Advertisement

European Radiology

, Volume 30, Issue 1, pp 186–194 | Cite as

Performance of gadoxetic acid MRI and diffusion-weighted imaging for the diagnosis of early recurrence of hepatocellular carcinoma

  • Jordi RimolaEmail author
  • Alejandro Forner
  • Víctor Sapena
  • Neus Llarch
  • Anna Darnell
  • Alba Díaz
  • Angeles García-Criado
  • Lluís Bianchi
  • Ramon Vilana
  • Álvaro Díaz-González
  • Carmen Ayuso
  • Jordi Bruix
  • María Reig
Hepatobiliary-Pancreas

Abstract

Objective

To determine the diagnostic accuracy and predictive value of gadoxetic acid liver MRI (Gd-EOB-DTPA MRI) alone or in combination with diffusion-weighted imaging (DWI) as a second-line tool for detecting early hepatocellular carcinoma (HCC) recurrence in cirrhotic patients with previous HCC treated with resection or ablation.

Methods

Between 2014 and 2017, we prospectively included 34 cirrhotic patients with complete response to resection and/or ablation of early HCC in whom a new focal lesion enhancing in the arterial phase without washout was detected during follow-up with EC-MRI. After signing the informed consent, all patients underwent DWI and Gd-EOB-DTPA MRI; two readers analyzed signal intensities on each phase of dynamic study and on DWI. The final diagnosis was established by histology or follow-up EC-MRI. We used cross-tabulation to calculate indices of diagnostic accuracy.

Results

We evaluated 34 patients (7 women; 73.5% with hepatitis C virus) with a total of 53 new arterial-phase-enhancing foci (median size, 10 [IQR 9–14] mm). The final diagnosis, reached by histopathology in 15 (35.7%) lesions and EC-MR follow-up in 27 (64.3%), was HCC in 42 (79.2%) and benign conditions in 11 (21.8%). Hepatobiliary-phase hypointensity on Gd-EOB-DTPA MRI plus hyperintensity on DWI yielded 54.8% sensitivity, 90.9% specificity, 95.8% positive predictive value, and 34.5% negative predictive value for diagnosing HCC recurrence.

Conclusion

Among potential indices, combining hypointensity on hepatobiliary-phase Gd-EOB-DTPA MRI and hyperintensity on DWI has the highest specificity and positive predictive value to optimally detect HCC recurrence prior to confident diagnosis by conventional imaging criteria on EC-MRI in cirrhotic liver.

Key Points

• In patients at risk of HCC recurrence, the use of gadoxetic acid liver MRI and DWI may improve the differentiation of unspecific new arterial-enhancing foci from early hypervascular HCC recurrence in patients with non-conclusive findings on extracellular liver MRI.

• Combined findings on hepatobiliary-phase gadoxetic acid–enhanced liver MRI and DWI had high specificity (90.9%) and positive predictive value (95.8%) for detecting early hypervascular HCC recurrence, but limited sensitivity.

• Combining hepatobiliary-phase hypointensity on gadoxetic acid MRI and hyperintensity on diffusion-weighted imaging allows early diagnosis of hypervascular hepatocellular carcinoma and may help select patients for salvage therapy.

Keywords

Cirrhosis Hepatocellular carcinoma Magnetic resonance imaging Gadoxetic acid 

Abbreviations

AASLD

American Association for the Study of Liver Diseases

DWI

Diffusion-weighted imaging

EASL

European Association for the Study of the Liver

EC-MRI

Extracellular gadolinium-enhanced liver MRI

Gd-EOB-DTPA

MRI using gadoxetic acid

HCC

Hepatocellular carcinoma

HR

Hazard ratio

IQR

Interquartile range

MRI

Magnetic resonance imaging

RR

Relative risk

Notes

Funding

This study has received funding by Sociedad Española de Radiología Médica (SERAM).

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Jordi Rimola.

Conflict of interest

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

Statistics and biometry

Victor Sapena kindly provided statistical advice for this manuscript.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• prospective

• diagnostic or prognostic study

• performed at one institution

Supplementary material

330_2019_6351_MOESM1_ESM.docx (1.1 mb)
ESM 1 (DOCX 1161 kb)

