LI-RADS

Dr Craig Hacking and Dr Matt A. Morgan et al.

LI-RADS (Liver Imaging Reporting and Data System) is both a set of standardized terminology and a classification system for imaging findings in liver lesions. The LI-RADS score for a liver lesion is an indication of its relative risk for hepatocellular carcinoma (HCC). The classification system is meant to be used in livers which have risk factors for HCC (e.g. cirrhotic livers, chronic HBV without cirrhosis). LI-RADS is not meant to be used in patients <18 years old, those with cirrhosis due to congenital hepatic fibrosis, and those with cirrhosis due to vascular disorders (e.g. Budd-Chiari syndrome).

The classification is meant to help decrease the variability in interpretation of liver lesions in at-risk patients. Standardisation also helps interpret therapeutic performance. The scoring system also potentially helps non-hepatologists interpret the potential suspiciousness of liver lesions in their patients.

  • hepatic phase enhancement
    • hyperenhancement: enhancement in the arterial phase is definitely greater than that of background liver
    • if unsure, classify as isoenhancing
  • "washout"
    • a visual assessment of relative hypointensity of the lesion compared with background liver on the portal venous and delayed phases
  • capsule/pseudocapsule
    • peripheral rim of smooth hyperenhancement seen in the portal venous or delayed phases
  • threshold growth
    • diameter increase ≥50% increase in ≤6 months
      • other prior criteria are now considered subthreshold growth, an ancillary feature
        • if prior exam >6 months, diameter ≥100% increase
        • a new lesion ≥10 mm in <24 months
    • threshold growth should be compared on similar sequences between studies
  • favouring malignancy, not HCC in particular
    • ultrasound visibility as a discrete nodule
    • subthreshold growth (see "threshold growth" in the major criteria section)
    • corona enhancement
    • fat sparing in solid mass
    • restricted diffusion
    • mild-moderate T2 hyperintensity
    • iron sparing in solid mass
    • transitional phase hypointensity
    • hepatobiliary phase hypointensity
  • favouring HCC in particular
    • nonenhancing "capsule"
    • nodule-in-nodule architecture
    • mosaic architecture
    • fat in mass, more than adjacent liver
    • blood products in mass
  • favouring benignity
    • size stability ≥2 years
    • size reduction
    • homogeneous marked T2 hyperintensity
    • homogeneous marked T2 or T2* hypointensity
    • undistorted vessels
    • parallels blood pool enhancement
    • hepatobiliary phase isointensity

Major criteria imaging findings often lead directly to the assignment of a LI-RADS score. If the assignment is unclear, ancillary findings may be useful as a "tie-breaker".

The LI-RADS score ranges from LR-1 (favour benignity) to LR-5 (favour malignancy).

  • imaging features diagnostic of a benign entity:
  • definite disappearance at follow-up in the absence of treatment is also indicative of LR-1
  • entities are similar to LR1, but the appearance is highly suggestive of the entity instead of 100% diagnostically certain
  • not a definitely benign entity, but not definitely HCC
  • includes entities that demonstrate
    • not a definite mass
    • mass with hepatic arterial phase iso- or hypoenhancement
      • <20 mm with no more than one of the following:
        • "washout"
        • capsule
        • threshold growth
      • ≥20 mm with no "washout," capsule, or threshold growth
    • mass with hepatic arterial phase hyperenhancement
      • <20 mm with no "washout," capsule, or threshold growth
  • no arterial phase hyperenhancement
    • <20 mm
      • two or more of the following
        • nonperipheral "washout"
        • enhancing capsule
        • threshold growth
    • ≥20 mm
      • one or more of the following
        • nonperipheral "washout"
        • enhancing capsule
        • threshold growth
  • non-rim arterial phase hyperenhancement
    • <10 mm
      • one or more of the following
        • nonperipheral "washout"
        • enhancing capsule
        • threshold growth
    • 10-19 mm
      • if the mass has an enhancing capsule but does not demonstrate threshold growth or nonperipheral washout
    • ≥20 mm
      • none of the following
        • nonperipheral "washout"
        • enhancing capsule
        • threshold growth
  • non-rim arterial phase hyperenhancement
    • 10-19 mm
      • one or more of the following
        • threshold growth
        • enhancing capsule
        • nonperipheral "washout"
      • but if enhancing capsule is the only major criterion, then LR-4
    • ≥20 mm
      • one or more of the following
        • threshold growth
        • enhancing capsule
        • nonperipheral "washout"

LR-M for liver lesions that are probably or definitely malignant, but not an appearance compatible with HCC. Examples of this include:

  • targetoid mass
  • non-targetoid mass with
    • infiltrative appearance
    • marked diffusion restriction
    • necrosis or severe ischemia
    • other appearance that in the radiologists' judgment suggests a non-HCC malignancy

LR-NC (LR-non-categorisable) for lesions in which the technical quality of the MRI does not allow evaluation of the major features

LR-TIV for unequivocal enhancing soft tissue invading the portal vein, regardless of whether an underlying parenchymal mass is visible. This is important to report since it is a contraindication to liver transplantation. Malignancies other than HCC can invade the portal venous system.

Suggested management:

  • LR1: continued routine surveillance
  • LR2: continued routine surveillance, consider repeat diagnostic imaging in six months or less
  • LR3: repeat or alternative diagnostic imaging in 3-6 months
  • LR4: multidisciplinary team discussion for tailored workup, may include biopsy
  • LR5: diagnosis confirmed - plan treatment
  • LR-NC: repeat or alternative diagnostic imaging in three months or less
  • ancillary features can upgrade or downgrade a lesion one category but cannot upgrade a lesion to LR5
  • if there are no LR4 or LR5 lesions, then LR3 should be reported, otherwise reporting of LR3 lesions is at the radiologist's discretion (they should be reported if previously LR4 or LR5)
  • late arterial phase is preferred for evaluation of arterial hyperenhancement
  • for masses with nodule-in-nodule appearance, measure the entire mass
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Article information

rID: 32465
Synonyms or Alternate Spellings:
  • Liver imaging reporting and data system (LI-RADS)

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Cases and figures

  • arterial phase: 9...
    Case 1: LI-RADS 3 lesions
    Drag here to reorder.
  • Intense enhanceme...
    Case 2: LI-RADS 5B lesion
    Drag here to reorder.
  • TR 4.1 / TE 2, 28...
    Case 3: LI-RADS 5B lesion
    Drag here to reorder.
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