0:01

The following patient presents to us a history

0:03

of cirrhosis, looking for hepatocellular

0:05

carcinoma, no priors to compare to, and so

0:08

we have our, have our images to evaluate.

0:11

Start off with the post-contrast imaging

0:13

sequences, and we see a bunch of nodules in

0:16

this liver, so we can certainly look at each

0:18

and every one of them, but the one I want to

0:20

focus on is right over here in segment six.

0:24

So this is T1, FATSAT, post-contrast, and

0:28

I'm showing you the arterial phase images.

0:31

And this is the nodule in

0:32

question that I want to focus on.

0:34

It certainly demonstrates non-RIM

0:37

arterial phase hyper-enhancement.

0:40

If we were to measure this, I've measured this,

0:42

uh, previously, and it falls somewhere between

0:44

10 and 19 millimeters, so that's the sort of

0:47

category that we're working with right now.

0:49

And again, to, to qualify this more, we need

0:52

to see if it has washout or pseudocapsule.

0:54

Because we don't have any priors, I can't

0:56

assess for growth, so it's really the

0:57

presence of washout and or pseudocapsule.

1:00

That will allow me to categorize

1:02

this into a LI-RADS category.

1:04

So here we have our T1 FATSAT post-contrast

1:07

portal venous phase image, and again this

1:09

is the lesion in question in segment 6.

1:13

And the one thing that I can say with a

1:15

reasonable amount of certainty is that

1:18

it does have a little capsule around it.

1:19

You can see this rim that's

1:21

enhancing surrounding it.

1:23

So, we had arterial phase hyper-enhancement,

1:26

as we saw in the um, arterial phase images,

1:29

we know it's between 10 and 19 millimeters,

1:31

and it has a pseudocapsule that surrounds it.

1:34

The question is, is the

1:35

inside of it washing out?

1:37

And again, somebody may look at this and

1:39

say, yes, it's washing out, but when you

1:41

compare it, sort of the inside of it,

1:43

compared to the adjacent liver parenchyma

1:44

around here, it looks very similar.

1:47

It's not 100 percent darker than some

1:50

of the adjacent liver parenchyma.

1:51

And again, with LI-RADS, if you're not 100

1:53

percent sure, the document and the people who've

1:55

come up with this lexicon suggest that you don't

1:58

call a category that you're not certain about.

2:01

So in this case, I'm not 100 percent certain

2:02

that this is washing out, so I'm going to

2:04

say questionable washout, which for practical

2:06

purposes means that there's no definite washout.

2:09

So we're really just left

2:10

with these three things.

2:11

And so when we have something that falls, you

2:14

know, in this size range with non-RIM arterial

2:16

phase and hyper-enhancement, if the only other

2:18

feature that it has is a pseudocapsule, that's

2:21

not enough to qualify this as a LI-RADS 5.

2:23

This will qualify as a LI-RADS 4.

2:26

If, however, this additional feature was washout

2:29

instead of the pseudocapsule, that would have

2:31

been sufficient to bump it up to a LI-RADS 5.

2:34

And that's sort of what

2:34

we saw in the prior case.

2:36

That instead of having the

2:37

capsule, it had washout.

2:39

And that actually allows it

2:40

to be bumped up to a LI-RADS 5.

2:41

If it just has the capsule without

2:43

washout, keep it as a LI-RADS 4 lesion.

2:46

This patient will still go to a

2:48

multidisciplinary tumor board.

2:50

Discussion will be had.

2:51

It may involve a biopsy prior to treatment.

2:54

The likelihood that this is going to be an HCC

2:56

is very high, but certainly it's not near 100%,

2:59

uh, like it would be for a LI-RADS 5 lesion.