Alternative surveillance methods for hepatocellular carcinoma (HCC) have gained popularity recently. In our presentation today, we will demonstrate our experience with our short non-contrast MRI surveillance (SMS) protocol for the detection of HCC.

Nowadays, surveillance for HCC is performed with abdominal ultrasound according to international guidelines from both Europe and the USA. However, ultrasound has several limitations which reduce the detection of small or early HCC by about 20%. This is especially the case in obese patients or fatty or severely fibrotic and cirrhotic livers. Beside these factors, the level of experience (or more precisely, inexperience) and skill of the sonographer plays an important role in the accuracy of ultrasound as a screening tool. Hence, more than half of HCC are missed in the early stage with ultrasound. Patients with early HCC have better outcomes with relatively easy treatment than with advanced HCC. It is therefore important to detect the tumour at an early stage.

An ideal screening method with imaging should be patient-friendly (no radiation exposure, non-invasive, and limited in time) with objective images that can be used for reference at future screening. Contrast-enhanced ultrasound has the same practical limitations as conventional ultrasound without contrast administration.

CT uses ionising radiation and intravenous contrast administration, which makes it less suitable for routine screening in our opinion. A full MRI protocol is time consuming and also invasive (contrast). Furthermore, there is ongoing debate about potential adverse effects of MRI contrast media. Consequently, a short MRI protocol, without the use of a contrast medium and with high diagnostic accuracy (sensitivity) for HCC, would fulfil our aims for a screening tool.

In today’s session we will demonstrate the results of our SMS protocol. All patients who underwent a full yearly MRI liver protocol for surveillance for HCC in the last decade were reviewed (these patients were deemed unsuitable for surveillance with ultrasound). Only three imaging series were selected: axial diffusion-weighted imaging, axial T2-weighted imaging (preferably with fat saturation) and axial T1 in and opposed phase with a total imaging time of approximately 11 minutes.

A 59-year-old patient with Hepatitis C and liver cirrhosis who underwent yearly MRI surveillance for HCC. MRI ten months earlier was negative (Figure A). Patient developed a lesion central in the liver, hyperintense on the DWI (Figure B) and T2FS (Figure C). T1 in and opposed phase (Figures D and E) also demonstrate the lesion and the severe liver steatosis which made this patient unsuitable for ultrasound surveillance. These series are the standard series used in the SMS protocol.

These series were sent (anonymised) to a separate server, and independently reviewed by three readers, with different levels of expertise. Diagnostic performance and interobserver agreement are very promising. The results are much better compared to ultrasound. My colleagues and I think this might be the future for surveillance of HCC.

Special thanks to my colleague and friend Roy Dwarkasing, MD, PhD, for his support, belief and devotion to this project.

François Willemssen, MD, is an abdominal radiologist at the Department of Radiology and Nuclear Medicine, Erasmus MC, in Rotterdam, the Netherlands.

Research Presentation Session
RPS 301b The role of imaging in hepatocellular carcinoma (HCC) management

Short MRI surveillance protocol for the detection of hepatocellular carcinoma: the SMS protocol
F. Willemssen, Q.G. de Lussanet de la Sablonière, R.S. Dwarkasing; Rotterdam/NL

Read the full abstract in the ECR 2020 Book of Abstracts
Willemsen F, et al. (2020) Short MRI surveillance protocol for the detection of hepatocellular carcinoma: the SMS protocol. Abstract RPS 301b-2 in: ECR 2020 Book of Abstracts. Insights Imaging 11, 34 (2020). DOI 10.1186/s13244-020-00851-0