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Liver imaging reporting and data

system (LI-RADS) version 2018: Imaging


Of Hepatocellular Carcinoma In At-risk
Patients
Pembimbing: dr. Febria Rahayuni S., Sp.Rad

Yohanes Setyo Widodo


(132011101044)
Puput Sagita Meysandra
(182010101008)
SMF ILMU RADIOLOGI RSD dr. SOEBANDI JEMBER
FAKULTAS KEDOKTERAN
UNIVERSITAS JEMBER
2019
Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
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Introduction
LI-RADS
 Provides standardization for hepatocellular carcinoma
(HCC) imaging in the contexts of screening and
surveillance, diagnosis, and treatment response
assessment
 categories accurately stratify the probability of HCC and
overall malignancy

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
History of LI-RADS
 The first version of LI-RADS was released in 2011 by the ACR
(American College of Radiology)

 The most recent update in 2018, LI-RADS was integrated into


AASLD (American Association for the Study of Liver Diseases)
clinical practice guidance.

 LI-RADS expanded to international multidisciplinary that is


presently composed of >250 members from >100 institutions and
>30 countries

 LI-RADS updates in 3-4 year cycle


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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Journal of Radiology.289(3):1-15
Implification for Patient Care

LI-RADS version 2018 updated the criteria for small (size


range,10–19 mm) LR-5 lesions and simplified the definition
for threshold growth

American Association for the Study of Liver Diseases 2018


HCC cinical practice guidance.

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
International Consideration
A long-term goal of LI-RADS is to unify HCC imaging and
diagnosis worldwide
• United States  liver transplantation for HCC
• Asia  early HCC detection for primary resection or
local-regional therapy

LI-RADS is a new paradigm in many radiology practices,


and it requires education. ACR website provides free
educational LI-RADS reference materials
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Imaging Context and Population
LI-RADS offers individual imaging algorithms designed for different clinical contexts :

US LI-RADS Surveilance

CT/MRI LI-RADS Diagnosis and Staging

Contrast material-
enhance US LI-RADS
Diagnosis

Treatment LI-RADS Asses response to local-regional therapies

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
LI-RADS OBSERVATION
LI-RADS observation an area with imaging appearance of the liver:
- true lesion or a pseudolesion
- benign to neoplastic
- premalignant to malignant
- Hepatocellular or nonhepatocellular

HCC is the most common primary hepatic malignancy in LI-RADS


Other: Intrahepatic cholangiocarcinoma (iCCA) and combined HCC-iCCA

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Changes in Categorization

Observations 10–19 mm with arterial phase hyperenhancement (APHE) and nonperipheral


“washout” are categorized as LR-5 (definite hepatocellular carcinoma)

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Journal of Radiology.289(3):1-15
Changes in Threshold growth
definition

Only 50% size increase in 6 months or less qualifies as threshold growth; all other size increases
qualify as subthreshold growth.
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
US LI-RADS
US For Surveillance

Repeated application of a
diagnostic test at a defined
interval in a population at
risk for developing a
disease

Identify HCC at an early


stage when it is
potentially curable
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
US LI-RADS
US Technique US Interpretation

-Gray-scale and color Doppler Provides scores for the entire


-Transverse, longitudinal views examination

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
US Categories
Cirrochis with
ascites but no focal
liver observation

Hyperechoic observation
is identified that follow up
in 3-6 month to ensure
stability

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Solid hypoechoic >10mm in left New thrombus in main Parenchymal distortion resulting
lobe of the liver portal vein in loss of normal portal triads
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Journal of Radiology.289(3):1-15
CT/MRI
For Diagnosis

The CT/MRI algorithm


permits definitive diagnosis
of HCC without pathologic
confirmation when applied
in patients at high risk

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
CT/MRI
Technique
Intravenous extracellular contrast agents are used for CT.
Extracelluler or hepatobilier used for MRI

MRI with gadoxate can detection small nonarterialized cancers in the


hepatobiliary phase  small HCC (<2 cm). That’s preferable in
clinical practice:
Asia : local-regional treatment or resection for small HCCs
United states : liver transplantation without biopsy confirmation in
the treatment of early stage HCC

Gadoxetate disodium and


gadobenate dimeglumine
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
CT/MRI
Image Interpretation

LR-1 (definitely benign)


LR-2 (probably benign)
simple cyst - distinctive nodules (<20 mm)
LR-3 (intermediate probability of HCC)
LR-4 (probably HCC),
LR-5 (definitely HCC),
LR-M (probably or definitely malignant, not specific for HCC)
LRTIV (malignancy with tumor in vein).

