Liver Lesion — Initial Characterization

Variant: 1   Indeterminate, greater than 1 cm liver lesion on initial imaging with US. Normal liver. No suspicion or evidence of extrahepatic malignancy or underlying liver disease.
Procedure Appropriateness Category
US abdomen with IV contrast Usually Appropriate
MRI abdomen without and with IV contrast Usually Appropriate
CT abdomen with IV contrast multiphase Usually Appropriate
MRI abdomen without IV contrast May Be Appropriate
Image-guided biopsy liver Usually Not Appropriate
CT abdomen without IV contrast Usually Not Appropriate
DOTATATE PET/CT skull base to mid-thigh Usually Not Appropriate
Liver spleen scan Usually Not Appropriate
RBC scan abdomen and pelvis Usually Not Appropriate
CT abdomen without and with IV contrast Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually Not Appropriate
Variant: 2   Indeterminate, greater than 1 cm liver lesion on initial imaging with CT (noncontrast or single-phase) or noncontrast MRI. Normal liver. No suspicion or evidence of extrahepatic malignancy or underlying liver disease.
Procedure Appropriateness Category
MRI abdomen without and with IV contrast Usually Appropriate
CT abdomen with IV contrast multiphase Usually Appropriate
US abdomen May Be Appropriate (Disagreement)
US abdomen with IV contrast May Be Appropriate
Image-guided biopsy liver Usually Not Appropriate
DOTATATE PET/CT skull base to mid-thigh Usually Not Appropriate
Liver spleen scan Usually Not Appropriate
RBC scan abdomen and pelvis Usually Not Appropriate
CT abdomen without and with IV contrast Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually Not Appropriate
Variant: 3   Indeterminate, greater than 1 cm liver lesion on initial imaging with US. Known history of an extrahepatic malignancy.
Procedure Appropriateness Category
MRI abdomen without and with IV contrast Usually Appropriate
CT abdomen with IV contrast multiphase Usually Appropriate
US abdomen with IV contrast May Be Appropriate
Image-guided biopsy liver May Be Appropriate
MRI abdomen without IV contrast May Be Appropriate
DOTATATE PET/CT skull base to mid-thigh May Be Appropriate
CT abdomen without and with IV contrast May Be Appropriate
FDG-PET/CT skull base to mid-thigh May Be Appropriate
Octreotide scan with SPECT or SPECT/CT chest and abdomen May Be Appropriate
CT abdomen without IV contrast Usually Not Appropriate
Liver spleen scan Usually Not Appropriate
RBC scan abdomen and pelvis Usually Not Appropriate
Variant: 4   Indeterminate, greater than 1 cm liver lesion on initial imaging with CT (noncontrast or single-phase) or noncontrast MRI. Known history of an extrahepatic malignancy.
Procedure Appropriateness Category
MRI abdomen without and with IV contrast Usually Appropriate
CT abdomen with IV contrast multiphase Usually Appropriate
FDG-PET/CT skull base to mid-thigh Usually Appropriate
US abdomen May Be Appropriate
US abdomen with IV contrast May Be Appropriate
Image-guided biopsy liver May Be Appropriate
DOTATATE PET/CT skull base to mid-thigh May Be Appropriate
CT abdomen without and with IV contrast May Be Appropriate
Octreotide scan with SPECT or SPECT/CT chest and abdomen May Be Appropriate
Liver spleen scan Usually Not Appropriate
RBC scan abdomen and pelvis Usually Not Appropriate
Variant: 5   Incidental liver lesion, greater than 1 cm on US, noncontrast or single-phase CT, or noncontrast MRI. Known chronic liver disease.
Procedure Appropriateness Category
US abdomen with IV contrast Usually Appropriate
MRI abdomen without and with IV contrast Usually Appropriate
CT abdomen with IV contrast multiphase Usually Appropriate
Image-guided biopsy liver May Be Appropriate
DOTATATE PET/CT skull base to mid-thigh Usually Not Appropriate
Liver spleen scan Usually Not Appropriate
RBC scan abdomen and pelvis Usually Not Appropriate
CT abdomen without and with IV contrast Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually Not Appropriate
Variant: 6   Indeterminate, less than 1 cm liver lesion on initial imaging with US. Known history of an extrahepatic malignancy.
Procedure Appropriateness Category
MRI abdomen without and with IV contrast Usually Appropriate
US abdomen with IV contrast May Be Appropriate
MRI abdomen without IV contrast May Be Appropriate
CT abdomen with IV contrast multiphase May Be Appropriate
Image-guided biopsy liver Usually Not Appropriate
CT abdomen without IV contrast Usually Not Appropriate
DOTATATE PET/CT skull base to mid-thigh Usually Not Appropriate
Liver spleen scan Usually Not Appropriate
RBC scan abdomen and pelvis Usually Not Appropriate
CT abdomen without and with IV contrast Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually Not Appropriate
Variant: 7   Indeterminate, less than 1 cm liver lesion on initial imaging with CT (noncontrast or single-phase) or noncontrast MRI. Known history of an extrahepatic malignancy.
Procedure Appropriateness Category
MRI abdomen without and with IV contrast Usually Appropriate
CT abdomen with IV contrast multiphase Usually Appropriate
US abdomen with IV contrast May Be Appropriate
Image-guided biopsy liver May Be Appropriate
US abdomen Usually Not Appropriate
DOTATATE PET/CT skull base to mid-thigh Usually Not Appropriate
Liver spleen scan Usually Not Appropriate
RBC scan abdomen and pelvis Usually Not Appropriate
CT abdomen without and with IV contrast Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually Not Appropriate
Variant: 8   Incidental liver lesion, less than 1 cm on US, noncontrast or single-phase CT, or noncontrast MRI. Known chronic liver disease.
Procedure Appropriateness Category
MRI abdomen without and with IV contrast Usually Appropriate
CT abdomen with IV contrast multiphase Usually Appropriate
US abdomen with IV contrast May Be Appropriate
Image-guided biopsy liver Usually Not Appropriate
DOTATATE PET/CT skull base to mid-thigh Usually Not Appropriate
Liver spleen scan Usually Not Appropriate
RBC scan abdomen and pelvis Usually Not Appropriate
CT abdomen without and with IV contrast Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually Not Appropriate

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please visit https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.































































































The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination