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Review
. 2015 Jan-Feb;48(1):43-51.
doi: 10.1590/0100-3984.2013.1794.

The role of gadoxetic acid as a paramagnetic contrast medium in the characterization and detection of focal liver lesions: a review

Renata Lilian Bormann  1 , Eduardo Lima da Rocha  1 , Marcelo Longo Kierzenbaum  1 , Bruno Cheregati Pedrassa  1 , Lucas Rios Torres  2 , Giuseppe D'Ippolito  3
Affiliations
Review

The role of gadoxetic acid as a paramagnetic contrast medium in the characterization and detection of focal liver lesions: a review

Renata Lilian Bormann et al. Radiol Bras. 2015 Jan-Feb.

Abstract
in English, Portuguese

Recent studies have demonstrated that the use of paramagnetic hepatobiliary contrast agents in the acquisition of magnetic resonance images remarkably improves the detection and differentiation of focal liver lesions, as compared with extracellular contrast agents. Paramagnetic hepatobiliary contrast agents initially show the perfusion of the lesions, as do extracellular agents, but delayed contrast-enhanced images can demonstrate contrast uptake by functional hepatocytes, providing further information for a better characterization of the lesions. Additionally, this intrinsic characteristic increases the accuracy in the detection of hepatocellular carcinomas and metastases, particularly the small-sized ones. Recently, a hepatobiliary contrast agent called gadolinium ethoxybenzyl dimeglumine, that is simply known as gadoxetic acid, was approved by the National Health Surveillance Agency for use in humans. The authors present a literature review and a practical approach of magnetic resonance imaging utilizing gadoxetic acid as contrast agent, based on patients' images acquired during their initial experiment.

Estudos recentes têm demonstrado que a utilização dos agentes de contraste paramagnéticos hepatobiliares na obtenção das imagens de ressonância magnética hepática melhoram de maneira expressiva a detecção e diferenciação das lesões hepáticas focais, em comparação com a utilização de meios de contraste de ação apenas extracelular. O uso do meio de contraste hepatobiliar permite uma avaliação inicial da perfusão do tumor, da mesma forma que os agentes de contraste extracelulares, além de uma avaliação tardia da captação pelos hepatócitos funcionantes, fornecendo informações adicionais que permitem uma melhor caracterização das lesões. Além disso, a utilização do agente de contraste hepatobiliar pode aumentar a acurácia do método na detecção de metástases e do carcinoma hepatocelular, especialmente os de pequenas dimensões. Recentemente, foram aprovadas pela Agência Nacional de Vigilância Sanitária a utilização e a comercialização de um agente de contraste hepatobiliar, o gadolínio etoxibenzil dimeglumine, conhecido genericamente com ácido gadoxético. Revisamos a literatura atual e apresentamos uma abordagem prática da utilização da ressonância magnética com o ácido gadoxético utilizando exemplos de imagens de pacientes da nossa experiência inicial.

Keywords: Contrast media; Gadolinium; Liver; Magnetic resonance imaging.

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Figures

Figure 1
Figure 1
FNH (diagnosis based on histological analysis after percutaneous biopsy). The two nodules in the right hepatic lobe (arrows) present with hyposignal on T1-weighted image (A), early and intense contrast enhancement in the arterial phase (B), persisting in the portal phase (C) and in the hepatobiliary phase performed 10 minutes after initiation of the intravenous gadoxetic acid injection (D)
Figure 2
Figure 2
Hepatic adenoma (diagnosis based on histological analysis after percutaneous biopsy). US demonstrates the presence of a hyperechogenic and homogeneous mass of 5.0 cm in diameter (marked with a caliper) (A). MRI out of phase image (B) demonstrates signal intensity drop as compared with the in-phase image (C), indicating the presence of intracellular fat component. After intravenous gadoxetic acid injection, with subtraction technique, a lesion (arrows) is observed with subtle contrast enhancement in the arterial phase (D), imperceptible in the portal phase (E) and without contrast uptake in the hepatobiliary phase (F)
Figure 3
Figure 3
Infiltrative and undifferentiated HCC (confirmed by percutaneous biopsy). At T1-weighted images before intravenous gadoxetic acid injection (A) and obtained in the arterial and portal contrast phases (B,C), the lesion is poorly defined as compared with the image obtained in the hepatobiliary phase (arrows), acquired 20 minutes after the utilization of the contrast medium (D). Notice that, in this phase, contrast uptake by the lesion is lower in relation to the hepatic parenchyma, indicating the absence of normal functional hepatocytes
Figure 4
Figure 4
Dysplastic nodule versus well differentiated HCC. At T1-weighted image (A) a bulky hypointense, homogeneous and well-defined mass is observed in the left liver lobe (arrows). In the arterial (B) and portal (C) phases, images acquired with the subtraction technique to potentialize the identification of the lesion enhancement, demonstrate an early, subtle enhancement, without unequivocal wash-out. In the hepatobiliary phase (D), obtained 20 minutes after the intravenous gadoxetic acid injection, no uptake by the lesion was observed. The histological analysis of the biopsy specimen could not differentiate between a high-grade dysplastic nodule and a well-differentiated HCC
Figure 5
Figure 5
Liver metastasis from breast neoplasm (diagnosis based on periodic follow-up). The CT images acquired in the portal contrast phase (A) and the MRI T2-weighted sequence (B) allow for the identification of a single liver nodule in the VII/VIII segment (arrows on A and B). Gadoxetic acid-enhanced MRI – portal phase (C) and hepatobiliary phase (D) allow for the identification of another small nodule (arrow on D), more clearly characterized in the delayed phase. Two cysts are also observed in the left lobe (arrowhead on B)
Figure 6
Figure 6
Hepatic hemangioma (diagnosis based on imaging findings). Presence of a lesion in the right liver lobe (arrows). MRI T2- weighted MRI sequence (A) demonstrates the typical hypersignal from the hemangioma, as well progressive, discontinuous and centripetal enhancement in the portal (B) and equilibrium (C) phases. In the hepatobiliary phase obtained 10 minutes after the intravenous gadoxetic acid injection, the liver/ lesion enhancement gradient inversion is observed, caused by the greater contrast uptake by the parenchyma, as compared with the low contrast uptake by the hemangioma, due to the absence of functioning hepatocytes (D)
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