Reproducibility and accuracy of non-contrast abbreviated magnetic resonance imaging of the liver in surveillance for early recurrence for hepatocellular carcinoma in a Western population: a multi-reader study

Reproducibility and accuracy of non-contrast abbreviated magnetic resonance imaging of the liver in surveillance for early recurrence for hepatocellular carcinoma in a Western population: a multi-reader study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reproducibility and accuracy of non-contrast abbreviated magnetic resonance imaging of the liver in surveillance for early recurrence for hepatocellular carcinoma in a Western population: a multi-reader study Jordi Rimola, Belén Saborido, Alba Igual, Andreu Roca, Anna Darnell, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6306750/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Jul, 2025 Read the published version in Abdominal Radiology → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose : Abbreviated MRI (AMRI) protocols may represent an alternative to conventional MRI (CMRI) for surveillance of hepatocellular carcinoma (HCC). We aimed to compare the inter-reader agreement and sensitivity of AMRI versus CMRI for HCC recurrence <2 years after curative ablation in at risk-population. Methods : Eight radiologists (4 with <5 years’ and 4 with ≥5 years’ experience) from three institutions independently reviewed 143 CMRI and AMRI image sets from 75 consecutive cirrhotic patients (84% HCV and/or alcohol-related) undergoing secondary screening after HCC ablation with ≥1 month between readings. We calculated the intra and inter-reader agreement by means Gwet’s AC1 for detection of local recurrence at the ablation site, new intrahepatic, and any type of recurrence (either local and/or new intrahepatic) with CMRI and AMRI. Reference diagnoses of recurrent HCC were based on histological or imaging-based criteria. Results : Early HCC recurrence was detected in 37 patients (49.3%). AC1 agreement was similarly high for AMRI and CMRI for local recurrence [0.87 (0.83‒0.90) vs. 0.87 (0.83‒0.92)], but higher for AMRI than for CMRI for new intrahepatic [0.85 (0.81‒0.9) vs. 0.6 (0.52‒0.67)] and any type [0.73 (0.67‒0.78) vs. 0.56 (0.49‒0.64)] recurrences. Sensitivity for detecting any type of HCC recurrence was higher for CMRI [0.83 (0.78‒0.87) vs. 0.39 (0.33‒0.45) for AMRI, p<0.0001]. Conclusions: For early detection of HCC recurrence in a cohort with predominantly HCV and/or alcohol-related cirrhosis, non-contrast AMRI yielded better interobserver agreement but lower sensitivity than CMRI. Hepatocellular carcinoma Magnetic Resonance Imaging Abbreviated Magnetic Resonance surveillance secondary screening recurrence Figures Figure 1 Figure 2 Introduction Hepatocellular carcinoma (HCC) is the most common primary liver cancer and the leading cause of death in patients with cirrhosis irrespective of etiology.[1; 2] Patients with very early- and early-stage HCC (stages 0 and A in the Barcelona Clinic Liver Cancer (BCLC) classification) are eligible for curative ablation or surgery, with an expected survival of > 5 years.[ 3 ] The treatment algorithm for primary HCC has been extrapolated to HCC recurrence after curative options (i.e HCC ablation), improving long-term survival of this group of patients. After successful treatment with resection or radiofrequency ablation, HCC recurs in 60–70% within 5 years, with up to 50% of recurrences detected within the first 12 months.[ 4 – 6 ] In contrast to patients in the intermediate stage of the BCLC classification, the early detection of recurrence after ablation is intended to offer new therapeutic options with curative intent. [ 3 ] Consequently, current HCC management guidelines prioritize continuous surveillance for recurrence after curative treatment; however, there is no clear consensus regarding the optimal technique for surveillance of HCC recurrence. Whereas major liver international society guidelines clearly recommend ultrasonography for HCC screening in patients at risk of development of HCC,[7; 8] given the greater risk of new HCC after curative treatment, survillance to detect early recurrence with multiphase contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) every 6 months seems reasonable. Contrast-enhanced MRI yield the highest sensitivity and very high specificity for detecting new or recurrent HCC, [9; 10] but using these techniques in HCC recurrence surveillance in cirrhotic patients can detect many inconclusive lesions (perfusion abnormalities, HCC precursors, etc.) that require additional examinations, especially in less-experienced centers, introducing the risk of overdiagnosis, overtreatment, and increased anxiety. Two recent meta-analyses found that abbreviated MRI protocols (AMRI) without intravenous contrast were comparable to conventional contrast-enhanced MRI (CMRI) for the detection of focal liver lesions [ 11 – 13 ], and another large study reported similar findings for monitoring late recurrence,[ 9 ] thus suggesting that these protocols might be useful in secondary surveillance after treatment for HCC. However, data on the reproducibility of AMRI protocols remains limited. Moreover, it is unknown whether other factors (e.g., rater experience, lesion size or underlying etiology of chronic liver disease) affect the reliability of detection of HCC recurrence. Thus, this retrospective study compared the diagnostic performance and inter-reader reliability of AMRI versus CMRI in detecting HCC recurrence in patients undergoing surveillance for HCC recurrence after curative ablation. Methods Our institutional review board approved this single-center retrospective study and waived the requirement for informed consent (HCB/2022/1289). We included BCLC-0/A HCC patients treated with percutaneous radiofrequency ablation or microwave ablation in the period comprising January 2016 through December 2019. To ascertain the efficacy of local ablation, the response was initially assessed with contrast-enhanced ultrasound (CEUS) 1 and 3 months after treatment. Patients who achieved a complete response in the ablated lesion underwent screening with serial liver MRI at 6-month intervals for early detection of HCC recurrence, in accordance with our standard-of-care protocol. Persistence of a complete response was defined as the absence of residual viable either intranodal or peri-nodal in a dynamic contrast-enhanced imaging test or necrosis encompassing all ablated tumor areas. The inclusion criteria were cirrhotic or chronic hepatitis B virus patients, with age ≥ 18 years, HCC diagnosed according to the European Association for the Study of the Liver (EASL) guidelines, [ 8 ] and percutaneous radiofrequency or microwave ablation as first-line therapy for HCC. Exclusion criteria was suboptimal non-diagnostic MRI quality (defined as LR-NC). In patients who underwent more than one MRI examination for surveillance of early HCC recurrence during the follow-up period, we selected the first MRI after CEUS confirmation of a complete response. For the purpose of this study, patients’ data were recorded until recurrence was detected or until they completed 2 years’ follow up or became lost to follow-up. In accordance with our standard procedure, new suspicious liver lesions identified on MRI whose diagnosis remained uncertain were studied with other techniques (e.g., CEUS, liver biopsy, or close MRI monitoring) to reach a conclusive diagnosis. Imaging protocol All patients underwent routine liver MRI on state-of-the-art 1.5T (Aera, Siemens Healthcare, Signa HD and HDxt GE Medical Systems) or 3T (Vida, Siemens Healthcare) multichannel systems. The protocol included axial single-shot fast spin-echo (SSFSE) or half-Fourier acquisition single-shot turbo spin-echo T2-weighted sequences with and without fat suppression, axial T1-weighted in-phase and opposed-phase sequences, axial diffusion-weighted imaging (DWI) with b-values 0-400-800 s/mm 2 for Siemens and 0-800 s/mm 2 for GE, and dynamic contrast-enhanced sequences. Supplementary Table 1 provides additional details about the MRI protocol. Images presented to readers: The study coordinator (JR), who was not involved in image interpretation, exported and codified two sets of MRI studies for included subjects: a conventional set including all available images from the standard liver CMRI protocol and a "simulated" non-contrast-AMRI set including only axial T2-weighted images with and without fat suppression, DWI (including the highest b-value available), and unenhanced 3D T1-weighted images with fat suppression. Each set of images was assigned a distinct alphanumeric code for identification purposes. The images in each set were randomly reordered and uploaded to a centralized image reading platform (Quibim Precision® software, Quibim; València, Spain). Images were presented to readers in two batches, first the AMRI images and then the CMRI images, with at least 1 month interval between batches. Image interpretation: After a nationwide call for readers in Spain, we selected readers based on their levels of experience, and their current affiliation to a dedicated HCC group with regular attendance at multidisciplinary tumor board meetings. A total of 8 radiologists from three academic institutions (5 women; median experience in liver imaging, 6.5 y; range 2‒30 y) independently evaluated the images. We grouped readers by experience in liver imaging, classifying 4 as novice (< 5 y experience) and 4 as experienced (≥ 5 y experience). Data were collected and managed using a REDCap (Research Electronic Data Capture) system hosted at our hospital. Readers were blinded to clinical information except the location of the ablated lesion. Readers reviewed MRI studies to screen for intrahepatic tumor recurrence, classifying observations as no recurrence, local recurrence, or new intrahepatic lesions. For screening purposes, any of the following AMRI findings were considered suspicious for local recurrence or new intrahepatic lesions: 1) focal mild-to-moderate hyperintensity on T2-weighted images, 2) focal hypointensity on fat-saturated 3D T1-weighted images; and/or 3) hyperintensity on DWI. If any of these findings suggestive of HCC were observed in readers were instructed to classify the lesion as a "suspicious lesion" that required additional work-up. Focal observations of high hyperintensity on T2-weighted images were categorized as benign, likely corresponding to cysts or hemangiomas. Analogous to the LIRADS-treatment response (LR-TR) definitions of equivocal or viable,[ 14 ] we considered the following CMRI findings positive for local recurrence: nodular or thick irregular tissue within or along the treated lesion with arterial phase hyperenhancement with or without washout. Because readers were blinded to previous examinations, we did not include the LR-TR criterion “enhancement pattern similar to pretreatment imaging” in our definition of local recurrence. To categorize new intrahepatic lesions on CMRI, we applied the same imaging criteria as used for AMRI, with the addition of any nodular arterial phase hyperenhancement ≥ 10 mm and/or hypointense nodular areas in the portal or venous phases. The LI-RADS v2018 category was assigned to each recorded observation based on its probability of the new intrahepatic lesion being malignant.