Management of Liver Cancer

Variant: 1 Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.

Procedure	Appropriateness Category
Liver transplantation	Usually Appropriate
Percutaneous ablation liver	Usually Appropriate
Surgical liver resection	Usually Appropriate
Combination locoregional therapy	May Be Appropriate
External beam radiation therapy	May Be Appropriate
Transarterial chemoembolization	May Be Appropriate
Transarterial radioembolization	May Be Appropriate
Bland transarterial embolization	May Be Appropriate
Systemic therapies	Usually Not Appropriate

Variant: 2 Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.

Procedure	Appropriateness Category
Liver transplantation	Usually Appropriate
Combination locoregional therapy	Usually Appropriate
Surgical liver resection	Usually Appropriate
Transarterial chemoembolization	Usually Appropriate
Transarterial radioembolization	Usually Appropriate
Bland transarterial embolization	May Be Appropriate
External beam radiation therapy	May Be Appropriate
Percutaneous ablation liver	May Be Appropriate
Systemic therapies	Usually Not Appropriate

Variant: 3 Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.

Procedure	Appropriateness Category
Transarterial chemoembolization	Usually Appropriate
Transarterial radioembolization	Usually Appropriate
Bland transarterial embolization	Usually Appropriate
Systemic therapies	Usually Appropriate
Combination locoregional therapy	May Be Appropriate
External beam radiation therapy	May Be Appropriate
Percutaneous ablation liver	Usually Not Appropriate
Surgical liver resection	Usually Not Appropriate
Liver transplantation	Usually Not Appropriate

Variant: 4 Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.

Procedure	Appropriateness Category
Systemic therapies	Usually Appropriate
Transarterial radioembolization	Usually Appropriate
Transarterial chemoembolization	May Be Appropriate
Bland transarterial embolization	May Be Appropriate
Combination locoregional therapy	May Be Appropriate
External beam radiation therapy	May Be Appropriate
Percutaneous ablation liver	Usually Not Appropriate
Surgical liver resection	Usually Not Appropriate
Liver transplantation	Usually Not Appropriate

Variant: 5 Intrahepatic cholangiocarcinoma: Peripheral hepatic lobar cholangiocarcinoma, less than 3 cm; no biliary ductal dilatation, macroscopic vascular invasion, regional lymphadenopathy, or distant metastases.

Procedure	Appropriateness Category
Surgical liver resection	Usually Appropriate
Percutaneous ablation liver	Usually Appropriate
Liver transplantation	May Be Appropriate
Systemic therapies	May Be Appropriate
Transarterial radioembolization	May Be Appropriate
External beam radiation therapy	May Be Appropriate
Transarterial chemoembolization	May Be Appropriate
Bland transarterial embolization	Usually Not Appropriate

Variant: 6 Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.

Procedure	Appropriateness Category
Systemic therapies	Usually Appropriate
Transarterial radioembolization	May Be Appropriate
External beam radiation therapy	May Be Appropriate
Bland transarterial embolization	Usually Not Appropriate
Transarterial chemoembolization	Usually Not Appropriate
Percutaneous ablation liver	Usually Not Appropriate
Surgical liver resection	Usually Not Appropriate
Liver transplantation	Usually Not Appropriate

Variant: 7 Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).

Procedure	Appropriateness Category
Long-acting somatostatin analogs	Usually Appropriate
Bland transarterial embolization	Usually Appropriate
Peptide receptor radionuclide therapy	Usually Appropriate
Transarterial chemoembolization	Usually Appropriate
Transarterial radioembolization	Usually Appropriate
Systemic therapies	May Be Appropriate
External beam radiation therapy	May Be Appropriate
Percutaneous ablation liver	May Be Appropriate
Surgical liver resection	May Be Appropriate
Combination locoregional therapy	Usually Not Appropriate
Liver transplantation	Usually Not Appropriate

Variant: 8 Metastatic liver disease: Solitary colorectal liver metastasis.

Procedure	Appropriateness Category
Systemic therapies	Usually Appropriate
Surgical liver resection	Usually Appropriate
Percutaneous ablation liver	Usually Appropriate
Combination locoregional therapy	May Be Appropriate
External beam radiation therapy	May Be Appropriate
Transarterial chemoembolization	May Be Appropriate
Transarterial radioembolization	May Be Appropriate
Bland transarterial embolization	Usually Not Appropriate
Hepatic arterial chemotherapy infusion	Usually Not Appropriate
Liver transplantation	Usually Not Appropriate

Variant: 9 Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).

