American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Hepatic Malignancy

Variant 1: Hepatocellular carcinoma: Solitary tumor <3 cm.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic chemotherapy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Resection Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Transplantation Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Chemical ablation May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Thermal ablation Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Stereotactic body radiotherapy (SBRT) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Transarterial embolization May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Selective internal radiation therapy (SIRT) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Hepatocellular carcinoma: Solitary tumor 5 cm.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic chemotherapy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Resection Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Transplantation Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Chemical ablation Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Thermal ablation May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Stereotactic body radiotherapy (SBRT) May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Transarterial embolization May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Selective internal radiation therapy (SIRT) Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) combined with thermal ablation Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Hepatocellular carcinoma: More than one tumor, at least one of the them >5 cm.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic chemotherapy May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Resection May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Transplantation Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Chemical ablation Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Thermal ablation Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Stereotactic body radiotherapy (SBRT) Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Transarterial embolization Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Selective internal radiation therapy (SIRT) Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) combined with thermal ablation May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Intrahepatic cholangiocarcinoma: 4 cm in diameter, no evidence of biliary obstruction.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic chemotherapy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Resection Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Transplantation May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Chemical ablation Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Thermal ablation May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Stereotactic body radiotherapy (SBRT) May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Transarterial embolization May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Selective internal radiation therapy (SIRT) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) combined with thermal ablation May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Long-acting octreotide Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Systemic chemotherapy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Resection Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Transplantation Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Chemical ablation Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Thermal ablation Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Stereotactic body radiotherapy (SBRT) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Transarterial embolization Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Selective internal radiation therapy (SIRT) Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) combined with thermal ablation May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Metastatic liver disease: Multifocal colorectal carcinoma (liver dominant or isolated).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic chemotherapy Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Resection May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Transplantation Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Chemical ablation Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Thermal ablation Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Stereotactic body radiotherapy (SBRT) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Hepatic arterial chemotherapy infusion May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Transarterial embolization May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Selective internal radiation therapy (SIRT) Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) combined with thermal ablation May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Solitary colorectal liver metastasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic chemotherapy Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Resection Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Transplantation Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Chemical ablation Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Thermal ablation Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Stereotactic body radiotherapy (SBRT) May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Hepatic arterial chemotherapy infusion May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Transarterial embolization May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Selective internal radiation therapy (SIRT) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Transarterial chemoembolization (TACE) combined with thermal ablation May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.