0:01

This patient, uh, has a history of

0:02

cirrhosis and presents, uh, for a screening

0:05

examination, a surveillance examination,

0:08

uh, to look for the presence, uh,

0:09

or absence of hepatocellular carcinoma.

0:12

So we'll go right to the post-contrast,

0:14

uh, dynamic post-contrast images.

0:16

And I'm going to scroll down and

0:18

there's going to be a lesion in question

0:20

as we scroll inferiorly in segment

0:22

five that I'm going to focus on.

0:24

So this image here is the T1 FATSAT post-

0:27

contrast image in the arterial phase.

0:30

This is the portal venous phase.

0:31

This is the equilibrium or

0:32

delayed phase over here.

0:34

And the lesion in question in

0:35

segment five is right over here.

0:38

And this demonstrates non-RIM arterial

0:43

phase hyperenhancement, right?

0:45

It's not just the periphery that's enhancing,

0:47

the whole lesion itself is enhancing.

0:49

We measure the size.

0:50

You'll, uh, the size that I got for this lesion

0:52

was about 14 millimeters, so it kind of goes

0:55

between the 9, 10 to 19 millimeter category.

0:58

I actually got it at about 14 millimeters.

1:00

In order for us to qualify it further,

1:03

we have to look at the remaining imaging

1:04

sequences to see if it has any other features.

1:07

If we look at the portal venous image,

1:09

portal venous phase images, the lesion's

1:10

approximately over here, doesn't really

1:12

wash out, certainly not darker than

1:14

the liver parenchyma, so we can't call

1:16

it washout, so I would say no washout.

1:18

And again in the equilibrium phase

1:20

image, not darker than liver parenchyma,

1:22

there's no definite pseudocapsule, and we

1:25

don't have a prior to assess for growth.

1:26

So what we're left with is really this

1:29

lesion that's 14 millimeters, demonstrates

1:31

arterial phase hyperenhancement

1:32

without any other imaging features.

1:35

So if we were to qualify it as a

1:37

LI-RADS category at this stage, this

1:39

would be consistent with a LI-RADS 3.

1:43

And that's fine, a LI-RADS 3 lesion, a patient

1:45

with a LI-RADS 3 lesion would then go back

1:47

to screening surveillance and they would get

1:49

one anywhere from three to six months from

1:51

now to see what happened to this lesion.

1:54

So we'll fast forward

1:55

approximately six months from now.

1:57

This was in January 2019, our

1:59

LI-RADS 3 lesion in segment 5.

2:03

This is in June 2019.

2:06

We're re-looking at the whole liver,

2:08

but we have to focus on this lesion.

2:10

And if we measure it out, this

2:12

lesion's actually increased in size.

2:14

So whereas here it was 14 mm,

2:16

it's actually grown

2:18

to 21 mm at this juncture.

2:22

This demonstrates, again, non-RIM

2:25

arterial phase hyperenhancement.

2:28

If we look at the, uh, portal venous and,

2:29

uh, delayed images, there's no washout still.

2:31

There's no pseudocapsule.

2:33

However, this growth is significant.

2:36

This growth from 14 to 21 qualifies

2:39

as more equal to 50% in a

2:42

time period of less than six months.

2:45

And so, based on that, we can actually

2:48

upgrade this lesion to a LI-RADS 5 category.

2:52

LI-RADS 5 category.

2:53

And that becomes important.

2:55

Because now we are almost certain this is going

2:58

to be nothing except a hepatocellular carcinoma.

3:01

We can bring this lesion and discuss it

3:03

in a tumor board setting and talk more

3:05

about the management of it rather than

3:07

deciding whether or not we should biopsy it.

3:10

So based on that interval growth of, uh,

3:12

more than 50 percent in less than six

3:13

months, we can qualify this as a LI-RADS 5.