Long-Term Prognosis of Indeterminate Lesions in the Cirrhotic Liver: Insights from the LI-RADS 3 Neutral Category

Motivation: Managing LI-RADS 3 (LR-3) liver observations is challenging due to high variability in risk of progression to hepatocellular carcinoma (HCC), leading to difficulties in management and costly follow-up imaging. Goal(s): To identify imaging and clinical factors predicting LR-3 observation progression to LR-5. Approach: A retrospective chart review and multivariable competing risk analysis were conducted on patients with LR-3 observations, evaluating outcomes based on characteristics and clinical factors. Results: In 427 patients with 795 LR-3 lesions, 26% of lesions were upgraded and 58% downgraded. Size, ancillary features, prior liver directed therapy, and coexisting lesions were predictors of LR-3 upgrade. Impact: The findings including key predictors of LR-3 lesion progression such as post-treatment liver status, larger lesion size, co-existence of other LR3+ lesions, older age, and alcoholic cirrhosis —offer guidance for personalized surveillance intervals and efficient resource allocation for HCC-risk patients.