• Sunyoung Lee, Kyoung Won Kim, Woo Kyoung Jeong, Myeong-Jin Kim, Gi Hong Choi, Jin Sub Choi, Gi-Won Song, and Sung-Gyu Lee.
• Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
• Eur Radiol. 2020 Feb 1; 30 (2): 987-995.

ObjectivesTo investigate the value of preoperative gadoxetic acid-enhanced MRI for tumor staging and recurrence prediction of hepatocellular carcinoma (HCC) after primary liver transplantation (LT).MethodsThis multicenter retrospective study included 122 recipients who underwent living donor LT (LDLT) for untreated HCC and pre-transplant gadoxetic acid-enhanced MRI from January 2009 to December 2013. Disease-free survival (DFS) was evaluated. Milan criteria, tumor grade, and microvascular invasion (MVI) were analyzed on the pathological examination of the explanted liver.ResultsThe 1-, 3-, 5-, and 7-year DFS rates were 93.3%, 90.7%, 88.9%, and 86.1%, respectively. In the multivariable analysis, independent predictors of HCC recurrence were "beyond the Milan criteria" (hazard ratio [HR], 3.54; 95% confidence interval [CI], 1.13-11.12; p = 0.030) and peritumoral hypointensity on hepatobiliary phase (HBP) (HR, 18.30; 95% CI, 4.33-77.34; p < 0.001). Pre-transplant MRI yielded a 90.2% accuracy to categorize the Milan criteria when compared with the explanted liver. Peritumoral hypointensity on HBP was significantly associated with a worse tumor grade (p = 0.010) and MVI (p < 0.001). The 5-year DFS rate in patients with "beyond the Milan criteria" but the absence of peritumoral hypointensity on HBP was not different from that in patients "within the Milan criteria" (92.2% vs. 92.9%, p = 0.438).ConclusionsPre-transplant gadoxetic acid-enhanced MRI may assist in the HCC recurrence risk prediction.Key Points• Lesions beyond the Milan criteria and peritumoral hypointensity on hepatobiliary phase (HBP) were independent predictors of HCC recurrence. • Peritumoral hypointensity on HBP significantly associated with a worse tumor grade and microvascular invasion.

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