Procedure	Appropriateness Category
Systemic therapies	Usually Appropriate
Hepatic arterial chemotherapy infusion	May Be Appropriate
Transarterial chemoembolization	May Be Appropriate
Transarterial radioembolization	May Be Appropriate
Bland transarterial embolization	May Be Appropriate (Disagreement)
Combination locoregional therapy	May Be Appropriate
Percutaneous ablation liver	May Be Appropriate
Surgical liver resection	May Be Appropriate
External beam radiation therapy	Usually Not Appropriate
Liver transplantation	Usually Not Appropriate

Panel Members

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
A. Systemic Therapies

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
B. Surgical Liver Resection

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
C. Liver Transplantation

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
D. Percutaneous Ablation Liver

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
E. External Beam Radiation Therapy

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
F. Bland Transarterial Embolization

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
G. Transarterial Chemoembolization

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
H. Transarterial Radioembolization

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
I. Combination Locoregional Therapy

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
A. Systemic Therapies

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
B. Surgical Liver Resection

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
C. Liver Transplantation

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
D. Percutaneous Ablation Liver

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
E. External Beam Radiation Therapy

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
F. Bland Transarterial Embolization

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
G. Transarterial Chemoembolization

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
H. Transarterial Radioembolization

Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
I. Combination Locoregional Therapy

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
A. Systemic Therapies

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
B. Surgical Liver Resection

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
C. Liver Transplantation

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
D. Percutaneous Ablation Liver

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
E. External Beam Radiation Therapy

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
F. Bland Transarterial Embolization

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
G. Transarterial Chemoembolization

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
H. Transarterial Radioembolization

Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
I. Combination Locoregional Therapy

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
A. Systemic Therapies

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
B. Surgical Liver Resection

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
C. Liver Transplantation

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
D. Percutaneous Ablation Liver

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
E. External Beam Radiation Therapy

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
F. Bland Transarterial Embolization

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
G. Transarterial Chemoembolization

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
H. Transarterial Radioembolization

Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
I. Combination Locoregional Therapy

Variant 5: Intrahepatic cholangiocarcinoma: Peripheral hepatic lobar cholangiocarcinoma, less than 3 cm; no biliary ductal dilatation, macroscopic vascular invasion, regional lymphadenopathy, or distant metastases.

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
A. Systemic Therapies

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
B. Surgical Liver Resection

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
C. Liver Transplantation

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
D. Percutaneous Ablation Liver

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
E. External Beam Radiation Therapy

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
F. Bland Transarterial Embolization

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
G. Transarterial Chemoembolization

Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
H. Transarterial Radioembolization

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
A. Long-Acting Somatostatin Analogs

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
B. Systemic Therapies

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
C. Surgical Liver Resection

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
D. Liver Transplantation

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
E. Percutaneous Ablation Liver

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
F. External Beam Radiation Therapy

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
G. Bland Transarterial Embolization

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
H. Transarterial Chemoembolization

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
I. Transarterial Radioembolization

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
J. Combination Locoregional Therapy

Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
K. Peptide Receptor Radionuclide Therapy

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
A. Systemic Therapies

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
B. Surgical Liver Resection

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
C. Liver Transplantation

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
D. Percutaneous Ablation Liver

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
E. External Beam Radiation Therapy

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
F. Hepatic Arterial Chemotherapy Infusion

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
G. Bland Transarterial Embolization

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
H. Transarterial Chemoembolization

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
I. Transarterial Radioembolization

Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
J. Combination Locoregional Therapy

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
A. Systemic Therapies

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
B. Surgical Liver Resection

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
C. Liver Transplantation

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
D. Percutaneous Ablation Liver

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
E. External Beam Radiation Therapy

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
F. Hepatic Arterial Chemotherapy Infusion

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
G. Bland Transarterial Embolization

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
H. Transarterial Chemoembolization

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
I. Transarterial Radioembolization

Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
J. Combination Locoregional Therapy

Summary of Recommendations

Supporting Documents

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 go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

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.

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Disclaimer

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.