AASLD 2011

Overview

Comprehensive management system

for HCC.

OPTN 2014
OPTN policy for liver transplant
candidates with HCC (in USA).

Includes algorithm for US-based

surveillance and CT-/MRI-based
diagnosis of HCC.

LI-RADS 2014
Comprehensive imaging diagnosis
system for HCC.

Includes CT and MRI criteria for

HCC to determine eligibility and
priority for liver transplantation.

Target population

Patients at risk for HCC in a

surveillance program.

Patients with HCC considered for

liver transplantation.

All patients at risk for HCC.

Intended users

Radiologists with expertise in liver

imaging.

Radiologists at liver transplantation

centers.

All radiologists.

Categorization of
observations

HCC
Indeterminate
Benign

Untreated definite HCC

Class 5A: 10-19 mm
Class 5B: 20-50 mm
Class 5X: > 50 mm or tumor in vein

Untreated observations
LR-1: definitely benign
LR-2: probably benign
LR-3: intermediate probability
LR-4: probably HCC
LR-5: definitely HCC
LR-5V: tumor in vein
LR-M: probably malignant, not
specific for HCC

Treated definite HCC

Class 5T (Treated)
Non-diagnostic exam
Class 0

Treated observations
LR-Treated
Imaging methods
addressed

US for surveillance; CT and MRI with

extracellular agents for diagnosis.

CT and MRI with extracellular

agents.

CT, MRI with extracellular agents,

and MRI with hepatobiliary agents.

Imaging features
addressed

Arterial phase hyper-enhancement

Washout appearance
Diameter

These features apply only to 10

mm observations detected at
surveillance ultrasound

Arterial phase hyper-enhancement

Washout appearance
Diameter
Diameter increase over time
Capsule appearance

Arterial phase hyper-enhancement

Washout appearance
Diameter
Diameter increase over time
Capsule appearance
Visibility at surveillance ultrasound
Multiple ancillary features

Imaging criteria for

tumor in vein provided

No

No

Yes

Lexicon and atlas

No

No

Yes

Reporting templates

No

Yes

Yes

LI-RADS

Intro

Overview Categories Reporting

Management Technique Index

v2014

Observation in high-risk patient

LR-Treated

My edits to the
diagonal boxes.

Untreated observation

Treated observation
Definitely
benign

Probably
benign

LR-1

LR-2

Neither definitely nor

probably benign
Probable malignancy,
not specific for HCC

LR-M

Tumor in vein

LR-5V

Arterial phase
hypo- or isoenhancement

Arterial phase
hyperenhancement

Diameter (mm):

< 20

20

< 10

10-19

20

Washout

None:

LR-3

LR-3

LR-3

LR-3

LR-4

Capsule

One:

LR-3

LR-4

LR-4

LR-4
LR-5

LR-5

Two:

LR-4

LR-4

LR-4

LR-5

LR-5

Threshold growth

Apply ancillary features and then tie-breaking rules to adjust category

LR-4
LR-5

Observations in this cell are categorized LR-4 except as follows:

LR-5g, if there is 50% diameter increase in 6 months. These observations are equivalent to OPTN 5A-g.
LR-5us, if there is both washout and visibility as discrete nodules at antecedent surveillance ultrasound, per AASLD HCC criteria.

LI-RADS Category

Concept and Definition

Concept: 100% certainty observation is benign.

LR-1

Definitely
Benign

LR-2

Probably
Benign
Intermediate
probability
for HCC

Concept: Both HCC and benign entity have moderate probability.

LR-3

Probably
HCC

Concept: High probability observation is HCC but there is not 100% certainty.

LR-4

LR-5

Definitely
HCC

Definition: Observation with imaging features diagnostic of a benign entity, or definite

disappearance at follow up in absence of treatment.
Concept: High probability observation is benign.

LR-5V

Definitely HCC with

Tumor in Vein

LR-M

Probable
malignancy, not
specific for HCC

LR-Treated

Treated
Observation

Definition: Observation with imaging features suggestive but not diagnostic of a benign
entity.
Definition: Observation that does not meet criteria for other LI-RADS categories.

Definition: Observation with imaging features suggestive but not diagnostic of HCC.

Concept: 100% certainty observation is HCC.