[ 15 ] Those categorized by CMRI as LR-3, LR-4, LR-5, or LR-M were considered suspicious for or consistent with new malignant intrahepatic lesions. In light of the elevated risk of recurrence observed in this clinical setting, as compared to that seen in HCC-naïve patients, we considered appropriate to include LR3 as an observation that should be subject to early follow-up and/or the performance of additional tests. Readers recorded the location and size of all relevant AMRI and CMRI observations classified as suspicious for or consistent with new intrahepatic lesions. Patients were considered HCC-negative when the diagnostic test that is being evaluated against the ground truth (from then on, index study) or in follow-up MRI studies observed no lesions or only observations scored as LR 1/2. Reference Standards The reference diagnosis of recurrent HCC was based on histological confirmation or imaging-based confirmation. A single radiologist (JR with 18 years’ experience in liver MRI) who was not involved in imaging analysis reviewed patients’ medical charts and imaging studies, recording HCC recurrence (1) in cases with histological confirmation, (2) in those where the index multiphase MRI study showed 1 or more observations classified as LR-5 for new intrahepatic lesions or as LR-TR viable for local recurrence, or (3) in those where additional workup CEUS or multiphase MRI ≤ 6 months after the index multiphase MRI showed 1 or more observations classified as LR 5 for new intrahepatic lesions or as LR-TR viable for local recurrence. To exclude false-negative findings in the index multiphase MRI study, the same radiologist (JR) reviewed follow-up dynamic CT or MRI studies done 6 to 12 months after the index study, as well as radiological reports and clinical charts. When an HCC was detected on follow-up dynamic MRI or described on MRI reports, the index study was reviewed to ensure it had no false-negative findings. Post-reading Delphi survey: After the reading the image sets but before knowing the results of the study, readers worked together online to build a consensus and improve the methodology of AMRI for early detection of tumor recurrence. Decision-making was facilitated through a process in which questions were raised and readers voted on the appropriateness of the statements developed.[16; 17] Sample size calculation: Based on the results of a previous study using similar sets of images[ 18 ], we estimated that determining the concordance between AMRI and CMRI in detecting suspicious intrahepatic lesions in this study with 8 readers with an alpha of 0.05 and statistical power of 0.80 would require a minimum sample of 136 images per set.[ 19 ] Statistical analyses We report continuous variables as medians and ranges and categorical variables as frequencies and percentages. To assess and to compare the reliability of AMRI for detecting recurrence of HCC, we conducted per-patient (suspicious of any type of HCC) and per-location analyses (local recurrence, new intrahepatic lesions, or any location). To determine and compare the intra- and inter-reader agreements for local recurrence at the ablation site, new intrahepatic lesions in other locations, or any recurrence, we calculated Gwet's concordance 1 (AC1), which compared with kappa statistics, corrects for prevalence dependence in categorizations.[20; 21] We classified inter-reader and intra-reader reliability based on AC1 as poor (< 0.0), slight (0.0–0.2), fair (0.21–0.4), moderate (0.41–0.6), substantial, 0.61–0.8, or near-perfect (0.81–1.0).[ 22 ] To compare inter-reader reliabilities, we analyzed whether their 95% confidence intervals overlapped. To evaluate the performance of AMRI as a screening tool, we calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AMRI and CMRI a per-patient basis. We aimed to identify sources of disagreement using a post-reading Delphi survey. A number of statements related to potential sources of disagreement were developed into a survey that was distributed to readers as part of a pilot survey. Comments and responses on content and format from the eight readers were included in the final survey. Each statement was rated on a Likert scale of 1–9, where 1 = 'strongly agree' and 9 = 'strongly disagree'. The selection of consensus statements was based on a two-step selection based on appropriateness and level of disagreement. In the first round of selection, statements that achieved a median of 1–3 or 7–9 would be appropriate in a positive or negative direction and would be retained as recommendations. In the second round of selection, we focused on the level of disagreement. Disagreement was considered present when ≥ 2 panelists rated appropriateness at different extremes of the scale (1–3 and 7–9). All tests were two-sided, and significance was set at 5%. All calculations and analyses were performed with SAS 9.4 software (SAS Institute, Cary, NC, USA). Results Study participants and radiologists A total of 100 cirrhotic patients underwent percutaneous radiofrequency ablation of HCC in the study period; of these, 25 were excluded. The flowchart in Fig. 1 explains the reasons for exclusion, and Table 1 reports the demographic and clinical characteristics of the 75 patients included in the study. All patients, except one who had chronic HBV, were cirrhotic. Altogether, we included 143 MRI studies [median per patient, 2 (IQR 1‒3); 110 (76.9%) acquired in 1.5T scanners and 33 (23.1%) in a 3T scanner]. HCC recurrence was detected in 37 (49.3%) patients: 12 had local recurrence alone, 21 had new intrahepatic lesions, and 4 had both local recurrence and new intrahepatic lesions. No vascular invasion was detected. Table 1 Demographics of subjects included in the study Abbreviations: HCV = hepatitis C virus, HBV = hepatitis B virus, SLD: steatotic liver disease Number of patients 75 Age, median (range) 67 (42–87) Male/female, n (%) 53 (71) /22 (29) Cirrhosis, n (%) 75 (100) Etiology, n (%) HCV 40 (53.3) Alcohol 18 (24) HCV + alcohol 5 (7.7) HBV 1 (1.3) HCV + HBV 2 (2.7) SLD 8 (10.6) SLD + alcohol 1 (1.3) Child-Pugh class A/B, N (%) 66 (88) /8 (10.7) Inter-reader agreement Table 2 reports the different measures of inter-reader agreement between AMRI and CMRI for each type of recurrence. Overall, the proportion of observed agreement (P 0 ) was high, but kappa values were low. After correcting for prevalence dependence (AC1), the overall reliability was near-perfect for AMRI and CMRI. However, the AC1 for detecting new intrahepatic lesions was higher for AMRI [0.85 (near-perfect) 95%CI:0.81‒0.90 vs. 0.60 (moderate) 95%CI:0.52‒0.67] for CMRI). Similarly, the AC1 for detecting any type of tumor recurrence was higher for AMRI [0.73 (substantial) 95%CI:0.67‒0.78 vs. 0.56 (moderate) 95%CI:0.49‒0.64 for CMRI]. Table 2 Inter-reader agreement measured by Gwet's AC1, by type of recurrence, for all readers and by level of experience. Abbreviations: CI: confidence interval; AMRI: Abbreviated MRI; CMRI: contrast-enhanced MRI; NIH: new intrahepatic recurrence Gwet's AC1 (95%CI) All readers Local Recurrence AMRI 0.87 (0.83‒0.90) CMRI 0.87 (0.83‒0.92) NIH Recurrence AMRI 0.85 (0.81‒0.90) CMRI 0.60 (0.52‒0.67) Any Type of Recurrence AMRI 0.73 (0.67‒0.78) CMRI 0.56 (0.49‒0.64) Novice readers (< 5 years’ experience) Local Recurrence AMRI 0.87 (0.82‒0.92) CMRI 0.87 (0.82‒0.93) NIH Recurrence AMRI 0.90 (0.86‒0.94) CMRI 0.51 (0.41‒0.61) Any Type of Recurrence AMRI 0.76 (0.70‒0.83) c-MRI 0.49 (0.39‒0.58) Experienced readers (≥ 5 years’ experience) Local Recurrence AMRI 0.86 (0.81‒0.91) CMRI 0.87 (0.82‒0.92) NIH Recurrence AMRI 0.80 (0.74‒0.86) CMRI 0.70 (0.61‒0.79) Any Type of Recurrence AMRI 0.68 (0.60‒0.76) CMRI 0.65 (0.56‒0.74) Inter-reader agreement according to reader experience Inter-reader agreement for the detection of local recurrence was similar among novice readers and among experienced readers, being near-perfect in both groups of readers. However, inter-reader agreement for the detection of new intrahepatic lesions differed between the two groups, both for AMRI, where it was lower among experienced readers [0.80 (substantial) 95%CI:0.74‒0.86] than among novice readers [0.90 (near-perfect) 95%CI:0.86‒0.94], and for CMRI, where it was higher among experienced readers [0.70 (substantial) 95%CI:0.61‒0.79] than among novices [0.51 (moderate) 95%CI:0.41‒0.61] (Table 2 ). Intra-reader agreement The overall intra-reader agreement was near-perfect for detecting local recurrence and moderate for detecting new intrahepatic lesions and for detecting any type of recurrence (Supplementary Table 2). Observations reported Pooling together the readings of the 8 radiologists, we obtained 1144 readings in each set (Supplementary Table 3). The median size of new intrahepatic lesions was 15 mm (IQR10‒25) in AMRI and 20 mm (IQR 12‒34) in CMRI (p = 0.89). Detection of HCC recurrence In the pooled readings, HCC recurrence of any type was detected in 190 AMRI sets and in 438 CMRI sets. Table 3 reports the per-patient and per-location diagnostic sensitivity, specificity, PPV, and NPV for HCC recurrence in CMRI and AMRI for the pooled results of all readers and for the two subgroups of readers (novice and experienced). Table 4 compares the sensitivities and specificities of AMRI and CMRI for detecting local recurrence, new intrahepatic lesions, and any type of HCC for all readers. The per-patient sensitivity for detecting local recurrence, new intrahepatic lesions, and any type of HCC recurrence was higher with CMRI than with AMRI (p < 0.0001). Table 3 Sensitivity, specificity, positive predictive value, and negative predictive value, by type of recurrence and readers’ level of experience. Number in parentheses are the 95% confidence intervals. Abbreviations: AMRI: abbreviated magnetic resonance imaging; CMRI: contrast-enhanced magnetic resonance imaging Local recurrence New intrahepatic lesion Any type recurrence AMRI CMRI AMRI CMRI AMRI CMRI All readers Sensitivity 0.22 (0.15‒0.30) 0.45 (0.36‒0.54) 0.29 (0.22‒0.35) 0.80 (0.74‒0.85) 0.39 (0.33‒0.45) 0.83 (0.78‒0.87) Specificity 0.94 (0.92‒0.95) 0.94 (0.92‒0.95) 0.95 (0.93‒0.96) 0.79 (0.77‒0.82) 0.91 (0.89‒0.93) 0.77 (0.74‒0.80) Positive Predictive Value 0.31 (0.22‒0.42) 0.47 (0.38‒0.56) 0.54 (0.44‒0.64) 0.45 (0.40‒0.51) 0.61 (0.53‒0.68) 0.56 (0.51‒0.61) Negative Predictive Value 0.91 (0.89‒0.92) 0.93 (0.91‒0.95) 0.86 (0.84‒0.88) 0.95 (0.93‒0.96) 0.81 (0.78‒0.83) 0.93 (0.91‒0.95) Experienced readers Sensitivity 0.19 (0.10‒0.30) 0.38 (0.26‒0.50) 0.28 (0.19‒0.38) 0.83 (0.74‒0.90) 0.43 (0.34‒0.51) 0.81 (0.74‒0.87) Specificity 0.93 (0.91‒0.95) 0.94 (0.91‒0.96) 0.93 (0.90‒0.95) 0.84 (0.80‒0.87) 0.90 (0.87‒0.93) 0.82 (0.78‒0.85) Positive Predictive Value 0.26 (0.14‒0.40) 0.43 (0.30‒0.57) 0.46 (0.33‒0.59) 0.53 (0.44‒0.61) 0.59 (0.49‒0.69) 0.61 (0.53‒0.67) Negative Predictive Value 0.90 (0.87‒0.93) 0.92 (0.9‒0.94) 0.86 (0.83‒0.89) 0.96 (0.94‒0.98) 0.82 (0.78‒0.85) 0.93 (0.89‒0.95) Novice readers Sensitivity 0.25 (0.15‒0.37) 0.52 (0.39‒0.64) 0.29 (0.20‒0.39) 0.77 (0.68‒0.85) 0.35 (0.27‒0.43) 0.85 (0.78‒0.90) Specificity 0.95 (0.92‒0.96) 0.94 (0.91‒0.95) 0.97 (0.95‒0.98) 0.75 (0.71‒0.79) 0.92 (0.90‒0.95) 0.73 (0.69‒0.77) Positive Predictive Value 0.37 (0.23‒0.53) 0.50 (0.37‒0.63) 0.66 (0.50‒0.80) 0.39 (0.32‒0.46) 0.62 (0.51‒0.72) 0.53 (0.46‒0.59) Negative Predictive Value 0.91 (0.88‒0.93) 0.94 (0.91‒0.96) 0.87 (0.83‒0.89) 0.94 (0.91‒0.96) 0.80 (0.77‒0.84) 0.93 (0.90‒0.96) Table 4 Comparison of overall sensitivities (true positive) and specificities (true negatives) between abbreviated non-contrast MRI and standard contrast-enhanced liver MRI. Abbreviations: AMRI: abbreviated magnetic resonance imaging; CMRI: contrast-enhanced magnetic resonance imaging Local Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 21 7 <0.0001 18 44 0.7532 No 36 64 47 907 New Intrahepatic Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 45 12 <0.0001 21 27 <0.0001 No 115 28 173 723 Any type Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 99 16 <0.0001 36 39 <0.0001 No 147 34 156 617 Effect of experience on detection of HCC recurrence The comparison of sensitivity and specificity in novice and experienced readers was analogous to that reported when the data from the radiologists were analyzed overall (Table 5 ). Table 5 Comparison of sensitivities (true positive) and specificities (true negatives) between abbreviated non-contrast MRI and standard contrast-enhanced liver MRI. Experienced readers Local Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 8 4 0.0073 11 24 0.6547 No 16 36 21 452 New Intrahepatic Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 24 4 <0.0001 15 18 <0.0001 No 59 13 60 378 Any type Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 56 7 <0.0001 21 22 <0.0001 No 64 21 57 324 Novice readers Local Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 13 3 0.0004 7 20 0.3763 No 20 28 26 455 New Intrahepatic Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 21 8 <0.0001 15 18 <0.0001 No 56 15 60 344 Any type Recurrence Yes (True positive) No (True negative) Group Class CMRI McNemar test (p-value) CMRI McNemar test (p-value) Yes No Yes No AMRI Yes 43 9 <0.0001 15 17 <0.0001 No 88 13 99 193 Abbreviations: AMRI: abbreviated magnetic resonance imaging; CMRI: contrast-enhanced magnetic resonance imaging The sensitivity for detecting any type of recurrence with AMRI was higher in the group of experienced radiologists [0.43 (0.34‒0.51) vs. 0.35 (0.27‒0.43) in the group of novices, p = 0.0343]. (Supplementary Table 4) Sources of disagreement The Delphi process identified the following factors that can potentially influence reader agreement and accuracy: (1) lesion characteristics (size and number of sequences where lesions can be detected); (2) liver background and underlying cause of cirrhosis; and (3) lack of intravenous contrast sequences (Supplementary Table 5). Readers’ experience was not perceived as a relevant factor. Discussion The current study explored the multi-reader reliability of a non-contrast AMRI for detecting early HCC recurrence in cirrhotic patients undergoing surveillance for early HCC recurrence following curative ablation of HCC to determine whether non-contrast AMRI might be a viable alternative to CMRI for surveillance in a Western population. We also evaluated and compared the sensitivities and the specificities of AMRI and CMRI in detecting the recurrence of HCC, as well as the impact of readers’ experience on the reliability and the validity of non-contrast AMRI and CMRI for the detection of HCC recurrence. HCC recurs in less than 2 years after ablation in up to 50% of cases, typically through occult tumor dissemination that often results in multifocal intrahepatic recurrence,[ 23 ] thus warranting intense surveillance including contrast-enhanced MRI, which is more sensitive than ultrasound for early tumor recurrence. [10; 24] Many studies have analyzed AMRI for primary screening for HCC, but fewer have examined its potential for screening of early HCC recurrence. The higher incidence of early recurrence after curative therapeutic options makes the application of AMRI appealing in this scenario. Three principal approaches to AMRI have been proposed: non-contrast AMRI, dynamic contrast-enhanced AMRI, and hepatobiliary-phase contrast-enhanced AMRI. The results of recent systematic reviews and meta-analyses indicate that the sensitivity of these three strategies in detecting liver lesions in at-risk populations is comparable.[11; 12; 25] In this context, the objective of AMRI is not to formally characterize observations, but rather to identify patients with suspicious findings. The technique is simple and does not require the injection of contrast media. As in Jeon et al.’s [ 9 ] recent retrospective study in Korean patients, we simulated non-contrast AMRI findings to explore this technique’s potential in the early detection of tumor recurrence. Their analysis of data acquired with a 3T system found no significant difference in detection between non-contrast AMRI or hepatobiliary-phase AMRI and full sequence gadoxetic acid-enhanced MRI during secondary surveillance for late (> 2 years) HCC recurrence after curative treatment in a cohort with predominant (79.4%) chronic VHB hepatitis, reporting per-patient sensitivities ranging 53.9% from 83.3% for non-contrast-AMRI. In our study, the overall sensitivity of AMRI reported by the eight readers was significantly lower than CMRI for early HCC recurrence, particularly due to AMRI’s worse performance in detecting new intrahepatic lesions. Our study provides important new information about the reproducibility of AMRI in surveillance for HCC recurrence. The inter-reader agreement of AMRI for the detection of local recurrence was similar to that of CMRI; however, the inter-reader agreement for new intrahepatic lesions and for any type of recurrence was higher for AMRI than for CMRI. This unexpected finding is due to readers identifying fewer lesions in the AMRI image sets and to AMRI’s overall lower sensitivity for detecting HCC recurrence. AMRI had significantly higher sensitivity in detecting any type of recurrence when used by experienced readers than when used by novice readers (p = 0.0343). Moreover, experienced readers had lower rates of false-positive interpretation of new intrahepatic lesions than novices (p = 0.0027), thus suggesting that expertise could potentially reduce the number of recall tests if AMRI were adopted for surveillance of HCC recurrence. Multiple factors can affect the sensitivity of a screening tool for detecting HCC recurrence and therefore its inter-reader agreement. Our Delphi survey revealed that readers perceived that sensitivity improves with the number of sequences where lesions can be identified. They also perceived that liver parenchyma heterogeneity caused by HCV and/or alcohol induced cirrhosis hindered the detection of HCC recurrence on T2-weighted and DWI sequences, which formed the backbone of our AMRI protocol. Most evidence regarding the accuracy of AMRI studies comes from Asian cohorts [13; 26; 27] where HBV was the predominant underlying cause of chronic liver disease and low rates of liver cirrhosis. Patients with HCV-related HCC are much more likely to have underlying liver cirrhosis than patients with HBV-related HCC [ 28 ], and the rate of HCC hyperintensity on DWI and T2-weighted images is higher in HBV than in HCV (Fig. 2 ). [ 29 ] All patients included in this study were cirrhotic, with the most prevalent causes (84%) were HCV infection and/or alcohol consumption. Thus, our cohort is fairly typical of HCC patients in Western countries. [ 2 ] The findings of our Delphi survey suggest that this difference in the characteristics of our patients results in increased parenchymal heterogeneity that hinders detection of HCC recurrence, especially new intrahepatic lesions, with non-contrast AMRI. We have focused in a cohort of HCC patients with very-early or early stage according to the BCLC classification, which is associated to a median survival time above 5 years. [ 3 ] The early detection of HCC recurrence in this scenario may be of paramount relevance to offer a new curative therapeutic option. A major strength of our study is that it analyzes the operational characteristics of AMRI with a total of eight readers from three centers, four with < 5 years’ experience and four with ≥ 5 years’ experience. This approach allowed us to analyze the effects of experience on the validity of AMRI for the detection of early HCC recurrence. Our study has limitations. Its retrospective design involves an inherent risk of selection bias; however, we included consecutive patients who underwent liver MRI for surveillance of early HCC recurrence following a complete response to curative treatment for HCC. Moreover, AMRI sets were simulated and extracted from contrast-enhanced liver MRI studies; acquiring AMRI sets separately might have led to different results, although it would have inconvenienced patients and increased costs. Finally, prioritizing the inclusion of consecutive patients rather than ensuring image sets were acquired on scanners from a single vendor with homogeneous magnetic fields meant that we had an imbalance of patients studied with 1.5T and 3T scanners. The image quality in the T2-weighted and DWI sequences that were the backbone of our AMRI protocol can vary depending on field strength and vendors, and this variation could affect our results. This technical aspect has been identified by a group of readers, albeit without sufficient consensus, as a possible explanation for the poor performance observed in the study, and we believe it warrants further investigation. In surveillance for early HCC recurrence, interobserver agreement for the detection of intrahepatic recurrence was higher for non-contrast AMRI than for CMRI. AMRI had significantly higher sensitivity in detecting any type of recurrence when used by experienced readers. However, in our cohort where HCV and/or alcohol-related cirrhosis were the predominant etiologies, as is typical in Western populations, the overall pooled sensitivity of AMRI was unacceptably lower than that of CMRI. Declarations Competing Interests Jordi Rimola has served as advisor to Roche, MEDIVIR and Universal Dx, and has received lecture or consultancy fees from Astrazeneca and Roche. Alicia Mesa has received lecture feed from GE Healthcare.María Reig has served as advisor and received lectures fee to AstraZeneca, Bayer, BMS, Eli Lilly, Geneos, Ipsen, Merck, Roche, Universal DX, Engitix Therapeutics, MEDIVIR, Biotoscana Farma S.A. Travel suppor by: Astrazeneca, Roche, Bayer, BMS, Lilly, Ipsen. Grant Research Support (to the institution): Bayer, Ipsen. Educational Support (to the institution): Bayer, Astrazeneca, BMS, Eisai- Merck MSD, Roche, Ipsen, Lilly, Terumo, Next, Boston Scientific, Ciscar Medical, Eventy 03 LLC (Egypt).The rest of the authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Author Contribution JR, MR: conception and design of the work; BS, AI, AD, SJ AM, VN, AS, CA: data acquisitionAR and JR analysis and interpretation of data;JR drafted the work ;All authors whose names appear on the submission revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Acknowledgement John Giba, native medical english corrector. Data Availability Data is provided within the manuscript or supplementary information files References Llovet JM, Kelley RK, Villanueva A et al (2021) Hepatocellular carcinoma. Nat Rev Dis Primers 7:6 Rumgay H, Arnold M, Ferlay J et al (2022) Global burden of primary liver cancer in 2020 and predictions to 2040. J Hepatol 77:1598–1606 Reig M, Forner A, Avila MA et al (2021) Diagnosis and treatment of hepatocellular carcinoma. Update of the consensus document of the AEEH, AEC, SEOM, SERAM, SERVEI, and SETH. Med Clin (Barc) 156:463 e461-463 e430 Sherman M (2008) Recurrence of hepatocellular carcinoma. N Engl J Med 359:2045–2047 Zytoon AA, Ishii H, Murakami K et al (2007) Recurrence-free survival after radiofrequency ablation of hepatocellular carcinoma. A registry report of the impact of risk factors on outcome. Jpn J Clin Oncol 37:658–672 Morimoto M, Numata K, Nozaki A, Tanaka K (2009) Prognosis following non-surgical second treatment in patients with recurrent hepatocellular carcinoma after percutaneous ablation therapy. Liver Int 29:443–448 Singal AG, Llovet JM, Yarchoan M et al (2023) AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 78:1922–1965 European Association for the Study of the Liver. Electronic address eee, European Association for the Study of the L (2024) EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma. J Hepatol. 