MRI for Liver Cancer Detection

Liver cancer is increasing globally, with hepatocellular carcinoma (HCC) as the most common primary liver cancer. Prognosis is highly stage-dependent: when HCC is detected early (≥2 cm, confined to the liver), five-year survival can exceed 70 per cent with curative therapies¹. However, once vascular invasion occurs, survival drops below 15 per cent. 

Early detection is therefore important, and gadoxetic acid-enhanced MRI (e.g., Eovist/Primovist) has emerged as the most sensitive modality for small HCCs, with an average sensitivity of 89 per cent, outperforming multiphasic computed tomography (CT) by about 10 per cent, and even more for tumours under 2 cm^1,2. These diagnostic advantages have prompted wider use of MRI in at-risk populations, especially those with cirrhosis. 

MRI protocols now exceed ultrasound in sensitivity for early-stage HCC screening and surveillance³. Given that earlier detection directly translates into better outcomes and access to treatment, MRI-based surveillance can help clinicians intervene sooner and extend survival for patients with liver disease.

Learn more about MRI for cancer detection here.

Why You Might Need a Liver MRI

There are several reasons why a liver MRI might be ordered, including:

Unexplained Laboratory Abnormalities

Persistent elevation of liver enzymes (ALT or AST) or a rising tumour marker such as alpha-fetoprotein (AFP) or carcinoembryonic antigen (CEA) can signal underlying liver pathology, especially when neither ultrasound nor CT can provide a clear explanation^4,5. MRI offers superior soft tissue characterisation, making it valuable in these ambiguous cases.

Clarifying a Mystery Nodule

If prior imaging identifies a “mystery nodule”, particularly lesions 2 cm or smaller, nodules with arterial phase enhancement (“arterial blush”), or those labelled indeterminate (e.g., LI-RADS 3), MRI is the method of choice for detailed characterisation⁶. Advanced MRI sequences can distinguish between benign and malignant liver nodules⁷.

High-Risk Backgrounds

Individuals with cirrhosis (due to hepatitis B or C), hereditary hemochromatosis, Wilson disease, or carriers of cancer-predisposing mutations (such as TP53) are at elevated risk for developing liver cancer⁸. MRI is more sensitive than ultrasound for early detection and ongoing surveillance in these high-risk groups⁹.

Staging and Searching for Metastases

When evaluating for metastatic spread, such as from colon, breast, pancreas, or melanoma, MRI can detect tiny liver metastases that might alter treatment plans^10,11. Its contract resolution and ability to use liver-specific agents give it an advantage over CT or PET in many scenarios.

Pre- and Post-Therapy Mapping

For patients undergoing interventions such as TACE (transarterial chemoembolization) or RFA (radiofrequency ablation), or those being evaluated for transplant or surgery, MRI helps accurately count and map tumours, assess for portal vein involvement, and gauge treatment response^12,13.

Vascular and Biliary Evaluation

Suspected complex vascular or biliary disorders, such as Budd-Chiari syndrome, arterio-venous shunts, cholangiocarcinoma, or intricate bile duct strictures, are best evaluated with MRI¹⁴. Its specialised sequences allow detailed visualisation of vessels and ducts, often clarifying diagnoses that ultrasound or CT cannot.

Metabolic and Hormone-Related Lesions

MRI plays a role in tracking metabolic or hormone-driven liver abnormalities, for example, monitoring hepatic adenoma growth in patients on long-term oestrogen or anabolic steroids, assessing cystic liver disease, or confirming a bile leak following abdominal trauma^15,16.

How to Prepare for Your Liver MRI

Here are a few tips to help you prepare for your MRI¹⁷:

• Take your usual medications and eat normally, unless instructed to fast for specific MRI protocols. Fasting is not always required however¹⁸. Avoid heavy caffeine intake and stay hydrated.
• Inform staff about any metal implants or devices, and bring safety cards for “MR-Conditional” implants, such as pacemakers or aneurysm clips.
• Remove all metal items, including jewellery, hairpins, dental plates, and transdermal patches with foil, to prevent image distortion.
• Bring your referral, prior brain images, and insurance pre-authorisation to avoid delays.
• Wear comfortable, metal-free clothing; ask about earplugs, music, or mirror goggles if you’re claustrophobic.
• If contrast is planned, fast for 4–6 hours prior to the procedure. Inform staff about any kidney issues or past reactions to contrast agents, as safer alternatives may be available.
• Arrange an escort home if you need sedation for claustrophobia.

