What is the best imaging modality to assess hepatocellular carcinoma (HCC) in a patient with chronic liver disease (CLD), elevated alpha-fetoprotein (AFP) levels, and impaired renal function?

From the Guidelines

For patients with chronic liver disease, elevated alpha-fetoprotein levels, and impaired renal function, MRI with hepatobiliary contrast agents is the best imaging modality to assess for hepatocellular carcinoma. This approach is supported by the most recent guidelines, including the 2025 EASL clinical practice guidelines on the management of hepatocellular carcinoma 1, which recommend the use of LI-RADS CT/MR v2018 or the LI-RADS CEUS v2017 criteria for non-invasive diagnosis of HCC. MRI with hepatobiliary contrast agents, such as gadoxetic acid or gadobenate dimeglumine, offers superior soft tissue contrast resolution and can detect smaller tumors, making it an ideal choice for patients with impaired renal function, as it avoids the nephrotoxicity risk associated with iodinated contrast used in CT scans.

The dynamic contrast enhancement patterns on MRI help distinguish HCC from other liver lesions, with typical HCC showing arterial phase hyperenhancement followed by washout in the portal venous or delayed phases. Additionally, MRI provides functional information through diffusion-weighted imaging, which can further improve diagnostic accuracy. The 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma also support the use of multiphasic MRI using hepatocyte-specific contrast agent as a first- and second-line imaging study for HCC diagnosis 1.

Some key points to consider when using MRI for HCC diagnosis include:

• The use of LI-RADS criteria to standardize the acquisition, description, and reporting of liver imaging examinations
• The combination of major imaging features, such as tumour size, rim and non-rim arterial hyperenhancement, peripheral and non-peripheral washout, enhancing capsule, and threshold growth, to reach a diagnosis of HCC
• The importance of avoiding nephrotoxicity in patients with impaired renal function, making MRI a safer choice than CT scans.

If MRI is contraindicated or unavailable, contrast-enhanced ultrasound may be considered as an alternative, though it is less sensitive for detecting smaller lesions and is more operator-dependent. However, the 2025 EASL guidelines recommend the use of CEUS as a second-line imaging modality, and the 2022 KLCA-NCC Korea guidelines support the use of contrast-enhanced US using blood-pool contrast agent or Kupffer cell-specific contrast agent as a second-line imaging study for HCC diagnosis 1.

From the Research

Imaging Modalities for HCC Assessment

In a patient with chronic liver disease (CLD), elevated alpha-fetoprotein (AFP) levels, and impaired renal function (creatinine 3.96), the best imaging modality to assess hepatocellular carcinoma (HCC) should be carefully selected. The following points summarize the key considerations:

• Computed Tomography (CT): According to 2, CT has a sensitivity of 77.5% and specificity of 91.3% for diagnosing HCC in adults with CLD. However, the study notes that CT may miss 22.5% of people with HCC, and 8.7% of people without HCC may be unnecessarily treated.
• Magnetic Resonance Imaging (MRI): 3 reports that MRI has a higher sensitivity (81%) compared to CT (68%) and ultrasound (60%) for diagnosing HCC. However, the study also mentions that the operative characteristics of CT are comparable to MRI.
• Abbreviated MRI (AMRI): 4 suggests that AMRI may be a promising alternative for HCC surveillance, offering a reduced acquisition time and improved cost-effectiveness. However, more studies are needed to confirm its effectiveness.
• Ultrasound: 5 highlights the importance of ultrasound in HCC surveillance, with semiannual ultrasound recommended by all liver societies. Advanced ultrasound techniques, such as elastography and contrast-enhanced ultrasound, may offer additional benefits.

Considerations for Impaired Renal Function

Given the patient's impaired renal function, it is essential to consider the potential risks associated with contrast-enhanced imaging modalities, such as CT and MRI. In this case, ultrasound or non-contrast MRI/CT may be preferred to minimize the risk of contrast-induced nephropathy.

Key Findings

The key findings from the studies are:

• CT has a moderate sensitivity and high specificity for diagnosing HCC in adults with CLD 2.
• MRI has a higher sensitivity compared to CT and ultrasound for diagnosing HCC 3.
• AMRI may be a promising alternative for HCC surveillance, but more studies are needed to confirm its effectiveness 4.
• Ultrasound plays a vital role in HCC surveillance, and advanced ultrasound techniques may offer additional benefits 5.