Skip to main content


Log in

Retrospective analysis of current guidelines for hepatocellular carcinoma diagnosis on gadoxetic acid–enhanced MRI in at-risk patients

  • Hepatobiliary-Pancreas
  • Published:
European Radiology Aims and scope Submit manuscript



To evaluate and compare the diagnostic performance of the updated HCC guidelines using gadoxetic acid–enhanced MRI.


In this study, patients at risk of HCC who underwent gadoxetic acid–enhanced MRI following US/CT surveillance were retrospectively recruited from 3 centers. Three radiologists independently evaluated hepatic nodule imaging features relevant to the diagnostic criteria outlined in each guideline. Per-lesion sensitivity, specificity, and accuracy were compared between guidelines using logistic regression with a generalized estimating equation. Inter-observer agreements on imaging features were determined using Fless κ statistics.


Altogether, 447 nodules (310 HCCs, 20 combined hepatocellular-cholangiocarcinomas, 2 cholangiocarcinomas, and 115 benign entities) measuring 1–3 cm from 386 patients were assessed. The KLCA-NCC and APASL guidelines showed the highest sensitivity (82.3–90.6%, p < .001) and accuracy (83.9–88.6%) among the five guidelines. The OPTN/UNOS guideline showed the highest specificity (94.9–97.1%), followed by the AASLD/LI-RADS, EASL, KLCA-NCC, and APASL guidelines, with significant difference only with the APASL guideline. The diagnostic performance of the updated AASLD/LI-RADS and EASL guidelines and of the KLCA-NCC and APASL guidelines was comparable (p > .05). Inter-observer agreement was substantial to almost perfect (κ = 0.73–0.87).


For the diagnosis of HCC using gadoxetic acid–enhanced MRI, the KLCA-NCC and APASL guidelines showed the highest sensitivity and accuracy. The OPTN/UNOS guideline showed the highest specificity. Acknowledging their relative strengths and weaknesses could help adapt the diagnostic criteria according to the clinical context.

Key Points

• APASL and KLCA-NCC provided significantly the highest sensitivity and accuracy, followed by AASLD/LI-RADS and EASL in an endemic area for hepatitis B.

• OPTN/UNOS showed the highest specificity, followed by AASLD/LI-RADS, EASL, KLCA-NCC, and APASL guidelines, with significant difference only with APASL.

• Broadened definition of arterial hyperenhancement, washout, and the size of the lesion eligible to apply diagnostic criteria may improve the diagnostic performance for HCC in an endemic area for hepatitis B.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others



American Association for the Study of Liver Diseases


Asian Pacific Association for the Study of the Liver


Arterial phase hyperenhancement


European Association for the Study of the Liver


Extracellular contrast agent


Hepatobiliary phase


Hepatocellular carcinoma


Korean Liver Cancer Association-National Cancer Center


Liver Imaging Reporting and Data System


Organ Procurement and Transplantation Network


Portal venous phase


United Network for Organ Sharing


  1. European Association for the Study of the Liver (2018) EASL clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 69:182–236

  2. Fattovich G, Stroffolini T, Zagni I, Donato F (2004) Hepatocellular carcinoma in cirrhosis: incidence and risk factors. Gastroenterology 127:S35–S50

    Article  Google Scholar 

  3. Omata M, Cheng AL, Kokudo N et al (2017) Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update. Hepatol Int 11:317–370

    Article  Google Scholar 

  4. Korean Liver Cancer Association (KLCA); National Cancer Center (NCC), Goyang, Korea (2019) 2018 Korean liver cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma. Korean J Radiol 20:1042–1113

  5. Heimbach JK, Kulik LM, Finn RS et al (2018) AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 67:358–380

    Article  Google Scholar 

  6. Chernyak V, Fowler KJ, Kamaya A et al (2018) Liver Imaging Reporting and Data System (LI-RADS) Version 2018: imaging of hepatocellular carcinoma in at-risk patients. Radiology. 289:816–830

    Article  Google Scholar 

  7. Erkan B, Meier J, Clark TJ, Kaplan J, Lambert JR, Chang S (2019) Non-invasive diagnostic criteria of hepatocellular carcinoma: comparison of diagnostic accuracy of updated LI-RADS with clinical practice guidelines of OPTN-UNOS, AASLD, NCCN, EASL-EORTC, and KLSCG-NCC. PLoS One 14:e0226291

    Article  CAS  Google Scholar 

  8. Tang A, Cruite I, Mitchell DG, Sirlin CB (2018) Hepatocellular carcinoma imaging systems: why they exist, how they have evolved, and how they differ. Abdom Radiol (NY) 43:3–12

    Article  Google Scholar 

  9. Fowler KJ, Tang A, Santillan C et al (2018) Interreader reliability of LI-RADS Version 2014 Algorithm and imaging features for diagnosis of hepatocellular carcinoma: a large international multireader study. Radiology 286:173–185

    Article  Google Scholar 

  10. Ehman EC, Behr SC, Umetsu SE et al (2016) Rate of observation and inter-observer agreement for LI-RADS major features at CT and MRI in 184 pathology proven hepatocellular carcinomas. Abdom Radiol (NY) 41:963–969

    Article  Google Scholar 

  11. Davenport MS, Khalatbari S, Liu PS et al (2014) Repeatability of diagnostic features and scoring systems for hepatocellular carcinoma by using MR imaging. Radiology 272:132–142