10.1016/j.jhep.2024.08.028 Jeon SK, Lee DH, Hur BY et al (2023) Abbreviated MRI for Secondary Surveillance of Recurrent Hepatocellular Carcinoma After Presumed Curative Treatment. J Magn Reson Imaging 58:1375–1383 Kim SY, An J, Lim YS et al (2017) MRI With Liver-Specific Contrast for Surveillance of Patients With Cirrhosis at High Risk of Hepatocellular Carcinoma. JAMA Oncol 3:456–463 Chan MV, Huo YR, Trieu N et al (2022) Noncontrast MRI for Hepatocellular Carcinoma Detection: A Systematic Review and Meta-analysis – A Potential Surveillance Tool ? Clinical Gastroenterology and Hepatology 20:44–56.e42 Gupta P, Soundararajan R, Patel A, Kumar-m P, Sharma V, Kalra N (2021) Abbreviated MRI for hepatocellular carcinoma screening: A systematic review and meta-analysis Abbreviated MRI for hepatocellular carcinoma screening : A. Journal of Hepatology 75:108–119 Maung ST, Deepan N, Decharatanachart P, Chaiteerakij R (2024) Abbreviated MRI for Hepatocellular Carcinoma Surveillance - A Systematic Review and Meta-analysis. Acad Radiol 31:3142–3156 LI-RADS ACoRCo (2024) Observation treated by nonradiation-based LRT or at surgical margin after resection, imaged with multiphase CT/MRI in at-risk patient. Chernyak V, Fowler KJ, Kamaya A et al (2018) Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients. Radiology 289:816–830 Brook RH (1994) Appropriateness: the next frontier. BMJ 308:218–219 Moher D, Schulz KF, Simera I, Altman DG (2010) Guidance for developers of health research reporting guidelines. PLoS Med 7:e1000217 McNamara MM, Thomas JV, Alexander LF et al (2018) Diffusion-weighted MRI as a screening tool for hepatocellular carcinoma in cirrhotic livers: correlation with explant data-a pilot study. Abdom Radiol (NY) 43:2686–2692 Walter SD, Eliasziw M, Donner A (1998) Sample size and optimal designs for reliability studies. Stat Med 17:101–110 Feinstein AR, Cicchetti DV (1990) High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 43:543–549 Wongpakaran N, Wongpakaran T, Wedding D, Gwet KL (2013) A comparison of Cohen's Kappa and Gwet's AC1 when calculating inter-rater reliability coefficients: a study conducted with personality disorder samples. BMC Med Res Methodol 13:61 Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174 Portolani N, Coniglio A, Ghidoni S et al (2006) Early and late recurrence after liver resection for hepatocellular carcinoma: prognostic and therapeutic implications. Ann Surg 243:229–235 Park HJ, Kim SY, Singal AG et al (2022) Abbreviated magnetic resonance imaging vs ultrasound for surveillance of hepatocellular carcinoma in high-risk patients. Liver Int 42:2080–2092 Kim DH, Hyun Choi S, Hyun Shim J et al (2021) Meta-Analysis of the Accuracy of Abbreviated Magnetic Resonance Imaging for Hepatocellular Carcinoma Surveillance: Magnetic Resonance Imaging. Cancers 13:1–13 Park HJ, Seo N, Kim SY (2022) Current Landscape and Future Perspectives of Abbreviated MRI for Hepatocellular Carcinoma Surveillance. Korean Journal of Radiology:1–17 Ronot M, Nahon P, Rimola J (2023) Screening of liver cancer with abbreviated magnetic resonance imaging. Hepatology. 10.1097/HEP.0000000000000339 Chen CH, Huang GT, Yang PM et al (2006) Hepatitis B- and C-related hepatocellular carcinomas yield different clinical features and prognosis. Eur J Cancer 42:2524–2529 Dunst D, Ream JM, Khalef V, Hajdu CH, Rosenkrantz AB (2016) Comparison of MRI features of pathologically proven hepatocellular carcinoma between patients with hepatitis B and hepatitis C infection. Clin Imaging 40:352–356 Additional Declarations Competing interest reported. Jordi Rimola has served as advisor to Roche, MEDIVIR and Universal Dx, and has received lecture or consultancy fees from Astrazeneca and Roche. Alicia Mesa has received lecture feed from GE Healthcare. María Reig has served as advisor and received lectures fee to AstraZeneca, Bayer, BMS, Eli Lilly, Geneos, Ipsen, Merck, Roche, Universal DX, Engitix Therapeutics, MEDIVIR, Biotoscana Farma S.A. Travel suppor by: Astrazeneca, Roche, Bayer, BMS, Lilly, Ipsen. Grant Research Support (to the institution): Bayer, Ipsen. Educational Support (to the institution): Bayer, Astrazeneca, BMS, Eisai- Merck MSD, Roche, Ipsen, Lilly, Terumo, Next, Boston Scientific, Ciscar Medical, Eventy 03 LLC (Egypt). The rest of the authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Supplementary Files Supplementarymaterialclean.pdf Cite Share Download PDF Status: Published Journal Publication published 09 Jul, 2025 Read the published version in Abdominal Radiology → Version 1 posted Editorial decision: Revision requested 14 Jun, 2025 Reviews received at journal 30 Mar, 2025 Reviewers agreed at journal 29 Mar, 2025 Reviewers invited by journal 29 Mar, 2025 Editor assigned by journal 27 Mar, 2025 Submission checks completed at journal 27 Mar, 2025 First submitted to journal 25 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6306750","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":438180563,"identity":"43fc4ce7-8fb8-4d6e-aaf3-1b0c1e75ede5","order_by":0,"name":"Jordi Rimola","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBACxgbGBgaGAgY5BnYgI4F4LQYMxgzMMC1sRNllwJDYwAzjENLCPPtw64YPBnbp/c3MbQ8e1DDI889vIOCwvsS2mzMMknNnHGZsN0g4xmA44xgBWxh7GNtu8xgw525gZmyTSAR5h0gt9ekGMC3yRGo5nADXYkCMFqBfjhsC/dImkXBMwnDjsQT8Wgx72J/d+FBRLc/f3v5M8keNjbzc4QMEtDSg8iUIuAoI5AkrGQWjYBSMghEPANaGPkm1LM4IAAAAAElFTkSuQmCC","orcid":"","institution":"1-\tBCLC group, Radiology Department. Hospital Clínic de Barcelona. Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.","correspondingAuthor":true,"prefix":"","firstName":"Jordi","middleName":"","lastName":"Rimola","suffix":""},{"id":438180564,"identity":"fa23b8c5-ed3d-49f8-ada3-e61097b60dbf","order_by":1,"name":"Belén Saborido","email":"","orcid":"","institution":"3-\tBCLC group, Fundació Clínic per la Recerca Biomèdica – Institut d’Investigacions Biomèdiques August Pi i Sunyer (FCRB-IDIBAPS), Barcelona, Spain","correspondingAuthor":false,"prefix":"","firstName":"Belén","middleName":"","lastName":"Saborido","suffix":""},{"id":438180565,"identity":"799f7695-43b8-4d27-b6a8-cb5889127bc7","order_by":2,"name":"Alba Igual","email":"","orcid":"","institution":"4-\tBCLC group, Radiology Department. Hospital Clínic de Barcelona, Barcelona, Spain.","correspondingAuthor":false,"prefix":"","firstName":"Alba","middleName":"","lastName":"Igual","suffix":""},{"id":438180566,"identity":"fd5e3416-e16e-492d-8221-d7dd7af676a7","order_by":3,"name":"Andreu Roca","email":"","orcid":"","institution":"5-\tStatistics core, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.","correspondingAuthor":false,"prefix":"","firstName":"Andreu","middleName":"","lastName":"Roca","suffix":""},{"id":438180567,"identity":"c386778e-0798-4cca-a899-426fa4361864","order_by":4,"name":"Anna Darnell","email":"","orcid":"","institution":"4-\tBCLC group, Radiology Department. Hospital Clínic de Barcelona, Barcelona, Spain.","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Darnell","suffix":""},{"id":438180568,"identity":"fe008d50-bbf2-4158-a36d-814fc9f0f6bb","order_by":5,"name":"Sergio Jiménez","email":"","orcid":"","institution":"6-\tRadiology Department. Hospital Clínic de Barcelona, Barcelona, Spain.","correspondingAuthor":false,"prefix":"","firstName":"Sergio","middleName":"","lastName":"Jiménez","suffix":""},{"id":438180569,"identity":"77a68ef5-8c4d-4ee1-9f61-174a91bfe539","order_by":6,"name":"Alicia Mesa","email":"","orcid":"","institution":"7-\tRadiology Department. Hospital Universitario Central de Asturias, Oviedo, Spain","correspondingAuthor":false,"prefix":"","firstName":"Alicia","middleName":"","lastName":"Mesa","suffix":""},{"id":438180570,"identity":"65e1bbf7-92b7-4389-8c96-07f69e8bfe3d","order_by":7,"name":"Vicente Navarro","email":"","orcid":"","institution":"8-\tAbdominal Radiology Department, Clinical Area of Medical Imaging. Hospital Universitari i Politècnic La Fe, València,","correspondingAuthor":false,"prefix":"","firstName":"Vicente","middleName":"","lastName":"Navarro","suffix":""},{"id":438180571,"identity":"65a14aa6-7d81-4451-9b7e-5ec9ac31ad58","order_by":8,"name":"Alexandre Soler","email":"","orcid":"","institution":"4-\tBCLC group, Radiology Department. Hospital Clínic de Barcelona, Barcelona, Spain.","correspondingAuthor":false,"prefix":"","firstName":"Alexandre","middleName":"","lastName":"Soler","suffix":""},{"id":438180572,"identity":"6693b4b6-ee0a-49de-ad3b-d45adfc9c748","order_by":9,"name":"Carmen Ayuso","email":"","orcid":"","institution":"4-\tBCLC group, Radiology Department. Hospital Clínic de Barcelona, Barcelona, Spain.","correspondingAuthor":false,"prefix":"","firstName":"Carmen","middleName":"","lastName":"Ayuso","suffix":""},{"id":438180573,"identity":"e7ff759b-13d8-4722-8040-4dc23e0ea886","order_by":10,"name":"María Reig","email":"","orcid":"","institution":"10-\tBarcelona Clinic Liver Cancer (BCLC) group. Liver Oncology Unit, Liver Unit, Hospital Clinic de Barcelona. Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"","lastName":"Reig","suffix":""}],"badges":[],"createdAt":"2025-03-25 20:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6306750/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6306750/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00261-025-05105-5","type":"published","date":"2025-07-09T15:57:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81018323,"identity":"a0c7a61c-6956-4552-a803-b8b997dbde12","added_by":"auto","created_at":"2025-04-21 09:17:39","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73794,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patients included in the study.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6306750/v1/812832b9771972d7e0f19d13.jpg"},{"id":81019388,"identity":"61dea16a-baf3-4e17-8443-3eee3266fa40","added_by":"auto","created_at":"2025-04-21 09:25:39","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":696932,"visible":true,"origin":"","legend":"\u003cp\u003eRecurrent hepatocellular carcinoma in a 49-year-old man with HCV-related liver cirrhosis, 18 months after ablation of HCC in segment V. A 1-cm nodule in liver segment III (arrows) shows mild hyperintensity on T2-weighted with fat suppression image (figure A) and hyperintensity on diffusion-weighted imaging (b = 800 sec/mm2) (figure B). The nodule shows non-rim hyperenhancement on arterial phase (figure C) but not convincing washout appearance on portal venous phase (figure D). The recurrence was confirmed after ultrasound guided biopsy (not shown). This lesion was categorized as new intrahepatic hepatocellular carcinoma recurrence by reviewers on non-contrast abbreviated magnetic resonance imaging.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6306750/v1/d2961fbb3c34d5e51f0c6d2f.jpg"},{"id":86699261,"identity":"3b07f10c-8942-4fcd-abda-88f3cf8a9c80","added_by":"auto","created_at":"2025-07-14 16:06:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2624285,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6306750/v1/17a8802a-f351-4b9c-a6f3-17f9392f783a.pdf"},{"id":81018321,"identity":"ab55c686-4e91-402d-9a46-823ffdb9e322","added_by":"auto","created_at":"2025-04-21 09:17:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":154923,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterialclean.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6306750/v1/f1a6e71ce980cb163f7c105c.pdf"}],"financialInterests":"Competing interest reported. Jordi Rimola has served as advisor to Roche, MEDIVIR and Universal Dx, and has received lecture or consultancy fees from Astrazeneca and Roche. \nAlicia Mesa has received lecture feed from GE Healthcare.\nMaría Reig has served as advisor and received lectures fee to AstraZeneca, Bayer, BMS, Eli Lilly, Geneos, Ipsen, Merck, Roche, Universal DX, Engitix Therapeutics, MEDIVIR, Biotoscana Farma S.A. Travel suppor by: Astrazeneca, Roche, Bayer, BMS, Lilly, Ipsen. Grant Research Support (to the institution): Bayer, Ipsen. Educational Support (to the institution): Bayer, Astrazeneca, BMS, Eisai- Merck MSD, Roche, Ipsen, Lilly, Terumo, Next, Boston Scientific, Ciscar Medical, Eventy 03 LLC (Egypt).\nThe rest of the authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.","formattedTitle":"Reproducibility and accuracy of non-contrast abbreviated magnetic resonance imaging of the liver in surveillance for early recurrence for hepatocellular carcinoma in a Western population: a multi-reader study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatocellular carcinoma (HCC) is the most common primary liver cancer and the leading cause of death in patients with cirrhosis irrespective of etiology.[1; 2]\u003c/p\u003e \u003cp\u003ePatients with very early- and early-stage HCC (stages 0 and A in the Barcelona Clinic Liver Cancer (BCLC) classification) are eligible for curative ablation or surgery, with an expected survival of \u0026gt;\u0026thinsp;5 years.