You can read more about preparation for Ezra’s Full Body Scan here.

What Happens During the Liver Scan?

Upon arrival for your MRI, you will need to check in and complete a screening form. This will allow you to confirm the presence of implants, allergies, and whether you might need any anxiety medication.

During the scan, you will lie down on a sliding table. A dedicated surface or phased-array coil is typically placed over the limb or region of interest¹⁹. The scan typically lasts 30-45 minutes of actual “table time”, during which the technician may acquire multiple sequences (settings), including localisers, axial and coronal T2 fast spin-echo images, in-phase and out-of-phase T1-weighted imaging to evaluate for fat and iron, diffusion-weighted imaging (DWI) with ADC maps, pre-contrast fat-suppressed 3D T1-weighted imaging, and dynamic post-contrast imaging using gadoxetic acid through arterial, portal-venous, and delayed phases, followed by a 20-minute hepatobiliary phase (HBP)^20–23. Optional sequences may include MR elastography for liver stiffness, secretin-enhanced MRCP or standard MRCP for biliary anatomy, dynamic contrast-enhanced perfusion imaging to assess tumour response, and extracellular volume (ECV) quantification^24–28.

You may be asked to hold your breath for short periods during the scan to minimise motion and improve image clarity.

You’ll hear a series of loud knocking or tapping sounds as the MRI machine works. This is completely normal. The scan usually takes about 20 to 45 minutes, and you’ll be offered earplugs or headphones to make the experience more comfortable. 

You’ll stay in touch with the team via a two-way intercom and a squeeze bulb, allowing you to communicate or pause the scan if needed. If contrast is required, it’s injected halfway through, possibly causing a brief cool sensation. After the final sequence, the coil is removed, and you’re free to go. 

At Ezra, our Full Body Plus scan takes around 60 minutes total, with 45 minutes of table time. Earplugs or headphones are available.

MRI Safety, Risks, & Side Effects

MRI is generally considered very safe when proper screening and protocols are followed, but certain risks and side effects should be understood:

• Metal and implants: The strong 3-Tesla magnet can pull or heat older pacemakers, aneurysm clips, or metal fragments²⁹. Most modern “MR-Conditional” devices (like cochlear implants or pain pumps) are safe after screening, but all implants must be checked before scanning³⁰.
• Gadolinium contrast: Macrocyclic gadolinium agents (e.g., gadobutrol) have an extremely low risk of allergic reactions or nephrogenic systemic fibrosis (NSF) when kidneys are healthy³¹. However, gadolinium can accumulate in tissues, and rare side effects such as headaches or skin changes have been reported. Many centres now offer contrast-free alternatives for routine follow-up³². You can read more about gadolinium contrast side effects here.
• Incidental findings: Focal liver lesions are the most frequent incidental findings on MRI, seen in up to 5-18 per cent of imaging studies, with the majority representing benign cysts, hemangiomas, or focal nodular hyperplasia^33–35.
• Claustrophobia: Anxiety inside the scanner is common. Wide-bore scanners, music, mirror goggles, or a single dose of oral sedative can help alleviate symptoms. Open MRI is an option if image detail can be sacrificed.
• Zero Ionising Radiation: MRI uses magnetic fields and radio waves, not X-rays, so there is no ionising radiation exposure, making it safer for repeated scans compared to CT scans³⁶.
• Minor Sensations: Expect loud knocking, mild table vibration, and a brief cool flush if contrast is injected. Rare side effects include headaches, fatigue, or mild skin heating.

A deeper dive into possible side effects (such as heat, headaches, and gadolinium deposition) is available in our full guide.

At Ezra, we employ a contrast-free approach using wide-bore T3 machines to deliver a comfortable scanning experience.

