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LI-RADS 4 – Psuedo Capsule

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The following patient presents to us a history

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of cirrhosis, looking for hepatocellular

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carcinoma, no priors to compare to, and so

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we have our, have our images to evaluate.

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Start off with the post-contrast imaging

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sequences, and we see a bunch of nodules in

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this liver, so we can certainly look at each

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and every one of them, but the one I want to

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focus on is right over here in segment six.

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So this is T1, FATSAT, post-contrast, and

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I'm showing you the arterial phase images.

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And this is the nodule in

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question that I want to focus on.

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It certainly demonstrates non-RIM

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arterial phase hyper-enhancement.

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If we were to measure this, I've measured this,

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uh, previously, and it falls somewhere between

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10 and 19 millimeters, so that's the sort of

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category that we're working with right now.

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And again, to, to qualify this more, we need

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to see if it has washout or pseudocapsule.

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Because we don't have any priors, I can't

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assess for growth, so it's really the

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presence of washout and or pseudocapsule.

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That will allow me to categorize

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this into a LI-RADS category.

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So here we have our T1 FATSAT post-contrast

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portal venous phase image, and again this

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is the lesion in question in segment 6.

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And the one thing that I can say with a

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reasonable amount of certainty is that

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it does have a little capsule around it.

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You can see this rim that's

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enhancing surrounding it.

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So, we had arterial phase hyper-enhancement,

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as we saw in the um, arterial phase images,

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we know it's between 10 and 19 millimeters,

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and it has a pseudocapsule that surrounds it.

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The question is, is the

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inside of it washing out?

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And again, somebody may look at this and

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say, yes, it's washing out, but when you

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compare it, sort of the inside of it,

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compared to the adjacent liver parenchyma

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around here, it looks very similar.

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It's not 100 percent darker than some

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of the adjacent liver parenchyma.

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And again, with LI-RADS, if you're not 100

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percent sure, the document and the people who've

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come up with this lexicon suggest that you don't

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call a category that you're not certain about.

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So in this case, I'm not 100 percent certain

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that this is washing out, so I'm going to

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say questionable washout, which for practical

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purposes means that there's no definite washout.

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So we're really just left

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with these three things.

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And so when we have something that falls, you

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know, in this size range with non-RIM arterial

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phase and hyper-enhancement, if the only other

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feature that it has is a pseudocapsule, that's

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not enough to qualify this as a LI-RADS 5.

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This will qualify as a LI-RADS 4.

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If, however, this additional feature was washout

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instead of the pseudocapsule, that would have

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been sufficient to bump it up to a LI-RADS 5.

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And that's sort of what

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we saw in the prior case.

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That instead of having the

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capsule, it had washout.

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And that actually allows it

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to be bumped up to a LI-RADS 5.

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If it just has the capsule without

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washout, keep it as a LI-RADS 4 lesion.

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This patient will still go to a

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multidisciplinary tumor board.

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Discussion will be had.

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It may involve a biopsy prior to treatment.

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The likelihood that this is going to be an HCC

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is very high, but certainly it's not near 100%,

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uh, like it would be for a LI-RADS 5 lesion.

Report

Faculty

Mahan Mathur, MD

Associate Professor, Division of Body Imaging; Vice Chair of Education, Dept of Radiology and Biomedical Imaging

Yale School of Medicine

Tags

Neoplastic

MRI

Liver

Gastrointestinal (GI)

Body

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