Preview

Variant: 1 Adult. Primary liver cancer. Screening.

Procedure	Appropriateness Category
US abdomen	Usually Appropriate
MRI abdomen without and with IV contrast	May Be Appropriate
MRI abdomen without IV contrast	May Be Appropriate
CT abdomen with IV contrast multiphase	May Be Appropriate
US abdomen with IV contrast	Usually Not Appropriate
MRI abdomen without and with IV contrast with MRCP	Usually Not Appropriate
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate
CT abdomen with IV contrast	Usually Not Appropriate
CT abdomen without IV contrast	Usually Not Appropriate
CT abdomen without and with IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 2 Adult. Primary liver cancer. Staging.

Procedure	Appropriateness Category
MRI abdomen without and with IV contrast	Usually Appropriate
CT abdomen with IV contrast multiphase	Usually Appropriate
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate
Bone scan whole body	May Be Appropriate
CT abdomen and pelvis with IV contrast	May Be Appropriate (Disagreement)
CT chest with IV contrast	May Be Appropriate (Disagreement)
CT chest without IV contrast	May Be Appropriate (Disagreement)
CT pelvis with IV contrast	May Be Appropriate
US abdomen transabdominal	Usually Not Appropriate
US abdomen with IV contrast	Usually Not Appropriate
MRI abdomen without IV contrast	Usually Not Appropriate
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate
CT abdomen and pelvis without IV contrast	Usually Not Appropriate
CT chest without and with IV contrast	Usually Not Appropriate
CT pelvis without IV contrast	Usually Not Appropriate
FDG-PET/MRI skull base to mid-thigh	Usually Not Appropriate
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate
CT pelvis without and with IV contrast	Usually Not Appropriate

Variant: 3 Adult. Primary liver cancer. Liver observations under active surveillance.

Procedure	Appropriateness Category
MRI abdomen without and with IV contrast	Usually Appropriate
CT abdomen with IV contrast multiphase	Usually Appropriate
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate
CT abdomen without and with IV contrast	May Be Appropriate
US abdomen transabdominal	Usually Not Appropriate
US abdomen with IV contrast	Usually Not Appropriate
MRI abdomen without IV contrast	Usually Not Appropriate
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate
CT abdomen with IV contrast	Usually Not Appropriate
CT abdomen without IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 4 Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.

Procedure	Appropriateness Category
MRI abdomen without and with IV contrast	Usually Appropriate
CT abdomen with IV contrast multiphase	Usually Appropriate
CT abdomen without and with IV contrast	Usually Appropriate
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate
US abdomen transabdominal	Usually Not Appropriate
US abdomen with IV contrast	Usually Not Appropriate
MRI abdomen without IV contrast	Usually Not Appropriate
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate
CT abdomen with IV contrast	Usually Not Appropriate
CT abdomen without IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Variant: 5 Adult. Primary liver cancer. Treated. Routine surveillance.

Procedure	Appropriateness Category
MRI abdomen without and with IV contrast	Usually Appropriate
CT abdomen with IV contrast multiphase	Usually Appropriate
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate
CT abdomen without and with IV contrast	May Be Appropriate
US abdomen transabdominal	Usually Not Appropriate
US abdomen with IV contrast	Usually Not Appropriate
MRI abdomen without IV contrast	Usually Not Appropriate
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate
CT abdomen with IV contrast	Usually Not Appropriate
CT abdomen without IV contrast	Usually Not Appropriate
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate

Elainea N. Smith, MD^a; Mustafa R. Bashir, MD^b; Alice Fung, MD^c; Brooks D. Cash, MD^d; Matthew Dixon, MD^e; Elizabeth M. Hecht, MD^f; Brendan M. McGuire, MD^g; Anjana A. Pillai, MD^h; Gregory K. Russo, MDⁱ; Rachna T. Shroff, MD, MS^j; Kiran H. Thakrar, MD^k; Abhinav Vij, MD, MPH^l; Shaun A. Wahab, MD^m; Terence Z. Wong, MD, PhDⁿ; Atif Zaheer, MD^o; Kathryn J. Fowler, MD^p.

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.

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

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.

