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Favor Malignant (Upgrade)
Visibility at nonenhanced US as a discrete nodule or mass corresponding to a CT- or MRI-detected observation.
Unequivocal growth of a mass, but less than 50% or greater size increase in 6 months.
Periobservation enhancement in the late arterial or early portal venous phase (PVP) attributable to venous drainage from the tumor.
Paucity of lipid in a solid mass compared with steatotic liver or in an inner nodule relative to a steatotic outer nodule. Steatotic tissue can be recognized at gradient-echo imaging when there is signal drop on out-of-phase images in comparison with in-phase images. Fat sparing in a solid mass is seen as absence of or lesser signal drop in an observation relative to its surroundings.
Increased signal intensity at DWI, not attributable solely to T2-weighted imaging shine-through, unequivocally higher than in liver and/or apparent diffusion coefficient (ADC) unequivocally lower than in liver parenchyma.
Signal intensity at T2-weighted imaging that is mildly or moderately higher than that of the liver and similar to or less than that of non–iron overloaded spleen parenchyma. This increased signal intensity is less than that of fluid.
Paucity of iron in an inner nodule compared with a siderotic outer nodule or to a solid mass containing less iron relative to iron-overloaded background liver. At gradient-echo imaging, iron-overloaded tissue shows decreased signal intensity on images with longer echo time (TE) (typically the in-phase images compared with the out-of-phase images when using a dual-echo gradient-echo sequence).
Signal intensity in the transitional phase (3 to 5 minutes after injection of gadoxetate disodium, Eovist) is unequivocally less, in whole or in part, than in the liver. It occurs after PVP and before the hepatobiliary phase (HBP).
Signal intensity in the HBP (20 minutes after injection of gadoxetate disodium, Eovist) is unequivocally less, in whole or in part, than in the liver. The HBP is hyperintense to hepatic blood vessels and there is excretion of contrast material into the biliary system. The HBP is suboptimal if the liver is not more intense than the hepatic blood vessels.
Favor HCC (Upgrade)
Capsule appearance that is not visible as an enhancing rim. This feature can appear as a hypointense rim on T2-weighted, nonenhanced T1-weighted, or HBP images. Nonenhancing “capsule” should be unequivocally thicker or more conspicuous than fibrotic tissue around background nodule.
Presence of smaller inner nodule within and having architecture different imaging features than larger outer nodule.
Nonperipheral temporal reduction in enhancement in whole or in part relative to composite liver tissue from earlier to later phase resulting in hypoenhancement in the extracellular phase. Can apply to any enhancing observation, even if no APHE.
Presence of randomly distributed internal nodules or compartments, usually with different imaging features. Internal compartments may differ because of the presence of fat, fibrosis, blood products, and vascular dynamics. Heterogeneity of compartments in mosaic appearance is better depicted on T2-weighted images than on T1-weighted images.
Excess fat within a mass, in whole or in part, relative to adjacent liver. Intracellular fat in HCCs can be diagnosed at MRI as a drop in signal intensity of a mass on opposed-phase gradient-echo images compared with in-phase images.
Favor Benign (Downgrade)
Absence of significant change in an observation size when measured at examinations 2 years or longer apart and in the absence of treatment. Size stability should be assessed between two examinations with measurements using the same sequence, phase, and plane.
Unequivocal spontaneous decrease in size of an observation over time unattributable to artifact, measurement error, technique differences, or resorption of hemorrhage.
Temporal pattern in which enhancement eventually reaches and then matches that of the blood pool (ie, enhancement similar to that of arterial structures in the arterial phase and the portal vein or IVC in the PVP, delayed phase, transitional phase, and HBP).
Vessels traversing an observation without displacement, deformation, or other alteration.
Excess iron in a mass relative to that in background liver. At gradient-echo imaging, iron-rich nodules show decreased signal intensity on images with longer echo time (ie, on the in-phase images) owing to shortening of transverse relaxation constants by the superparamagnetic effect of iron.
Signal intensity of an observation on T2-weighted images markedly higher than that of the liver and similar to that of the bile ducts and other fluid-filled structures.
Signal intensity of an observation in the HBP (20 minutes after injection of gadoxetate disodium, Eovist) is nearly identical to that of the background liver.