2/21/2014. Disclosure statement CT, MRI, LI-RADS. CT and MRI as first-line modalities PLAN. CT- and MRI-based diagnosis. Role of CT and MRI

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Ancillary features that may favor HCC LR1 LR2 LR3 LR4 LR5 Ancillary features that may favor benignity,, LI-RADS An Tang, MD, MSc CHUM, University of Montreal CASL HCC Meeting: Consensus,

1 Ancillary features that may favor HCC LR1 LR2 LR3 LR4 LR5 Ancillary features that may favor benignity,, LI-RADS An Tang, MD, MSc CHUM, University of Montreal CASL HCC Meeting: Consensus, Controversies and Future Directions Tuesday, February 11 th 2014 Disclosure statement No conflict of interest to report i.e. no industry funding received or other commercial relationships ACKNOWLEDGMENTS Fulbright Scholarship Canadian Institutes of Health Research (CIHR) Fellowship Award# PLAN and as first-line modalities Organizations APASL 2010 EASL-EORTC 2012 UNOS-OPTN 2011 JSH 2010 AASLD 2010 LI-RADS 2013 North America North America Continent Asia Asia Europe North America This session will focus on: and for diagnosis and staging of HCC LI-RADS - Moving toward standardized reporting First-line imaging modalities Dynamic Dynamic Dynamic : 3-phase helical Dynamic : 3-phase dynamic contrast-enhanced Dynamic : 4-phase MD Dynamic : 4-phase dynamic contrast-enhanced Dynamic : 4-phase MD Dynamic : contrast-enhanced Dynamic : Dynamic : Late arterial phase, and portal venous phase, portal venous phase and delayed phase are required are mandatory Dynamic : Dynamic : Contrast-enhanced Contrast-enhanced Unenhanced T1w Unenhanced T1w IP and OP IP and OP T2-weighted Unenhanced T2w DWI suggested Second-line Gadoxetate, imaging modalities CEUS (Sonazoid) HA, AP Gadoxetate CEUS (Sonazoid or Levovist) s Kudo, Dig Dis 2011; 29: Omata, Hepatol Int 2010; 4: EASL-EORTC, J Hepatol 2012; 56: Bruix J, Sherman M, OPTN/UNOS policy Hepatology 2011; : LI-RADS version www. acr.org/quality- Safety/Resources/LI RADS/ Cruite I, Tang A, Sirlin CB. Imaging-based diagnostic systems for HCC. AJR 2013;201(1): Role of and - and -based diagnosis 1. Detection, diagnosis and staging of HCC 2. Management guidance 3. Prognosis 4. Evaluation of treatment response Malignant HCC Cholangiocarcinoma* Non-hepatocellular malignancy Non-malignant Cirrhosis-associated nodules: -cirrhotic nodules -low-grade dysplastic -high-grade dysplastic Benign lesions: -Hemangiomas Pseudolesions: -Perfusion anomalies -Focal confluent fibrosis Bruix J, Sherman M. Management of HCC: an update. Hepatology ;53(3): s Singh P et al. Current Opinion in Gastroenterology. 2006;22(3):

Diagnostic performance Diagnostic performance in comparative studies Per-lesion sensitivity (extra-cellular contrast agents) All sizes 1,2,3 54-91% 72-100% > 2 cm 1 100% 100% Technique US Pooled