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

1. [33538338] Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021;71:209-49.
2. [24840647] Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res 2014;74:2913-21.
3. [34902568] Singal AG, Reddy S, Radadiya Aka Patel H, et al. Multicenter Randomized Clinical Trial of a Mailed Outreach Strategy for Hepatocellular Carcinoma Surveillance. Clinical Gastroenterology & Hepatology. 20(12):2818-2825.e1, 2022 12.
4. [29624699] Marrero JA, Kulik LM, Sirlin CB, et al. Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 68(2):723-750, 2018 Aug.
5. [30445016] van der Pol CB, Lim CS, Sirlin CB, et al. Accuracy of the Liver Imaging Reporting and Data System in Computed Tomography and Magnetic Resonance Image Analysis of Hepatocellular Carcinoma or Overall Malignancy-A Systematic Review. Gastroenterology. 156(4):976-986, 2019 03.
6. [27158749] Llovet JM, Zucman-Rossi J, Pikarsky E, et al. Hepatocellular carcinoma. Nat Rev Dis Primers 2016;2:16018.
7. [34643782] Polikoff A, Wessner CE, Balasubramanya R, et al. Imaging appearance of residual HCC following incomplete trans-arterial chemoembolization on contrast-enhanced imaging. Abdominal Radiology. 47(1):152-160, 2022 01.
8. [29268722] Kim HA, Kim KA, Choi JI, et al. Comparison of biannual ultrasonography and annual non-contrast liver magnetic resonance imaging as surveillance tools for hepatocellular carcinoma in patients with liver cirrhosis (MAGNUS-HCC): a study protocol. BMC Cancer. 17(1):877, 2017 12 21.
9. [27657493] Kim SY, An J, Lim YS, et al. MRI With Liver-Specific Contrast for Surveillance of Patients With Cirrhosis at High Risk of Hepatocellular Carcinoma. JAMA Oncol. 3(4):456-463, 2017 Apr 01.
10. [25714281] Marks RM, Ryan A, Heba ER, et al. Diagnostic per-patient accuracy of an abbreviated hepatobiliary phase gadoxetic acid-enhanced MRI for hepatocellular carcinoma surveillance. AJR Am J Roentgenol. 204(3):527-35, 2015 Mar.
11. [31524775] Demirtas CO, Gunduz F, Tuney D, et al. Annual contrast-enhanced magnetic resonance imaging is highly effective in the surveillance of hepatocellular carcinoma among cirrhotic patients. Eur J Gastroenterol Hepatol. 32(4):517-523, 2020 04.
12. [27558976] Sutherland T, Watts J, Ryan M, et al. Diffusion-weighted MRI for hepatocellular carcinoma screening in chronic liver disease: Direct comparison with ultrasound screening. J Med Imaging Radiat Oncol. 61(1):34-39, 2017 Feb.
13. [11592607] Bruix J, Sherman M, Llovet JM, et al. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol 2001;35:421-30.
14. [15042359] Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol 2004;130:417-22.
15. [29981779] Moon AM, Weiss NS, Beste LA, et al. No Association Between Screening for Hepatocellular Carcinoma and Reduced Cancer-Related Mortality in Patients With Cirrhosis. Gastroenterology. 155(4):1128-1139.e6, 2018 10.
16. [27775821] Atiq O, Tiro J, Yopp AC, et al. An assessment of benefits and harms of hepatocellular carcinoma surveillance in patients with cirrhosis. Hepatology. 65(4):1196-1205, 2017 04.
17. [35486579] Nguyen SA, Merrill CD, Burrowes DP, Medellin GA, Wilson SR. Hepatocellular Carcinoma in Evolution: Correlation with CEUS LI-RADS. Radiographics. 42(4):1028-1042, 2022 Jul-Aug.
18. [33956204] Motz VL, White R, Lee R, Vu T, Shin B, McGillen KL. Contrast-enhanced ultrasound for screening hepatocellular carcinoma: an implemented program at a semi-rural academic center. Abdominal Radiology. 46(9):4170-4177, 2021 09.
19. [28612162] Tang A, Fowler KJ, Chernyak V, Chapman WC, Sirlin CB. LI-RADS and transplantation for hepatocellular carcinoma. [Review]. Abdominal Radiology. 43(1):193-202, 2018 01.
20. [29518452] Chalaye J, Costentin CE, Luciani A, et al. Positron emission tomography/computed tomography with 18F-fluorocholine improve tumor staging and treatment allocation in patients with hepatocellular carcinoma. J Hepatol. 69(2):336-344, 2018 08.
21. [10845666] Khan MA, Combs CS, Brunt EM, et al. Positron emission tomography scanning in the evaluation of hepatocellular carcinoma. J Hepatol 2000;32:792-7.
22. [30568386] Au KP, Chok KSH. Multidisciplinary approach for post-liver transplant recurrence of hepatocellular carcinoma: A proposed management algorithm. [Review]. World Journal of Gastroenterology. 24(45):5081-5094, 2018 Dec 07.
23. [28859233] Roberts LR, Sirlin CB, Zaiem F, et al. Imaging for the diagnosis of hepatocellular carcinoma: A systematic review and meta-analysis. [Review]. Hepatology. 67(1):401-421, 2018 01.
24. [33596330] Mirdad RS, Madison Hyer J, Diaz A, et al. Postoperative imaging surveillance for hepatocellular carcinoma: How much is enough?. J Surg Oncol. 123(7):1568-1577, 2021 Jun.
25. [-3197194] American College of Radiology Committee on LI-RADS®. Liver Imaging Reporting & Data System (LI-RADS®). Available at: https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/LI-RADS
26. [-3199262] American College of Radiology. LI-RADS® CEUS Nonradiation TRA. v2024 Core. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/RADS/LI-RADS/LI-RADS-CEUS-Nonradiation-TRA-v2024-Core.pdf
27. [29628281] European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 2018;69:182-236.
28. [28859222] Kulik L, Heimbach JK, Zaiem F, et al. Therapies for patients with hepatocellular carcinoma awaiting liver transplantation: A systematic review and meta-analysis. Hepatology 2018;67:381-400.
29. [35286054] National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022.
30. [-3128692] American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

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

Staging and Follow-up of Primary Liver Cancer