Advanced Imaging Modalities for Hepatocellular Carcinoma: Is MRI with EOVIST Really Better?

Research Article

Austin J Gastroenterol. 2016; 3(3): 1067.

Advanced Imaging Modalities for Hepatocellular Carcinoma: Is MRI with EOVIST Really Better?

Annamalai A1,2*, Chen M², Reich H², Nourredin M2,3, Klein A1,2, Nissen N1,2 and Ayoub WS2,3

¹Department of Surgery, Cedars Sinai Medical Center, USA

²Comprehensive Transplant Center, Cedars Sinai Medical Center, USA

³Department of Gastroenterology, Cedars Sinai Medical Center, USA

*Corresponding author: Annamalai A, Department of Surgery, Cedars Sinai Medical Center, Comprehensive Transplant Center, 8900 Beverly Blvd, 2nd fl. Suite 262, Los Angeles, CA 90048, USA

Received: June 08, 2016; Accepted: September 16, 2016; Published: September 20, 2016


Background: Hepatocellular cancer (HCC) is the third leading cause of cancer-related death worldwide and the third most common indication for liver transplantation in the United States. Efforts toward perfecting imaging-based diagnosis have increased to avoid the need for liver biopsy. Eovist (gadolinium- EOB-DTPA), compared to conventional gadolinium-enhanced MRI (MRI-Gd) or triple-phase contrast-enhanced computed tomography (CT), is considered a superior method for detection of hepatocellular cancer (HCC). In patients with cirrhosis, Eovist enhances lesion-to-liver contrast and differentiates vascular shunts and dysplastic nodules from HCC, an important distinction as outcomes of transplantation depend on the degree of cancer burden. We investigate whether MRI with Eovist (MRI-E) is more accurate for evaluation of HCC than MRI-Gd or CT.

Methods: Retrospective analysis of all patients with HCC undergoing liver transplantation at Cedars-Sinai Medical Center from 2009-2014 was conducted. Multicentric tumors were included if they could be uniquely identified across modalities based on anatomic location. Number and size of lesions measured by MRI-E, MRI-Gd, or CT were compared to explant pathology using repeated measures ANOVA and linear regression analysis. Viability on imaging vs. pathology was compared using chi-squared tests.

Results: Sixty-four patients with 137 HCC tumors were imaged with MRI-E (n=96), MRI-Gd (n=63), and/or CT (n=53); 33 tumors were measured with all 3 modalities. The number of lesions identified by MRI-E was highly concordant with pathology and higher than the number detected by MRI-Gd or CT (p<0.05). All three imaging modalities underestimated maximum tumor diameter relative to pathology (p=.0003). Maximum tumor diameter by MRI-Gd had stronger correlation with pathology than MRI-E or CT (p=0.008). MRI-E (χ2=3.52, p=0.061) and CT (χ2=3.57, p=0.059) were better at assessing viability than MRI-Gd (χ2=1.22, p=0.268).

Conclusions: This is the first study to compare imaging of HCC using MRI-E, MRI-Gd, or CT to explant pathology. MRI with Eovist is a useful adjunct for liver transplant candidacy evaluation with superior assessment of the number of HCC lesions, but it may have limited precision when assessing lesion size.

Keywords: Hepatocellular cancer; Cirrhosis; Liver transplant; Eovist


Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy and accounts for nearly 50% of deaths for patients with cirrhosis [1]. The standard of care since the incorporation of Milan criteria for the treatment of HCC in patients with cirrhosis and HCC is liver transplantation in those with early stage but unresectable lesions [2]. Transplantation for cirrhosis and hepatocellular carcinoma has the highest success for potential cure by eliminating both the cancer and the cirrhotic liver, which is the biggest risk factor for development of HCC. One year and five year survival after liver transplant for HCC is approximately 92% and 80% [3] and has been largely dependent upon early detection and staging [4]. Even with careful patient selection and adjunct therapies while waiting on the transplant list, HCC still recurs post-transplant at a rate of 3.5-21%, and is associated with increased mortality compared to recipients without recurrence [5]. HCC is unique in that the positive predictive value of imagining findings nears 100%; hence, tissue diagnosis, with its associated complications including post-procedural pain, bleeding, risk of tumor seeding, and difficulties in evaluating multiple lesions over long periods of time in patients with cirrhosis, has become increasingly unpopular [6,7]. Advanced imaging modalities, in lieu of tissue diagnosis, are used to discriminate HCC from other types of liver lesions and to reliably characterize the number, size, and viability of HCC lesions and to determine candidacy for transplantation.

Currently, the American Association for the Study of Liver Disease (AASLD) published guidelines for surveillance and diagnosis of HCC includes screening ultrasound (US) every 6 months until there is evidence of a lesion, at which point computed tomography and/or magnetic resonance imaging become the more appropriate method used for staging [8] (Figure 1). The Organ Procurement Transplant Network (OPTN) and United Network for Organ Sharing (UNOS) has also recently published its minimum accepted criteria for the evaluation and classification of HCC if to be considered for transplantation exception listing, and includes: liver imaging with multiphase contrast enhanced radiography (CT or MRI) performed or interpreted at a transplant center, single lesion =2 cm and =5 cm, or 2 or 3 lesions =1 cm and =3 cm in size, and meet specific imaging characteristics [9] (Table 1). Lesions which have characteristics that are beyond these criteria have a significantly worse prognosis with transplantation.