Quality of Gadoxetate-enhanced MRI versus US during Hepatocellular Carcinoma Screening in Participants with Cirrhosis

Background Hepatocellular carcinoma (HCC) surveillance typically involves US, although gadoxetate-enhanced MRI may improve sensitivity. Identifying factors impacting image quality is essential, but comparative data between US and MRI are lacking. Purpose To compare image quality and its determinants in gadoxetate-enhanced MRI versus US in participants with cirrhosis who are undergoing HCC screening in a prospective bicenter study. Materials and Methods In a secondary analysis of a prospective bicenter North American HCC screening study (September 2020 to May 2023), participants with cirrhosis underwent contemporaneous gadoxetate-enhanced MRI and liver US. Two independent observers evaluated MRI scans for dynamic phase motion, hepatobiliary phase liver uptake, and diffusion-weighted imaging quality. Sums of these assessments were trichotomized into MRI scores (MR-A: no or minimal limitations; MR-B: moderate limitations; and MR-C: severe limitations). US quality was scored per the Liver Imaging Reporting and Data System (US-A: no or minimal limitations; US-B: moderate limitations; and US-C: severe limitations). Clinical factors and quality were assessed using univariable and/or multivariable analyses. Proportions of quality scores were compared (McNemar χ² test). Results Among the 245 participants with cirrhosis (median age, 61 years; 133 men), MRI quality scores were classified as MR-A in 80.4% (197 of 245 participants), MR-B in 18.4% (45 of 245 participants), and MR-C in 1.2% (three of 245 participants), whereas available US visualization scores were classified as US-A in 24.2% (58 of 240 participants), US-B in 61.7% (148 of 240 participants), and US-C in 14.1% (34 of 240 participants). The proportion of examination scores with no or minimal limitations was higher for MRI than US in 240 participants with both set of scores (P < .001). Obesity (body mass index ≥ 30, calculated as weight in kilograms divided by height in meters squared) reduced quality for both modalities (MRI univariable odds ratio [OR], 4.20 [95% CI: 1.20, 22.6], P = .01; US OR, 2.50 [95% CI: 1.00, 6.00], P = .04), not confirmed at multivariable analysis. Child-Pugh score of B and/or C reduced MRI quality at univariable (OR, 2.60 [95% CI: 1.05, 6.30]; P = .03) and multivariable (adjusted OR, 3.95 [95% CI: 1.50, 10.42]; P = .006) analysis. Conclusion Most participants undergoing HCC screening had excellent MRI quality even when US was limited. Quality was adversely affected by obesity (both modalities) and Child-Pugh score (MRI only). ClinicalTrials.gov Identifier: NCT04539717 © The Author(s) 2026. Published by the Radiological Society of North America under a CC BY 4.0 license. Supplemental material is available for this article.