Staging and Follow-up of Primary Liver Cancer

Variant: 1 Adult. Primary liver cancer. Screening.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
MRI abdomen without and with IV contrast	May Be Appropriate	O
MRI abdomen without IV contrast	May Be Appropriate	O
CT abdomen with IV contrast multiphase	May Be Appropriate	☢☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
MRI abdomen without and with IV contrast with MRCP	Usually Not Appropriate	O
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate	O
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	Relative Radiation Level
MRI abdomen without and with IV contrast	Usually Appropriate	O
CT abdomen with IV contrast multiphase	Usually Appropriate	☢☢☢☢
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
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	O
US abdomen with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate	O
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	Relative Radiation Level
MRI abdomen without and with IV contrast	Usually Appropriate	O
CT abdomen with IV contrast multiphase	Usually Appropriate	☢☢☢☢
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
CT abdomen without and with IV contrast	May Be Appropriate	☢☢☢☢
US abdomen transabdominal	Usually Not Appropriate	O
US abdomen with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate	O
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	Relative Radiation Level
MRI abdomen without and with IV contrast	Usually Appropriate	O
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	O
US abdomen transabdominal	Usually Not Appropriate	O
US abdomen with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate	O
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	Relative Radiation Level
MRI abdomen without and with IV contrast	Usually Appropriate	O
CT abdomen with IV contrast multiphase	Usually Appropriate	☢☢☢☢
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
CT abdomen without and with IV contrast	May Be Appropriate	☢☢☢☢
US abdomen transabdominal	Usually Not Appropriate	O
US abdomen with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast with MRCP	Usually Not Appropriate	O
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	☢☢☢☢

Panel Members

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.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Discussion of Procedures by Variant

Variant 1: Adult. Primary liver cancer. Screening.

Variant 1: Adult. Primary liver cancer. Screening.
A. CT abdomen with IV contrast

Variant 1: Adult. Primary liver cancer. Screening.
B. CT abdomen with IV contrast multiphase

Variant 1: Adult. Primary liver cancer. Screening.
C. CT abdomen without and with IV contrast

Variant 1: Adult. Primary liver cancer. Screening.
D. CT abdomen without IV contrast

Variant 1: Adult. Primary liver cancer. Screening.
E. FDG-PET/CT skull base to mid-thigh

Variant 1: Adult. Primary liver cancer. Screening.
F. MRI abdomen without and with IV contrast

Variant 1: Adult. Primary liver cancer. Screening.
G. MRI abdomen without and with IV contrast with MRCP

Variant 1: Adult. Primary liver cancer. Screening.
H. MRI abdomen without IV contrast

Variant 1: Adult. Primary liver cancer. Screening.
I. MRI abdomen without IV contrast with MRCP

Variant 1: Adult. Primary liver cancer. Screening.
J. US abdomen

Variant 1: Adult. Primary liver cancer. Screening.
K. US abdomen with IV contrast

Variant 2: Adult. Primary liver cancer. Staging.

Variant 2: Adult. Primary liver cancer. Staging.
A. Bone scan whole body

Variant 2: Adult. Primary liver cancer. Staging.
B. CT abdomen and pelvis with IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
C. CT abdomen and pelvis without and with IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
D. CT abdomen and pelvis without IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
E. CT abdomen with IV contrast multiphase

Variant 2: Adult. Primary liver cancer. Staging.
F. CT chest with IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
G. CT chest without and with IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
H. CT chest without IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
I. CT pelvis with IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
J. CT pelvis without and with IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
K. CT pelvis without IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
L. FDG-PET/MRI skull base to mid-thigh

Variant 2: Adult. Primary liver cancer. Staging.
M. MRI abdomen without and with IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
N. MRI abdomen without and with IV contrast with MRCP

Variant 2: Adult. Primary liver cancer. Staging.
O. MRI abdomen without IV contrast

Variant 2: Adult. Primary liver cancer. Staging.
P. MRI abdomen without IV contrast with MRCP

Variant 2: Adult. Primary liver cancer. Staging.
Q. US abdomen transabdominal

Variant 2: Adult. Primary liver cancer. Staging.
R. US abdomen with IV contrast

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

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
A. CT abdomen with IV contrast

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
B. CT abdomen with IV contrast multiphase

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
C. CT abdomen without and with IV contrast

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
D. CT abdomen without IV contrast

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
E. FDG-PET/CT skull base to mid-thigh

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
F. MRI abdomen without and with IV contrast

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
G. MRI abdomen without and with IV contrast with MRCP

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
H. MRI abdomen without IV contrast

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
I. MRI abdomen without IV contrast with MRCP

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
J. US abdomen transabdominal

Variant 3: Adult. Primary liver cancer. Liver observations under active surveillance.
K. US abdomen with IV contrast

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

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
A. CT abdomen with IV contrast

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
B. CT abdomen with IV contrast multiphase

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
C. CT abdomen without and with IV contrast

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
D. CT abdomen without IV contrast

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
E. FDG-PET/CT skull base to mid-thigh

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
F. MRI abdomen without and with IV contrast

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
G. MRI abdomen without and with IV contrast with MRCP

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
H. MRI abdomen without IV contrast

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
I. MRI abdomen without IV contrast with MRCP

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

Variant 4: Adult. Primary liver cancer. Posttreatment evaluation after liver directed therapy or neoadjuvant chemotherapy.
K. US abdomen with IV contrast

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

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
A. CT abdomen with IV contrast

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
B. CT abdomen with IV contrast multiphase

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
C. CT abdomen without and with IV contrast

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
D. CT abdomen without IV contrast

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
E. FDG-PET/CT skull base to mid-thigh

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
F. MRI abdomen without and with IV contrast

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
G. MRI abdomen without and with IV contrast with MRCP

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
H. MRI abdomen without IV contrast

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
I. MRI abdomen without IV contrast with MRCP

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
J. US abdomen transabdominal

Variant 5: Adult. Primary liver cancer. Treated. Routine surveillance.
K. US abdomen with IV contrast

Summary of Highlights

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.

Gender Equality and Inclusivity Clause

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 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.

Relative Radiation Level Information

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.”

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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.