# Assessment of intrahepatic cholangiocarcinoma with LI-RADS in the high-risk population: MRI diagnosis and postoperative survival

## TL;DR

This study evaluates how the LI-RADS system helps diagnose and predict outcomes for intrahepatic cholangiocarcinoma in high-risk patients using MRI and survival data.

## Contribution

The study shows that LI-RADS categories can independently predict postoperative survival in high-risk patients with iCCA or HCC.

## Key findings

- The LR-M category accurately classified most iCCAs with high sensitivity and specificity.
- LI-RADS category was independently associated with recurrence-free survival.
- Some iCCAs were miscategorized as HCC, but the LR-5 category remained highly specific for ruling out iCCA.

## Abstract

The precise impact of LI-RADS-defined risk factors on the diagnosis and prognosis of intrahepatic cholangiocarcinoma (iCCA) remains unclear.

To assess the value of LI-RADS categories and features for iCCA diagnosis, focusing on the diagnostic and prognostic implications of LI-RADS-defined risk factors.

Totally 214 high risk patients, including 107 surgically-confirmed solitary iCCAs and 107 hepatocellular carcinomas (HCC) from two centers were retrospectively enrolled. Clinical and MRI features based on LI-RADS v2018 were compared, and the performance of targetoid features for discriminating iCCA was evaluated. Recurrence-free survival (RFS) was compared across different pathologic diagnoses and LI-RADS categories. Multivariate Cox analysis was performed to identify the independent risk factors for RFS.

In the LI-RADS defined high-risk patients, iCCAs differed from HCCs in MRI manifestation. The LR-M category enabled the accurate classification of most iCCAs (89/107, 83.2%), achieving high sensitivity (83.2%), specificity (85.1%), and accuracy (84.1%). The optimal diagnostic performance for iCCA was achieved when at least one targetoid appearance was required for LR-M categorization (AUC = 0.828). Although 26.2% iCCAs presented at least one major feature and 15.0% iCCAs were miscategorized as probably or definitely HCC, only one iCCA case was categorized as LR-5. RFS varied according to both pathologic diagnosis (P = 0.030) and LI-RADS category (P = 0.028), with LI-RADS category demonstrating an independent association with RFS (HR = 1.736, P = 0.033).

In high-risk patients, iCCAs frequently exhibit HCC major features, leading to miscategorization as probable HCC. However, the LR-5 category remains highly specific for ruling out iCCA. Furthermore, in high-risk patients with solitary resected iCCA or HCC, LI-RADS category enables the prediction of postsurgical prognosis independently from pathological diagnosis.

The online version contains supplementary material available at 10.1186/s40644-025-00860-6.