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LI-RADS 5 – Non-peripheral Washout (NPWO)

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0:01

Here we have another patient with

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cirrhosis, and they're doing this MRI

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to look for hepatocellular carcinoma.

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We'll start off looking at the post

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contrast imaging sequences, and I'm going

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to focus on a lesion right about here.

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And so here's the T1 FATSAT post

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contrast arterial phase images.

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Here we have the portal venous phase images.

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Here we have the equilibrium

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or delayed phase images.

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And the lesion that I want you to focus

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on is really centered in Segment 8, maybe

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a little bit of extension to Segment 7.

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Look in the post contrast arterial phase

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images, there is unequivocal arterial phase

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hyperenhancement that is non-RIM-like.

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Alright, so it's not the periphery that's

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enhancing, the whole lesion is enhancing

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arterial phase hyperenhancement.

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Now if we were to measure this,

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I've measured this, and it falls

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somewhere between 10-19 millimeters.

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So that's the sort of category of lesion

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that we're looking at, non-RIM arterial

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hyperenhancement, 10 to 19 millimeters.

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And to further assess what LI-RADS category

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it fits into, we need to see if there's

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washout, pseudocapsule, or growth.

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In terms of growth, I'll tell you

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there's no prior studies to compare

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it in this patient, so we have to

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look for washout and or pseudocapsule.

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So if we look at it both on the portal

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venous and equilibrium phase images, there

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is definite washout within this lesion.

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So let's look at this lesion over here.

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There's portions of it, specifically down

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here, that have internally less signal

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within it than the adjacent liver parenchyma.

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So I would say that there is non-

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peripheral washout within this lesion.

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And in terms of a pseudocapsule,

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I would say equivocal.

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Some people may look at this and say

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there's a pseudocapsule over here.

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Some people may not be 100 percent sure,

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and as I said, if you're not 100 percent

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sure, the LI-RADS lexicon suggests that you

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don't call these features that are not,

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that you're not 100 percent sure about

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in terms of their presence or absence.

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So, what we're really left with then is

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a lesion that demonstrates non-RIM

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arterial phase hyperenhancement, that falls

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between 10 to 19 millimeters in size, that

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has definite non-peripheral washout, and

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we're not really sure about the capsule.

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So, I'll just put a question mark

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capsule, and I'll put this in parentheses,

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because effectively we're saying that

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there's no definite pseudocapsule.

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Putting it together in the LI-RADS lexicon,

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it only has one other feature, those

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additional categories, but that one other

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feature is enough to specifically the washout.

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To bump this to a LI-RADS 5 category.

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Okay, so if we work through the sort of

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LI-RADS lexicon and lesion at between 10 and

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19 millimeters with arterial phase hyper

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enhancement that does demonstrate washout,

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it will qualify as a LI-RADS 5 lesion, which is

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what this was, and this went on to our tumor

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board and was subsequently treated.

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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