2 Diagnostic performance Diagnostic performance in comparative studies Per-lesion sensitivity (extra-cellular contrast agents) All sizes 1,2, % % > 2 cm 1 100% 100% Technique US Pooled Sensitivity (%) (95% CI) Pooled Specificity (%) (95% CI) Adapted from: 60.5 (44-76) 96.9 (95-98) 67.5 (55-80) 92.5 (89-96) 80.6 (70-81) 84.8 (77-93) Colli A et al. Accuracy of ultrasonography, spiral, magnetic resonance, and alpha-fetoprotein in diagnosing HCC: a systematic review. Am J Gastroenterol. 2006;101(3): cm 1, % 44-89% < 1 cm 1,5, % 29-43% s 1. Burrel M et al. Hepatology. 2003;38(4): Rode A et al. JCAT. 2001;25(3): Kim YK et al. AJR 2006;186(1): Sangiovanni A et al. Gut. 2010;59(5): Krinsky GA et al. Radiology. 2001;219(2): Lim JH et al. AJR. 2000;175(3): Yu NC et al. Clin Gastroenterol Hepatol. 2001;9(2): Pros and cons Advantages Disadvantages -Widely available -Rapid -Robust -Easier to perform -Easier to interpret -Radiation exposure -Lower soft tissue contrast -Higher soft tissue contrast -Assessment of several tissue properties -Limited availability -Time-consuming -Less robust -Prone to artifacts -Expertise required LI-RADS CONTRIBUTORS Need for standardization LI-RADS Committee Mustafa Bashir 1,2 Alexander Kagen Giuseppe Brancatelli Daniel Margolis James Brink Frank Miller 1 Jeffrey Brown Don Mitchell 1,2 Irene Cruite 1,2 Mariam Moshiri Guilherme Cunha 2 Aliya Qayyum Richard Do Daniel Rubin 1 Michael Federle Dushyant Sahani Sebastian Flacke 1 Riad Salem Kathryn Fowler Cynthia Santillan 1,2 Alessandro Furlan Amol Shah 2 Karthik Ganesan 1 Claude Sirlin, Chair 1,2 Jeff Geschwind An Tang 1,2 Jay Heiken 1,2 Bachir Taouli 1 Tom Hope 1,2 Jeff Weinreb 1 Hero Hussain 1 Benjamin Yeh 1,2 Shahid Hussain Reena Jha 1 Consultants to LI-RADS Committee Elizabeth Brunt Rajender Reddy Robert Gish Mario Strazzabosco Zachary Goodman Christoph Wald Marquis Hart Julie Heimbach Alan Hemming Image Contribution Emil Achmad Giuseppe Brancatelli Irene Cruite Guilherme Cunha Richard Do Karthik Ganesan Reena Jha Alexander Kagen Daniel Margolis Arian Mashhood Dushyant Sahani Cynthia Santillan Amol Shah Claude Sirlin An Tang Bachir Taouli Design Guilherme Cunha Amol Shah Claude Sirlin An Tang Phase 1 & 2 Readers Dean Asher Garney Fendley Karthik Ganesan Alexander Guimaraes Masoom Haider Jay Heiken Reena Jha Kartik Jhaveri Donald Mitchell Irene Cruite Jinha Park Cynthia Santillan Claude Sirlin Jeffrey Weinreb Benjamin Yeh ACR Laura Coombs Mythreyi B Chatfield Probability of HCC Growth Vascular phase Radiologists Indeterminate Equivocal Uncertain significance Suspicious for HCC Definite growth Probable growth Washout Washout appearance Fade appearance -HCC or non HCC Guidelines -Most guidelines do not define growth -Portal phase -Equilibrium phase -Parenchymal phase -Late venous phase -Later contrast phase -Delayed phase 1 Steering committee, 2 Working group 2

Objectives of LI-RADS Structure of LI-RADS Atlas 1. To improve communication by radiologists with clinicians 2. To reduce variability and error in image interpretation 3.

To facilitate outcome monitoring, performance auditing, quality assurance, research, and meta-analysis of published manuscripts.

