0:01

Following is, uh, a patient with a

0:02

history of cirrhosis who presents

0:04

for a surveillance imaging study

0:05

looking for hepatocellular carcinoma.

0:08

So we'll start off by looking

0:09

at our post-contrast sequences.

0:10

We have, uh, dynamic post-contrast

0:12

images, and I want to focus on a

0:14

lesion in the right hepatic lobe.

0:16

So the first image here is, uh,

0:19

T1 FATSAT post-contrast arterial phase.

0:22

Here we have the portal venous phase.

0:24

Here we have the equilibrium phase.

0:27

And this is the lesion in question.

0:29

It's in, uh, segment 7.

0:31

And we see that, after giving

0:33

contrast, there's unequivocal

0:35

non-rim arterial phase hyper-enhancement.

0:39

If we were to measure the lesion, we'll see

0:40

that it's less than 10 millimeters in size.

0:43

If we go to the portal venous phase,

0:45

we're going to be looking around this

0:46

area in equilibrium, around this area.

0:49

And, you know, if you look at it and scroll

0:51

up and down a window, maybe, maybe you

0:53

can see an area of, uh, washout or a rim

0:57

capsule, but there's nothing that's definite.

0:59

And one thing to note about the LI-RADS

1:01

lexicon, when you use it, if you're

1:03

unsure about an imaging finding,

1:05

don't count it as if it's present.

1:07

And so I think the best sort of interpretation,

1:09

or the most, uh, safest and perhaps most

1:11

consistent interpretation of this is that

1:14

there's non-RIM hyperenhancements, less than

1:16

10 millimeters, and there's really no definite,

1:19

uh, washout and no definite pseudocapsule.

1:22

There's no prior studies that we have

1:24

to see if there's growth in the interim.

1:26

And so just based on sort of these values,

1:30

this would qualify as a LI-RADS 3 lesion.

1:34

Now the reason I wanted to show this case is

1:36

that in addition to these features that I've

1:39

talked about, there is a list of additional

1:42

features that can upgrade LI-RADS nodules

1:46

or can in fact downgrade LI-RADS nodules.

1:48

You're only allowed to upgrade

1:50

or downgrade by one point.

1:52

And you can never upgrade anything

1:54

to a LI-RADS 5 based on what we call

1:55

these ancillary imaging features.

1:58

So let's look at the ancillary

1:59

imaging feature that would potentially

2:02

upgrade this nodule to a LI-RADS 4.

2:04

In this case, the ancillary feature

2:06

that upgrades this nodule is the

2:07

presence of T2 hyperintensity.

2:11

So this is an axial T2-weighted

2:14

image with fat saturation.

2:17

And as we said, this nodule is arterial

2:20

phase hyperenhancement, non-RIM.

2:23

It's less than 10 millimeters, there's

2:25

no washout, there's no pseudocapsule,

2:29

qualifies therefore as a LI-RADS 3, but

2:31

if you look at the T2-weighted images, this

2:33

feature, the hyperintensity, upgrades

2:36

this to a LI-RADS 4 lesion, and this

2:41

should go to a multidisciplinary tumor

2:44

board setting for further discussion.

2:46

And if you look at the LI-RADS PDF document

2:49

through the ACR website, there's a whole

2:51

list of features that favor malignancy

2:53

and allow you to upgrade the nodule and,

2:56

or benignity that downgrade the nodule.

2:58

And some of the ones that I think we come across

3:00

perhaps the most often is the presence of this

3:02

T2 hyperintensity that allows you to upgrade it.

3:05

And the presence of nodule within a nodule

3:08

appearance that was shown in one of the

3:10

earlier cases within this case series, as

3:13

well as the presence of fat in a lesion.

3:17

Cycle back to fat within liver lesions in

3:20

patients with cirrhosis in a different case.

3:22

But these are three things that upgrade nodules.

3:25

As I said, there's a whole list of them which I

3:26

encourage you to look at as you go through the

3:29

ACR document on the LI-RADS lexicon terminology.