Agnès Rode

Small nodule detection in cirrhotic livers : Evaluation with US, spiral CT, and MRI and correlation with Pathologic examination of explanted liver

Purpose The purpose of this work was to evaluate the detection and characterization of nodules ≥8 mm and small hepatocellular carcinomas (HCCs) in liver cirrhosis. Method Pathologic examination and results of US, helical CT, and dynamic MRI with gadolinium were compared after orthotopic liver transplantation (OLT) of 43 cirrhotic patients. Nodules were classified as macroregenerative nodules (MRNs), borderline nodules (BNs), and HCC. Results Pathologic examination classified 69 nodules: 50 MRNs, 6 BNs, and 13 HCCs. Sensitivities of MRN, BN, and HCC detection were, respectively, for US imaging 2% (1/50), 33.3% (2/6), and 46.2% (6/13); for helical CT 2% (1/50), 50% (3/6), and 53.8% (7/13); and for MRI 42% (21/50), 50% (3/6), and 76.9% (10/13). MRI detected 21 MRNs. They presented on T1/T2-weighted images as hyperintense/hypointense (n = 8), hyperintense/isointense (n = 7), hypointense/hypointense (n = 4), hypointense/isointense (n = 1), and hypointense depicted only on echo planar imaging (n = 1). The three detected BNs were hyperintense/hypointense nodules. The 10 detected HCCs appeared hyperintense/isointense (n = 7), hyperintense/hypointense (n = 2), and hypointense/isointense (n = 1). None of the MRNs but eight HCCs and one BN were enhanced after gadolinium injection. Conclusion Contrast-enhanced MRI is the most sensitive technique for detecting liver nodules. No MR signal intensity pattern characteristic of small HCCs enables differentiation from benign nodules, however. Gadolinium enhancement is the most sensitive and specific characteristic of HCC.

Anatomical variations of the hepatic artery: study of 932 cases in liver transplantation

The aim of this study was to identify and to classify anatomical hepatic artery (HA) variations concerning 932 HA dissections in liver transplantation (LT). Normal HA distribution was found in 68.1%. Variations of HA were detected in 31.9% and were divided into three groups describing 48 common hepatic artery (CHA) anomalies, 236 left or right hepatic artery (RHA) anomalies and 13 rare variations including one case of RHA stemmed from the inferior mesenteric artery and one case of normal CHA passed behind the portal vein. The authors propose a modified classification for HA anomalies which are based on the origin of the hepatic arterial supply (either by the CHA as the only source of the arterial vascularization or by additional or replaced right and left arteries) in order to improve management of liver disease thus as in LT.

Hepatic outflow study after piggyback liver transplantation

BACKGROUND Hepatic vein outflow is discussed in liver transplantation after preservation of recipient retrohepatic vena cava. The aim of this study was to compare two methods of suparahepatic caval anastomosis. METHODS From January 1993 to January 1995, 81 patients received 88 liver transplants because of liver cirrhosis (n = 70), acute liver failure (n = 7), elective retransplantation after hepatic artery thrombosis (n = 2), giant hemangioma (n = 1), and combined liver-small bowel transplantation (n = 1). Seven patients underwent urgent retransplantation, 12 had preoperative transjugular intrahepatic portocaval stent, and 11 had portal vein thrombosis. Five patients required extracorporeal venous shunt. A total of 82 liver transplantations had preservation of RHVC, and 70 patients received temporary end-to-side portacaval shunt. Suprahepatic caval anastomosis was carried out in 52 patients (group 1) between the graft suprahepatic vena cava and the ostia of recipient left and median hepatic veins. Thirty patients (group 2) had associated 3 cm vertical cavotomy with partial clamping of RHVC. In the fourth postoperative month 20 patients from each group had pressure and gradient measurement made among the hepatic veins, right atria, and the RHVC. RESULTS Mean pressure gradient between hepatic veins and right atria was 0.75 +/- 0.49 mm Hg in group 1 and 2.06 +/- 0.85 mm Hg in group 2. Between the RHVC and the right atria it was 0.63 +/- 0.5 mm Hg in group 1 and 2.22 +/- 1.29 mm Hg in group 2. A pressure gradient higher than 3 mm Hg was considered hemodynamically significant. This pressure gradient was found between the hepatic veins and right atria in 10% of patients in group 1 and 40% of patients in group 2 (p = 0.03) and between the RHVC and right atria in 15% of patients in group 1 and 30% of patients in group 2 (p = 0.3). CONCLUSIONS Preservation of the recipient RHVC with recipient caval anastomosis at the ostia of the median and left hepatic veins is a reliable technique without any hepatic venous outflow alteration. Associated cavotomy is not necessary.

