Conflict of interest

The authors of this article declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

The same study cohort has been previously reported in Eur Radiol 2015; 25: 2859-68.


• Retrospective, diagnostic study, performed at one institution

Supplementary material

330_2018_5727_MOESM1_ESM.docx (18 kb)
ESM 1 (DOCX 17 kb)


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  • Ijin Joo
    • 1
    • 2
  • Jeong Min Lee
    • 1
    • 2
    • 3
    Email author
  • Dong Ho Lee
    • 1
    • 2
  • Ju Hyeon Jeon
    • 4
  • Joon Koo Han
    • 1
    • 2
    • 3
  1. 1.Department of RadiologySeoul National University HospitalSeoulRepublic of Korea
  2. 2.Department of RadiologySeoul National University College of MedicineSeoulRepublic of Korea
  3. 3.Institute of Radiation MedicineSeoul National University Medical Research CenterSeoulRepublic of Korea
  4. 4.Department of RadiologyMediplex Sejong HospitalIncheonRepublic of Korea

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