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

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1 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 carcinoma in at-risk patients 2. To inform radiologists about some of the changes in the newest release of with 3. To update radiologists about additional content in, including ultrasound and treatment response assessment guidelines Working Groups Steering Committee Claude Sirlin Atlas & Lexicon Tech Apps Evidence Reporting Technique Treatment Response Radiology- Pathology Surveillance US Management Hepatobiliary Contrast Outreach/ Education Contrast Enhanced US Treated observation Observation in high-risk patient Untreated observation Definitely benign Probably benign Neither definitely nor probably benign LR-Treated Probable malignancy, not specific for HCC Tumor in vein V Washout Capsule Threshold growth Diameter (mm): None: One: Two: erial phase hypo- or isoenhancement < erial phase hyperenhancement < Released October 2014 Diagnosis Diagnosis Screening/ Surveillance Apply ancillary features and then tie-breaking rules to adjust category Observations in this cell are categorized except as follows: g, if there is 50% diameter increase in 6 months. These observations are equivalent to OPTN 5A-g. us, if there is both washout and visibility as discrete nodules at antecedent surveillance ultrasound, per AASLD HCC criteria. US

2 US Surveillance US imaging in high-risk patient Non-multiphase CT or MRI in high-risk patient Multiphase CT or MRI in high-risk patient Surveillance US imaging in high-risk patient US Observation detected US-1 Negative Adequate exam AND No focal observation OR Only definitely benign observations Repeat US in 6 mos US-2 Subthreshold Focal observation(s) <10mm AND Not definitely benign Repeat US in 3-6 mos US-3 Positive Focal observation(s) 10mm AND Not definitely benign OR New thrombus in vein Diagnostic imaging US-3 Locoregional treatment? TR or multiphase TR LR-TR Nonevaluable Pure blood pool agents LR-TR Nonviable LR-TR Equivocal LR-TR Viable How to measure thick irregular viable tumor Nonenhancing area How to measure nodular viable tumor Nonenhancing area TR Categories Enhancing area Largest enhancing area LR-TR Nonevaluable LR-TR Nonviable Definitely benign Probably benign Intermediate probability for HCC Probably HCC LR-TR Equivocal Definitely HCC V Definitely HCC with Tumor in Vein LR-TR Viable LR-Treated Probable Malignancy not specific for HCC Treated observation

3 LR-NC LR-TIV LR-Treated Categories Not categorizable Definitely benign Probably benign Intermediate probability for HCC Probably HCC Definitely HCC ± Tumor in Vein Malignant, not specific for HCC ± Tumor in Vein Tumor in Vein Treated observation Released June 2017 Observation High-risk patient LR-NC 1 Major features can t be assessed Possible categories range from benign to malignant LR-TIV Enhancing soft tissue in vein Reported at radiologist discretion Report likely etiology HCC, non-hcc, unsure

4 Do not treat as HCC without additional information Do not treat as HCC without additional information Table Released June 2017 Washout Capsule Threshold growth Diameter (mm): None: One: Two: erial phase hypo- or isoenhancement < erial phase hyperenhancement < Observations in this cell are categorized except as follows: g, if there is 50% diameter increase in 6 months. These observations are equivalent to OPTN 5A-g. us, if there is both washout and visibility as discrete nodules at antecedent surveillance ultrasound, per AASLD HCC criteria. ±V Intermediate probability for HCC Probably HCC Definitely HCC Table Evaluate for ancillary features

5 Evaluate for ancillary features DWI TP 10mm 63mm Delay IP DWI OP 45mm Delay 22mm 22mm Delay

6 Tie-breaking rules: 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. 27mm 17mm Early Late TP 52mm DWI 20mos ago Procedure: [MRI Abdomen with and without contrast (date)] Indication: [Underlying liver disease, surveillance for hepatocellular carcinoma, history of treatment] Comparison: [Include modality, presence/absence of contrast material on prior, and date] Assign Category Technique: [contrast and dynamic postcontrast MR imaging of the abdomen was performed.] [MRCP was also performed.] [Additional sequences may be described at institutional discretion.] Examination [meets technical recommendations.] [is compromised by the following factor(s): ().] Intravenous contrast agent: [type] Volume: [] ml Rate: [] ml/sec [medication/adverse events:] Findings: Liver: [morphology and signal intensity, diffuse findings] Focal hepatic observations: [for each observation, provide diameter and series/image on which it was measured, hepatic segment, major features, category, and change since prior; describe vascular involvement if applicable]. [Observation 1 (category), (features as above).] [Observation 2 (category), (features as above).] [Observation 3 (category), (features as above).] ADJUSTING CATEGORY TIE-BREAKING RULES Sure about category? Assign final Category No Apply ancillary features Sure about category? Assign final Category No Apply tie-breaking rules Assign final Category versus versus versus versus versus versus versus Hepatic vasculature: [anatomic variants, patency]