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The treatment algorithm for primary HCC has been extrapolated to HCC recurrence after curative options (i.e HCC ablation), improving long-term survival of this group of patients. After successful treatment with resection or radiofrequency ablation, HCC recurs in 60\u0026ndash;70% within 5 years, with up to 50% of recurrences detected within the first 12 months.[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] In contrast to patients in the intermediate stage of the BCLC classification, the early detection of recurrence after ablation is intended to offer new therapeutic options with curative intent. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Consequently, current HCC management guidelines prioritize continuous surveillance for recurrence after curative treatment; however, there is no clear consensus regarding the optimal technique for surveillance of HCC recurrence. Whereas major liver international society guidelines clearly recommend ultrasonography for HCC screening in patients at risk of development of HCC,[7; 8] given the greater risk of new HCC after curative treatment, survillance to detect early recurrence with multiphase contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) every 6 months seems reasonable.\u003c/p\u003e \u003cp\u003eContrast-enhanced MRI yield the highest sensitivity and very high specificity for detecting new or recurrent HCC, [9; 10] but using these techniques in HCC recurrence surveillance in cirrhotic patients can detect many inconclusive lesions (perfusion abnormalities, HCC precursors, etc.) that require additional examinations, especially in less-experienced centers, introducing the risk of overdiagnosis, overtreatment, and increased anxiety.\u003c/p\u003e \u003cp\u003eTwo recent meta-analyses found that abbreviated MRI protocols (AMRI) without intravenous contrast were comparable to conventional contrast-enhanced MRI (CMRI) for the detection of focal liver lesions [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and another large study reported similar findings for monitoring late recurrence,[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] thus suggesting that these protocols might be useful in secondary surveillance after treatment for HCC. However, data on the reproducibility of AMRI protocols remains limited. Moreover, it is unknown whether other factors (e.g., rater experience, lesion size or underlying etiology of chronic liver disease) affect the reliability of detection of HCC recurrence. Thus, this retrospective study compared the diagnostic performance and inter-reader reliability of AMRI versus CMRI in detecting HCC recurrence in patients undergoing surveillance for HCC recurrence after curative ablation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e Our institutional review board approved this single-center retrospective study and waived the requirement for informed consent (HCB/2022/1289).\u003c/p\u003e \u003cp\u003eWe included BCLC-0/A HCC patients treated with percutaneous radiofrequency ablation or microwave ablation in the period comprising January 2016 through December 2019. To ascertain the efficacy of local ablation, the response was initially assessed with contrast-enhanced ultrasound (CEUS) 1 and 3 months after treatment. Patients who achieved a complete response in the ablated lesion underwent screening with serial liver MRI at 6-month intervals for early detection of HCC recurrence, in accordance with our standard-of-care protocol. Persistence of a complete response was defined as the absence of residual viable either intranodal or peri-nodal in a dynamic contrast-enhanced imaging test or necrosis encompassing all ablated tumor areas.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were cirrhotic or chronic hepatitis B virus patients, with age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, HCC diagnosed according to the European Association for the Study of the Liver (EASL) guidelines, [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and percutaneous radiofrequency or microwave ablation as first-line therapy for HCC. Exclusion criteria was suboptimal non-diagnostic MRI quality (defined as LR-NC).\u003c/p\u003e \u003cp\u003eIn patients who underwent more than one MRI examination for surveillance of early HCC recurrence during the follow-up period, we selected the first MRI after CEUS confirmation of a complete response. For the purpose of this study, patients\u0026rsquo; data were recorded until recurrence was detected or until they completed 2 years\u0026rsquo; follow up or became lost to follow-up. In accordance with our standard procedure, new suspicious liver lesions identified on MRI whose diagnosis remained uncertain were studied with other techniques (e.g., CEUS, liver biopsy, or close MRI monitoring) to reach a conclusive diagnosis.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eImaging protocol\u003c/h2\u003e \u003cp\u003eAll patients underwent routine liver MRI on state-of-the-art 1.5T (Aera, Siemens Healthcare, Signa HD and HDxt GE Medical Systems) or 3T (Vida, Siemens Healthcare) multichannel systems. The protocol included axial single-shot fast spin-echo (SSFSE) or half-Fourier acquisition single-shot turbo spin-echo T2-weighted sequences with and without fat suppression, axial T1-weighted in-phase and opposed-phase sequences, axial diffusion-weighted imaging (DWI) with b-values 0-400-800 s/mm\u003csup\u003e2\u003c/sup\u003e for Siemens and 0-800 s/mm\u003csup\u003e2\u003c/sup\u003e for GE, and dynamic contrast-enhanced sequences. Supplementary Table\u0026nbsp;1 provides additional details about the MRI protocol.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImages presented to readers:\u003c/h3\u003e\n\u003cp\u003eThe study coordinator (JR), who was not involved in image interpretation, exported and codified two sets of MRI studies for included subjects: a conventional set including all available images from the standard liver CMRI protocol and a \"simulated\" non-contrast-AMRI set including only axial T2-weighted images with and without fat suppression, DWI (including the highest b-value available), and unenhanced 3D T1-weighted images with fat suppression. Each set of images was assigned a distinct alphanumeric code for identification purposes. The images in each set were randomly reordered and uploaded to a centralized image reading platform (Quibim Precision\u0026reg; software, Quibim; Val\u0026egrave;ncia, Spain). Images were presented to readers in two batches, first the AMRI images and then the CMRI images, with at least 1 month interval between batches.\u003c/p\u003e\n\u003ch3\u003eImage interpretation:\u003c/h3\u003e\n\u003cp\u003e After a nationwide call for readers in Spain, we selected readers based on their levels of experience, and their current affiliation to a dedicated HCC group with regular attendance at multidisciplinary tumor board meetings. A total of 8 radiologists from three academic institutions (5 women; median experience in liver imaging, 6.5 y; range 2‒30 y) independently evaluated the images. We grouped readers by experience in liver imaging, classifying 4 as novice (\u0026lt;\u0026thinsp;5 y experience) and 4 as experienced (\u0026ge;\u0026thinsp;5 y experience).\u003c/p\u003e \u003cp\u003eData were collected and managed using a REDCap (Research Electronic Data Capture) system hosted at our hospital. Readers were blinded to clinical information except the location of the ablated lesion. Readers reviewed MRI studies to screen for intrahepatic tumor recurrence, classifying observations as no recurrence, local recurrence, or new intrahepatic lesions.\u003c/p\u003e \u003cp\u003eFor screening purposes, any of the following AMRI findings were considered suspicious for local recurrence or new intrahepatic lesions: 1) focal mild-to-moderate hyperintensity on T2-weighted images, 2) focal hypointensity on fat-saturated 3D T1-weighted images; and/or 3) hyperintensity on DWI. If any of these findings suggestive of HCC were observed in readers were instructed to classify the lesion as a \"suspicious lesion\" that required additional work-up. Focal observations of high hyperintensity on T2-weighted images were categorized as benign, likely corresponding to cysts or hemangiomas.\u003c/p\u003e \u003cp\u003eAnalogous to the LIRADS-treatment response (LR-TR) definitions of equivocal or viable,[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] we considered the following CMRI findings positive for local recurrence: nodular or thick irregular tissue within or along the treated lesion with arterial phase hyperenhancement with or without washout. Because readers were blinded to previous examinations, we did not include the LR-TR criterion \u0026ldquo;enhancement pattern similar to pretreatment imaging\u0026rdquo; in our definition of local recurrence. To categorize new intrahepatic lesions on CMRI, we applied the same imaging criteria as used for AMRI, with the addition of any nodular arterial phase hyperenhancement\u0026thinsp;\u0026ge;\u0026thinsp;10 mm and/or hypointense nodular areas in the portal or venous phases. The LI-RADS v2018 category was assigned to each recorded observation based on its probability of the new intrahepatic lesion being malignant.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Those categorized by CMRI as LR-3, LR-4, LR-5, or LR-M were considered suspicious for or consistent with new malignant intrahepatic lesions. In light of the elevated risk of recurrence observed in this clinical setting, as compared to that seen in HCC-na\u0026iuml;ve patients, we considered appropriate to include LR3 as an observation that should be subject to early follow-up and/or the performance of additional tests.\u003c/p\u003e \u003cp\u003eReaders recorded the location and size of all relevant AMRI and CMRI observations classified as suspicious for or consistent with new intrahepatic lesions.\u003c/p\u003e \u003cp\u003ePatients were considered HCC-negative when the diagnostic test that is being evaluated against the ground truth (from then on, index study) or in follow-up MRI studies observed no lesions or only observations scored as LR 1/2.\u003c/p\u003e \u003cp\u003e \u003cem\u003eReference Standards\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe reference diagnosis of recurrent HCC was based on histological confirmation or imaging-based confirmation. A single radiologist (JR with 18 years\u0026rsquo; experience in liver MRI) who was not involved in imaging analysis reviewed patients\u0026rsquo; medical charts and imaging studies, recording HCC recurrence (1) in cases with histological confirmation, (2) in those where the index multiphase MRI study showed 1 or more observations classified as LR-5 for new intrahepatic lesions or as LR-TR viable for local recurrence, or (3) in those where additional workup CEUS or multiphase MRI\u0026thinsp;\u0026le;\u0026thinsp;6 months after the index multiphase MRI showed 1 or more observations classified as LR 5 for new intrahepatic lesions or as LR-TR viable for local recurrence.\u003c/p\u003e \u003cp\u003eTo exclude false-negative findings in the index multiphase MRI study, the same radiologist (JR) reviewed follow-up dynamic CT or MRI studies done 6 to 12 months after the index study, as well as radiological reports and clinical charts. When an HCC was detected on follow-up dynamic MRI or described on MRI reports, the index study was reviewed to ensure it had no false-negative findings.\u003c/p\u003e\n\u003ch3\u003ePost-reading Delphi survey:\u003c/h3\u003e\n\u003cp\u003eAfter the reading the image sets but before knowing the results of the study, readers worked together online to build a consensus and improve the methodology of AMRI for early detection of tumor recurrence. Decision-making was facilitated through a process in which questions were raised and readers voted on the appropriateness of the statements developed.