MRI for screening and surveillance for hepatocellular cancer in NAFLD and NASH

Chronic liver disease is an important risk factor for the development of hepatocellular carcinoma (HCC), with 80%-90% developing in the background of cirrhosis, primarily due to alcohol abuse and chronic viral infection with hepatitis B and C. Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) related HCC is rising due to the global epidemic of obesity and diabetes. NAFLD also potentiates other risk factors of HCC, such as chronic hepatitis C and alcoholic liver injury. Furthermore, HCC may complicate non-cirrhotic NAFLD, greatly expanding the population potentially at risk. Screening and surveillance for HCC with ultrasonography (US) in this patient population pose challenges related to body habitus, liver morphology, and co-morbidities. Magnetic resonance imaging (MRI) applying various image sequence protocols and contrast agents could aid in early detection and improved prognosis of HCC. It is of utmost importance to define the most cost-effective dynamic imaging protocol for use in patients where high-quality ultrasonography images cannot be obtained and for patients undergoing surveillance for lesions identified with US. Furthermore, standardization of MRI protocols will help to define potential unique HCC features in this population. A scoring system including patient-derived factors may help to identify high-risk patients. Standardized protocols as part of prospective cohort studies and randomized clinical trials will help to stratify high-risk patients and to aid the development of professional guidelines for screening and surveillance of HCC in patients with NAFLD and NASH using dynamic imagining techniques.