Terms You Might See in Your MRI Report (And What They Might Mean)

MRI reports for liver scans often include specialised terms. Here’s a guide to some common phrases and what they mean for your diagnosis:

• Arterial-phase hyper-enhancement (APHE): This means the lesion “lights up” early during the arterial phase of contrast imaging³⁷. It is often the first indicator suggestive of hepatocellular carcinoma (HCC).
• Wash-out: A lesion showing “wash-out” becomes darker than the surrounding liver tissue on the portal venous or delayed phase images. This feature supports malignancy and is part of the LI-RADS criteria for HCC diagnosis³⁸.
• Capsule appearance: A smooth rim around a lesion seen on delayed phase imaging³⁷. This capsule is typical for HCC and helps confirm the diagnosis.
• LI-RADS 5: This is a definitive classification for HCC. A lesion meeting size, APHE, and wash-out or capsule criteria will be assigned a LI-RADS 5 diagnosis, indicating a hepatocellular carcinoma without the need for biopsy³⁸. 
• Hepatobiliary phase hypointense: The lesion appears darker on the hepatobiliary phase, reflecting a lack of functioning hepatocytes. This is common in HCC, metastases, and some adenomas³⁷.
• Restricted diffusion/low ADC value: Areas with limited water molecule motion (e.g., ADC ~0.9 x 10^-3 mm²/s) on diffusion-weighted imaging often correspond to high cellularity and are suggestive of malignancy³⁷.
• Portal-vein tumour thrombus: Malignant tumour invasion into the portal vein, which may impact treatment decisions like transplant eligibility³⁸.
• Fat signal drop: Loss of signal on out-of-phase imaging due to intracellular fat within a lesion³⁷. This is evident in certain adenomas and subtypes of HCC. 

Ezra provides a radiologist-reviewed report in a non-technical and easy-to-understand format on your dashboard.

After the MRI Scan

After the MRI scan, you will be free to go home and continue with your day without any precautions³⁹. If you received a sedative, you will need another person to pick you up. You will also not be able to drive, consume alcohol or operate heavy machinery 24 hours after the sedative. 

A team of experts will review your results and determine whether a follow-up is necessary and recommend the appropriate treatment if needed. If abnormalities are found, you may undergo ongoing monitoring every 2-3 months to track recurrence. You can receive support in the form of counselling and advice on how to handle aspects like claustrophobia. 

If you have a scan with us here at Ezra, you will receive your report within five to seven days and have the option to discuss it with a medical practitioner. You can also access your scan images through the online portal.

What MRI Can Show About Pancreatic Cancer

The Classic HCC Triple Sign

MRI can identify HCCs using a highly specific combination of features, known as the “triple sign”. These include arterial phase hyper-enhancement, wash-out, and capsule appearance^40,41.  The presence of all three findings strongly suggests HCC, especially in patients with cirrhosis or chronic liver disease.

Hepatobiliary-Phase Hypointensity

When hepatobiliary contrast agents are used, healthy liver tissue takes up contrast and appears bright in the hepatobiliary phase, while malignant lesions, lacking functioning hepatocytes, remain dark. This finding is especially useful for identifying small (<1 cm) HCCs and distinguishing them from benign nodules or regenerative tissue. Lesions such as HCC or metastases are typically hypointense compared to the glowing background of the normal liver^42–44.

Diffusion Restriction: Highlighting Highly Cellular Tumours and Tiny Metastases

Diffusion-weighted imaging (DWI) is highly sensitive to cellular structure. Malignant liver tumours, due to their high cellular density, restrict water motion, resulting in a markedly increased signal and corresponding low apparent diffusion coefficient (ADC) values. This property enables detection of HCCs and even very small metastases that might be missed by CT, and can help differentiate malignant from benign or treated lesions.

Macro- and Microvascular Invasion

MRI is the reference standard for assessing vascular invasion, including detection of portal vein tumour thrombosis (PVTT)⁴⁵. Identifying PVTT is critical since its presence may contraindicate liver transplantation or alter surgical planning. Features suggesting tumour thrombus include enhancement of the thrombus on post-contrast MRI and vessel expansion.

Underlying Liver Stiffness: MR Elastography as a Prognostic Marker

MR elastography non-invasively measures liver stiffness, a surrogate for fibrosis and risk of future decompensation^46,47. Elevated liver stiffness on MR elastography is a strong predictor of adverse outcomes, including risk for developing new HCCs or liver failure after treatment. This measurement aids in prognostic stratification and monitoring treatment response for patients with chronic liver disease or cirrhosis.

Ezra utilises DWI as part of our whole-body MRI scans and artificial intelligence (AI) to enhance MRI images and convert radiology reports into layman's term translations.

Types of Liver Tumours and How They Look on MRI

• Hepatocellular carcinoma (HCC): Shows arterial-phase hyper-enhancement, wash-out on portal/delayed phases, a possible enhancing capsule, and remains hypointense (dark) on the hepatobiliary phase⁴⁸.

