Focal Lesions in the Cirrhotic Liver: Their Pivotal Role in Gadoxetic Acid-Enhanced MRI and Recognition by the Western Guidelines

Abstract

Hepatocellular carcinoma (HCC) is a major health concern, and early HCC diagnosis is a primary radiological concern. The goal of imaging liver cirrhosis is the early identification of high-grade dysplastic nodules/early HCC since their treatment is associated with a higher chance of radical cure and lower recurrence rates. The newly introduced MRI contrast agent gadoxetic acid (gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid, Gd-EOB-DTPA) has enabled the concurrent assessment of tumor vascularity and hepatocyte-specific contrast enhancement during the hepatobiliary phase (HBP), which can help to detect and characterize smaller HCCs and their precursors. HBP-EOB-MRI identifies hypovascular HCC nodules that are difficult to detect using ultrasonography or computed tomography, which do not show the diagnostic HCC hallmarks of arterial washin and portal/delayed washout. During the HBP, typical HCC and early HCC appear hypointense on EOB-MRI, whereas low-grade dysplastic or regenerative nodules appear as iso- or hyperintense lesions. The diagnostic accuracy of EOB-MRI for the diagnosis of early HCC is approximately 95-100%. One third of hypovascular hypointense nodules in HBP become hypervascular ‘progressed' HCC, with a 1- and 3-year cumulative incidence of 25 and 41%, respectively. Therefore, these hypovascular nodules should be strictly followed up or definitely treated as typical HCC. Due to this capability of identifying the precursors and biological behavior of HCC, EOB-MRI has rapidly become a key imaging tool for the diagnosis of HCC and its precursors, despite the scarce MRI availability throughout Europe. With increasing experience, EOB-MRI may eventually be established as the diagnostic imaging modality of choice in this setting. Full recognition by the Western EASL-AASLD guidelines is expected.

Delayed enhancement in differential diagnosis of salivary gland neoplasm

“…and malignant parotid lesions (4,(13)(14)(15)(16). However, recent studies have demonstrated a comparable high sensitivity and specificity between these imaging modalities (7,17,18).…”

Major and ancillary magnetic resonance features of LI-RADS to assess HCC: an overview and update

“…Despite these limits several researches have demonstrated that EOB-GD-DTPA can favor the detection and the characterization of HCC nodule [50–56]. According to Golfieri et al [53], during the hepatospecific phase, typical HCC and early HCC appear hypointense, whereas low-grade dysplastic or regenerative nodules appear as iso- or hyperintense lesions. The diagnostic accuracy of EOB-MRI for the diagnosis of early HCC is approximately 95–100% [53].…”

“…According to Golfieri et al [53], during the hepatospecific phase, typical HCC and early HCC appear hypointense, whereas low-grade dysplastic or regenerative nodules appear as iso- or hyperintense lesions. The diagnostic accuracy of EOB-MRI for the diagnosis of early HCC is approximately 95–100% [53]. One third of hypovascular hypointense nodules in hepatospecific phase become hypervascular ‘progressed’ HCC, with a 1 and 3-year.…”

“…One third of hypovascular hypointense nodules in hepatospecific phase become hypervascular ‘progressed’ HCC, with a 1 and 3-year. Therefore, the authors suggested that these hypovascular nodules should be strictly followed up or definitely treated as typical HCC [53]. In the study by Ahn et al [54], 9 out of 84 HCCs (10.7%) were exclusively identified by hepatospecific phase and three were early HCCs, while in Golfieri et al [55] 19 out of 20 early HCC remained unclassified at dynamic MRI alone because of atypical behavior and were diagnosed only in the hepatospecific phase.…”

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

“…The latter has advanced to a widely recommended imaging technique based on its metabolic information with respect to the degree of enhancement in the late hepatobiliary phase [9]. This phase helps for better detection of even smaller lesions [10] and also for characterization of HCC-precursors which are expected to take up this contrast agent to different degrees compared to normal liver tissue and thus serve as a discriminator between HCC and its predecessors [11]. …”