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



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.


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.


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.


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.


Cirrhosis Hepatocellular carcinoma Magnetic resonance imaging Gadoxetic acid 



American Association for the Study of Liver Diseases


Diffusion-weighted imaging


European Association for the Study of the Liver


Extracellular gadolinium-enhanced liver MRI


MRI using gadoxetic acid


Hepatocellular carcinoma


Hazard ratio


Interquartile range


Magnetic resonance imaging


Relative risk



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

Compliance with ethical standards


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.


• 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)


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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

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