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Summary of CT/MR LI-RADS 2018
Siva P. Raman, MD
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KEY FACTS

  • Terminology

    TERMINOLOGY

    • Definitions

      • Liver Imaging Reporting and Data System (LI-RADS) for CT and MR is standardized system for diagnosis and reporting of hepatocellular carcinoma (HCC) in cirrhotic (and other high-risk) patients
      • LI-RADS can be utilized using CT, MR with extracellular contrast agents (e.g., Gadavist), and MR with hepatobiliary agents (e.g., Eovist)
      • LI-RADS also includes treatment response to locoregional treatment (e.g., chemoembolization, Y-90 embolization, etc.) using CT or MR
      • LI-RADS guidelines are concordant with American Association for the Study of Liver Diseases (AASLD) practice guidelines and National Comprehensive Cancer Network (NCCN) guidelines
      • Organ Procurement and Transplantation Network (OPTN) guidelines (which assigns "points" for liver transplant candidates based on HCC status) are very similar to LI-RADS with exception of few subtle differences
        • Latest version of LI-RADS designed to achieve greater concordance between LI-RAD, AASLD, and OPTN guidelines
    • Patient Populations Covered by LI-RADS

      • Patients with cirrhosis or chronic viral hepatitis B infection (even in absence of cirrhosis) or either current or prior diagnosis of HCC
      • Can include patients who are liver transplant candidates or who have already received transplant liver
      • LI-RADS does not apply to any other patient group, including pediatric patients (< 18 years old) and patients with cirrhosis due to congenital hepatic fibrosis, hereditary hemorrhagic telangiectasia (HHT), Budd-Chiari, chronic portal vein occlusion, congestive hepatopathy, diffuse nodular regenerative hyperplasia, and other vascular disorders
        • Vascular causes of cirrhosis can be associated with hyperplastic nodules that can resemble HCC and therefore are not included in LI-RADS system
      • LI-RADS does not apply to pathologically proven malignancies
      • Treatment LI-RADS covers only locoregional therapy (e.g., chemoembolization, ablation, etc., and does not include systemic treatment)
    • Study Types Covered by LI-RADS

      • Multiphase CT or multiphase MR (either with hepatocellular or extracellular agents)
        • LI-RADS should not be applied to single-phase studies
      • Technical recommendations for CT include multidetector CT scanner with ≥ 8 detector rows and multiphase imaging with arterial, venous, and delayed phases (precontrast images suggested but not mandatory)
      • Technical recommendations for MR with extracellular contrast agents include 1.5 or 3T with torso phased-array coil, T2-weighted images, noncontrast T1 in- and out-of-phase images, and multiphase T1-weighted images (precontrast, arterial, portal venous, and delayed)
        • DWI, subtraction imaging, and multiplanar images suggested but not mandatory
      • Technical recommendations for MR with hepatobiliary specific contrast agent include 1.5 or 3T with torso phased-array coil, noncontrast T1 in- and out-of-phase images, T2-weighted images, multiphase T1-weighted images [precontrast, arterial, portal venous, transitional phase (2-5 minutes)], and hepatobiliary phase (~ 20 minutes)
        • DWI, subtraction imaging, and multiplanar images suggested but not mandatory
      • Acquiring arterial-phase images in late arterial phase strongly recommended for both CT and MR (full enhancement of hepatic artery and branches with enhancement of portal vein), as this phase provides better enhancement and conspicuity of HCC

    CLINICAL IMPLICATIONS

    • LI-RADS Diagnostic Categories

      • LI-RADS Treatment Response Categories

        • Key Principles of LI-RADS Diagnostic Algorithm for CT/MR

          • Summary of Key Steps in Applying LI-RADS Diagnostic Algorithm

            Selected References

            1. Bae JS et al: Performance of LI-RADS version 2018 on CT for determining eligibility for liver transplantation according to milan criteria in patients at high risk for hepatocellular carcinoma. AJR Am J Roentgenol. ePub, 2022
            2. Ranathunga D et al: Progression rates of LR-2 and LR-3 observations on MRI to higher LI-RADS categories in patients at high risk of hepatocellular carcinoma: a retrospective study. AJR Am J Roentgenol. 218(3):462-70, 2022
            3. Shin J et al: MRI-diagnosis of category LR-M observations in the Liver Imaging Reporting and Data System v2018: a systematic review and meta-analysis. Eur Radiol. ePub, 2022
            4. van der Pol CB et al: CT/MRI and CEUS LI-RADS major features association with hepatocellular carcinoma: individual patient data meta-analysis. Radiology. 302(2):326-35, 2022
            5. Marks RM et al: LI-RADS: past, present, and future, from the AJR special series on radiology reporting and data systems. AJR Am J Roentgenol. 216(2):295-304, 2021
            6. van der Pol CB et al: MRI LI-RADS version 2018: impact of and reduction in ancillary features. AJR Am J Roentgenol. 216(4):935-42, 2021
            7. Kierans AS et al: Diagnostic performance of LI-RADS version 2018, LI-RADS version 2017, and OPTN criteria for hepatocellular carcinoma. AJR Am J Roentgenol. 215(5):1085-92, 2020
            8. Lee S et al: CT and MRI liver imaging reporting and data system version 2018 for hepatocellular carcinoma: a systematic review with meta-analysis. J Am Coll Radiol. 17(10):1199-206, 2020
            9. American College of Radiology Committee on LI-RADS (Liver): CT/MRI LI-RADS v2018 Core. Accessed March 2022. https://www.acr.org/-/media/ACR/Files/RADS/LI-RADS/LI-RADS-2018-Core.pdf?la=en
            10. Kidder GW et al: Oxygenation of frog gastric mucosa in vitro. Am J Physiol. 229(6):1510-3, 1975
            Related Anatomy
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            References
            Tables