References

  1. 1.
    Poon RT, Fan ST, Lo CM, Liu CL, Wong J (2002) Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function. Ann Surg 235:373–382CrossRefGoogle Scholar
  2. 2.
    Tabrizian P, Jibara G, Shrager B, Schwartz M, Roayaie S (2015) Recurrence of hepatocellular cancer after resection: patterns, treatments, and prognosis. Ann Surg 261:947–955CrossRefGoogle Scholar
  3. 3.
    Sala M, Llovet JM, Vilana R et al (2004) Initial response to percutaneous ablation predicts survival in patients with hepatocellular carcinoma. Hepatology 40:1352–1360CrossRefGoogle Scholar
  4. 4.
    European Association for the Study of the Liver (2018) EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 69:182–236CrossRefGoogle Scholar
  5. 5.
    Marrero JA, Kulik LM, Sirlin CB et al (2018) Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 68:723–750CrossRefGoogle Scholar
  6. 6.
    Forner A, Vilana R, Ayuso C et al (2008) Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma. Hepatology 47:97–104CrossRefGoogle Scholar
  7. 7.
    Sangiovanni A, Manini MA, Iavarone M et al (2010) The diagnostic and economic impact of contrast imaging techniques in the diagnosis of small hepatocellular carcinoma in cirrhosis. Gut 59:638–644CrossRefGoogle Scholar
  8. 8.
    Khalili K, Kim TK, Jang H-J et al (2011) Optimization of imaging diagnosis of 1-2 cm hepatocellular carcinoma: an analysis of diagnostic performance and resource utilization. J Hepatol 54:723–728CrossRefGoogle Scholar
  9. 9.
    Joo I, Lee JM, Lee DH, Jeon JH, Han JK, Choi BI (2015) Noninvasive diagnosis of hepatocellular carcinoma on gadoxetic acid-enhanced MRI: can hypointensity on the hepatobiliary phase be used as an alternative to washout? Eur Radiol 25:2859–2868CrossRefGoogle Scholar
  10. 10.
    Granito A, Galassi M, Piscaglia F et al (2013) Impact of gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance on the noninvasive diagnosis of small hepatocellular carcinoma: a prospective study. Aliment Pharmacol Ther 37:355–363CrossRefGoogle Scholar
  11. 11.
    Haradome H, Unno T, Morisaka H et al (2017) Gadoxetic acid disodium-enhanced MR imaging of cholangiolocellular carcinoma of the liver: imaging characteristics and histopathological correlations. Eur Radiol 27:4461–4471CrossRefGoogle Scholar
  12. 12.
    Bruix J, Sherman M, Llovet JM et al (2001) Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol 35:421–430CrossRefGoogle Scholar
  13. 13.
    Tremosini S, Forner A, Boix L et al (2012) Prospective validation of an immunohistochemical panel (glypican 3, heat shock protein 70 and glutamine synthetase) in liver biopsies for diagnosis of very early hepatocellular carcinoma. Gut 61:1481–1487CrossRefGoogle Scholar
  14. 14.
    International Consensus Group for Hepatocellular Neoplasia The International Consensus Group for Hepatocellular Neoplasia (2009) Pathologic diagnosis of early hepatocellular carcinoma: A report of the International Consensus Group for Hepatocellular Neoplasia. Hepatology 49:658–664CrossRefGoogle Scholar
  15. 15.
    Rimola J, Forner A, Tremosini S et al (2012) Non-invasive diagnosis of hepatocellular carcinoma ≤ 2 cm in cirrhosis. Diagnostic accuracy assessing fat, capsule and signal intensity at dynamic MRI. J Hepatol 56:1317–1323CrossRefGoogle Scholar
  16. 16.
    Iavarone M, Sangiovanni A, Forzenigo LV et al (2010) Diagnosis of hepatocellular carcinoma in cirrhosis by dynamic contrast imaging: the importance of tumor cell differentiation. Hepatology 52:1723–1730CrossRefGoogle Scholar
  17. 17.
    Darnell A, Forner A, Rimola J et al (2015) Liver imaging reporting and data system with MR imaging: evaluation in nodules 20 mm or smaller detected in cirrhosis at screening US. Radiology 275:141–132CrossRefGoogle Scholar
  18. 18.
    Choi JW, Lee JM, Kim SJ et al (2013) Hepatocellular carcinoma: imaging patterns on gadoxetic acid–enhanced MR images and their value as an imaging biomarker. Radiology 267:776–786CrossRefGoogle Scholar
  19. 19.
    Sugimoto K, Kim SR, Imoto S et al (2015) Characteristics of hypovascular versus hypervascular well-differentiated hepatocellular carcinoma smaller than 2 cm - focus on tumor size, markers and imaging detectability. Dig Dis 33:721–727CrossRefGoogle Scholar
  20. 20.
    Yoon JH, Lee JM, Kang H et al (2019) Quantitative assessment of liver function by using gadoxetic acid–enhanced MRI: hepatocyte uptake ratio. Radiology 290:125–133CrossRefGoogle Scholar
  21. 21.
    Kim AY, Kim YK, Lee MW et al (2012) Detection of hepatocellular carcinoma in gadoxetic acid-enhanced MRI and diffusion-weighted MRI with respect to the severity of liver cirrhosis. Acta Radiol 53:830–838CrossRefGoogle Scholar
  22. 22.
    Nakamura Y, Tashiro H, Nambu J et al (2013) Detectability of hepatocellular carcinoma by gadoxetate disodium-enhanced hepatic MRI: tumor-by-tumor analysis in explant livers. J Magn Reson Imaging 37:684–691CrossRefGoogle Scholar
  23. 23.
    Motosugi U, Ichikawa T, Sou H et al (2010) Distinguishing hypervascular pseudolesions of the liver from hypervascular hepatocellular carcinomas with gadoxetic acid-enhanced MR imaging. Radiology 256:151–158CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • Jordi Rimola
    • 1
    • 2
    Email author
  • Alejandro Forner
    • 2
    • 3
    • 4
  • Víctor Sapena
    • 4
    • 5
  • Neus Llarch
    • 3
  • Anna Darnell
    • 1
    • 2
  • Alba Díaz
    • 6
  • Angeles García-Criado
    • 1
    • 2
  • Lluís Bianchi
    • 1
    • 2
  • Ramon Vilana
    • 1
  • Álvaro Díaz-González
    • 3
  • Carmen Ayuso
    • 1
    • 2
    • 4
  • Jordi Bruix
    • 2
    • 3
    • 4
  • María Reig
    • 3
    • 4
  1. 1.BCLC group, Radiology DepartmentHospital Clínic BarcelonaBarcelonaSpain
  2. 2.University of BarcelonaBarcelonaSpain
  3. 3.BCLC group, Liver UnitHospital Clínic BarcelonaBarcelonaSpain
  4. 4.IDIBAPSBarcelonaSpain
  5. 5.BCLC group, Statistics coreBarcelonaSpain
  6. 6.BCLC group, Pathology DepartmentHospital Clínic BarcelonaBarcelonaSpain

Personalised recommendations