Gadoxetic acid disodium (Gd-EOB-DTPA) contrast-enhanced abbreviated magnetic resonance imaging (MRI) for hepatocellular carcinoma surveillance in at-risk patients: a multi-center study in China

Abstract

Background: Given the limited capacity and suboptimal sensitivity of ultrasonography (US), gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) demonstrates good diagnostic performance for hepatocellular carcinoma (HCC). Some researchers have proposed that the abbreviated MRI (AMRI) protocols have potential as a surveillance tool. However, few studies have compared multiple AMRI protocols with complete Gd-EOB-DTPA contrast-enhanced MRI for HCC surveillance. We aimed to explore and compare the diagnostic performance of 3 AMRI protocols as HCC surveillance in high-risk patients.

Methods: This multi-center, retrospective, blinded reader study conducted in China consecutively enrolled 339 patients with hepatitis and/or cirrhosis who underwent complete Gd-EOB-DTPA contrast-enhanced MRI for HCC surveillance from 2020 to 2023. We extracted 3 additional AMRI protocols: noncontrast-AMRI [NC-AMRI: T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI)]; dynamic-AMRI (Dyn-AMRI: early and late arterial phases, portal venous phase, and DWI); and hepatobiliary phase-AMRI (HBP-AMRI: T2WI, DWI, and HBP). Then, 2 independent radiologists assessed the AMRI and complete Gd-EOB-DTPA contrast-enhanced MRI protocols. Patients were classified as HCC positive/HCC negative based on the reference standard. Agreement was assessed using Kappa statistics. The acquisition time differences of the 4 MRI protocols were analyzed by analysis of variance (ANOVA). Per-lesion HCC diagnostic performances were compared by Cochran's Q test. Receiver operating characteristic (ROC) curves for the 3 AMRI protocols were evaluated, and the area under the ROC curve (AUROC) was calculated and compared by DeLong's test.

Results: A total of 353 lesions were detected in the 339 included patients, and 21/339 patients were diagnosed with HCC (prevalence, 6.2%). The inter-observer agreement was good for all 4 MRI protocols (k>0.75). Acquisition times differed significantly (P<0.001), from the shortest to the longest: NC-AMRI (263.44±5.05 s) < HBP-AMRI (269.18±4.93 s) < Dyn-AMRI (307.71±4.93 s) < complete Gd-EOB-DTPA contrast-enhanced MRI (582.03±3.59 s). The sensitivity (Cochran's Q=14.667, P=0.002) and specificity (Cochran's Q=59.682, P<0.001) of 4 MRI protocols were statistically significant. HBP-AMRI showed the highest sensitivity (84.00%), whereas Dyn-AMRI exhibited the highest specificity (99.39%) among 3 AMRI protocols. The per-lesion positive predictive value (PPV) for the NC-AMRI, Dyn-AMRI, and HBP-AMRI was 41.66%, 88.89%, and 47.72%, the corresponding negative predictive value (NPV) was 96.21%, 97.31%, and 98.70%, and the number needed to diagnose (NND) for the NC-AMRI, Dyn-AMRI, HBP-AMRI, and complete Gd-EOB-DTPA contrast-enhanced MRI was: 1.865, 1.577, 1.234, and 1.569, respectively. DeLong's test showed the AUROC value of either Dyn-AMRI or HBP-AMRI was significantly higher than that of NC-AMRI (Z=2.330, P=0.019; Z=2.680, P=0.007, respectively), but no significant difference between HBP-AMRI and Dyn-AMRI (Z=1.643, P=0.100).

Conclusions: AMRI protocols can be implemented in clinical practice as a patient-centered and tailored regimen for HCC surveillance in China. NC-AMRI might become an optional tool due to its minimal scanning time, lower cost, and exemption from contrast agents. Dyn-AMRI, achieving the highest specificity, is a reliable surveillance strategy. HBP-AMRI as a favorable alternative showed a high sensitivity and NPV while maintaining considerable specificity and NND.

Keywords: Hepatocellular carcinoma (HCC); abbreviated magnetic resonance imaging (AMRI); gadoxetic acid disodium (Gd-EOB-DTPA); surveillance.

Figure 1

Flowchart of study patient collection. HCC, hepatocellular carcinoma; TACE, hepatectomy, transcatheter arterial chemoembolization; Gd-EOB-DTPA, gadoxetic acid disodium; MRI, magnetic resonance imaging.

Figure 2

The scheme of three AMRI protocols, each with its corresponding scanning time. The lesions are indicated by white arrows. Gd-EOB-DTPA, gadoxetic acid disodium; MRI, magnetic resonance imaging; NC-AMRI, non-contrast AMRI; Dyn-AMRI, dynamic-AMRI; HBP AMRI, hepatobiliary phase AMRI; T2WI, T2-weighted imaging; AP-1, early AP; AP-2, late AP; DWI, diffusion-weighted imaging; PVP, portal venous phase; HBP, hepatobiliary phase; AP, arterial phase; TP, transitional phase; AMRI, abbreviated magnetic resonance imaging.

