Advanced Ultrasound in Diagnosis and Therapy ›› 2025, Vol. 9 ›› Issue (4): 357-374.doi: 10.26599/AUDT.2025.250102
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Xu Junmeia, Tahmasebi Aylina, Mohammed Amra, Pour Bahareh Kiana, Liu Ji-Bina, Eisenbrey John R.a,*(
)
Received:2025-09-25
Revised:2025-10-13
Accepted:2025-10-21
Online:2025-12-30
Published:2025-11-06
Contact:
Department of Radiology, Thomas Jefferson University, 132 South 10th St, Philadelphia PA, USA (John R. Eisenbrey),e-mail: John.Eisenbrey@jefferson.edu (JR E).,
Xu Junmei, Tahmasebi Aylin, Mohammed Amr, Pour Bahareh Kian, Liu Ji-Bin, Eisenbrey John R.. Contrast-enhanced Ultrasound LI-RADS for Nonradiation Treatment Response Assessment in Liver Tumor: A Pictorial Review Based on LR-TR v2024. Advanced Ultrasound in Diagnosis and Therapy, 2025, 9(4): 357-374.
Figure 1
ACR CEUS LI-RADS categorization (A) [13] and diagnostic algorithm implementation (B) [14]."
Figure 2
ACR CEUS LR-TR categories v2024 [27]. This flowchart illustrates the stepwise assessment of both intralesional and perilesional tumor viability using CEUS imaging criteria. Color-coded boxes indicate the final LR-TR categories, including green=Nonviable, yellow=Equivocal, and red=Viable. The algorithm incorporates a tiebreaking rule and reconciliation process to assign a single TRA category. Applicable for treated lesions after transarterial embolization (cTACE/DEB-TACE/TAE) and percutaneous ablation (RFA/MWA/PEI)."
Figure 3
Flowchart in NLT with CEUS assessment covered by LR-TR v2024. CEUS, contrast-enhanced ultrasound; LR-TR, liver imaging reporting and data system treatment response algorithm; NLT, nonradiation locoregional therapy; cTACE, conventional transarterial chemoembolization; DEB-TACE, drug-eluting bead transarterial chemoembolization; TAE, bland transarterial embolization; RFA, radiofrequency ablation; MWA, microwave ablation; PEI, percutaneous ethanol injection; HCC, hepatocellular carcinoma; BCLC-B, Barcelona Clinic Liver Cancer stage B."
Figure 4
LR-TR Nonviable. Example of a nonviable tumor 14 days after TACE. (A) B-mode image shows two heterogeneous hyperechoic lesions (thick arrow) with irregular shape, measuring 17 mm and 18 mm in segment VI; (B-E) CEUS shows no intralesional enhancement with perilesional enhancement identical to the surrounding liver parenchyma in all phases. Findings are consistent with LR-TR Nonviable."
Figure 5
LR-TR Equivocal. Example of a treated tumor 36 days after TACE. (A) B-mode image shows a hypoechoic lesion (thick arrow) with ill-defined margins, measuring 36 mm in segment V; (B-C) CEUS shows intralesional ringlike hypoenhancement with early mild washout in the arterial phase; (D) The lesion shows ringlike hypoenhancement with marked washout in the portal venous phase; (E) The lesion shows complete washout in the late phase. Perilesional enhancement remains identical to the surrounding liver parenchyma throughout all phases. Findings are consistent with LR-TR Equivocal."
Figure 6
LR-TR Equivocal. Example of a treated tumor 16 days after TACE. (A) B-mode image a heterogeneous hyperechoic lesion (thick arrow) with well-defined margins, measuring 32 mm in segment VIII; (B-C) CEUS shows no intralesional enhancement with perilesional hyperenhancement in the arterial phase; (D-E) The lesion remains no intralesional enhancement with perilesional identical to the surrounding liver parenchyma without washout in the portal venous and late phases. Findings are consistent with LR-TR Equivocal."
Figure 7
LR-TR Equivocal. Example of a treated tumor 22 days after TACE. (A) B-mode image shows a hyperechoic lesion (thick arrow) with well-defined margins, measuring 47 mm in segment VIII; (B-C) CEUS shows intralesional hypoenhancement with nodular protrusions along the margin and early marked washout during the arterial phase; (D-E) The lesion shows complete washout in the portal venous and late phases. Perilesional APHE persists without washout throughout all phases (thin arrow). Findings are consistent with LR-TR Equivocal."
Figure 8
LR-TR Viable. Example of a treated tumor 36 days after TACE. (A) B-mode image shows a heterogeneous echogenic lesion (thick arrow) with irregular shape, measuring 115 mm in segment II and III; (B-C) CEUS shows intralesional heterogeneous hyperenhancement during the arterial phase; (D-E) The lesion shows partial mild washout in the portal venous and late phases. Perilesional enhancement remains identical to the surrounding liver parenchyma throughout all phases. Findings are consistent with LR-TR Viable."
