For an untreated observation in a patient at high risk for hepatocellular carcinoma. The CT/MRI tab walks the v2018 algorithm – LR-NC, LR-TIV, LR-1/2, LR-M, then the diagnostic table with optional ancillary-feature adjustment. The Ultrasound tab scores a surveillance exam (US-1/2/3 and VIS-A/B/C) and gives the management that depends on it and on AFP.
Disclaimer:
Implements ACR CT/MRI LI-RADS v2018 and LI-RADS US Surveillance v2024 for patients at high risk for HCC (cirrhosis, chronic hepatitis B, or current or prior HCC). Not for patients under 18, with congenital hepatic fibrosis, or with cirrhosis from a vascular cause. Provided "as is" without warranty of any kind, express or implied, including accuracy, completeness or fitness for a particular purpose. For educational purposes only. The user is solely responsible for verifying results against the source guideline and for all clinical decisions.
LR-4 (capsule) / LR-5 (washout or threshold growth)
LR-5
Two or more
LR-4
LR-4
LR-4
LR-5
LR-5
Major features: nonrim APHE, nonperipheral washout, enhancing capsule, threshold growth (≥ 50 % in ≤ 6 months). If unsure whether a feature is present, treat it as absent.
LR-M is assigned before the table: a targetoid mass (rim APHE, peripheral washout, delayed central enhancement, targetoid restriction or targetoid TP/HBP appearance) or a non-targetoid mass with infiltrative appearance, marked diffusion restriction, necrosis or another non-HCC feature.
Ancillary features are optional: one or more favouring malignancy upgrade by one category up to LR-4; one or more favouring benignity downgrade by one; both present, no change. They never upgrade to LR-5.
Tie-break: when unsure between two categories choose the one with lower certainty (LR-3 over LR-2 or LR-4, LR-M over LR-4/5 when unsure of hepatocellular origin).
Positive predictive values are pooled estimates from the 2019 systematic review (van der Pol): LR-3 ≈ 38 %, LR-4 ≈ 74 %, LR-5 ≈ 94 % HCC; LR-M ≈ 93 % malignant but only ≈ 36 % HCC.
Management (AASLD and LI-RADS consensus, v2018)
LR-NC: repeat or alternative diagnostic imaging in ≤ 3 months. LR-1 and LR-2: return to surveillance in 6 months (LR-2: consider repeat diagnostic imaging in ≤ 6 months).
LR-3: repeat or alternative diagnostic imaging in 3–6 months. LR-4, LR-M and LR-TIV: multidisciplinary discussion for tailored work-up, which may (LR-M: often does) include biopsy. LR-5: HCC confirmed; multidisciplinary discussion for consensus management.
Ultrasound surveillance (v2024)
US-1 negative: no observation, or only definitely benign ones → repeat ultrasound in 6 months. US-2 subthreshold: observation < 10 mm, not definitely benign → repeat ultrasound in 3–6 months, up to twice; if it disappears or stays < 10 mm it is considered benign. US-3 positive: observation ≥ 10 mm, parenchymal distortion, or new vein thrombus → diagnostic multiphase CT or MRI, or CEUS.
VIS-C (severe limitations) with US-1/2: repeat ultrasound within 3 months once, or go straight to an alternative surveillance modality (abbreviated MRI, multiphase CT) when MASH or alcohol-related cirrhosis, Child-Pugh B/C or BMI ≥ 35 predict another VIS-C exam. A positive AFP without a US-3 correlate goes to diagnostic MRI or CT.
References
Chernyak V, Fowler KJ, Kamaya A, et al. Liver Imaging Reporting and Data System (LI-RADS) Version 2018: Imaging of Hepatocellular Carcinoma in At-Risk Patients. Radiology. 2018;289(3):816–830.
doi:10.1148/radiol.2018181494 · free full text
van der Pol CB, Lim CS, Sirlin CB, et al. Accuracy of the Liver Imaging Reporting and Data System in Computed Tomography and Magnetic Resonance Image Analysis of Hepatocellular Carcinoma or Overall Malignancy – A Systematic Review. Gastroenterology. 2019;156(4):976–986.
doi:10.1053/j.gastro.2018.11.020
Morgan TA, Maturen KE, Dahiya N, Sun MRM, Kamaya A. US LI-RADS: ultrasound liver imaging reporting and data system for screening and surveillance of hepatocellular carcinoma. Abdom Radiol (NY). 2018;43(1):41–55.
doi:10.1007/s00261-017-1317-y