HCC screening: assessment of an abbreviated non-contrast MRI protocol

Michael Vinchill Chan, Stephen J McDonald, Yang-Yi Ong, Katerina Mastrocostas, Edwin Ho, Ya Ruth Huo, Cositha Santhakumar, Alice Unah Lee, Jessica Yang, Michael Vinchill Chan, Stephen J McDonald, Yang-Yi Ong, Katerina Mastrocostas, Edwin Ho, Ya Ruth Huo, Cositha Santhakumar, Alice Unah Lee, Jessica Yang

Abstract

Background: Hepatocellular carcinoma (HCC) guidelines recommend ultrasound screening in high-risk patients. However, in some patients, ultrasound image quality is suboptimal due to factors such as hepatic steatosis, cirrhosis, and confounding lesions. Our aim was to investigate an abbreviated non-contrast magnetic resonance imaging (aNC-MRI) protocol as a potential alternative screening method.

Methods: A retrospective study was performed using consecutive liver MRI studies performed over 3 years, with set exclusion criteria. The unenhanced T2-weighted, T1-weighted Dixon, and diffusion-weighted sequences were extracted from MRI studies with a known diagnosis. Each anonymised aNC-MRI study was read by three radiologists who stratified each study into either return to 6 monthly screening or investigate with a full contrast-enhanced MRI study.

Results: A total of 188 patients were assessed; 28 of them had 42 malignant lesions, classified as Liver Imaging Reporting and Data System 4, 5, or M. On a per-patient basis, aNC-MRI had a negative predictive value (NPV) of 97% (95% confidence interval [CI] 95-98%), not significantly different in patients with steatosis (99%, 95% CI 93-100%) and no steatosis (97%, 95% CI 94-98%). Per-patient sensitivity and specificity were 85% (95% CI 75-91%) and 93% (95% CI 90-95%).

Conclusion: Our aNC-MRI HCC screening protocol demonstrated high specificity (93%) and NPV (97%), with a sensitivity (85%) comparable to that of ultrasound and gadoxetic acid contrast-enhanced MRI. This screening method was robust to hepatic steatosis and may be considered an alternative in the case of suboptimal ultrasound image quality.

Keywords: Carcinoma (hepatocellular); Diffusion magnetic resonance imaging; Liver cirrhosis; Magnetic resonance imaging; Screening.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Liver Imaging Reporting and Data System ultrasound visualisation scores. a Example of ultrasound visualisation score A: no or minimal limitations with complete visualisation of the diaphragm (arrowhead). b Example of ultrasound visualisation score B: moderate limitations. Shadowing and attenuation from heterogeneous liver parenchyma may obscure small masses and less than 50% visualisation of the liver (arrowhead). c Example of ultrasound visualisation score C: severe limitations. Marked attenuation in a patient with severe fatty liver leads to poor visualisation of the majority of the liver and diaphragm (arrowhead), with corresponding computed tomography image shown in (d)
Fig. 2
Fig. 2
A 59-year-old patient with chronic hepatitis B and cirrhosis who has at least 10 hypoechoic lesions on US (a) measuring 2–3 cm (arrowhead). On gadoxetic acid-enhanced magnetic resonance imaging (b, c), these are shown to be focal nodular hyperplasia (FNH)-like nodules in cirrhosis (arrowheads). This patient cannot be reliably screened with ultrasound. In fact, FNH-like nodules are identical to classic FNH and are benign. They occur in cirrhosis and are believed to originate from acquired hyperplastic responses to vascular alterations associated with cirrhosis
Fig. 3
Fig. 3
A 58-year-old female patient with chronic hepatitis B and polycystic liver. a Heterogeneous posterior acoustic enhancement (arrowhead) limits lesion detection on ultrasound. b The cysts do not affect liver parenchymal visibility with MRI
Fig. 4
Fig. 4
Flow chart of study population
Fig. 5
Fig. 5
Lesion size and Liver Imaging Reporting and Data System (LI-RADS) category versus detection by readers. LR LI-RADS

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