LI-RADS Ultrasound Surveillance Version 2024: Comparison With Version 2017 for Hepatocellular Carcinoma Detection and Risk Factors for Visualization Score C

Background: The LI-RADS Ultrasound Surveillance algorithm was updated in 2024, incorporating alpha-fetoprotein (AFP) and visualization score of VIS-C into management recommendations after nonpositive results. Objective: This study aimed to compare the diagnostic performance of LI-RADS Ultrasound Surveillance version 2017 (v2017) and version 2024 (v2024) for hepatocellular carcinoma (HCC) detection in at-risk patients and to identify predictors of VIS-C on follow-up surveillance examinations. Methods: This retrospective analysis included 407 patients (median age, 56 years; 230 male, 177 female) with cirrhosis who underwent rounds of semi-annual surveillance ultrasound as part of a prospective trial from November 2011 to December 2012. Two radiologists independently assigned ultrasound categories to round-1 examinations and visualization scores to round-1 and round-2 examinations; a third radiologist adjudicated disagreements. AFP was considered positive if elevated or increasing from pre-enrollment values, per v2024 criteria. Reference standard for HCC was positive biopsy or LR-5 observation on MRI. Diagnostic performance was compared between v2017 and v2024. Logistic regression analyses were performed to identify predictors of round-2 VIS-C, with attention to risk factors for VIS-C described in v2024. Results: HCC was diagnosed in 28 (6.9%) patients. For reader 1, v2024, compared with v2017, showed greater sensitivity for reader 1 (64.3% vs 42.9%, p=.03) and reader 2 (64.3% vs 39.3%, p=.02), and lower specificity for reader 1 (82.0% vs 92.6%, p<.001) and reader 2 (82.3% vs 92.9%, p<.001). All seven patients with HCC detected by v2024 but not v2017 using consensus assessments had an increasing AFP; two also had an elevated AFP. In 299 patients who underwent round-2 ultrasound after negative round-1 v2024 surveillance results, the only independent predictor of round-2 VIS-C was round-1 VIS-C (adjusted OR=21.0, [95% CI, 10.8-40.8], p<.001). In 88 of these patients with round-1 VIS-C, no v2024 risk factor showed significant univariable association with repeat VIS-C. Conclusion: Compared with v2017, LI-RADS Ultrasound Surveillance v2024 had higher sensitivity but lower specificity for HCC detection, related primarily to increasing, rather than elevated, AFP. The only independent predictor of VIS-C on subsequent ultrasound was initial VIS-C result. Clinical Impact: The findings support use of v2024 to improve HCC detection in at-risk patients.