[16; 17]\u003c/p\u003e\n\u003ch3\u003eSample size calculation:\u003c/h3\u003e\n\u003cp\u003eBased on the results of a previous study using similar sets of images[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], we estimated that determining the concordance between AMRI and CMRI in detecting suspicious intrahepatic lesions in this study with 8 readers with an alpha of 0.05 and statistical power of 0.80 would require a minimum sample of 136 images per set.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eWe report continuous variables as medians and ranges and categorical variables as frequencies and percentages.\u003c/p\u003e \u003cp\u003eTo assess and to compare the reliability of AMRI for detecting recurrence of HCC, we conducted per-patient (suspicious of any type of HCC) and per-location analyses (local recurrence, new intrahepatic lesions, or any location). To determine and compare the intra- and inter-reader agreements for local recurrence at the ablation site, new intrahepatic lesions in other locations, or any recurrence, we calculated Gwet's concordance 1 (AC1), which compared with kappa statistics, corrects for prevalence dependence in categorizations.[20; 21]\u003c/p\u003e \u003cp\u003eWe classified inter-reader and intra-reader reliability based on AC1 as poor (\u0026lt;\u0026thinsp;0.0), slight (0.0\u0026ndash;0.2), fair (0.21\u0026ndash;0.4), moderate (0.41\u0026ndash;0.6), substantial, 0.61\u0026ndash;0.8, or near-perfect (0.81\u0026ndash;1.0).[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] To compare inter-reader reliabilities, we analyzed whether their 95% confidence intervals overlapped.\u003c/p\u003e \u003cp\u003eTo evaluate the performance of AMRI as a screening tool, we calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AMRI and CMRI a per-patient basis.\u003c/p\u003e \u003cp\u003eWe aimed to identify sources of disagreement using a post-reading Delphi survey. A number of statements related to potential sources of disagreement were developed into a survey that was distributed to readers as part of a pilot survey. Comments and responses on content and format from the eight readers were included in the final survey. Each statement was rated on a Likert scale of 1\u0026ndash;9, where 1 = 'strongly agree' and 9 = 'strongly disagree'. The selection of consensus statements was based on a two-step selection based on appropriateness and level of disagreement. In the first round of selection, statements that achieved a median of 1\u0026ndash;3 or 7\u0026ndash;9 would be appropriate in a positive or negative direction and would be retained as recommendations. In the second round of selection, we focused on the level of disagreement. Disagreement was considered present when \u0026ge;\u0026thinsp;2 panelists rated appropriateness at different extremes of the scale (1\u0026ndash;3 and 7\u0026ndash;9).\u003c/p\u003e \u003cp\u003eAll tests were two-sided, and significance was set at 5%. All calculations and analyses were performed with SAS 9.4 software (SAS Institute, Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy participants and radiologists\u003c/h2\u003e\n \u003cp\u003eA total of 100 cirrhotic patients underwent percutaneous radiofrequency ablation of HCC in the study period; of these, 25 were excluded. The flowchart in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e explains the reasons for exclusion, and Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e reports the demographic and clinical characteristics of the 75 patients included in the study. All patients, except one who had chronic HBV, were cirrhotic. Altogether, we included 143 MRI studies [median per patient, 2 (IQR 1‒3); 110 (76.9%) acquired in 1.5T scanners and 33 (23.1%) in a 3T scanner]. HCC recurrence was detected in 37 (49.3%) patients: 12 had local recurrence alone, 21 had new intrahepatic lesions, and 4 had both local recurrence and new intrahepatic lesions. No vascular invasion was detected.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographics of subjects included in the study Abbreviations: HCV\u0026thinsp;=\u0026thinsp;hepatitis C virus, HBV\u0026thinsp;=\u0026thinsp;hepatitis B virus, SLD: steatotic liver disease\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eNumber of patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAge, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (42\u0026ndash;87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eMale/female, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (71) /22 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eCirrhosis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eEtiology, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHCV\u0026thinsp;+\u0026thinsp;alcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHBV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHCV\u0026thinsp;+\u0026thinsp;HBV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSLD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSLD\u0026thinsp;+\u0026thinsp;alcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eChild-Pugh class A/B, N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (88) /8 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eInter-reader agreement\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e reports the different measures of inter-reader agreement between AMRI and CMRI for each type of recurrence. Overall, the proportion of observed agreement (P\u003csub\u003e0\u003c/sub\u003e) was high, but kappa values were low. After correcting for prevalence dependence (AC1), the overall reliability was near-perfect for AMRI and CMRI. However, the AC1 for detecting new intrahepatic lesions was higher for AMRI [0.85 (near-perfect) 95%CI:0.81‒0.90 vs. 0.60 (moderate) 95%CI:0.52‒0.67] for CMRI). Similarly, the AC1 for detecting any type of tumor recurrence was higher for AMRI [0.73 (substantial) 95%CI:0.67‒0.78 vs. 0.56 (moderate) 95%CI:0.49‒0.64 for CMRI].\u0026nbsp;\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInter-reader agreement measured by Gwet\u0026apos;s AC1, by type of recurrence, for all readers and by level of experience. Abbreviations: CI: confidence interval; AMRI: Abbreviated MRI; CMRI: contrast-enhanced MRI; NIH: new intrahepatic recurrence\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGwet\u0026apos;s AC1 (95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll readers\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eLocal Recurrence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87 (0.83‒0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87 (0.83‒0.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNIH Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85 (0.81‒0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.60 (0.52‒0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny Type of Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73 (0.67‒0.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56 (0.49‒0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNovice readers (\u0026lt;\u0026thinsp;5 years\u0026rsquo; experience)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87 (0.82‒0.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87 (0.82‒0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNIH Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90 (0.86‒0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51 (0.41‒0.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny Type of Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76 (0.70‒0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ec-MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49 (0.39‒0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced readers (\u0026ge;\u0026thinsp;5 years\u0026rsquo; experience)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86 (0.81‒0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87 (0.82‒0.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNIH Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.80 (0.74‒0.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.70 (0.61‒0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny Type of Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68 (0.60‒0.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65 (0.56‒0.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eInter-reader agreement according to reader experience\u003c/h2\u003e\n \u003cp\u003eInter-reader agreement for the detection of local recurrence was similar among novice readers and among experienced readers, being near-perfect in both groups of readers. However, inter-reader agreement for the detection of new intrahepatic lesions differed between the two groups, both for AMRI, where it was lower among experienced readers [0.80 (substantial) 95%CI:0.74‒0.86] than among novice readers [0.90 (near-perfect) 95%CI:0.86‒0.94], and for CMRI, where it was higher among experienced readers [0.70 (substantial) 95%CI:0.61‒0.79] than among novices [0.51 (moderate) 95%CI:0.41‒0.61] (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eIntra-reader agreement\u003c/h2\u003e\n \u003cp\u003eThe overall intra-reader agreement was near-perfect for detecting local recurrence and moderate for detecting new intrahepatic lesions and for detecting any type of recurrence (Supplementary Table\u0026nbsp;2).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eObservations reported\u003c/h2\u003e\n \u003cp\u003ePooling together the readings of the 8 radiologists, we obtained 1144 readings in each set (Supplementary Table\u0026nbsp;3). The median size of new intrahepatic lesions was 15 mm (IQR10‒25) in AMRI and 20 mm (IQR 12‒34) in CMRI (p\u0026thinsp;=\u0026thinsp;0.89).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eDetection of HCC recurrence\u003c/h2\u003e\n \u003cp\u003eIn the pooled readings, HCC recurrence of any type was detected in 190 AMRI sets and in 438 CMRI sets. Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e reports the per-patient and per-location diagnostic sensitivity, specificity, PPV, and NPV for HCC recurrence in CMRI and AMRI for the pooled results of all readers and for the two subgroups of readers (novice and experienced). Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e compares the sensitivities and specificities of AMRI and CMRI for detecting local recurrence, new intrahepatic lesions, and any type of HCC for all readers. The per-patient sensitivity for detecting local recurrence, new intrahepatic lesions, and any type of HCC recurrence was higher with CMRI than with AMRI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSensitivity, specificity, positive predictive value, and negative predictive value, by type of recurrence and readers\u0026rsquo; level of experience. Number in parentheses are the 95% confidence intervals. Abbreviations: AMRI: abbreviated magnetic resonance imaging; CMRI: contrast-enhanced magnetic resonance imaging\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eLocal recurrence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eNew intrahepatic lesion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAny type recurrence\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAMRI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCMRI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAMRI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCMRI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAMRI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCMRI\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAll readers\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSensitivity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22 (0.15‒0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.45 (0.36‒0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.29 (0.22‒0.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.80 (0.74‒0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39 (0.33‒0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83 (0.78‒0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecificity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 (0.92‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 (0.92‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95 (0.93‒0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.79 (0.77‒0.