CEUS LI-RADS

Last revised by Henry Knipe on 3 May 2024

The Contrast-enhanced Ultrasound Liver Imaging Reporting and Data System (CEUS LI-RADS) is a standardized classification system, algorithm, and terminology for diagnosing hepatocellular carcinoma (HCC) in high-risk patients using CEUS with blood-pool intravenous contrast agents.

The current version is CEUS LI-RADS v2017 Core. For other LI-RADS algorithms, see: LI-RADS (overview).

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Article:

  • CEUS LI-RADS is for diagnosis only and not for staging; it is only practical to characterize a limited number of targetted observations for each examination

  • real-time assessment with CEUS eliminates arterial phase mistiming and offers potentially higher sensitivity for the detection of arterial phase hyperenhancement

  • washout characteristics with CEUS are different to CT/MRI, allowing assessment of true washout; hence, the CT/MRI LI-RADS terms "washout" or "washout appearance" are not used

  • real-time assessment of washout allows (subjective) quantitative assessment, including onset (early or late) and degree (mild or marked)

  • "capsule" is not detected with CEUS

  • arterioportal shunts or vascular pseudolesions are not depicted with CEUS, although transient hepatic echogenicity differences (THED) can still be seen2

  • multiple injections of microbubble intravascular contrast can be performed, allowing for more complete assessment of an observation

Suitable for patients at high risk for HCC, including:

  • adult patients with known cirrhosis

  • adult patients with chronic hepatitis B virus infection regardless or cirrhosis status

  • current or prior HCC

Patients not suitable for CEUS LI-RADS include:

Observations suitable for CEUS LI-RADS must be ≥10 mm in size and visible with unenhanced ultrasound. It cannot be applied to previously treated observations, see: CT/MRI Treatment Response LI-RADS.

CEUS LI-RADS is only suitable for intravascular blood-pool contrast agents (e.g. Lumason/SonoVue or Definity/Luminity). Intravascular contrast agents taken up by Kupffer cells such as Sonazoid are unsuitable for use with CEUS LI-RADS.

Recommended algorithm:

  • determine if patient and examination is suitable for CEUS LI-RADS (see above)

  • identify and categorize observation(s)

  • apply CEUS ancillary features (optional)

  • apply tie-breaking rules if required

  • review and determine if final category seems reasonable and appropriate

LI-RADS define an "observation" as a distinctive area compared to background liver. Focal abnormalities are not referred to as lesions or nodules.

If an observation has been biopsied and the diagnosis is certain, then the pathological diagnosis should be reported, rather than the CEUS LI-RADS category. If there is uncertainty of the pathological diagnosis, or it is a HCC precursor (regenerative or dysplastic nodule), then the CEUS LI-RADS category and pathological diagnosis should be reported together.

  • non-rim arterial phase hyperenhancement (APHE)

    • enhancement must not be rim-like or peripheral discontinous globular

    • enhancement must be unequivocally hyperechoic to the background liver

  • washout

    • temporal reduction in enhancement (whole or part of the observation) relative to the background liver, during or after the arterial phase and becoming hypoenhancing to the background liver

    • can be applied to the observation even in absence of APHE

    • see also: characterizing washout below

Washout characteristics are different with CEUS compared to CT/MRI, and typically all malignant nodules (not just HCC) washout on CEUS:

  • microbubbles used for CEUS intraveous contrast are too large, and do not extravasate into the interstitium like CT/MRI agents

  • CEUS intravenous blood-pool contrast agents reflects the relative blood volume of the lesion compared to background liver

To maintain specificity for HCC, "onset" and "degree" of washout must be assessed:

  • onset: time after contrast injection in seconds when washout is first detected

    • early: < 60 seconds after injection

    • late: ≥ 60 seconds after injection

  • degree: comparing nodule to background liver at 2 minutes after contrast injection

    • marked: nodule devoid of enhancement "punched-out" by 2 minutes

    • mild: nodule less enhanced than liver, but not devoid of enhancement at 2 minutes

Interpretation of washout:

  • early marked: typical of intrahepatic cholangiocarcinoma and metastases

  • early mild: suggestive of malignancy in general, not specific for type

  • late marked: suggestive of malignancy in general, not specific for type

  • late mild: typical of HCC and HCC precursor nodules

Favoring malignancy in general, not HCC in particular:

  • definite growth

    • unequivocal increase in observation size

    • "threshold growth" is not a CEUS LI-RADS term

Favoring HCC in particular:

  • nodule-in-nodule architecture

    • presence of smaller inner nodule with different imaging features than the outer larger nodule

  • mosaic architecture

    • presence of randomly distributed internal nodules or areas, usually with different imaging features to the overall larger nodule

Favoring benignity:

  • size stability ≥2 years

  • size reduction

  • cyst

  • hemangioma

  • hepatic fat deposition/sparing

  • distinct isoenhancing solid nodule < 10 mm

    • if isoenhancing nodule ≥ 10 mm, then apply CEUS LR-3

  • non-mass like isoenhancing observation of any size not typical of hepatic fat deposition/sparing

  • CEUS LR-3 nodules with size stability for ≥ 2 years

  • nodule < 20 mm no APHE and no washout, or with late and mild washout

  • nodule ≥ 20 mm no APHE and no washout

  • nodule < 10 mm with APHE and no washout

  • nodule ≥ 20 mm no APHE, and with late and mild washout

  • nodule < 10 mm with APHE, and with late and mild washout

  • nodule ≥ 10 mm with APHE, and no washout

  • nodule ≥ 10 mm with APHE, and with late and mild washout

  • rim (non-peripheral discontinous globular) APHE, or

  • early (< 60 s) washout, or

  • marked washout

  • unequivocal enhancing soft tissue in vein, regardless of visualization of a parenchymal mass

    • early visualization of intravenous contrast in the vein (approximately same time as hepatic artery opacification) favors tumor in vein

    • late visualization of intravenous contrast in the vein (approximately 10 seconds after hepatic artery opacification) favors portal flow in a patent non-occlusive or recanalized bland thrombus

  • cannot be categorized due to image degradation or omission

  • if unsure if definitely tumor in vein, then do not categorize as CEUS LR-TIV

  • if unsure between two categories, choose the one reflecting lower certainty

    • If LR-1 or LR-2 and unsure if definitely benign, then upgrade up to LR-3 (intermediate risk)

    • If LR-4 or LR-5 and unsure if definitely maglinant, then downgrade up to LR-3 (intermediate risk)

    • If LR-4 or LR-5 but unsure if definite hepatocellular orgin, then categorize as LR-M

Suggested management:

  • CEUS LR-NC

    • assess with alternative diagnostic imaging (e.g. CT or MRI) in ≤ 3 months

    • repeat CEUS in ≤ 3 months

  • CEUS LR-1

    • return to 6 monthly surveillance

  • CEUS LR-2

    • return to 6 monthly surveillance

  • CEUS LR-3

    • assess with alternative diagnostic imaging (e.g. CT or MRI) in ≤ 6 months

    • repeat CEUS in ≤ 6 months

    • consider multi-disciplinary discussion for consensus management in selected cases

  • CEUS LR-4

    • consider multi-disciplinary discussion for consensus management

    • if biopsy or treatment is not planned, repeat assessment with CEUS or alternative diagnostic imaging in ≤ 3 months

  • CEUS LR-5

    • multi-disciplinary discussion for consensus management

  • CEUS LR-M

    • multi-disciplinary discussion for consensus management

  • CEUS LR-TIV

    • multi-disciplinary discussion for consensus management

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