Diagnostic value of using ancillary features to upgrade LI-RADS from LR-4 to LR-5 observations in the LI-RADS system: a systematic review

Abstract Background The purpose of this study is to evaluate the performance and capability of ancillary features to upgrade LR-4 to LR-5 for the hepatocellular carcinoma diagnosis. Upgrading a liver lesion from LI-RADS category LR-4 (probably HCC) to LR-5 (definitely HCC) enhances diagnostic confidence by confirming a definitive noninvasive diagnosis of HCC. This upgrade facilitates prompt initiation of curative or locoregional treatments without the need for biopsy, aligns patients with eligibility criteria for liver transplantation under established guidelines, and supports timely inclusion in treatment planning pathways. Transitioning from LR-4 to LR-5 also shifts clinical management from surveillance to active treatment, ultimately aiming to improve patient outcomes. Main body of the abstract Up to 2025, PubMed, Scopus, Web of Science, and Embase were searched comprehensively. All studies discussing the role of ancillary features in upgrading LI-RADS from 4 to 5 were included except review articles, articles published in a language other than English, and case reports or series of cases. A literature review and data extraction were performed by two independent reviewers. A checklist for diagnostic studies developed by The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) scale was used to assess sources of bias. This systematic review included seven studies. Conclusions The current systematic review reveals the good performance of ancillary features in combination with major features for upgrading LR-4 lesions to LR-5 so that these features provide high sensitivity while maintaining acceptable specificity for diagnosing hepatocellular carcinoma. We strongly recommend the routine integration of ancillary features in LI-RADS assessments to improve diagnostic accuracy and guide appropriate management, which ultimately results in better patient’s outcomes.