Risk-stratified MRI surveillance for hepatocellular carcinoma in cirrhosis: a prospective cohort study.

Abstract

Current hepatocellular carcinoma (HCC) surveillance relies on semiannual ultrasonography, which has limited sensitivity for early-stage detection. We evaluated the effectiveness of HCC surveillance using gadoxetic acid-enhanced MRI at risk-stratified screening intervals in patients with cirrhosis. We prospectively enrolled 86 patients with cirrhosis between May 2021 and October 2022. All patients underwent HCC surveillance using gadoxetic acid-enhanced MRI for 3 years at risk-stratified screening intervals ranging from 3 to 36 months, according to the assigned risk category defined by LI-RADS criteria on baseline MRI (low, intermediate, and high risk with LI-RADS LR-3 or LR-4 observations). The primary outcome was surveillance failure, defined as the detection of HCC beyond the Milan criteria. HCC was diagnosed in 13 patients during the study period. The HCC incidence differed markedly across the MRI risk categories, ranging from 1.9 per 100 person-years in patients with low risk to 73.4 per 100 person-years in those with LR-4 observations. The primary endpoint was met with no surveillance failures (0%; 95% CI: 0-24.7%). Ten cases (76.9%) were identified at a very early stage, and there was one interval cancer (7.7%). Compared to a uniform semiannual surveillance strategy, the risk-stratified approach reduced the number of surveillance examinations by 44.2%. HCC surveillance using gadoxetic acid-enhanced MRI at risk-stratified screening intervals resulted in no surveillance failures, a high rate of early-stage tumor detection, and a low incidence of interval cancer. This approach may improve surveillance effectiveness while reducing examination frequency. QuestionWhether risk-stratified surveillance intervals for gadoxetic acid-enhanced MRI can maintain early HCC detection while reducing examination burden in cirrhosis remains unknown. FindingsRisk-stratified MRI surveillance detected all 13 incident HCCs within Milan criteria, with zero surveillance failures and a 44.2% reduction in examinations. Clinical relevanceRisk-stratified gadoxetic acid-enhanced MRI surveillance enables personalized screening intervals based on imaging risk categories, maintaining early-stage HCC detection while substantially reducing examination frequency in patients with cirrhosis.