New ACR LI-RADS Ultrasound Version Increases Sensitivity for HCC

According to a manuscript published in the American Journal of Roentgenology (AJR), the ACR’s LI-RADS Ultrasound Surveillance v2024, compared with v2017, had higher sensitivity, albeit lower specificity, for detecting hepatocellular carcinoma (HCC)—related primarily to increasing, rather than elevated, alpha-fetoprotein (AFP).

Noting that the only independent predictor of limitations that significantly reduce the ability to detect observations (VIS-C) on subsequent ultrasound was initial VIS-C result, “the findings support a multidisciplinary surveillance framework that integrates ultrasound findings and AFP values to guide management recommendations in at-risk patients,” wrote corresponding author Sang Hyun Choi, MD, PhD, from the Research Institute of Radiology at Ulsan College of Medicine and Asan Medical Center in Seoul, Korea.

Choi et al. included 407 patients (median age, 56 years; 230 male, 177 female) with cirrhosis who underwent rounds of semi-annual surveillance ultrasound as part of a prospective trial (November 2011–December 2012). Two radiologists independently assigned ultrasound categories to round-1 examinations and visualization scores to round-1 and round-2 examinations; then, a third radiologist adjudicated disagreements. AFP was considered positive if elevated or increasing from pre-enrollment values (per v2024 criteria). Reference standard for HCC was positive biopsy or LR-5 observation on MRI. Diagnostic performance was compared between v2017 and v2024.

Ultimately, LI-RADS Ultrasound Surveillance v2024, versus v2017, demonstrated higher sensitivity for HCC (reader 1: 64.3% vs. 42.9%; reader 2: 64.3% vs. 39.3%) but lower specificity (reader 1: 82.0% vs. 92.6%; reader 2: 82.3% vs. 92.9%). Importantly, the only independent predictor of VIS-C on subsequent ultrasound was VIS-C on initial ultrasound (adjusted OR=21.0).

“This study is the first to my knowledge to compare v2024 to the earlier algorithm,” Kathryn McGillen, MD, radiologist at Penn State Health’s Milton. S Hershey Medical Center, replied in her AJR editorial comment. Noting that definitive risk factors for predicting repeat VIS-C scores remain elusive, “such predictive ability would help guide decisions regarding how and when follow-up after VIS-C scores should occur,” added Dr McGillen.