0:00

So here we have a patient with cirrhosis,

0:02

getting a screening examination looking

0:04

for a hepatocellular carcinoma.

0:06

We have no priors to compare this to, so let's

0:08

go ahead and have a look at the images.

0:11

So as we've been doing for the other

0:12

cases in this course, we're gonna look

0:15

at the dynamic post-contrast images.

0:18

I'm gonna focus on a lesion over here.

0:21

And so we can see this is a T1

0:23

fat-saturated post-contrast arterial phase

0:26

image, portal venous phase image.

0:27

This is the equilibrium phase image.

0:30

And this lesion's in the caudate lobe,

0:32

demonstrates non-rim arterial phase hyperenhancement

0:36

at the inside of its enhancing.

0:38

If we were to measure it, longest length

0:40

is more than 20 millimeters in size.

0:43

And if we look at the portal venous

0:44

and equilibrium phase images, in a

0:46

lesion that's approximately in this

0:48

area, it's very difficult to assess

0:51

whether there's definite washout or not.

0:52

You may qualify a portion of this as washout,

0:55

not 100% certain.

0:57

Certainly, if you scroll through these images,

0:59

through and through, it's not certain that

1:01

that portion corresponds to the lesion itself.

1:04

And again, with LI-RADS, if you're not

1:05

sure, it's better to not over-call it.

1:08

Sort of, it's better to under-call it.

1:09

And that's what they want you to do for LI-RADS.

1:12

And so, I'm going to say that there is, um,

1:15

you know, sort of questionable washout.

1:17

I certainly don't see any pseudocapsule.

1:18

There's nothing that looks like it's

1:19

a capsule surrounding a lesion like

1:21

this, um, on any of those images.

1:24

And so, we'll say that there's no

1:25

pseudocapsule associated with this.

1:27

And we don't have any priors, and

1:30

so we, uh, really can't assess

1:32

for, uh, growth either.

1:34

So what we're left with is a, um, sizable

1:36

lesion at 20 millimeters, which has

1:39

non-rim arterial phase hyperenhancement.

1:41

Those are the two imaging

1:42

features that we're certain about.

1:44

And so in the last few cases, we've seen

1:46

large lesions that qualify as a LI-RADS 5.

1:49

And this one actually qualifies as a LI-RADS 4.

1:52

It would have qualified as a LI-RADS

1:53

5 if it had any of these additional

1:56

features: washout, pseudocapsule, or growth.

1:59

But because we're not certain about some

2:01

of them and some we don't see, we

2:03

stick to a LI-RADS 4 category for this.

2:06

Now you can certainly look at all the other

2:08

imaging sequences that you have to see if

2:10

there are any ancillary features that could

2:12

bump this up, such as T2 signal, high

2:16

T2 signal, fat, etc., things like that.

2:18

But remember, the ancillary

2:20

features cannot upgrade this

2:22

to a LI-RADS 5 lesion.

2:24

So they can upgrade LI-RADS lesions,

2:25

but it cannot upgrade it to 5.

2:27

Even in instances where this was

2:29

present in this lesion, we would not

2:31

be able to bump this up any further.

2:34

So this stays as a LI-RADS 4 lesion.

2:36

This is the sort of lesion that is then

2:38

brought up in tumor board, and a decision

2:40

is made after talking to surgeons,

2:43

hepatologists, gastroenterologists, etc.,

2:46

about how best to proceed

2:48

with the next step for this.

2:49

Do we treat it based on the

2:51

assumption that it could be an HCC?

2:53

Do we biopsy it?

2:54

Do we do close follow-up, etc.?

2:56

So this is a LI-RADS 4 lesion that's more than

2:59

20 millimeters in size and demonstrates no

3:02

additional features to bump it up to a LI-RADS 5.