Figure 3

A 49-year-old man with HBV-related cirrhosis, surgically confirmed well-differentiated HCC (10 mm in diameter) in S7 of the liver. The lesion demonstrated hyperintensity on T2WI (arrow, A), diffusion restriction on DWI (arrow, B), hyperenhancement on AP (arrow, C), washout on PVP (arrow, D), and hypointensity on HBP (arrow, E). The patient was correctly diagnosed as HCC positive by 3 AMRI and the complete MRI protocols. HBV, hepatitis B virus; HCC, hepatocellular carcinoma; T2WI, T2-weighted imaging; DWI, diffusion-weighted imaging; AP, arterial phase; PVP, portal venous phase; HBP, hepatobiliary phase; AMRI, abbreviated magnetic resonance imaging; MRI, magnetic resonance imaging.

Figure 4

The ROC curve showed the AUROC of 4 scanning protocols in the diagnostic performance of HCC. NC-AMRI, non-contrast AMRI; Dyn-AMRI, dynamic-AMRI; HBP-AMRI, HBP, hepatobiliary phase AMRI; ROC, receiver operating characteristic; AUROC, the area under the receiver operating characteristic curve; HCC, hepatocellular carcinoma; AMRI, abbreviated magnetic resonance imaging.

Figure 5

A 46-year-old woman with HBV-related cirrhosis, confirmed cavernous hemangioma (28 mm in diameter) in S2 of the liver. The lesion demonstrated hyperintensity on T2WI (arrow, A), diffusion restriction on DWI (arrow, B), and hypointensity on HBP (arrow, C). The patient was diagnosed as HCC positive on HBP-AMRI and NC-AMRI whereas correctly diagnosed as HCC negative on Dyn-AMRI and complete Gd-EOB-DTPA contrast-enhanced MRI, as the lesion exhibited peripheral nodular enhancement on AP (arrow, D), and the trend of centripetal enhancement on PVP (arrow, E). HBV, hepatitis B virus; T2WI, T2-weighted imaging; DWI, diffusion-weighted imaging; HBP, hepatobiliary phase; HCC, hepatocellular carcinoma; AMRI, abbreviated magnetic resonance imaging; NC-AMRI, non-contrast AMRI; Dyn-AMRI, dynamic-AMRI; Gd-EOB-DTPA, gadoxetic acid disodium; MRI, magnetic resonance imaging; AP, arterial phase; PVP, portal venous phase.

Figure 6

A 54-year-old man with HBV related cirrhosis, pathologically confirmed HGDN by biopsy with a diameter of 25 mm in S8 of the liver. The lesion demonstrated mild hyperintensity on T2WI (arrow, A), slight hyperintensity on DWI (arrow, B), no enhancement on AP (C), isointensity on PVP (D), and hypointensity on HBP (arrow, E). The patient was diagnosed as HCC positive on NC-AMRI and HBP-AMRI, and diagnosed as HCC negative on Dyn-AMRI and complete Gd-EOB-DTPA contrast-enhanced MRI. HBV, hepatitis B virus; HGDN, high-grade dysplastic nodule; T2WI, T2-weighted imaging; DWI, diffusion-weighted imaging; AP, arterial phase; PVP, portal venous phase; HBP, hepatobiliary phase; HCC, hepatocellular carcinoma; NC-AMRI, non-contrast AMRI; Dyn-AMRI, dynamic-AMRI; Gd-EOB-DTPA, gadoxetic acid disodium; MRI, magnetic resonance imaging.

Figure 7

A 49-year-old man with chronic HBV-related cirrhosis, histopathologically-diagnosed intrahepatic cholangiocarcinoma (20 mm in diameter) in S6 of the liver. The lesion showed hyperintensity on T2WI (arrow, A), rim APHE (arrow, B), peripheral enhancement on PVP (arrow, C), targetoid restriction on DWI (arrow, D), and targetoid sign on HBP (arrow, E). The patient was correctly diagnosed as HCC negative by 3 AMRI and the complete MRI protocol. HBV, hepatitis B virus; T2WI, T2-weighted imaging; APHE, AP hyperenhancement; PVP, portal venous phase; DWI, diffusion-weighted imaging; HBP, hepatobiliary phase; HCC, hepatocellular carcinoma; AMRI, abbreviated magnetic resonance imaging; MRI, magnetic resonance imaging.

Figure 8

A 60-year-old man with HBV-related cirrhosis, surgically confirmed HCC (7.9 mm in diameter) in S8 of the liver. The lesion demonstrated no enhancement on AP (A), isointensity on PVP (B), hypointensity on HBP (arrow, C), subtle hyperintensity on T2WI (arrow, D), and diffusion restriction on DWI (arrow, E). Due to the absence of APHE on AP, and lacking washout on PVP, the patient was diagnosed as HCC negative on Dyn-AMRI and complete Gd-EOB-DTPA contrast-enhanced MRI. Thus, the patient was diagnosed as HCC positive on NC-AMRI and HBP-AMRI. HBV, hepatitis B virus; T2WI, T2-weighted imaging; PVP, portal venous phase; DWI, diffusion-weighted imaging; AP, arterial phase; PVP, portal venous phase; HBP, hepatobiliary phase; AMRI, abbreviated magnetic resonance imaging; HCC, hepatocellular carcinoma; MRI, magnetic resonance imaging; APHE, AP hyperenhancement; Dyn-AMRI, dynamic-AMRI; Gd-EOB-DTPA, gadoxetic acid disodium.