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular
CT/MRI
The LI-RADS lexicon divides imaging features into:
1. Major features (LR-5 categorization) include
• nonrim APHE
• nonperipheral “washout” appearanceportal venous phase with gadoxetate
disodium or gadobenate dimeglumine
• enhancing “capsule” appearance
• size and threshold growth at least 50% in 6 month or less
2. LR-M features
include a targetoid or nontargetoid mass with one or more of the following findings:
infiltrative appearance, marked diffusion restriction, necrosis, or other features
suggestive of non-HCC malignancy
3. Ancillary features
Improve the accuracy of categorization and lesion detection or diagnostic
confidence. Detailed
discussion of ancillary features can be found on the ACR website
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Journal of Radiology.289(3):1-15
CT/MRI Categories

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
CT/MRI Categories

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
CT/MRI Categories

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
CT/MRI
Image Interpretation
 Tumor in vein is often associated with HCCit can occur in the
setting of non-HCC malignancy.
 Malignant lesions  confirmed with biopsy (eg, HCC, iCCA)
 Benign lesions of nonhepatocellular origin (eg, hemangioma) do
not require LI-RADS categorization unless:
1. There is discordance between imaging and pathology
findings
2. There is some other doubt about the diagnosis.

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Contrast-enhanced US
• Performed with intravenous injection of a microbubble contrast

• Most suitable for problem solving, categorizing individual


observations, and differentiating tumor in vein from bland thrombus
rather than for staging the entire liver.

• Real-time imaging is performed continuously for the 1st (arterial


phase). This is followed by intermittent scanning every 30–60
seconds for up to about 5 minutes to evaluate washout.

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Contrast-enhanced US
• Microbubbles = pure blood pool agents, confined within the blood
space, do not leak through endothelial fenestrations into the tumor
or parenchymal interstitium --> their distribution on postarterial
phase images reflects the relative blood volume.

• HCC --> have only slightly lower blood volume than the liver -->
exhibit mild and late-onset washout

• ICCAs, non-HCC malignancies --> lower blood volume --> early


washout

• Contrast enhanced US LI-RADS requires assessment for both


presence of washout and its time of onset after injection
and its degree. 23
Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Treatment Response
• LI-RADS treatment response algorithm applies to
CT or MRI used to assess response after local-regional
therapy, which includes: 
– percutaneous therapy
– transcatheter therapy
– external beam radiation therapy.

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Treatment Response
• The LI-RADS treatment response algorithm also applies
to observations at the surgical margin after resection of HCC
• does not apply to systemic chemo-, targeted, or
immunologic therapies, nor does it apply to treatment
response using contrastenhanced US
• In patients who underwent both systemic therapy and local-
regional treatment, the LI-RADS treatment response
algorithm can be applied at the discretion of the interpreting
radiologist.
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Treatment Response
Analogous in concept to the diagnostic algorithms,
LIRADS treatment response category codes reflect the
relative probability of tumor viability after local-regional
therapy to guide management decisions.

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular
Carcinoma.Journal of Radiology.289(3):1-15
Reporting
• Surveillance reports should include LI-RADS US category
and visualization scores
• Diagnostic and staging reports should describe
individual observations, including their size, major features
(and ancillary features if used for category adjustment), and
final diagnostic category. 
• Treatment response reports should assign a LI-RADS
treatment response category, include the pretreatment
LIRADS category (or histologic diagnosis, if known), and
provide a measure of viable or equivocally viable tumor. 
Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
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Management
• Strongly influenced by the imaging observation with the
highest risk of malignancy 
• Although radiologists provide an initial estimate of the
relative likelihood of HCC or viable tumor, the estimate may
be refined by clinical history, biomarker levels, and other
factors.
• Decisions between management options do not follow solely
from the estimated probability of HCC. Thus, management
decisions should be determined with a multidisciplinary
approach.
Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular
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Carcinoma.Journal of Radiology.289(3):1-15
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Biopsy Considerations
• Biopsy may assist management decisions in patients
with LR-3, LR-4, or LR-M observations
• LR-5 observations do not require pathologic proof of
diagnosis.

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Biopsy Considerations

Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
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Journal of Radiology.289(3):1-15
LI-RADS: Emerging Evidence

• In patients at risk for disease, nonrim APHE is a sensitive


imaging feature for progressed HCC
• The combination of nonrim APHE and nonperipheral
washout appearance provides high specificity
• Capsule appearance yields high specificity 

• Threshold growth helps differentiate HCC from benign


entities
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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Gaps and Future Directions
• There are still insufficient high-quality data for many
questions in HCC imaging
• Interrater reliability is controversial for "capsule" and
poorly understood for ancillary feature
• Newer components of LI-RADS (treatment response,
diagnostic criteria) still requires validation.

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Gaps and Future Directions
• Studies are needed to define the optimal work-up strategy
of indeterminate (LR3) and suspicious (LR-4) observations.
• Although these lesions carry the risk of being or progressing
to HCC, it is unclear how long they require monitoring with
diagnostic imaging, if they should undergo biopsy, and
whether patients can ever return to the original surveillance
schedule. 

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma.
Conclusion
• LI-RADS provides algorithm for diagnostic criteria,
surveillance, treatment response, and contrast
enhanced US-based diagnosis
• All LI-RADS algorithms are built on the foundation of
standardized lexicon, technique, management, and
reporting guidelines.

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Chernyak, V., dkk.2018. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular
THANK YOU

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