0:01

This patient also presents, uh, to us for

0:04

screening or surveillance for hepatocellular

0:06

carcinoma as a history of cirrhosis.

0:08

So let's go ahead and look at

0:09

the images and see what we find.

0:11

So we'll start off with our dynamic

0:13

post-contrast images, and we can

0:15

scroll through these sequences.

0:17

I'm going to focus on this lesion

0:19

over here, and this is in segment six.

0:22

This, of course, is the T1 FATSAT post-contrast

0:26

arterial phase image, portal venous phase image,

0:28

equilibrium phase image, and, uh, this lesion

0:31

here in segment six demonstrates unequivocal non-

0:35

rim arterial phase hyperenhancement, so that's

0:39

the first thing we need to decide: is there

0:40

arterial phase hyperenhancement or is there not?

0:42

If we do decide that there is, we look

0:44

at the size of the lesion and we measure

0:46

it out, and this lesion falls somewhere

0:48

between 10 to 19 millimeters in size.

0:52

And once that happens, we need to look

0:53

at the other features to see if, uh, we

0:56

qualify this as a, uh, LI-RADS 3, 4, or 5.

1:00

The other features, we look at the portal

1:01

venous phase and equilibrium phase images.

1:03

We're looking for washout,

1:05

portions of the lesion that are

1:06

darker than the liver parenchyma.

1:08

We're also trying to see if

1:09

there's a capsule around it.

1:10

If we look in the approximate

1:12

location of where we expect to see

1:14

this lesion, we just don't see it.

1:16

It's quite iso-intense on both the portal venous

1:19

phase images and the equilibrium phase images.

1:21

So, in terms of washout, no washout here. In

1:24

terms of pseudocapsule, no pseudocapsule here.

1:27

And in terms of growth, no priors to compare

1:30

to, so can't really talk about growth.

1:32

I'll just say no growth for the

1:33

sake of simplicity over here.

1:35

And so putting all this together, this

1:38

qualifies this lesion as a LI-RADS 3 lesion.

1:42

Now, one thing is we've seen a bunch of

1:45

cases already regarding this arterial

1:47

phase hyperenhancement in this sort of

1:48

size category of 10 to 19 millimeters.

1:50

If there's no other features,

1:52

it's going to be a LI-RADS 3.

1:54

If it has two or more of these

1:56

features, it'll be a LI-RADS 5.

1:59

But if it only has one of these other

2:01

categories, if that category is washout or

2:06

growth, that qualifies it as a LI-RADS 5 lesion.

2:11

However, if that one category

2:12

is just a pseudocapsule, that

2:14

keeps it as a LI-RADS 4 lesion.

2:18

Alright, so if there's two plus,

2:19

it's going to be a LI-RADS 5.

2:20

If there's only one, depending on

2:22

what that one is, it actually is a 5

2:24

or a 4 lesion.

2:26

And remember, in some of the cases I've shown

2:27

you previously, you know, I'm just showing

2:29

you the post-contrast images, you have to

2:31

look at all the remaining sequences to see if

2:33

there's any other ancillary imaging features

2:35

that can bump this up from a LI-RADS 3 to a

2:38

4 or downgrade it from a LI-RADS 3 to a 2.

2:41

Remember, some of the ancillary features

2:42

that bump it up include, or the common ones

2:45

that can bump it up include hyperintensity

2:46

T2 signal, presence of fat within it. So

2:49

these are two things that I look at in all

2:51

these lesions to see if I can bump up these,

2:53

uh, nodules to a LI-RADS IV potentially.