The arterial phase is a post-contrast injection time range in which images have the following characteristics: Arterial Portal Venous Delayed : In LI-RADS, the arterial phase refers to the hepatic

3 Objectives of LI-RADS Structure of LI-RADS Atlas 1. To improve communication by radiologists with clinicians 2. To reduce variability and error in image interpretation 3. To reduce omission of relevant information from radiology reports Algorithm Lexicon 4. To reduce the frequency of technically inadequate examinations 5. To facilitate outcome monitoring, performance auditing, quality assurance, research, and meta-analysis of published manuscripts. Index Early Arterial Late Arterial Portal Venous Delayed : In LI-RADS, the arterial phase refers to the hepatic arterial phase unless otherwise specified. The arterial phase is a post-contrast injection time range in which images have the following characteristics: Arterial Portal Venous Delayed : In LI-RADS, the arterial phase refers to the hepatic arterial phase unless otherwise specified. The arterial phase is a post-contrast injection time range in which images have the following characteristics: Hepatic artery and branches are fully enhanced. Hepatic artery and branches are fully enhanced. Hepatic veins not yet enhanced by antegrade flow. Hepatic veins not yet enhanced by antegrade flow. Early Arterial Phase Late Arterial Phase Comments: Comments: imaging is required for both and. imaging is required for both and. Hepatic arterial phase may be subclassified as early and late hepatic arterial phase. Hepatic arterial phase may be subclassified as early and late hepatic arterial phase. Early hepatic arterial phase: portal vein is not yet enhanced. Early hepatic arterial phase: portal vein is not yet enhanced. Late hepatic arterial phase: portal vein is enhanced. Late hepatic arterial phase: portal vein is enhanced. : Schematic diagrams depict pre-contrast and post-extracellular contrast early arterial, late arterial, portal venous, and delayed phase images. is defined by full enhancement of hepatic arteries and absence of antegrade enhancement of hepatic veins. In the early arterial phase, portal vein is unenhanced. In later arterial phase, portal vein is enhanced. Late arterial phase is strongly preferred for HCC diagnosis and staging. Late hepatic arterial phase is strongly preferred for HCC diagnosis and staging, because the degree of enhancement in HCC usually is higher in the late than in the early hepatic arterial phase. Some HCCs may show hyperenhancement only in the late hepatic arterial phase. (): Late arterial phase image shows strong enhancement of aorta, hepatic artery branches (red arrows), and intrahepatic portal vein branches. Hepatic veins (white arrows) are not enhanced. Note characteristic heterogeneous enhancement of spleen. Late hepatic arterial phase is strongly preferred for HCC diagnosis and staging, because the degree of enhancement in HCC usually is higher in the late than in the early hepatic arterial phase. Some HCCs may show hyper-enhancement only in the late hepatic arterial phase. Arterial Portal Venous Delayed : In LI-RADS, the arterial phase refers to the hepatic arterial phase unless otherwise specified. The arterial phase is a post-contrast injection time range in which images have the following characteristics: Hepatic artery and branches are fully enhanced. Category Codes LI-RADS Category LR-1 Definitely Benign Concept 100% certainty observation is benign. Hepatic veins not yet enhanced by antegrade flow. Comments: LR-2 Probably Benign High probability observation is benign. imaging is required for both and. Hepatic arterial phase may be subclassified as early and late hepatic arterial phase. Early hepatic arterial phase: portal vein is not yet enhanced. Intermediate probability for HCC Probably HCC Both HCC and benign entity have moderate probability. High probability observation is HCC but there is not 100% certainty. Late hepatic arterial phase: portal vein is enhanced. LR-5 Definitely HCC 100% certainty observation is HCC. Late hepatic arterial phase is strongly preferred for HCC diagnosis and staging, because the degree of enhancement in HCC usually is higher in the late than in the early hepatic arterial phase. Some HCCs may show hyper-enhancement only in the late hepatic arterial phase. (): Late arterial phase MR image shows strong enhancement of aorta, hepatic artery branch (red arrow), and intrahepatic portal vein branches. Hepatic veins (white arrows) are not enhanced. Note characteristic heterogeneous enhancement of spleen. 3

