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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)


 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

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

 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

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.
International Consideration

A long-term goal of LI-RADS is to unify HCC imaging and

diagnosis worldwide

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

it requires education. ACR website provides free educational
LI-RADS reference materials
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

Treatment LI-RADS Asses response to local-regional therapies

LI-RADS observation an area with imaging appearance that is distinctive from the rest
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
Observations 10–19 mm with arterial phase hyperenhancement (APHE) and nonperipheral
“washout” are categorized as LR-5 (definite hepatocellular carcinoma)
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
US Technique US Interpretation

-Gray-scale and color Provides scores for the

Doppler entire examination
-Transverse, longitudinal
US Categories
Cirrochis with
ascites but no focal
liver observation

Hyperechoic observation
is identified that follow up
in 3-6 month to ensure
Solid hypoechoic >10mm in left
New thrombus in vein Parenchymal distortion
lobe of the liver
For Diagnosis

The CT/MRI algorithm

permits definitive diagnosis
of HCC without pathologic
confirmation when applied in
patients at high risk
 Intravenous extracellular contrast agents are used for CT. Extracelluler or
hepatobilier used for MRI
 MRI with gadoxate can detection arterialized cancer in dynamic phases
and small nonarterialized cancers in the hepatobiliary phase  small
HCC (<2 cm)

That’s preferable in clinical practice paradigms (Asia) that emphasize

aggressive local-regional treatment or resection for small HCCs

Gadoxetate disodium and

gadobenate dimeglumine
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).
CT/MRI Categories
CT/MRI Categories
CT/MRI Categories
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.
Contrast-enhanced US
• performed with intravenous injection of a microbubble contrast

• 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.
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.
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.
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.
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.
• 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.
• Strongly influenced by the imaging observation with the highest risk of

• 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.
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
Biopsy Considerations
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

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.
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.
• 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