LI-RADS and transplantation: challenges and controversies


Patients with early stage hepatocellular carcinoma (HCC) can be cured by liver transplantation. HCC imaging features on CT or MRI are specific enough to allow for definitive diagnosis and treatment without the need of confirmatory biopsy. When applied to the appropriate at-risk population the Liver Imaging Reporting and Data System (LI-RADS) imaging criteria achieve high specificity and positive predictive value for the diagnosis of HCC. The Organ Procurement and Transplantation Network (OPTN) is the United States organization that aims to assure the adequate and fair distribution of livers across candidates. Given the importance of fair organ allocation, OPTN also provides stringent imaging criteria for the diagnosis of HCC aiming to avoid false positive diagnosis. Although most imaging criteria are identical for both systems, discrepancies between LI-RADS and the current OPTN classification system for HCC diagnosis exists. Main differences include, but are not limited to, the binary approach of OPTN to classify lesions as HCC or not, versus the probabilistic algorithmic approach of LI-RADS, technical and interpretation considerations, and the approach towards treated lesions. The purpose of this article is to highlight the similarities and discrepancies between LI-RADS and the current OPTN criteria for HCC diagnosis and the implications that these differences may have on the management of patients who are transplant candidates.

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Fig. 1
Fig. 2

[adapted from (17) Elsayes KM, Kielar AZ, Chernyak V, Morshid A, Furlan A, Masch WR, et al. LI-RADS: a conceptual and historical review from its beginning to its recent integration into AASLD clinical practice guidance. J Hepatocell Carcinoma. 2019 Feb 5;6:49–69]

Fig. 3
Fig. 4

[adapted from (66) Kielar A, Fowler KJ, Lewis S, Yaghmai V, Miller FH, Yarmohammadi H, et al. Locoregional therapies for hepatocellular carcinoma and the new LI-RADS treatment response algorithm. Abdom Radiol (NY). 2018 Jan;43(1):218–230]



Hepatocellular Carcinoma


Liver transplantation


United Network for Organ Sharing


Organ Procurement and Transplantation Network


Model for End-Stage Liver Disease


Liver Imaging Reporting and Data System


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Correspondence to Guilherme M. Cunha.

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Cunha, G.M., Tamayo-Murillo, D.E. & Fowler, K.J. LI-RADS and transplantation: challenges and controversies. Abdom Radiol 46, 29–42 (2021).

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  • Hepatocellular carcinoma
  • Imaging diagnosis
  • Staging
  • Transplantation