0:01

Here we have another patient with

0:02

cirrhosis, and they're doing this MRI

0:04

to look for hepatocellular carcinoma.

0:07

We'll start off looking at the post

0:09

contrast imaging sequences, and I'm going

0:11

to focus on a lesion right about here.

0:14

And so here's the T1 FATSAT post

0:17

contrast arterial phase images.

0:19

Here we have the portal venous phase images.

0:21

Here we have the equilibrium

0:22

or delayed phase images.

0:24

And the lesion that I want you to focus

0:26

on is really centered in Segment 8, maybe

0:29

a little bit of extension to Segment 7.

0:32

Look in the post contrast arterial phase

0:34

images, there is unequivocal arterial phase

0:36

hyperenhancement that is non-RIM-like.

0:39

Alright, so it's not the periphery that's

0:41

enhancing, the whole lesion is enhancing

0:43

arterial phase hyperenhancement.

0:45

Now if we were to measure this,

0:46

I've measured this, and it falls

0:48

somewhere between 10-19 millimeters.

0:51

So that's the sort of category of lesion

0:53

that we're looking at, non-RIM arterial

0:54

hyperenhancement, 10 to 19 millimeters.

0:57

And to further assess what LI-RADS category

0:59

it fits into, we need to see if there's

1:01

washout, pseudocapsule, or growth.

1:03

In terms of growth, I'll tell you

1:04

there's no prior studies to compare

1:06

it in this patient, so we have to

1:07

look for washout and or pseudocapsule.

1:10

So if we look at it both on the portal

1:11

venous and equilibrium phase images, there

1:14

is definite washout within this lesion.

1:16

So let's look at this lesion over here.

1:19

There's portions of it, specifically down

1:21

here, that have internally less signal

1:24

within it than the adjacent liver parenchyma.

1:26

So I would say that there is non-

1:28

peripheral washout within this lesion.

1:31

And in terms of a pseudocapsule,

1:33

I would say equivocal.

1:34

Some people may look at this and say

1:35

there's a pseudocapsule over here.

1:37

Some people may not be 100 percent sure,

1:39

and as I said, if you're not 100 percent

1:41

sure, the LI-RADS lexicon suggests that you

1:43

don't call these features that are not,

1:46

that you're not 100 percent sure about

1:47

in terms of their presence or absence.

1:49

So, what we're really left with then is

1:51

a lesion that demonstrates non-RIM

1:54

arterial phase hyperenhancement, that falls

1:56

between 10 to 19 millimeters in size, that

1:59

has definite non-peripheral washout, and

2:02

we're not really sure about the capsule.

2:03

So, I'll just put a question mark

2:04

capsule, and I'll put this in parentheses,

2:07

because effectively we're saying that

2:08

there's no definite pseudocapsule.

2:10

Putting it together in the LI-RADS lexicon,

2:12

it only has one other feature, those

2:15

additional categories, but that one other

2:17

feature is enough to specifically the washout.

2:20

To bump this to a LI-RADS 5 category.

2:24

Okay, so if we work through the sort of

2:25

LI-RADS lexicon and lesion at between 10 and

2:27

19 millimeters with arterial phase hyper

2:30

enhancement that does demonstrate washout,

2:33

it will qualify as a LI-RADS 5 lesion, which is

2:36

what this was, and this went on to our tumor

2:39

board and was subsequently treated.