Case Control Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 7, 2019; 25(21): 2636-2649
Published online Jun 7, 2019. doi: 10.3748/wjg.v25.i21.2636
Gadoxetic acid-enhanced magnetic resonance imaging can predict the pathologic stage of solitary hepatocellular carcinoma
Yi-Chen Chou, I-Ha Lao, Pei-Ling Hsieh, Ying-Ying Su, Chee-Wai Mak, Ding-Ping Sun, Ming-Jen Sheu, Hsing-Tao Kuo, Tzu-Ju Chen, Chung-Han Ho, Yu-Ting Kuo
Yi-Chen Chou, I-Ha Lao, Pei-Ling Hsieh, Ying-Ying Su, Chee-Wai Mak, Department of Medical Imaging, Chi Mei Medical Center, Tainan 710, Taiwan
I-Ha Lao, Biomedical Sciences, National Sun Yat-sen University, Kaohsiung 804, Taiwan
I-Ha Lao, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
Ding-Ping Sun, Department of Surgery, Chi Mei Medical Center, Tainan 710, Taiwan
Ding-Ping Sun, Department of Food Science and Technology, Chia Nan University of Pharmacy and Science, Tainan 717, Taiwan
Ming-Jen Sheu, Hsing-Tao Kuo, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 710, Taiwan
Ming-Jen Sheu, Department of Medicinal Chemistry, Chia Nan University of Pharmacy and Science, Tainan 717, Taiwan
Hsing-Tao Kuo, Department of Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan 717, Taiwan
Tzu-Ju Chen, Department of Pathology, Chi-Mei Medical Center, Tainan 710, Taiwan
Tzu-Ju Chen, Department of Optometry, Chung Hwa University of Medical Technology, Tainan 717, Taiwan
Tzu-Ju Chen, Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung 804, Taiwan
Chung-Han Ho, Department of Medical Research, Chi-Mei Medical Center, Tainan 710, Taiwan
Chung-Han Ho, Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan 717, Taiwan
Yu-Ting Kuo, Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
Yu-Ting Kuo, Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
Author contributions: All authors participated in the research. Kuo YT obtained funding, designed methodology, supervised the research, and wrote the article. Chou YC conducted investigations and wrote the original draft. Lao IH, Hsieh PL, Su YY, May CW, Sun DP, Sheu MJ, Kuo HT, and Chen TJ contributed to clinical survey and input of research methodology. Ho CH performed data curation and statistical analysis.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of Chi Mei Medical Center, Taiwan. IRB Serial No. 10702-007.
Informed consent statement: The need for informed consent was waived by the Institutional Review Board of Chi Mei Medical Center, Taiwan because of the retrospective nature of the study.
Conflict-of-interest statement: All authors declare no conflicts-of-interest related to this article.
Data sharing statement: No additional data are available.
STROBE statement: The manuscript was prepared according to the STROBE checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Yu-Ting Kuo, MD, PhD, Doctor, Department of Medical Imaging, Chi Mei Medical Center, 901 Chung-Hwa Road, Yung-Kang District, Tainan 710, Taiwan. y.kuo@mail.chimei.org.tw
Telephone: +886-6-2812811
Received: February 22, 2019
Peer-review started: February 22, 2019
First decision: March 27, 2019
Revised: April 30, 2019
Accepted: May 8, 2019
Article in press: May 8, 2019
Published online: June 7, 2019
Abstract
BACKGROUND

Although important for determining long-term outcome, pathologic stage of hepatocellular carcinoma (HCC) is difficult to predict before surgery. Current state-of-the-art magnetic resonance imaging (MRI) using gadoxetic acid provides many imaging features that could potentially be used to classify single HCC as pT1 or pT2.

AIM

To determine which gadoxetic acid-enhanced MRI (EOB-MRI) findings predict pathologic stage T2 in patients with solitary HCC (cT1).

METHODS

Pre-operative EOB-MRI findings were reviewed in a retrospective cohort of patients with solitary HCC. The following imaging features were examined: Hyperintensity in unenhanced T2-weighted images, hypointensity in unenhanced T1-weighted images, arterial enhancement, corona enhancement, washout appearance, capsular appearance, hypointensity in the tumor tissue during the hepatobiliary (HB) phase, peritumoral hypointensity in the HB phase, hypointense rim in the HB phase, intratumoral fat, hyperintensity on diffusion-weighted imaging, hypointensity on apparent diffusion coefficient map, mosaic appearance, nodule-in-nodule appearance, and the margin (smooth or irregular). Surgical pathology was used as the reference method for tumor staging. Univariate and multivariate analyses were performed to identify predictors of microvascular invasion or satellite nodules.

RESULTS

There were 39 (34.2%; 39 of 114) and 75 (65.8%; 75 of 114) pathological stage T2 and T1 HCCs, respectively. Large tumor size (≥ 2.3 cm) and two MRI findings, i.e., corona enhancement [odds ratio = 2.67; 95% confidence interval: 1.101-6.480] and peritumoral hypointensity in HB phase images (odds ratio = 2.203; 95% confidence interval: 0.961-5.049) were associated with high risk of pT2 HCC. The positive likelihood ratio was 6.25 (95% confidence interval: 1.788-21.845), and sensitivity of EOB-MRI for detecting pT2 HCC was 86.2% when two or three of these MRI features were present. Small tumor size and hypointense rim in the HB phase were regarded as benign features. Small HCCs with hypointense rim but not associated with aggressive features were mostly pT1 lesions (specificity, 100%).

CONCLUSION

Imaging features on EOB-MRI could potentially be used to predict the pathologic stage of solitary HCC (cT1) as pT1 or pT2.

Keywords: Tumor invasiveness, Gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid, Hepatobiliary, Contrast agent, Magnetic resonance imaging, Hepatocellular carcinoma

Core tip: Gadoxetic acid-enhanced-magnetic resonance imaging (EOB-MRI) has been shown to outperform other hepatocellular carcinoma (HCC) diagnostic tools. Our aim was to determine whether EOB-MRI findings could be used to predict pathologic stage T2 in patients with solitary HCC, clinical stage T1 (cT1). EOB-MRI was performed in 114 patients with solitary HCC [39 with pathologic stage T2 (pT2) and 75 with pT1]. Large tumor size, corona enhancement, and peritumoral hypointensity in hepatobiliary phase images were associated with high risk of pT2 HCC. The sensitivity of EOB-MRI for detecting pT2 HCC was 86.2% when two or three of these MRI features were present.