Gd-EOB-DTPA-Enhanced MRI Combined with ALBI Score and AFP for Predicting Histologic Grade in Hepatocellular Carcinoma: A Multicentre Study from Vietnam

Objectives: The histologic grade is an important prognostic factor in hepatocellular carcinoma (HCC). A Gd-EOB-DTPA-enhanced MRI may provide noninvasive imaging markers related to tumour differentiation. This study aimed to evaluate the association of Gd-EOB-DTPA-enhanced MRI features, together with the albumin–bilirubin (ALBI) score and alpha-fetoprotein (AFP), with the HCC histologic grade and to assess the performance of combined predictive models. Methods: In this prospective cross-sectional study, 75 patients (mean age, 56.4 years; 66 men) with 88 histopathologically confirmed HCC lesions were enrolled. Patients were classified into well-differentiated (grades I–II, n = 24) and poorly differentiated (grades III–IV, n = 51) groups according to the Edmondson–Steiner system. The MRIs were performed on a 1.5-T scanner and included T1-weighted in-phase/opposed-phase imaging; T2-weighted imaging; diffusion-weighted imaging; and dynamic Gd-EOB-DTPA-enhanced sequences, including arterial, portal venous, transitional, and 20 min hepatobiliary phases. Two radiologists, blinded to the pathology, assessed predefined imaging features, and the lesion-to-liver ratio (LLR) was measured. Group comparisons were performed using Student’s t-test, a Mann–Whitney U test, and a chi-square or Fisher’s exact test, followed by a multivariable logistic regression and ROC analysis with bootstrap resampling. Results: Compared with well-differentiated HCC, poorly differentiated HCC showed a higher frequency of peritumoral hepatobiliary phase (HBP) hypointensity (62.7% vs. 4.2%, p < 0.001) and peritumoral arterial hyperintensity (39.2% vs. 0%, p < 0.001). In the multivariable analysis, peritumoral HBP hypointensity remained independently associated with poorly differentiated HCC (OR = 30.89, p = 0.002). The two-parameter MRI model, including peritumoral HBP hypointensity and HBP tumour signal, yielded an AUC of 0.84. The combined MRI + ALBI + AFP model yielded an AUC of 0.87 and an accuracy of 78.7%, representing only a small exploratory improvement over the two-parameter MRI model (AUC = 0.84) in this cohort. Conclusions: Gd-EOB-DTPA-enhanced MRI features, particularly peritumoral HBP hypointensity, were associated with a high histologic grade in HCC. In this surgically treated, predominantly HBV-related cohort with mostly preserved liver function, these findings provide a preliminary basis for preoperative histologic risk stratification; however, they remain exploratory and require external validation in larger, more diverse cohorts before broader clinical application.