    Article  Google Scholar 

  12. Bashir MR, Huang R, Mayes N et al (2015) Concordance of hypervascular liver nodule characterization between the organ procurement and transplant network and liver imaging reporting and data system classifications. J Magn Reson Imaging 42:305–314

    Article  Google Scholar 

  13. Barth BK, Donati OF, Fischer MA et al (2016) Reliability, validity, and reader acceptance of LI-RADS—an in-depth analysis. Acad Radiol 23:1145–1153

    Article  Google Scholar 

  14. Park SH, Kim B, Kim SY et al (2020) Characterizing computed tomography-detected arterial hyperenhancing-only lesions in patients at risk of hepatocellular carcinoma: can non-contrast magnetic resonance imaging be used for sequential imaging? Korean J Radiol 21:280–289

    Article  Google Scholar 

  15. Park SH, Kim B, Kim SY et al (2020) Abbreviated MRI with optional multiphasic CT as an alternative to full-sequence MRI: LI-RADS validation in a HCC-screening cohort. Eur Radiol 30:2302–2311

    Article  Google Scholar 

  16. Rosenkrantz AB, Campbell N, Wehrli N, Triolo MJ, Kim S (2015) New OPTN/UNOS classification system for nodules in cirrhotic livers detected with MR imaging: effect on hepatocellular carcinoma detection and transplantation allocation. Radiology 274:426–433

    Article  Google Scholar 

  17. Lee HS, Kim JK, Cheong JY et al (2010) Prediction of compensated liver cirrhosis by ultrasonography and routine blood tests in patients with chronic viral hepatitis. Korean J Hepatol 16:369

    Article  Google Scholar 

  18. Choi BI, Lee KH, Han JK, Lee JM (2002) Hepatic arterioportal shunts: dynamic CT and MR features. Korean J Radiol 3:1–15

    Article  Google Scholar 

  19. Hussain SM, Reinhold C, Mitchell DG (2009) Cirrhosis and lesion characterization at MR imaging. Radiographics 29:1637–1652

    Article  Google Scholar 

  20. An H, Park H, Kim Y, Jung S, Jeon H (2013) Focal nodular hyperplasia: characterisation at gadoxetic acid-enhanced MRI and diffusion-weighted MRI. Br J Radiol 86:20130299

    Article  CAS  Google Scholar 

  21. Lee S, Kim MJ, Kim SS et al (2020) Retrospective comparison of EASL 2018 and LI-RADS 2018 for the noninvasive diagnosis of hepatocellular carcinoma using magnetic resonance imaging. Hepatol Int 14:70–79

    Article  Google Scholar 

  22. Lee SM, Lee JM, Ahn SJ, Kang HJ, Yang HK, Yoon JH (2019) LI-RADS Version 2017 versus Version 2018: diagnosis of hepatocellular carcinoma on gadoxetate disodium-enhanced MRI. Radiology 292:655–663

    Article  Google Scholar 

  23. Kim YY, An C, Kim S, Kim MJ (2018) Diagnostic accuracy of prospective application of the Liver Imaging Reporting and Data System (LI-RADS) in gadoxetate-enhanced MRI. Eur Radiol 28:2038–2046

    Article  Google Scholar 

  24. Fraum TJ, Tsai R, Rohe E et al (2018) Differentiation of hepatocellular carcinoma from other hepatic malignancies in patients at risk: diagnostic performance of the liver imaging reporting and data system version 2014. Radiology 286:158–172

    Article  Google Scholar 

  25. 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 275:698–707

    Article  Google Scholar 

  26. Lee S, Kim SS, Chang DR, Kim H, Kim MJ (2020) Comparison of LI-RADS 2018 and KLCA-NCC 2018 for noninvasive diagnosis of hepatocellular carcinoma using magnetic resonance imaging. Clin Mol Hepatol 26:340–351

    Article  Google Scholar 

Download references


This study was supported by a grant from the National Research Foundation of Korea (2017R1A2B3011475) and the Gachon University research fund of 2017 (GCU-2017-5256).

Author information

Authors and Affiliations


Corresponding author

Correspondence to Bohyun Kim.

Ethics declarations


The scientific guarantor of this publication is Bohyun Kim.

Conflict of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Statistics and biometry

Ji Hyun Park, who is one of the authors, performed the statistical analysis. Additional analysis was provided by the Office of Biostatistics, Ajou Research Institute for Innovation Medicine, Ajou University Medical Center, Suwon, Korea.

Informed consent

The requirement for written informed consent was waived by the institutional review board of three institutions.

Ethical approval

Institutional Review Board approval of Asan Medical Center, Gil Medical Center, and Ajou University Hospital was obtained.

Study subjects or cohorts overlap

Of the 386 patients in the current study, 280 patients were included in the two prior studies exploring the application of abbreviated MRI in HCC diagnosis. Prior studies differ considerably from current study in terms of the purpose, design, and statistical analysis.


• Retrospective

• Diagnostic or prognostic study

• Multicenter study

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information


(DOCX 37 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Park, S.H., Shim, Y.S., Kim, B. et al. Retrospective analysis of current guidelines for hepatocellular carcinoma diagnosis on gadoxetic acid–enhanced MRI in at-risk patients. Eur Radiol 31, 4751–4763 (2021).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: