Editing Hepatocellular carcinoma (section)

== '''Imaging (see 'liver lesions' under 'Radiology' for more)''' ==

* Either CT or MRI can be specific individually, but both scans may be required to increase sensitivity in difficult cases
* LI-RADS can be assessed on either contrast CT or MRI
** LI-RADS 5 (Definitely HCC) - MDT discussion for management consensus
*** '''Arterial phase enhancement, washout, capsule appearance'''
** 4 (High probability - 31%-79% chance of HCC) - MDT discussion for further workup
** 3 (intermediate - 6-9%) - repeat imaging 3-6 months
** 2 (probably benign - 0%) - repeat diagnostic imaging in 6 months
** 1 - return to surveillance in 6 months
** LR-M (other malignancy)
** LR-TIV (Tumour in vein)
* Features assessed:
** Arterial enhancement, size, washout, enhancing 'capsule', and growth
* Inclusion criteria for LI-RADS (must be high pre-test probability): chronic HBV or cirrhosis or current/prior hx HCC or transplant recipient
* Exclusion criteria: vascular aetiology of liver disease, congenital hepatic fibrosis, nodular regenerative hyperplasia, paediatric patients

{| class="wikitable"
|'''LI-RADS categorization of liver lesions in patients at risk for hepatocellular carcinoma'''
|
|
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|-
|'''Category'''
|'''Assessment'''
|'''Diagnostic considerations'''
|'''Action'''
|-
|LR-1
|Definitely benign
|Includes hemangiomas with characteristic features or cysts.
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** Continue routine surveillance imaging for HCC Δ
|-
|LR-2
|Probably benign
|Includes hemangioma without characteristic features and wedge-shaped arterioportal shunts.
|
** For most patients, continue routine surveillance imaging for HCCΔ
** For some patients, image with a different modality or MRI contrast agent◊
|-
|LR-3
|Intermediate probability of malignancy
|Includes dysplastic nodules, benign lesions without characteristic features, and rounded arterioportal shunts.
|
** Repeat contrast-enhanced CT, MRI, or ultrasound for liver lesion evaluation in 3 to 6 months¶
** Continue serial imaging every 3 to 6 months while the lesion remains LR-3 for ≥2 years or until the lesion has a conclusive diagnosis§
** If the lesion remains LR-3 for ≥2 years on imaging follow-up, return to routine surveillance imaging for HCCΔ
|-
|LR-4
|Probably HCC
|Includes HCC with some characteristic features.¥
|
** Multidisciplinary consultation to tailor further management. Options include:
** Alternative or follow-up imaging
** Biopsy the lesion
** Presumptive treatment without conclusive diagnosis
|-
|LR-5
|Definitely HCC†
|HCC with characteristic features.**
|
** Treatment for HCC
** No biopsy needed
|-
|LR-M
|Probably or definitely malignant, not specific for HCC
|Most LR-M lesions are malignant.

Includes HCC without characteristic features¶¶ and other malignancies (eg, cholangiocarcinoma, combined hepatocellular carcinoma and cholangiocarcinoma, lymphoma, or metastasis).
|
** Multidisciplinary consultation to tailor further management. Options include:
** Evaluate for underlying malignancyΔΔ
** Perform biopsy if it will alter management◊◊
|-
|LR-NC
|Not categorizable
|Images are insufficient for assessment.

Common reasons include imaging protocol not tailored for liver lesion or images degraded from patient motion.
|
** Repeat imaging for liver lesion evaluation with same or alternate modality in ≤3 months
|-
|LR-TIV
|Tumor in vein
|Unequivocal enhancing soft tissue in vein indicating tumor, either from HCC or another malignancy.
|
** Multidisciplinary consultation to tailor further management. Options include: 
** Alternative or follow-up imaging
** Biopsy the tumor in vein
** Presumptive treatment without histologic confirmation
|}