Modified on: Thu, 4 Aug, 2022 at 2:36 PM
FAQ-117: Why should I use Ultrasound LI-RADS?
The goal of all LI-RADS algorithms is to improve the outcomes of patients at risk for HCC by providing a unified, comprehensive system for liver imaging. The use of standardized terminology and reporting allows for clear and concise communication between radiologists and referring clinicians. The use of a standardized US protocol helps to ensure that all relevant images are acquired and improves the ability to compare studies over time. US LI-RADS technical recommendations provide imaging tips for improving liver visualization. Furthermore, standardized performance and interpretation of screening and surveillance US studies facilitate research within and across institutions, which will help shape further refinements in US LI-RADS.
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FAQ-118: A patient presents for a liver US. Should I use US LI-RADS?
Consider the following patient scenarios:
Scenario 1: A patient with newly diagnosed hepatitis C presents for screening/surveillance liver US, and the liver appears normal. Can I apply US LI-RADS?
Scenario 2: A patient has recently diagnosed HCV or non-alcoholic steatohepatitis (NASH). Biopsy shows only minimal or mild fibrosis but not cirrhosis. Can I use US LI-RADS?
Scenario 3: A patient has recently diagnosed HCV or NASH. Biopsy shows stage 3 fibrosis but not cirrhosis. Can I use US LI-RADS?
Scenario 4: A patient has recently diagnosed cirrhosis, but the liver looks normal on US. Can I use US LI-RADS?
Scenario 5: A patient was referred for screening/surveillance liver US but I cannot find any information on biopsy results or whether the patient has cirrhosis. Can I use US LI-RADS?
US LI-RADS may not apply to all patients who present for liver US; however, in some circumstances, one can apply US LI-RADS and include a conditional category. For example, the report can include the following phrase: “If the patient is considered high risk for HCC, meeting criteria for US screening/surveillance, the study is US-1, Negative—no evidence for HCC.”
Some hepatologists request HCC screening/surveillance US in hepatitis C or NASH patients who have stage F3 fibrosis; however, each center should clarify the criteria that meets HCC screening/surveillance in their region. In the absence of liver biopsy, alternative strategies such as serum fibrosis panel, liver elastography, or reliance on clinical diagnosis of cirrhosis can be used at the time of liver US to screen for clinically significant levels of fibrosis or cirrhosis and guide management.
Recommended screening and surveillance populations in North America (as defined by AASLD) include: Patients with cirrhosis of any etiology Noncirrhotic chronic HBV patients who meet any of the following criteria: Asian male > 40 Asian female > 50 African/North American Blacks with HBV Family history of HCC
The benefit of surveillance is uncertain in the following populations and the decision to screen depends on local or geographic preferences: Non-cirrhotic chronic hepatitis C with stage 3 fibrosis Non-cirrhotic HBV carriers with active hepatitis Non-cirrhotic NAFLD
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FAQ-119: We would like to start using US LI-RADS for HCC screening and surveillance. What is the best way to get started?
Identify and support an US LI-RADS champion in your department.
Introduce US LI-RADS to your colleagues, sonographers, and referring physicians.
You can access the US LI-RADS CORE here for more information.
Implement the standardized US LI-RADS HCC screening/surveillance imaging protocol at your institution so all studies are performed similarly and with a focus on complete liver visualization.
See US Core for technical requirements here.
Create a dictation template that captures the recommended LI-RADS reporting information (see reporting section of FAQ) and launches automatically when the ultrasound exam is selected.”
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FAQ-120: Should I use US LI-RADS on ER patients or inpatients?
Generally, no. US LI-RADS should not be used for exams performed on acutely ill patients, as the conditions are not typically optimized for complete liver screening/surveillance. This includes fasting status and ability to comply with breathing and positioning instructions. An US study in the emergency department or inpatient setting is typically performed for acute conditions such as suspected cholecystitis, cholangitis, new or worsening portal vein thrombosis, biliary ductal dilatation, ascites, rapidly progressive malignancy, or a new diagnosis of cirrhosis, etc., rather than primarily screening for HCC. Applying LI-RADS in this setting may, in fact, incorrectly imply that a full screening study was performed. Further, because visualization is more likely to be compromised in these settings, a higher visualization score does not accurately reflect the sonographic visualization of the liver under optimal conditions and could have unintended downstream effects. If, however, the study reveals a suspicious observation, a multiphase contrast enhanced examination may be recommended for further characterization when clinically appropriate.
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FAQ-121: Screening US detects a solid nodule ≥ 10 mm. Could that represent a malignancy other than HCC?
Although the majority of malignancies in at-risk individuals are HCC, the prevalence of iCCA and combined HCC-CCA are also increased in this population and cannot be reliably differentiated from pure HCC, especially on an imaging exam without intravenous contrast such as screening US. Therefore, any solid observation that is not definitely benign could potentially represent any of the above tumors. The goal of US is to detect observations while the goal of a multiphase contrast-enhanced examination is to characterize observations. Any liver observation ≥ 1 cm that is not definitely benign should be categorized as US-3 and prompt further characterization with a contrast-enhanced examination (or if < 1 cm, categorized as US-2 with short-interval follow-up).
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FAQ-122: Should we use US LI-RADS in patients transplanted for HCC who have renal insufficiency and cannot undergo multiphase contrast enhanced CT/MRI?
For patients who have undergone liver transplantation for HCC, AASLD recommends contrast-enhanced CT/MRI every 6 months for 2 years to assess for HCC recurrence. However, other imaging tests such as US, CEUS, or unenhanced MRI of the liver may be considered on a case-by-case basis.
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FAQ-123: Can US LI-RADS be used for patients who have had HCC treatment (ablation, embolization, partial hepatectomy)?
The US screening and surveillance population for HCC is, by definition, for those who have no current or prior HCC. Therefore, patients with current, prior or treated HCC should not be screened with US (unless transplanted). Without the benefit of intravenous contrast, differentiating nonviable from viable tumor is not possible. Therefore, patients who have undergone HCC treatment are preferentially screened with multiphase contrast-enhanced CT/MRI or CEUS. Thus, we do not advocate applying US LI-RADS to this patient population.
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