            Tables

            KEY FACTS

            • Terminology

              TERMINOLOGY

              • Definitions

                • Liver Imaging Reporting and Data System (LI-RADS) for CT and MR is standardized system for diagnosis and reporting of hepatocellular carcinoma (HCC) in cirrhotic (and other high-risk) patients
                • LI-RADS can be utilized using CT, MR with extracellular contrast agents (e.g., Gadavist), and MR with hepatobiliary agents (e.g., Eovist)
                • LI-RADS also includes treatment response to locoregional treatment (e.g., chemoembolization, Y-90 embolization, etc.) using CT or MR
                • LI-RADS guidelines are concordant with American Association for the Study of Liver Diseases (AASLD) practice guidelines and National Comprehensive Cancer Network (NCCN) guidelines
                • Organ Procurement and Transplantation Network (OPTN) guidelines (which assigns "points" for liver transplant candidates based on HCC status) are very similar to LI-RADS with exception of few subtle differences
                  • Latest version of LI-RADS designed to achieve greater concordance between LI-RAD, AASLD, and OPTN guidelines
              • Patient Populations Covered by LI-RADS

                • Patients with cirrhosis or chronic viral hepatitis B infection (even in absence of cirrhosis) or either current or prior diagnosis of HCC
                • Can include patients who are liver transplant candidates or who have already received transplant liver
                • LI-RADS does not apply to any other patient group, including pediatric patients (< 18 years old) and patients with cirrhosis due to congenital hepatic fibrosis, hereditary hemorrhagic telangiectasia (HHT), Budd-Chiari, chronic portal vein occlusion, congestive hepatopathy, diffuse nodular regenerative hyperplasia, and other vascular disorders
                  • Vascular causes of cirrhosis can be associated with hyperplastic nodules that can resemble HCC and therefore are not included in LI-RADS system
                • LI-RADS does not apply to pathologically proven malignancies
                • Treatment LI-RADS covers only locoregional therapy (e.g., chemoembolization, ablation, etc., and does not include systemic treatment)
              • Study Types Covered by LI-RADS

                • Multiphase CT or multiphase MR (either with hepatocellular or extracellular agents)
                  • LI-RADS should not be applied to single-phase studies
                • Technical recommendations for CT include multidetector CT scanner with ≥ 8 detector rows and multiphase imaging with arterial, venous, and delayed phases (precontrast images suggested but not mandatory)
                • Technical recommendations for MR with extracellular contrast agents include 1.5 or 3T with torso phased-array coil, T2-weighted images, noncontrast T1 in- and out-of-phase images, and multiphase T1-weighted images (precontrast, arterial, portal venous, and delayed)
                  • DWI, subtraction imaging, and multiplanar images suggested but not mandatory
                • Technical recommendations for MR with hepatobiliary specific contrast agent include 1.5 or 3T with torso phased-array coil, noncontrast T1 in- and out-of-phase images, T2-weighted images, multiphase T1-weighted images [precontrast, arterial, portal venous, transitional phase (2-5 minutes)], and hepatobiliary phase (~ 20 minutes)
                  • DWI, subtraction imaging, and multiplanar images suggested but not mandatory
                • Acquiring arterial-phase images in late arterial phase strongly recommended for both CT and MR (full enhancement of hepatic artery and branches with enhancement of portal vein), as this phase provides better enhancement and conspicuity of HCC

              CLINICAL IMPLICATIONS

              • LI-RADS Diagnostic Categories

                • LI-RADS Treatment Response Categories

                  • Key Principles of LI-RADS Diagnostic Algorithm for CT/MR

                    • Summary of Key Steps in Applying LI-RADS Diagnostic Algorithm

                      Selected References

                      1. Bae JS et al: Performance of LI-RADS version 2018 on CT for determining eligibility for liver transplantation according to milan criteria in patients at high risk for hepatocellular carcinoma. AJR Am J Roentgenol. ePub, 2022
                      2. Ranathunga D et al: Progression rates of LR-2 and LR-3 observations on MRI to higher LI-RADS categories in patients at high risk of hepatocellular carcinoma: a retrospective study. AJR Am J Roentgenol. 218(3):462-70, 2022
                      3. Shin J et al: MRI-diagnosis of category LR-M observations in the Liver Imaging Reporting and Data System v2018: a systematic review and meta-analysis. Eur Radiol. ePub, 2022
                      4. van der Pol CB et al: CT/MRI and CEUS LI-RADS major features association with hepatocellular carcinoma: individual patient data meta-analysis. Radiology. 302(2):326-35, 2022
                      5. Marks RM et al: LI-RADS: past, present, and future, from the AJR special series on radiology reporting and data systems. AJR Am J Roentgenol. 216(2):295-304, 2021
                      6. van der Pol CB et al: MRI LI-RADS version 2018: impact of and reduction in ancillary features. AJR Am J Roentgenol. 216(4):935-42, 2021
                      7. Kierans AS et al: Diagnostic performance of LI-RADS version 2018, LI-RADS version 2017, and OPTN criteria for hepatocellular carcinoma. AJR Am J Roentgenol. 215(5):1085-92, 2020
                      8. Lee S et al: CT and MRI liver imaging reporting and data system version 2018 for hepatocellular carcinoma: a systematic review with meta-analysis. J Am Coll Radiol. 17(10):1199-206, 2020
                      9. American College of Radiology Committee on LI-RADS (Liver): CT/MRI LI-RADS v2018 Core. Accessed March 2022. https://www.acr.org/-/media/ACR/Files/RADS/LI-RADS/LI-RADS-2018-Core.pdf?la=en
                      10. Kidder GW et al: Oxygenation of frog gastric mucosa in vitro. Am J Physiol. 229(6):1510-3, 1975