Multiparametric imaging for detection and characterization of hepatocellular carcinoma using gadoxetic acid-enhanced MRI and perfusion-CT: which parameters work best?

Abstract

Background: MRI and perfusion-CT (PCT) are both useful imaging techniques for detection and characterization of liver lesions. The aim of this study was to compare the diagnostic accuracy of imaging parameters derived from PCT and gadoxetic acid-enhanced MRI in patients with hepatocellular carcinoma (HCC).

Methods: 36 patients with liver cirrhosis and a total of 67 lesions referred to our hospital for multi-parametric diagnosis of HCC-suspected liver lesions in the setting of liver cirrhosis were prospectively enrolled and underwent PCT and MRI. HCC diagnosis was confirmed either by histology (n = 60) or interval growth (n = 7). For PCT, mean/max blood flow (BF), blood volume (BV), k-trans, arterial liver perfusion (ALP), portal venous perfusion (PVP) and hepatic perfusion index (HPI) were quantified. Two readers identified the lesions based on single maps each being blinded to the number of lesions. MRI-protocol included fat-suppressed T1w-VIBE sequences obtained before, 2, 5, 10 and 20 min after the injection of gadoxetic acid as well as non-enhanced coronal HASTE, axial T1w-VIBE, fat-suppressed T2w-TSE and DWI. Quantitative analysis was performed using enhancement ratios between tumor and liver parenchyma for post-contrast in the hepatobiliary phase (RIR_HB), arterial (ER_a) and late-venous (ER_v) phases as well as signal intensity ratios (liver/parenchyma) on T1w (RIR_T1) and T2w (RIR_T2).

Results: In PCT analysis, all lesions exhibited high BF_max values (63-250 mL/100 g tissue) and were visible on HPI maps with high degrees of arterial blood supply of (HPI > 96%). In MRI, RIR_HB was negative in 8/67. 12/67 HCCs were missed on DWI. 46/67 HCCs showed wash-in and 47/67 HCC showed wash-out of contrast agent. 6/67 HCCs were missed on T1w and 11/67 were missed on T2w-sequences when analyzed separately, while analysis of multiparametric MRI combining typical enhancement pattern, visibility on hepatobiliary phase and T1w-images the same number of lesions as PCT irrespective of their size (1-19 cm) were detected. Quantification of early enhancement by ER_a or ER_v did not improve detection rates.

Conclusions: Perfusion-CT and gadoxetic acid-enhanced MRI were comparable in detecting HCC lesions. For PCT a mean HPI > 96% proved to be a very robust parameter for detection and characterization of HCC.

Keywords: Hepatocellular Carcinoma; MRI; contrast agent; perfusion; perfusion-CT.

Fig. 1

64-year-old male patient with 2.5 cm large HCC in liver segment 8 (arrows). Maximum intensity projection (a) and perfusion-CT (PCT) blood flow (b), blood volume (c) and arterial liver perfusion (d) color-coded maps are shown. Signal intensity on unenhanced fat-saturated (fs) T1w (e) is hyperintense with typical wash-in enhancement pattern on post-contrast fs T1w in the arterial (f), phase. No contrast wash-out is seen in the late post-contrast phase (g) whereas in the hepatobiliary (h) phase the tumor stays isointense to the background liver parenchyma. The tumor was hyperintense on T2w (not shown) including DWI (i, T2-shine through effect), but there was no restriction of water diffusivity. Calculated ER_a was 117.8. On PCT the HPI was 100%, BF_max = 250.9 mL/100 g tissue; BV = 13.1 mL/100 g tissue; ALP = 35.3 mL/100 g tissue. Notably, despite exclusive arterial supply of the histologically proven tumor, there was no wash-out in the late venous phase (h) and also poor delineation of the tumor in the hepatobiliary phase (g)