2:00

It makes it very difficult for the person receiving

2:02

the report to know what exactly you mean.

2:04

If you give it a number 1 2 3 4 5 and we have

2:08

some data behind it, it allows everybody,

2:10

whether it's me and one center to another radiologist

2:13

in another country or another center or to a clinician,

2:16

they can all at least understand what we're saying. Even if we

2:19

might use different words in real life. In terms of content,

2:24

we want to make sure that we put all the relevant things that the

2:27

surgeons and clinicians that receive

2:28

our reports actually need.

2:30

So if we have a standard way of doing doing things, we won't

2:33

forget that because it prompts us during our dictation to

2:36

ensure we do that. And then in terms of data collection,

2:38

it's important that we standardize in terms of

2:41

literature so that we can do larger data aggregates

2:44

and figure out what's going on.

2:47

So LI-RADS was started in 20...

2:49

or the first version came out in 2011 and there have been a

2:52

few versions since. The most recent one is version 2018,

2:56

and we're working on a new version, which we do every three

2:58

years or so based on the literature.

3:00

This particular LI-RADS version has an ultrasound component,

3:06

contrast-enhanced ultrasound,

3:08

how to diagnose HCC, I'm not going to talk about that today.

3:11

I'll focus on the CT and MRI portion and then there's

3:15

a treatment response section for people who have undergone

3:18

local regional therapy, and I will touch on that today.

3:21

The important thing to remember for LI-RADS is

3:23

it's specifically to patients with cirrhosis

3:27

or who have chronic hepatitis B,

3:30

because we know that they have an increased risk of getting

3:32

hepatocellular carcinoma, even if they don't have cirrhosis.

3:36

LI-RADS does not apply to people who

3:38

don't have risk factors for HCC.

3:41

It does not apply to children at this point.

3:43

And it doesn't apply to people who have

3:45

vascular causes such as Budd–Chiari and HHT,

3:50

and cardiac congestion cirrhosis.

3:52

Because the imaging characteristics in these particular

3:56

subgroup of patients are two similar between HCC

4:00

and their various vascular abnormalities that they get.

4:04

This is a small subset of people who

4:06

have liver disease at risk for HCC,

4:08

but we have chosen to exclude them because

4:10

it causes too much overlap.

4:13

And one of the things that's really important with LI-RADS

4:15

is we have to be very specific with final diagnosis.

4:19

Particularly if you're calling something in HCC,

4:21

which would be LI-RADS 5, because it's one of the only imaging...

4:26

it's one of the only studies where the radiology

4:28

imaging report is enough to bypass biopsy,

4:32

and allow patients to undergo definitive therapy or

4:35

local regional therapy without actual pathology.

4:39

So it's really important that we be specific

4:41

in what we're talking about.

4:43

I'll just touch on the ultrasound portion.

4:45

So most patients when they first come in to the screening

4:49

setting, many are evaluated with ultrasound.

4:52

There are centers that do evaluate and screen people with CT,

4:56

but for most places in North America and Canada,

5:00

where I'm from, ultrasound is the first test and it's done every

5:04

six months in people with cirrhosis or at risk for HCC,

5:07

which includes patients with chronic hepatitis B.

5:11

So, the three options you have with your ultrasound is either

5:13

it's negative. So you see nothing.

5:15

You have a lesion that's less than 10 mm,

5:18

and that's called sub threshold.

5:20

And then, you have your type ultrasound version 3,

5:24

which is positive,

5:24

in which case these patients would be then recommended

5:27

to go on to CT or MRI for more definitive characterization.

5:32

The other one short thing about the ultrasound is that there's

5:36

visualization score because we know that in certain patients

5:39

who have cirrhosis, like the bottom image here,

5:41

there's a lot of attenuation of the sound and

5:43

we can't actually see the body, you know,

5:46

posterior half of the liver in this case.

5:48

So this would be a limited study,

5:50

the one on the bottom, compared to the one on the top.

5:53

And in this case,

5:54

we may actually be better off imaging this patient.

5:56

Whether it's screening or characterization with CT or MRI.

6:00

So this patient would not be somebody who should be

6:02

screened with ultrasound. Everybody else are fine.

6:07

Now, this is the algorithm for CT and MRI.

6:09

So patient comes in at risk for HCC.

6:12

You do the CT or the MRI and you apply this.

6:16

And this is part one.

6:18

And, of course,

6:18

remember they have to have HCC

6:21

and then this is the second part.

6:22

So first, I'll go back to this part.

6:25

So if you can't image, interpret

6:27

the images because they've missed a bunch of sequences,

6:29

the timings way off or the patient breathed, or coughed,

6:32

or whatever might have happened,

6:34

then you would characterize it, is not...

6:37

not characterizable.

6:39

And then it goes 1 and 2, which is benign.

6:42

And then there's this black one here,

6:44

called tumor in vein,

6:45

and that's really a bad prognostic factor for patients.

6:48

And this is really important for us to look for initially,

6:51

because it trumps everything else that we see below.