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91 (0.89‒0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.77 (0.74‒0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive Predictive Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31 (0.22‒0.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.47 (0.38‒0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.54 (0.44‒0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.45 (0.40‒0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61 (0.53‒0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56 (0.51‒0.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative Predictive Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91 (0.89‒0.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93 (0.91‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86 (0.84‒0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95 (0.93‒0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.81 (0.78‒0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93 (0.91‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced readers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSensitivity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19 (0.10‒0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38 (0.26‒0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.28 (0.19‒0.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83 (0.74‒0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.43 (0.34‒0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.81 (0.74‒0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecificity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93 (0.91‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 (0.91‒0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93 (0.90‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.84 (0.80‒0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90 (0.87‒0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82 (0.78‒0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive Predictive Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26 (0.14‒0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.43 (0.30‒0.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46 (0.33‒0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53 (0.44‒0.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.59 (0.49‒0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61 (0.53‒0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative Predictive Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90 (0.87‒0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92 (0.9‒0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86 (0.83‒0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.96 (0.94‒0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82 (0.78‒0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93 (0.89‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNovice readers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSensitivity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.25 (0.15‒0.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52 (0.39‒0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.29 (0.20‒0.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.77 (0.68‒0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.35 (0.27‒0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85 (0.78‒0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecificity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95 (0.92‒0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 (0.91‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97 (0.95‒0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75 (0.71‒0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92 (0.90‒0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73 (0.69‒0.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive Predictive Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37 (0.23‒0.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50 (0.37‒0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.66 (0.50‒0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39 (0.32‒0.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62 (0.51‒0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53 (0.46‒0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative Predictive Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91 (0.88‒0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 (0.91‒0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87 (0.83‒0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94 (0.91‒0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.80 (0.77‒0.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93 (0.90‒0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of overall sensitivities (true positive) and specificities (true negatives) between abbreviated non-contrast MRI and standard contrast-enhanced liver MRI. Abbreviations: AMRI: abbreviated magnetic resonance imaging; CMRI: contrast-enhanced magnetic resonance imaging\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" style=\"width: 809px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 503px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eAMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e0.7532\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e907\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" style=\"width: 809px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNew Intrahepatic Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 503px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eAMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" style=\"width: 809px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny type Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 503px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eAMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eEffect of experience on detection of HCC recurrence\u003c/h2\u003e\n \u003cp\u003eThe comparison of sensitivity and specificity in novice and experienced readers was analogous to that reported when the data from the radiologists were analyzed overall (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of sensitivities (true positive) and specificities (true negatives) between abbreviated non-contrast MRI and standard contrast-enhanced liver MRI.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced readers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 793px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 489px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 304px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e0.0073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e0.6547\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 793px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNew Intrahepatic Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 489px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 304px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e378\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 793px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny type Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 489px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 304px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e324\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNovice readers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 793px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 489px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 304px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e0.0004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e0.3763\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e455\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 793px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNew Intrahepatic Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 489px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 304px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 793px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny type Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 489px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (True positive)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 304px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (True negative)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClass\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMcNemar test (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eAbbreviations: AMRI: abbreviated magnetic resonance imaging; CMRI: contrast-enhanced magnetic resonance imaging\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThe sensitivity for detecting any type of recurrence with AMRI was higher in the group of experienced radiologists [0.43 (0.34‒0.51) vs. 0.35 (0.27‒0.43) in the group of novices, p\u0026thinsp;=\u0026thinsp;0.0343]. (Supplementary Table\u0026nbsp;4)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eSources of disagreement\u003c/h2\u003e\n \u003cp\u003eThe Delphi process identified the following factors that can potentially influence reader agreement and accuracy: (1) lesion characteristics (size and number of sequences where lesions can be detected); (2) liver background and underlying cause of cirrhosis; and (3) lack of intravenous contrast sequences (Supplementary Table\u0026nbsp;5). Readers\u0026rsquo; experience was not perceived as a relevant factor.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study explored the multi-reader reliability of a non-contrast AMRI for detecting early HCC recurrence in cirrhotic patients undergoing surveillance for early HCC recurrence following curative ablation of HCC to determine whether non-contrast AMRI might be a viable alternative to CMRI for surveillance in a Western population. We also evaluated and compared the sensitivities and the specificities of AMRI and CMRI in detecting the recurrence of HCC, as well as the impact of readers’ experience on the reliability and the validity of non-contrast AMRI and CMRI for the detection of HCC recurrence.\u003c/p\u003e\u003cp\u003eHCC recurs in less than 2 years after ablation in up to 50% of cases, typically through occult tumor dissemination that often results in multifocal intrahepatic recurrence,[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] thus warranting intense surveillance including contrast-enhanced MRI, which is more sensitive than ultrasound for early tumor recurrence. [10; 24]\u003c/p\u003e\u003cp\u003eMany studies have analyzed AMRI for primary screening for HCC, but fewer have examined its potential for screening of early HCC recurrence. The higher incidence of early recurrence after curative therapeutic options makes the application of AMRI appealing in this scenario. Three principal approaches to AMRI have been proposed: non-contrast AMRI, dynamic contrast-enhanced AMRI, and hepatobiliary-phase contrast-enhanced AMRI. The results of recent systematic reviews and meta-analyses indicate that the sensitivity of these three strategies in detecting liver lesions in at-risk populations is comparable.[11; 12; 25] In this context, the objective of AMRI is not to formally characterize observations, but rather to identify patients with suspicious findings. The technique is simple and does not require the injection of contrast media.\u003c/p\u003e\u003cp\u003eAs in Jeon et al.’s [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] recent retrospective study in Korean patients, we simulated non-contrast AMRI findings to explore this technique’s potential in the early detection of tumor recurrence. Their analysis of data acquired with a 3T system found no significant difference in detection between non-contrast AMRI or hepatobiliary-phase AMRI and full sequence gadoxetic acid-enhanced MRI during secondary surveillance for late (\u0026gt; 2 years) HCC recurrence after curative treatment in a cohort with predominant (79.4%) chronic VHB hepatitis, reporting per-patient sensitivities ranging 53.9% from 83.3% for non-contrast-AMRI. In our study, the overall sensitivity of AMRI reported by the eight readers was significantly lower than CMRI for early HCC recurrence, particularly due to AMRI’s worse performance in detecting new intrahepatic lesions.