Definition: Observation with imaging features diagnostic of HCC or proven to be HCC
at histology.
Concept: 100% certainty that observation is HCC invading vein.
Definition: Observation with imaging features diagnostic of HCC invading vein.
Concept: High probability that observation is a malignancy, but imaging features are
not specific for HCC.
Definition: Observation with one or more imaging features that favor non-HCC
malignancy.
Concept: Loco-regionally treated observation.
Definition: Observation that has undergone loco-regional treatment

LI-RADS Features
Major
Arterial phase features
Arterial phase hypo- or isoenhancement
Arterial phase hyperenhancement
Diameter
For arterial phase hypo- or
iso-enhancing masses:
Diameter < 20mm
Diameter 20 mm
For arterial phase hyperenhancing masses:
Diameter < 10mm
Diameter 10-19mm
Diameter 20 mm
Washout appearance
Capsule appearance
Threshold growth

Ancillary for Malignancy

Ancillary for Benignity

Mild-moderate T2 hyperintensity
Restricted diffusion
Corona enhancement*
Mosaic architecture*
Nodule-in-nodule architecture*
Intra-lesional fat*
Lesional iron sparing
Lesional fat sparing
Blood products
Diameter increase less than
threshold growth
Hepatobiliary phase hypointensity
Distinctive rim*

Homogeneous marked T2
hyper-intensity
Homogeneous marked T2 or
T2* hypo-intensity
Undistorted vessels traversing
observation
Parallels blood pool
enhancement
Diameter reduction
Diameter stability 2 years
Hepatobiliary-phase
isointensity

Whats New in LI-RADS v2014

LI-RADS v2014 features several enhancements:
Updated algorithmic display.
Simplified algorithm
Removal of unnecessary decision nodes
Deleted A and B designation in Categories LR-4 and LR-5
Treated observations are identified at the beginning of the algorithm, more reflective of radiologist
thought process
Major features are listed in a separate box from the remainder of the table to improve clarity
Expanded and refined LI-RADS lexicon.
Expanded illustrative atlas.
New material on imaging technique, management, and reporting, including reporting template.
New tie-breaking rules to guide assignment of final LI-RADS category.
New material comparing LI-RADS with AASLD and OPTN.
LI-RADS v2014 also includes a key modification to achieve congruency between LR-5 and OPTN Class
5 and AASLD:
10-19mm observations with arterial phase hyper-enhancement and one major feature can sometimes be
categorized as LR-5 rather than LR-4
Observations with washout appearance and visibility on antecedent surveillance ultrasound meet
criteria for HCC using AASLD criteria. These observations can be categorized as LR-5us.
Observations with 50% diameter increase in 6 months meet criteria for OPTN 5A-g HCC. These
observations can be categorized as LR-5g.

LI-RADS
v2014

LR-1

versus

LR-2

LR-2

LR-2

versus

LR-3

LR-3

LR-3

versus

LR-4

LR-3

LR-4

versus

LR-5

LR-4

LR-3

versus

LR-M

LR-3

LR-4

versus

LR-M

LR-M

LR-5

versus

LR-M

LR-M

Tie-breaking rules: Schematic diagram illustrates application of tie-breaking rules to adjust category. If, after application of ancillary
features, a radiologist is still unsure about the final category for an observation, tie-breaking rules should be applied. The tie-breaking rules
move observations to a category with a lower degree of certainty.

Introduction
What is LI-RADS (Liver Imaging Reporting And Data System)?
A system of standardized terminology and criteria to interpret and report imaging examinations of the liver.
Supported and endorsed by the American College of Radiology (ACR).
LI-RADS is a dynamic document: it will be expanded and refined as knowledge accrues and in response to
user feedback.
Who is developing LI-RADS?
LI-RADS is being developed by an ACR-supported committee of diagnostic radiologists with expertise in liver
imaging.
The committee receives input from hepatobiliary surgeons, hepatologists, hepatopathologists, and
interventionalists.
In what patient population does LI-RADS apply?
LI-RADS currently applies to patients with cirrhosis or at risk for HCC.
What imaging modalities are addressed by LI-RADS?
LI-RADS currently applies to CT and MRI performed with extracellular and hepatobiliary contrast agents.
Surveillance ultrasound findings as incorporated into AASLD guidelines for diagnosis of HCC
Who can use LI-RADS?
LI-RADS may be used by community and academic radiologists.
How does LI-RADS work?
LI-RADS categorizes observations from LR-1 to LR-5, reflecting probability of benignity or HCC in at-risk
patients.