Page 58 - Read Online

Page 8 of 11 Kanmaniraja et al. Hepatoma Res 2020;6:51 I http://dx.doi.org/10.20517/2394-5079.2020.46

A B

C

Figure 8. LR-5 (Definite hepatocellular carcinoma). Axial computed tomography in a 60-year-old man with hepatitis C cirrhosis.
Arterial phase (A); portal venous phase (B); and delayed phases (C) demonstrate a 21-mm observation with nonrim arterial phase
hyperenhancement [arrow (a)], nonperipheral washout appearance [arrow (B,C)], and enhancing capsule appearance [arrowhead (c)]

involves multidisciplinary discussion and may include repeat or alternate imaging within three months,
biopsy, or, in some patients, definitive treatment without confirmatory biopsy [16,18] .

LR-5: definitely HCC
Observations in this category have 100% certainty of being HCC [Figure 8] [7,15] . Ninety-four percent of
[17]
observations in this category are HCC and 97% are malignant . Since HCC can be diagnosed based on
imaging features alone and treated without the need for pathologic confirmation, observations in this
category have specificity close to 100% with resulting modest sensitivity in the range of 50%-80% [21-23] . Size ≥
10 mm and nonrim APHE are absolute requirements to LR-5 categorization [7,15] . Observations measuring >
20 mm with ≥ 1 additional major feature and observations measuring 10-19 mm with ≥ 2 additional major
features are included in this category [7,15] . Observations measuring 10-19 mm with either nonperipheral
“washout” or threshold growth as the only additional major feature are also categorized LR-5. [7,15] . Ancillary
features cannot be used to upgrade LR-4 observations to LR-5 in order to maintain the required high
specificity in this category [7,15] . Management includes multidisciplinary discussion for staging and treatment
without the need for a biopsy [16,18] . In some patients, a tissue sample may be required for histologic grading,
molecular characterization, or enrollment in clinical trials [16,18] .

INTEGRATION INTO AASLD
LI-RADS has undergone several major updates since its initial release in 2011. The most recent update
(LI-RADS v2018) has revised its criteria for LR-5 (definite HCC), and as a result LI-RADS has been
[6]
integrated into the AASLD HCC practice guidelines and simplified . In v2018, 10-19-mm observations
with nonrim APHE and nonperipheral “washout” are categorized LR-5, regardless of visualization on the