FAQ-058: LI-RADS indicates that it may be appropriate to recommend alternative diagnostic imaging in ≤ 6 months if there is no observation. Can you explain the rationale?
In most cases in which no observation is detected at multiphase CT or MRI, return to routine surveillance in 6 months suffices. However, there may be cases where the antecedent screening test is so strongly positive (e.g., a definite solid nodule on ultrasound or a markedly elevated AFP) that alternative imaging may be needed to exclude a false negative result on the initial CT or MRI. In such cases, use your judgment for recommending the appropriate alternative imaging exam and time interval. If available at your institution, CEUS may be particularly helpful in cases in which screening ultrasound detected a solid nodule that was not identified at follow-up diagnostic multiphasic CT or MRI.
FAQ-059: Does optimal patient management derive directly from the LI-RADS category?
No, optimal management is determined by a combination of the LI-RADS category and a clinical assessment that integrates patient preferences, co-morbidities, hepatic disease burden, eligibility for liver transplantation, socioeconomic and health insurance status, and appointment availability. Since radiologists may not know all relevant factors, multidisciplinary discussion for consensus-based management may be helpful in difficult cases.
FAQ-060: If I think that biopsy will be needed to establish a diagnosis, should I recommend this?
It is reasonable to state that biopsy might be necessary to establish a diagnosis, but there are factors other than the imaging test itself that might influence a decision to biopsy, as mentioned above. Beyond providing information to be considered, it is best to not compel a clinician to undertake an invasive procedure, since there may be reasons unknown to the radiologist why this may not be appropriate for a given patient.
FAQ-061: I am concerned my clinical colleagues will not want me to recommend imaging follow-up time frames in my reports. Am I required to include that information in my reports?
No, the follow-up time frames listed on page 13 are typical times, but use your judgment about whether to include specific time frames in your reports.
FAQ-062: The management for LR-3 is different in the CEUS and CT/MRI algorithms. Why is that?
As shown by recent studies, most CT- or MRI-detected LR-3 observations are benign perfusion alterations or indolent lesions that can be followed safely without multidisciplinary discussion.
Less is known about the natural history of LR-3 observations detected at CEUS, but indirect evidence suggests that such observations warrant close scrutiny. By definition, all CEUS observations are visible on precontrast B-mode images. In a cirrhotic liver, sonographically visible nodules have high probability of being HCC, unless contrast enhancement features are diagnostic of hemangioma or other benign entity. Verifying the high HCC probability, a recent retrospective study3 found that 60% (45/75) of CEUS LR-3 observations are HCC.