4 Category Codes LI-RADS v2014 LI-RADS Category Concept Observation in high-risk patient LR-1 Definitely Benign 100% certainty observation is benign. Treated observation Untreated observation LR-2 Probably Benign High probability observation is benign. Definitely benign Probably benign Neither definitely nor probably benign Intermediate probability for HCC Both HCC and benign entity have moderate probability. LR-Treated LR-1 LR-2 Possible non-hcc malignancy LR-M Probably HCC High probability observation is HCC but there is not 100% certainty. Tumor in vein LR-5V LR-5 LR-5V Definitely HCC Definitely HCC with Tumor in Vein 100% certainty observation is HCC. 100% certainty that observation is HCC invading vein. hypo- or isoenhancement Diameter (mm): < hyperenhancement < LR-Treated Treated HCC A loco-regionally treated HCC. Washout Capsule None: One: LR-5 LR-M Other Malignancy High probability that observation is a malignancy other than HCC. Threshold growth Two: LR-5 LR-5 Apply ancillary features and then tie-breaking rules to adjust category Size criteria and major features hyperenhancement hypo- or isoenhancement hyperenhancement Arterial Arterial Diameter (mm): < < Washout None: In whole In part Capsule One: LR-5 Threshold growth Two: LR-5 LR-5 hyperenhancement hyperenhancement is characteristic of HCC, but not specific, as it can be observed in other lesions (hemangiomas, FNH, A-P shunts). Arterial Portal Venous Delayed hyperenhancement s Modality Sensitivity Specificity PPV NPV Sangiovanni, Gut Sangiovanni, Gut Kim, Radiology Forner, Hepatology Rimola, J of Hepatol Efremidis SC. European Radiology. 2002;12(4):

5 Washout appearance Washout appearance Arterial Portal Venous Delayed Washout appearance is defined as temporal reduction in enhancement relative to liver from an earlier to a later phase resulting in portal venous or delayed phase hypoenhancement. Arterial Portal Venous Delayed Washout appearance s Modality Sensitivity Specificity PPV NPV Sangiovanni, Gut Sangiovanni, Gut Hallmark diagnostic features of HCC hyperenhancement followed by portal venous or delayed phase washout appearance. Arterial Portal Venous Delayed Kim, Radiology Rimola, J of Hepatol In patients with cirrhosis or other risk factors for HCC, this enhancement pattern provides near 100% specificity for the diagnosis of HCC. s Burrel M, et al, Hepatology. 2003;38(4): Forner A, et al. Hepatology. 2008;47(1): Sangiovanni A, et al. Gut. 2010;59(5): Kim TK, et al. Radiology. 2011;259(3): Hallmark enhancement pattern s Modality Sensitivity Specificity PPV NPV Capsule appearance Arterial Portal Venous Delayed Burrel, Hepatology Burrel, Hepatology Marrero, Liver Transpl Forner, Hepatology Sangiovanni, Gut Sangiovanni, Gut Kim, Radiology Rimola, J of Hepatol

6 Capsule Capsule appearance, in combination with arterial phase hyperenhancement is highly suggestive of HCC, even in the absence of washout appearance. Arterial Portal Venous Delayed Capsule appearance s Modality Sensitivity Specificity PPV NPV Khan, J 2010 Hallmark enhancement Capsule Rimola, J of Hepatol 2012 Hallmark enhancement Capsule s Rimola J, et al. J Hepatol. 2012;56(6): Khan AS, et al. J. 2010; 32(2): Grazioli L, et al. European Radiology. 1999;9(1):62-7. Ishigami K, et al. Radiology. 2009; 250(2): Lim JH, et al. European Radiology. 2006;16(10): s Rimola J, et al. J Hepatol. 2012;56(6): Khan AS, et al. J. 2010;32(2): Threshold Growth Threshold Growth Prior (Comparison) Exam Current Exam > 6 months earlier Any prior exam 6 months earlier 50% diameter increase or minimum of 5 mm 100% diameter increase i.e., diameter must at least double s Doubling Time Range (days) Saito, Journal of Gastroenterology 1998 Well-differentiated HCC Moderately-differentiated HCC Nakajima, Human Pathology 2002 Well-differentiated HCC Moderately-differentiated HCC Poorly-differentiated HCC New 10mm mass 10 mm s Saito Y, et al. Journal of Gastroenterology. 1998;33(2): Nakajima T. et al., Human Pathology. 2002;33(1):92-9. Ancillary features Ancillary features that may favor HCC LR1 LR2 LR3 LR4 LR5 Features that may favor HCC: Mild-moderate T2 hyper-intensity 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 Ancillary features that may favor benignity Features that may favor benignity: Homogeneous marked T2 hyper-intensity Homogeneous marked T2 or T2* hypo-intensity Undistorted vessels Parallels blood pool enhancement Diameter reduction Diameter stability 2 years 6