Diagnostic value and tolerance of Lipiodol-computed tomography for the detection of small hepatocellular carcinoma : correlation with pathologic examination of explanted livers

BACKGROUND/AIMS This study aimed to assess the tolerance and the real sensitivity of Lipiodol-computed tomography in the detection of small hepatocellular carcinoma by comparison with pathological examination of the explanted livers. METHODS Seventy-two patients with cirrhosis (Child A=8, B=36, C=28) awaiting orthotopic liver transplantation underwent Lipiodol-computed tomography to determine the presence, number and location of possible hepatocellular carcinoma nodules. Before liver transplantation six patients had a presumed single hepatocellular carcinoma diagnosed by biopsy. Liver transplantation was performed a mean of 6 months after Lipiodol-computed tomography. Explanted livers were sectioned at 0.8- to 1-cm intervals. Lipiodol-computed tomography staging and pathologic findings were compared. RESULTS Pathologic studies showed 24 hepatocellular carcinoma nodules (diameter, 2-42 mm) not diagnosed before liver transplantation in 14 of the 72 livers. Lipiodol-computed tomography detected 6 of these 24 nodules, but none of the daughter lesions (n=9) in the six patients with a presumed single hepatocellular carcinoma. Lesion-by-lesion analysis revealed a sensitivity of 37%. Lipiodol-computed tomography falsely detected three additional nodules not confirmed by pathologic examination (1 haemangioma, 2 nondysplastic regenerating nodules). One Child C patient developed variceal bleeding within 2 days after injection of Lipiodol. CONCLUSIONS Tolerance of this procedure was satisfactory, even in Child C patients. Lipiodol-computed tomography has a low sensitivity in the detection of small hapatocellular carcinoma. These results must be considered when liver resection or liver transplantation is proposed for the treatment of hepatocellular carcinoma.

Characterization of hepatocellular carcinoma and colorectal liver metastasis by means of perfusion MRI.

To characterize and compare hepatocellular carcinoma and liver metastases of colorectal metastatic cancer (CMC) by means of quantitative liver perfusion MRI.

Impact of diffusion-weighted MR imaging on the characterization of small hepatocellular carcinoma in the cirrhotic liver.

PURPOSE The purpose of this study was to determine whether or not adding diffusion-weighted magnetic resonance imaging (DWI) to conventional magnetic resonance (MR) imaging sequences improves the characterization of small hepatocellular carcinoma (HCC) (≤2 cm) in the setting of cirrhotic liver compared to conventional sequences alone. MATERIALS AND METHODS A total of 62 cirrhotic liver patients with 82 nodules smaller than 2 cm in diameter were enrolled, and all lesions were pathologically confirmed. For the first reading session, which included precontrast T1- and T2-weighted images and T1 dynamic contrast-enhanced images, preindicated lesions by a study coordinator were characterized by two radiologists. They determined the confidence levels in consensus for the presence of small HCC into four grades. In another session, respiratory-triggered diffusion-weighted MR images (b factor=50, 400 and 800 s/mm(2)) were added to the previously reviewed images, and the same two radiologists again determined the confidence levels. The diagnostic performance of the combined DWI-conventional sequences set and the conventional sequences alone set was evaluated using receiver operating characteristic curves. Sensitivity and specificity values for characterizing small HCCs were also calculated. RESULTS The area under the receiver operating characteristic curve for the second interpretation session (0.86) was significantly higher (P=.038) than that of the first session (0.76). The sensitivity was significantly increased from 75.7% to 87.8% by adding DWI to the conventional sequences (P=.015). No significant differences were observed for specificity values. CONCLUSION Adding DWI to conventional imaging modalities improves the diagnosis of small HCCs in the cirrhotic liver in terms of diagnostic performance and sensitivity by increasing reader confidence.

