Estimating postsurgical outcomes of patients with a single hepatocellular carcinoma using gadoxetic acid–enhanced MRI: risk scoring system development and validation

Objectives: To develop and validate risk scoring systems using gadoxetic acid–enhanced liver MRI features and clinical factors that predict recurrence-free survival (RFS) of a single hepatocellular carcinoma (HCC). Methods: Consecutive 295 patients with treatment-naïve single HCC who underwent curative surgery were retrospectively enrolled from two centers. Cox proportional hazard models developed risk scoring systems whose discriminatory powers were validated using external data and compared to the Barcelona Clinic Liver Cancer (BCLC) or American Joint Committee on Cancer (AJCC) staging systems using Harrell’s C-index. Results: Independent variables—tumor size (per cm; hazard ratio [HR], 1.07; 95% confidence interval [CI]: 1.02–1.13; p = 0.005), targetoid appearance (HR, 1.74; 95% CI: 1.07–2.83; p = 0.025), radiologic tumor in vein or tumor vascular invasion (HR, 2.59; 95% CI: 1.69–3.97; p < 0.001), the presence of a nonhypervascular hypointense nodule on the hepatobiliary phase (HR, 4.65; 95% CI: 3.03–7.14; p < 0.001), and pathologic macrovascular invasion (HR, 2.60; 95% CI: 1.51–4.48; p = 0.001)—with tumor markers (AFP ≥ 206 ng/mL or PIVKA-II ≥ 419 mAU/mL) derived pre- and postoperative risk scoring systems. The risk scores showed comparably good discriminatory powers in the validation set (C-index, 0.75–0.82) and outperformed the BCLC (C-index, 0.61) and AJCC staging systems (C-index, 0.58; ps < 0.05). The preoperative scoring system stratified the patients into low-, intermediate-, and high-risk for recurrence, whose 2-year recurrence rate was 3.3%, 31.8%, and 85.7%, respectively. Conclusion: The developed and validated pre- and postoperative risk scoring systems can estimate RFS after surgery for a single HCC. Key Points: • The risk scoring systems predicted RFS better than the BCLC and AJCC staging systems (C-index, 0.75–0.82 vs. 0.58–0.61; ps < 0.05). • Five variables—tumor size, targetoid appearance, radiologic tumor in vein or vascular invasion, the presence of a nonhypervascular hypointense nodule on the hepatobiliary phase, and pathologic macrovascular invasion—combined with tumor markers derived risk scoring systems predicting postsurgical RFS for a single HCC. • In the risk scoring system using preoperatively-available factors, patients were classified into three distinct risk groups, with 2-year recurrence rates in the low-, intermediate-, and high-risk groups being 3.3%, 31.8%, and 85.7% in the validation set.