Imaging Features AASLD LI-RADS < 10 mm with washout appearance Probable HCC (LR4) < 10 mm with corona enhancement Probable HCC (LR4) 10-19 mm with washout appearance HCC Probable HCC (LR4) 10-19 mm

7 Imaging Features AASLD LI-RADS < 10 mm with washout appearance Probable HCC (LR4) < 10 mm with corona enhancement Probable HCC (LR4) mm with washout appearance HCC Probable HCC (LR4) mm with capsule appearance Probable HCC (LR4) mm with both washout and capsule appearances HCC HCC (LR5) mm with corona enhancement Probable HCC (LR4) mm with 50% diameter increase in < 6 months Probable HCC (LR4) mm with 100% diameter increase in 9 months HCC (LR5A) mm with hepatobiliary phase hypo-intensity at gadoxetate 20 mm with washout appearance HCC HCC (LR5) 20 mm with capsule appearance HCC (LR5) 20 mm with corona enhancement Probable HCC (LR4) 20 mm with 50% diameter increase in < 6months HCC (LR5) 20 mm with 100% diameter increase in 9 months HCC (LR5) 20 mm with hepatobiliary phase hypo-intensity at gadoxetate Cruite I et al, Imaging-based diagnostic systems for HCC. AJR 2013; 201:41-55 Key Points Consensus Statements: All major clinical practice guidelines endorse multi-phasic and with extracellular contrast agents as the first-line modalities for diagnosis and staging of HCC [Level 2A]. LI-RADS is a standardized system for interpretation and data collection of and liver examinations. LI-RADS categorizes observations along a 5-point ordinal scale ranging from LR1 LR-1 (definitely benign) to LR5 LR-5 (definitely HCC). LR5 observations have high PPV and specificity for HCC. LR5V LR-5V indicates macrovascular invasion. LR-Treated LR5T indicates loco-regionally treated HCC. The major imaging criteria for HCC are based on evidence [Level 3B]. The application of LI-RADS has not been validated yet [Level 5]. 8. Patients at risk for HCC with a lesion >1cm detected on ultrasound should undergo a contrast-enhanced or contrast-enhanced to establish the diagnosis of HCC and stage the disease [Level 2A]. 9. The Liver Imaging Reporting and Data System (LI-RADS) is recommended to standardize the reporting of and in patients with cirrhosis or other risk factors for HCC because it allows for consistent terminology, reduced interpretation variability, enhanced communication with clinicians and facilitates quality assurance and research [Level 5]. 7

Objectives. LI-RADS v2017. Working Groups. Cynthia Santillan. Released October 2014 Diagnosis. Screening/ Surveillance. Diagnosis

Objectives. LI-RADS v2017. Working Groups. Cynthia Santillan. Released October 2014 Diagnosis. Screening/ Surveillance. Diagnosis LR-NC Cynthia Santillan LR-TIV Objectives 1. To teach participants how to apply the Liver Imaging Reporting and Data System () to their interpretation of imaging studies for the evaluation of hepatocellular