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

OBJECTIVES: 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. MATERIALS AND METHODS: 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. RESULTS: 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%. CONCLUSION: 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. KEY POINTS: 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.