Return To The Previous Page
Buy a Package
Number Of Visible Items Remaining : -40 Item

Liver lesion evaluation in patients at risk for hepatocellular carcinoma using Liver Imaging Reporting and Data System (LI-RADS) categorization

Liver lesion evaluation in patients at risk for hepatocellular carcinoma using Liver Imaging Reporting and Data System (LI-RADS) categorization

Select the target population:

Patients who have a liver lesion on imaging (eg, ultrasound) and who are at risk for HCC due to at least 1 of the following:

  • Cirrhosis, with certain exceptions*
  • Chronic hepatitis B virus infection
  • Concurrent or prior diagnosis of HCC
Perform 1 of the following studies, tailored for liver lesion evaluation:
  • Contrast-enhanced CT
  • Contrast-enhanced MRI
  • Contrast-enhanced ultrasound (CEUS)Δ
Categorize lesion(s) using LI-RADS
LI-RADS categorization of liver lesions in patients at risk for hepatocellular carcinoma
Category Assessment Diagnostic considerations Action
LR-1 Definitely benign Includes hemangiomas with characteristic features or cysts.
  • Continue routine surveillance imaging for HCC ◊
LR-2 Probably benign Includes hemangioma without characteristic features and wedge-shaped arterioportal shunts.
  • For most patients, continue routine surveillance imaging for HCC◊
  • For some patients, image with a different modality or MRI contrast agent§
LR-3 Intermediate probability of malignancy Includes dysplastic nodules, benign lesions without characteristic features, and rounded arterioportal shunts.
  • Repeat contrast-enhanced CT, MRI, or ultrasound for liver lesion evaluation in 3 to 6 months
  • Continue serial imaging every 3 to 6 months while the lesion remains LR-3 for ≥2 years or until the lesion has a conclusive diagnosis¥
  • If the lesion remains LR-3 for ≥2 years on imaging follow-up, return to routine surveillance imaging for HCC◊
LR-4 Probably HCC Includes HCC with some characteristic features.‡
  • Multidisciplinary consultation to tailor further management. Options include:
    • Alternative or follow-up imaging
    • Biopsy the lesion
    • Presumptive treatment without conclusive diagnosis
LR-5 Definitely HCC† HCC with characteristic features.**
  • Treatment for HCC
  • No biopsy needed
LR-M Probably or definitely malignant, not specific for HCC

Most LR-M lesions are malignant.

Includes HCC without characteristic features¶¶ and other malignancies (eg, cholangiocarcinoma, combined hepatocellular carcinoma and cholangiocarcinoma, lymphoma, or metastasis).
  • Multidisciplinary consultation to tailor further management. Options include:
    • Evaluate for underlying malignancyΔΔ
    • Perform biopsy if it will alter management◊◊
LR-NC Not categorizable

Images are insufficient for assessment.

Common reasons include imaging protocol not tailored for liver lesion or images degraded from patient motion.
  • Repeat imaging for liver lesion evaluation with same or alternate modality in ≤3 months
LR-TIV Tumor in vein Unequivocal enhancing soft tissue in vein indicating tumor, either from HCC or another malignancy.
  • Multidisciplinary consultation to tailor further management. Options include:
    • Alternative or follow-up imaging
    • Biopsy the tumor in vein
    • Presumptive treatment without histologic confirmation
Evaluation of liver lesions in patients not at high risk for HCC is described elsewhere in UpToDate and is not addressed in this table. If there are multiple lesions, this table can be applied to each lesion. However, management choice is driven by the lesion that is the most suspicious (eg, growing, largest, and not definitely benign).

CT: computed tomography; HCC: hepatocellular carcinoma; LI-RADS: Liver Imaging Reporting and Data System; MRI: magnetic resonance imaging; OPTN: Organ Procurement and Transplantation Network.

* LI-RADS assessment should not be applied to patients <18 years old or those with cirrhosis from congenital hepatic fibrosis or secondary to vascular disorders (eg, Budd-Chiari syndrome, chronic portal vein occlusion, cardiac congestion, hereditary hemorrhagic telangiectasia).

¶ Imaging technology and performance should adhere to standards required for liver lesion characterization, which are more stringent than those for routine abdominal imaging. Contrast-enhanced CT or MRI is preferred over ultrasound (CEUS) to characterize lesions where index of suspicion for HCC or malignancy is high or in patients with multiple lesions requiring LI-RADs categorization. Should the lesion prove to be LR-4, LR-5, or LR-M, CEUS cannot evaluate the entire liver to assess tumor burden for treatment planning nor diagnose HCC using the OPTN criteria for transplant evaluation. In addition, for technical reasons, CEUS cannot categorize multiple lesions simultaneously.

Δ If the lesion was diagnosed on CEUS, contrast-enhanced CT or MRI tailored for liver lesion evaluation should be performed to plan therapy.

◊ Surveillance imaging for adults at risk for HCC, usually performed with abdominal ultrasound without contrast, is described elsewhere in UpToDate.

§ Choice of additional imaging should be made in consultation with the radiologist.

¥ While the two-year follow-up represents our practice, stability over that time does not confirm that a lesion is benign.

‡ On contrast-enhanced CT or MRI, in order to be categorized as LR-4, lesions that measure <1 cm should be arterially enhancing and demonstrate at least 1 of these 3 features: nonperipheral washout, enhancing capsule, or growth. Lesions that are not arterially enhancing can also be categorized as LR-4 if they measure >2 cm and demonstrate 1 of the 3 features or measure <2 cm and demonstrate 2 of the 3 features. On CEUS, in order to be categorized as LR-4, lesions should be arterially enhancing without washout and measure >1 cm, arterially enhancing with late and mild washout and measure <1 cm, or not arterially enhancing with late and mild washout and measure >2 cm.

† For patients who are candidates for liver transplant, most LR-5 lesions meet OPTN criteria for diagnosis of HCC. Refer to UpToDate content for description of pertinent exceptions.

** On contrast-enhanced CT or MRI, in order to be categorized as LR-5, lesions must be arterially enhancing and measure >1 cm. Additionally, those measuring >2 cm should demonstrate at least 1 of the following 3 features, and those measuring >1 but <2 cm should demonstrate at least 2 of the 3 features: non-peripheral washout, enhancing capsule, or growth. On CEUS, in order to be categorized as LR-5, lesions should measure >1 cm and demonstrate arterial enhancement with late and mild washout. Growth is defined as ≥50% increase in size in ≤6 months with a threshold of ≥5 mm change to avoid error from measurement variability.

¶¶ Examples of HCC without characteristic features are those without arterial enhancement or those with both arterial and delayed enhancement suggesting cholangiocarcinoma.

ΔΔ Approximately 95% of LR-M lesions are malignant. Slightly less than one-half of malignant cases are HCC and the remainder are non-HCC malignancies (eg, cholangiocarcinoma, combined HCC-cholangiocarcinomas, lymphoma, or metastases).

◊◊ Biopsy may alter management for patients being evaluated for liver transplant or for other nonsurgical locoregional therapies (eg, thermal ablation), or if serum tumor markers suggest intrahepatic cholangiocarcinoma or metastasis from an extrahepatic malignancy.

Prepared with additional information from:
  • 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; 289:816.
Graphic 116155 Version 4.0