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LI-RADS Practical Tips and Case-Based Review, Dr. Ania Kielar (6-9-20)

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2:00

It makes it very difficult for the person receiving

2:02

the report to know what exactly you mean.

2:04

If you give it a number 1 2 3 4 5 and we have

2:08

some data behind it, it allows everybody,

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whether it's me and one center to another radiologist

2:13

in another country or another center or to a clinician,

2:16

they can all at least understand what we're saying. Even if we

2:19

might use different words in real life. In terms of content,

2:24

we want to make sure that we put all the relevant things that the

2:27

surgeons and clinicians that receive

2:28

our reports actually need.

2:30

So if we have a standard way of doing doing things, we won't

2:33

forget that because it prompts us during our dictation to

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ensure we do that. And then in terms of data collection,

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it's important that we standardize in terms of

2:41

literature so that we can do larger data aggregates

2:44

and figure out what's going on.

2:47

So LI-RADS was started in 20...

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or the first version came out in 2011 and there have been a

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few versions since. The most recent one is version 2018,

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and we're working on a new version, which we do every three

2:58

years or so based on the literature.

3:00

This particular LI-RADS version has an ultrasound component,

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contrast-enhanced ultrasound,

3:08

how to diagnose HCC, I'm not going to talk about that today.

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I'll focus on the CT and MRI portion and then there's

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a treatment response section for people who have undergone

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local regional therapy, and I will touch on that today.

3:21

The important thing to remember for LI-RADS is

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it's specifically to patients with cirrhosis

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or who have chronic hepatitis B,

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because we know that they have an increased risk of getting

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hepatocellular carcinoma, even if they don't have cirrhosis.

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LI-RADS does not apply to people who

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don't have risk factors for HCC.

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It does not apply to children at this point.

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And it doesn't apply to people who have

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vascular causes such as Budd–Chiari and HHT,

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and cardiac congestion cirrhosis.

3:52

Because the imaging characteristics in these particular

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subgroup of patients are two similar between HCC

4:00

and their various vascular abnormalities that they get.

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This is a small subset of people who

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have liver disease at risk for HCC,

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but we have chosen to exclude them because

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it causes too much overlap.

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And one of the things that's really important with LI-RADS

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is we have to be very specific with final diagnosis.

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Particularly if you're calling something in HCC,

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which would be LI-RADS 5, because it's one of the only imaging...

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it's one of the only studies where the radiology

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imaging report is enough to bypass biopsy,

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and allow patients to undergo definitive therapy or

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local regional therapy without actual pathology.

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So it's really important that we be specific

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in what we're talking about.

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I'll just touch on the ultrasound portion.

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So most patients when they first come in to the screening

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setting, many are evaluated with ultrasound.

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There are centers that do evaluate and screen people with CT,

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but for most places in North America and Canada,

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where I'm from, ultrasound is the first test and it's done every

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six months in people with cirrhosis or at risk for HCC,

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which includes patients with chronic hepatitis B.

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So, the three options you have with your ultrasound is either

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it's negative. So you see nothing.

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You have a lesion that's less than 10 mm,

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and that's called sub threshold.

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And then, you have your type ultrasound version 3,

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which is positive,

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in which case these patients would be then recommended

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to go on to CT or MRI for more definitive characterization.

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The other one short thing about the ultrasound is that there's

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visualization score because we know that in certain patients

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who have cirrhosis, like the bottom image here,

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there's a lot of attenuation of the sound and

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we can't actually see the body, you know,

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posterior half of the liver in this case.

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So this would be a limited study,

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the one on the bottom, compared to the one on the top.

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And in this case,

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we may actually be better off imaging this patient.

5:56

Whether it's screening or characterization with CT or MRI.

6:00

So this patient would not be somebody who should be

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screened with ultrasound. Everybody else are fine.

6:07

Now, this is the algorithm for CT and MRI.

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So patient comes in at risk for HCC.

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You do the CT or the MRI and you apply this.

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And this is part one.

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And, of course,

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remember they have to have HCC

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and then this is the second part.

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So first, I'll go back to this part.

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So if you can't image, interpret

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the images because they've missed a bunch of sequences,

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the timings way off or the patient breathed, or coughed,

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or whatever might have happened,

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then you would characterize it, is not...

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not characterizable.

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And then it goes 1 and 2, which is benign.

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And then there's this black one here,

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called tumor in vein,

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and that's really a bad prognostic factor for patients.

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And this is really important for us to look for initially,

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because it trumps everything else that we see below.

Report

Faculty

Ania Z Kielar, MD

Abdominal Radiologist

Joint Department of Medical imaging in Toronto, Canada

Tags

Gastrointestinal (GI)

Body

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