\u003c/p\u003e\u003cp\u003eOur study provides important new information about the reproducibility of AMRI in surveillance for HCC recurrence. The inter-reader agreement of AMRI for the detection of local recurrence was similar to that of CMRI; however, the inter-reader agreement for new intrahepatic lesions and for any type of recurrence was higher for AMRI than for CMRI. This unexpected finding is due to readers identifying fewer lesions in the AMRI image sets and to AMRI’s overall lower sensitivity for detecting HCC recurrence.\u003c/p\u003e\u003cp\u003eAMRI had significantly higher sensitivity in detecting any type of recurrence when used by experienced readers than when used by novice readers (p = 0.0343). Moreover, experienced readers had lower rates of false-positive interpretation of new intrahepatic lesions than novices (p = 0.0027), thus suggesting that expertise could potentially reduce the number of recall tests if AMRI were adopted for surveillance of HCC recurrence.\u003c/p\u003e\u003cp\u003eMultiple factors can affect the sensitivity of a screening tool for detecting HCC recurrence and therefore its inter-reader agreement. Our Delphi survey revealed that readers perceived that sensitivity improves with the number of sequences where lesions can be identified. They also perceived that liver parenchyma heterogeneity caused by HCV and/or alcohol induced cirrhosis hindered the detection of HCC recurrence on T2-weighted and DWI sequences, which formed the backbone of our AMRI protocol.\u003c/p\u003e\u003cp\u003eMost evidence regarding the accuracy of AMRI studies comes from Asian cohorts [13; 26; 27] where HBV was the predominant underlying cause of chronic liver disease and low rates of liver cirrhosis. Patients with HCV-related HCC are much more likely to have underlying liver cirrhosis than patients with HBV-related HCC [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and the rate of HCC hyperintensity on DWI and T2-weighted images is higher in HBV than in HCV (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003e). [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAll patients included in this study were cirrhotic, with the most prevalent causes (84%) were HCV infection and/or alcohol consumption. Thus, our cohort is fairly typical of HCC patients in Western countries. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] The findings of our Delphi survey suggest that this difference in the characteristics of our patients results in increased parenchymal heterogeneity that hinders detection of HCC recurrence, especially new intrahepatic lesions, with non-contrast AMRI. We have focused in a cohort of HCC patients with very-early or early stage according to the BCLC classification, which is associated to a median survival time above 5 years. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The early detection of HCC recurrence in this scenario may be of paramount relevance to offer a new curative therapeutic option.\u003c/p\u003e\u003cp\u003eA major strength of our study is that it analyzes the operational characteristics of AMRI with a total of eight readers from three centers, four with \u0026lt; 5 years’ experience and four with ≥ 5 years’ experience. This approach allowed us to analyze the effects of experience on the validity of AMRI for the detection of early HCC recurrence.\u003c/p\u003e\u003cp\u003eOur study has limitations. Its retrospective design involves an inherent risk of selection bias; however, we included consecutive patients who underwent liver MRI for surveillance of early HCC recurrence following a complete response to curative treatment for HCC. Moreover, AMRI sets were simulated and extracted from contrast-enhanced liver MRI studies; acquiring AMRI sets separately might have led to different results, although it would have inconvenienced patients and increased costs. Finally, prioritizing the inclusion of consecutive patients rather than ensuring image sets were acquired on scanners from a single vendor with homogeneous magnetic fields meant that we had an imbalance of patients studied with 1.5T and 3T scanners. The image quality in the T2-weighted and DWI sequences that were the backbone of our AMRI protocol can vary depending on field strength and vendors, and this variation could affect our results. This technical aspect has been identified by a group of readers, albeit without sufficient consensus, as a possible explanation for the poor performance observed in the study, and we believe it warrants further investigation.\u003c/p\u003e\u003cp\u003eIn surveillance for early HCC recurrence, interobserver agreement for the detection of intrahepatic recurrence was higher for non-contrast AMRI than for CMRI. AMRI had significantly higher sensitivity in detecting any type of recurrence when used by experienced readers. However, in our cohort where HCV and/or alcohol-related cirrhosis were the predominant etiologies, as is typical in Western populations, the overall pooled sensitivity of AMRI was unacceptably lower than that of CMRI.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003eJordi Rimola has served as advisor to Roche, MEDIVIR and Universal Dx, and has received lecture or consultancy fees from Astrazeneca and Roche. Alicia Mesa has received lecture feed from GE Healthcare.Mar\u0026iacute;a Reig has served as advisor and received lectures fee to AstraZeneca, Bayer, BMS, Eli Lilly, Geneos, Ipsen, Merck, Roche, Universal DX, Engitix Therapeutics, MEDIVIR, Biotoscana Farma S.A. Travel suppor by: Astrazeneca, Roche, Bayer, BMS, Lilly, Ipsen. Grant Research Support (to the institution): Bayer, Ipsen. Educational Support (to the institution): Bayer, Astrazeneca, BMS, Eisai- Merck MSD, Roche, Ipsen, Lilly, Terumo, Next, Boston Scientific, Ciscar Medical, Eventy 03 LLC (Egypt).The rest of the authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJR, MR: conception and design of the work; BS, AI, AD, SJ AM, VN, AS, CA: data acquisitionAR and JR analysis and interpretation of data;JR drafted the work ;All authors whose names appear on the submission revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eJohn Giba, native medical english corrector.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplementary information files\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLlovet JM, Kelley RK, Villanueva A et al (2021) Hepatocellular carcinoma. 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Cancers 13:1\u0026ndash;13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark HJ, Seo N, Kim SY (2022) Current Landscape and Future Perspectives of Abbreviated MRI for Hepatocellular Carcinoma Surveillance. Korean Journal of Radiology:1\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRonot M, Nahon P, Rimola J (2023) Screening of liver cancer with abbreviated magnetic resonance imaging. Hepatology. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/HEP.0000000000000339\u003c/span\u003e\u003cspan address=\"10.1097/HEP.0000000000000339\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen CH, Huang GT, Yang PM et al (2006) Hepatitis B- and C-related hepatocellular carcinomas yield different clinical features and prognosis. 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Clin Imaging 40:352\u0026ndash;356\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"abdominal-radiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aima","sideBox":"Learn more about [Abdominal Radiology](http://link.springer.com/journal/261)","snPcode":"261","submissionUrl":"https://submission.springernature.com/new-submission/261/3","title":"Abdominal Radiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Hepatocellular carcinoma, Magnetic Resonance Imaging, Abbreviated Magnetic Resonance, surveillance, secondary screening, recurrence ","lastPublishedDoi":"10.21203/rs.3.rs-6306750/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6306750/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eAbbreviated MRI (AMRI) protocols may represent an alternative to conventional MRI (CMRI) for surveillance of hepatocellular carcinoma (HCC). We aimed to compare the inter-reader agreement and sensitivity of AMRI versus CMRI for HCC recurrence \u0026lt;2 years after curative ablation in at risk-population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eEight radiologists (4 with \u0026lt;5 years’ and 4 with ≥5 years’ experience) from three institutions independently reviewed 143 CMRI and AMRI image sets from 75 consecutive cirrhotic patients (84% HCV and/or alcohol-related) undergoing secondary screening after HCC ablation with ≥1 month between readings.\u003c/p\u003e\n\u003cp\u003eWe calculated the intra and inter-reader agreement by means Gwet’s AC1 for detection of local recurrence at the ablation site, new intrahepatic, and any type of recurrence (either local and/or new intrahepatic) with CMRI and AMRI. Reference diagnoses of recurrent HCC were based on histological or imaging-based criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eEarly HCC recurrence was detected in 37 patients (49.3%). AC1 agreement was similarly high for AMRI and CMRI for local recurrence [0.87 (0.83‒0.90) vs. 0.87 (0.83‒0.92)], but higher for AMRI than for CMRI for new intrahepatic [0.85 (0.81‒0.9) vs. 0.6 (0.52‒0.67)] and any type [0.73 (0.67‒0.78) vs. 0.56 (0.49‒0.64)] recurrences. Sensitivity for detecting any type of HCC recurrence was higher for CMRI [0.83 (0.78‒0.87) vs. 0.39 (0.33‒0.45) for AMRI, p\u0026lt;0.0001].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor early detection of HCC recurrence in a cohort with predominantly HCV and/or alcohol-related cirrhosis, non-contrast AMRI yielded better interobserver agreement but lower sensitivity than CMRI.\u003c/p\u003e","manuscriptTitle":"Reproducibility and accuracy of non-contrast abbreviated magnetic resonance imaging of the liver in surveillance for early recurrence for hepatocellular carcinoma in a Western population: a multi-reader study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 09:17:35","doi":"10.21203/rs.3.rs-6306750/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-14T18:17:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-30T17:44:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155993464271874373259107426150006911067","date":"2025-03-30T01:34:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-30T00:20:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-27T04:31:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-27T04:29:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"Abdominal Radiology","date":"2025-03-25T20:46:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"abdominal-radiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aima","sideBox":"Learn more about [Abdominal Radiology](http://link.springer.com/journal/261)","snPcode":"261","submissionUrl":"https://submission.springernature.com/new-submission/261/3","title":"Abdominal Radiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"338f511e-91b5-4d76-8d5d-d65a48de2026","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T15:59:10+00:00","versionOfRecord":{"articleIdentity":"rs-6306750","link":"https://doi.org/10.1007/s00261-025-05105-5","journal":{"identity":"abdominal-radiology","isVorOnly":false,"title":"Abdominal Radiology"},"publishedOn":"2025-07-09 15:57:02","publishedOnDateReadable":"July 9th, 2025"},"versionCreatedAt":"2025-04-21 09:17:35","video":"","vorDoi":"10.1007/s00261-025-05105-5","vorDoiUrl":"https://doi.org/10.1007/s00261-025-05105-5","workflowStages":[]},"version":"v1","identity":"rs-6306750","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6306750","identity":"rs-6306750","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}