Figure 9
LR-TR Viable. Example of a treated tumor 13 days after TACE. (A) B-mode image shows a hyperechoic lesion (thick arrow) with well-defined margins, measuring 46 mm in segment VI; (B-C) CEUS shows intralesional heterogeneous hyperenhancement and early mild washout during the arterial phase; (D-E) The lesion shows marked washout in the portal venous and late phases. Perilesional enhancement remains identical to the surrounding liver parenchyma throughout all phases. Findings are consistent with LR-TR Viable."
Figure 10
LR-TR Viable. A 56-year-old male with HCC, 1 year after RF ablation. (A) B-mode image shows a heterogeneous mildly hypoechoic lesion (thick arrow) with poor-defined margins in segment VII; (B) Post-treatment CEUS shows intralesional heterogeneous hyperenhancement; (C) The lesion shows mild washout in the portal venous phase; (D) The lesion shows marked washout in the late phase. Perilesional enhancement remains identical to the surrounding liver parenchyma throughout all phases. Findings are consistent with LR-TR Viable. (This case and figures were contributed by Dr. Qiang Lu from Huaxi Hospital of Sichuan University)"
Figure 11
LR-TR Viable. Example of a treated tumor 49 days after TACE. (A) B-mode image shows a hypoechoic lesion (thick arrow) with well-defined margins, measuring 22 mm in segment IV; (B-C) CEUS shows intralesional heterogeneous hyperenhancement with early marked washout and perilesional enhancement identical to the surrounding liver parenchyma during the arterial phase; (D) The lesion shows marked washout with perilesional mild hyperenhancement in the portal venous phase; (E) The lesion shows marked washout with partial perilesional mild washout in late phase. Findings are consistent with LR-TR Viable."
Figure 12
LR-TR Viable. Example of a treated tumor 55 days after TACE. (A) B-mode image shows a hypoechoic lesion (thick arrow) with well-defined margins, measuring 52 mm in segment III; (B) CEUS shows intralesional hyperenhancement with nodular protrusions along the margin (arrowhead) and perilesional hyperenhancement (thin arrow) during the arterial phase; (C-D) The lesion shows intralesional (arrowhead) and perilesional isoenhancement (thin arrow) without washout in the portal venous and late phases. Findings are consistent with LR-TR Viable."
Figure 13
LR-TR Viable. Example of a treated tumor 46 days after TACE. (A) B-mode image shows a hypoechoic lesion (thick arrow) with ill-defined margins, measuring 22 mm in segment VIII; (B-C) CEUS shows intralesional hyperenhancement with early marked washout and perilesional hyperenhancement during the arterial phase; (D-E) The lesion shows intralesional marked washout and perilesional partial mild washout (thin arrow) in the portal venous and late phases. Findings are consistent with LR-TR Viable."
Figure 14
LR-TR Viable. Example of a treated tumor 16 days after TACE. (A) B-mode image shows a cystic-solid heterogeneous echogenic lesion with a peripheral hypoechoic band (thick arrow), measuring 71 mm in segment V and VI; (B-C) CEUS shows intralesional partial hyperenhancement (arrowhead) with perilesional hyperenhancement (thin arrow) during the arterial phase; (D-E) The lesion shows intralesional marked washout (arrowhead) and perilesional partial marked washout (thin arrow) in the portal venous and late phases. Findings are consistent with LR-TR Viable."
Figure 15
LR-TR Viable. Example of a treated tumor 29 days after TACE. (A) B-mode image shows a heterogeneous mildly hypoechogenic lesion with well-defined margins (thick arrow), measuring 85 mm in segment II and III; (B-C) CEUS shows partial intralesional hyperenhancement with perilesional hyperenhancement (thin arrow) during the arterial phase; (D-E) The lesion shows intralesional and perilesional (thin arrow) gradual washout in the portal venous and late phases. Findings are consistent with LR-TR Viable."
Figure 16
LR-TR Viable. Example of a treated tumor 15 days after TACE. (A) B-mode image shows slightly hyperechoic lesion with well-defined margins (thick arrow), measuring 22 mm in segment IV; (B-D) CEUS shows perilesional hyperenhancement (thin arrow) during the arterial and portal venous phases; (E) The lesion shows perilesional marked washout (thin arrow) in the late phase. No intralesional enhancement throughout all phases. Findings are consistent with LR-TR Viable."
Figure 17
LR-TR Nonevaluable. Example of a treated tumor 22 days after TACE. (A) B-mode image shows a slightly hyperechoic target lesion measuring 24 mm in segment IV; (B) CEUS shows mild hypoenhancement of the lesion at 14 s during the arterial phase; (C) A non enhancing lesion measuring 16 mm on US distinct from the target lesion is observed at 24 s of the arterial phase; (D) The lesion is not visualized in the portal venous phase. This finding represents inadequate arterial-phase coverage and is defined as a nonevaluable lesion."
Figure 18
Artifact. Example of a treated tumor 101 days after TACE. (A) B-mode image shows two slightly hyperechoic lesions with scattered punctate calcifications (short arrow), measuring approximately 38 mm and 32 mm in segment VI and VII; (B-E) CEUS shows persistent intralesional flocculent hypoenhancement with punctate hyper- or isoenhancement (short arrow) throughout all phases, without evidence of contrast diffusion. This finding is considered an artifact."
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