• Cholangiocarcinoma: Characterised by progressive rim or target-type enhancement, capsular retraction, and upstream biliary ductal dilatation⁴⁹.
• Metastases (e.g., from colon or breast): Often present as multiple lesions with high signal on diffusion-weighted imaging, peripheral (ring) enhancement, and appear dark on the hepatobiliary phase^50,51.
• Hemangioma: Displays peripheral nodular enhancement that slowly fills in toward the centre, appears very bright on T2-weighted images, and is usually iso- to hyperintense on hepatobiliary phase imaging⁵².

• Focal nodular hyperplasia (FNH): Exhibits homogeneous arterial enhancement with a central scar (bright on T2 and delayed enhancement), and appears iso- to hyperintense on the hepatobiliary phase due to retained contrast⁵³.
• Hepatic adenoma: Shows arterial-phase enhancement (sometimes with fat components), is typically hypointense on the hepatobiliary phase, and may contain areas of intralesional haemorrhage⁵⁴.

Ezra screens for over 500 conditions, including liver abnormalities.

Types of MRI Scans Used in Liver Cancer Detection

There are multiple types of MRI scans, all using different methods to give a better visualisation of liver tumours.

• Gadoxetic Acid - Enhanced Multiphase MRI with Hepatobiliary Phase: This is the gold standard for characterising focal liver lesions, offering detailed imaging through multiple contrast phases, including a hepatobiliary phase, improving sensitivity for small metastases and lesion differentiation².
• Extracellular Contrast Multiphase MRI: This technique, used when hepatocyte-specific agents are unavailable, utilises conventional contrast and offers a longer delayed wash-out window, enabling the assessment of vascular and parenchymal features crucial for surgical planning⁵⁵.
• Abbreviated Non-Contrast MRI (T2 + DWI ± In/Out-Phase): A rapid, contrast-free protocol useful for surveillance when contrast is contraindicated, combining T2 and diffusion-weighted sequences to maintain good diagnostic accuracy⁵⁶.
• DWI: Focuses on detecting metastases through cellularity-sensitive imaging; it is fast and does not require contrast, but has limited specificity as some benign lesions may appear similar⁵⁷.
• MR Elastography: Quantitatively measures tissue stiffness to aid fibrosis staging and tumour grading, providing noninvasive information that helps distinguish cancerous or fibrotic tissue from normal tissue⁵⁸.

Ezra uses whole-body DWI imaging to get a full picture of the body and catch any potential abnormalities.

MRI vs. Other Imaging Tests for Liver Cancer Detection

MRI Scan Cost

Ezra’s Full Body Plus MRI scan in the UK costs £2,695 and is currently available at their partner clinic in Marylebone, London, with more locations planned in the future. No referral is required, so you can book your scan directly without first consulting a GP or specialist. Most people pay out of pocket, as insurance typically does not cover self-referred scans, but you may be able to seek reimbursement depending on your policy. 

Frequently Asked Questions

What does liver cancer look like on MRI? 

Liver cancer often appears as a mass that is darker than normal liver on T1-weighted images, brighter on T2-weighted images and shows early contrast enhancement with “washout” in delayed phases.

How long does a liver MRI with contrast take?

A liver MRI with contrast typically takes between 10 and 30 minutes, with a total visit lasting up to an hour, including preparation time.

What does a liver MRI with contrast show?

A liver MRI with contrast provides detailed images that help visualise liver structures, blood vessels, and abnormal growths, allowing for the assessment of both anatomical and functional changes. This makes it highly effective in detecting tumours and other liver diseases.

Does your whole body go in for liver MRI?

Typically, only your upper body is positioned in the MRI scanner for a liver MRI, not your entire body. 

How to detect liver cancer early?

Liver cancer can be detected early through regular screening in high-risk individuals using ultrasound and/or blood tests for alpha-fetoprotein (AFP), as early liver cancer rarely causes symptoms.

Key Takeaways

• MRI with gadoxetic acid can detect very early-stage hepatocellular carcinoma (HCC), often before symptoms develop or blood vessels are invaded, supporting curative treatment when possible.
• Abbreviated MRI protocols are emerging as a more sensitive and practical alternative to ultrasound for routine surveillance in people with cirrhosis, and can sometimes be performed without contrast.
• Prompt follow-up or therapy for any abnormal findings on liver MRI significantly increases long-term survival, highlighting the crucial impact of early detection on patient outcomes.