Comparison of no-touch multi-bipolar vs. monopolar radiofrequency ablation for small HCC

BACKGROUND & AIMS The primary aim of this study was to compare the rate of global radiofrequency ablation (RFA) failure between monopolar RFA (MonoRFA) vs. no-touch multi-bipolar RFA (NTmbpRFA) for small hepatocellular carcinoma (HCC) ⩽5cm in cirrhotic patients. METHODS A total of 362 cirrhotic patients were included retrospectively across four French centres (181 per treatment group). Global RFA failure (primary RFA failure or local tumour progression) was analysed using the Kaplan-Meier method after coarsened exact matching. Cox regression models were used to identify factors associated with global RFA failure and overall survival (OS). RESULTS Patients were well matched according to tumour size (⩽30/>30mm); tumour number (one/several); tumour location (subcapsular and near large vessel); serum AFP (<10; 10-100; >100ng/ml); Child-Pugh score (A/B) and platelet count (</⩾100G/L), p=1 for all. One case of perioperative mortality was observed in the NTmbpRFA group and the rate of major complications was 7.2% in both groups (p=1). The cumulative rates of global RFA failure at 1, 3 and 5years were respectively 13.3%, 31% and 36.7% for MonoRFA vs. 0.02%, 7.9% and 9.2% for NTmbpRFA, p<0.001. Monopolar RFA, tumour size >30mm and HCC near large vessel were independent factors associated with global RFA failure. Five-year OS was 37.2% following MonoRFA vs. 46.4% following NTmbpRFA p=0.378. CONCLUSIONS This large multicentre case-matched study showed that NTmbpRFA provided better primary RFA success and sustained local tumour response without increasing severe complications rates, for HCC ⩽5cm. LAY SUMMARY Using no-touch multi-bipolar radiofrequency ablation for hepatocellular carcinoma ⩽5cm provide a better sustained local tumour control compared to monopolar radiofrequency ablation.

Hepatocellular adenoma: evaluation with contrast-enhanced ultrasound and MRI and correlation with pathologic and phenotypic classification in 26 lesions.

Purpose. To review the contrast-enhanced ultrasonographic (CEUS) and magnetic resonance (MR) imaging findings in 25 patients with 26 hepatocellular adenomas (HCAs) and to compare imaging features with histopathologic results from resected specimen considering the new immunophenotypical classification. Material and Methods. Two abdominal radiologists reviewed retrospectively CEUS cineloops and MR images in 26 HCA. All pathological specimens were reviewed and classified into four subgroups (steatotic or HNF 1α mutated, inflammatory, atypical or β-catenin mutated, and unspecified). Inflammatory infiltrates were scored, steatosis, and telangiectasia semiquantitatively evaluated. Results. CEUS and MRI features are well correlated: among the 16 inflammatory HCA, 7/16 presented typical imaging features: hypersignal T2, strong arterial enhancement with a centripetal filling, persistent on delayed phase. 6 HCA were classified as steatotic with typical imaging features: a drop out signal, slight arterial enhancement, vanishing on late phase. Four HCA were classified as atypical with an HCC developed in one. Five lesions displayed important steatosis (>50%) without belonging to the HNF1α group. Conclusion. In half cases, inflammatory HCA have specific imaging features well correlated with the amount of telangiectasia and inflammatory infiltrates. An HCA with important amount of steatosis noticed on chemical shift images does not always belong to the HNF1α group.

Transjugular intra-hepatic portosystemic shunt for refractory variceal bleeding.

Background The most dramatic complication of portal hypertension in cirrhotic patients is oesophageal variceal bleeding. Moreover, patients with bleeding unresponsive to medical and endoscopic treatment have a poor prognosis. Objective The aim of this study was to evaluate the efficacy of early transjugular intra-hepatic portosystemic shunt (TIPS) in patients with refractory variceal bleeding. Patients and methods TIPS was performed for 28 patients (17 were stage Child C), successfully in 26. Variceal bleeding was controlled in all but one successfully stented patient. Results There was no mortality associated with the procedure. The two patients with a failure of TIPS insertion died of persistent bleeding in the first 48 h after failed TIPS. The 40-day mortality rate was 25%. Five patients died (one from persistent bleeding from gastric varices and four from multi-organ failure). Using multivariate analysis, the only independent factor associated with early mortality was the total bilirubin value. Fifteen surviving patients were listed for liver transplantation: four deaths occurred, eight patients were transplanted in the 6 months after TIPS and three are still waiting. Among the six patients who survived but were ineligible for transplantation, two died and four are still alive. Two episodes of early rebleeding and eight of late rebleeding occurred. Actuarial survival was 75% at one year and 52% at two years. Conclusions Early TIPS is an effective rescue therapy for controlling refractory variceal bleeding.

Direct-acting antiviral therapy decreases hepatocellular carcinoma recurrence rate in cirrhotic patients with chronic hepatitis C

Arrival of direct‐acting antiviral agents against hepatitis C virus with high‐sustained virological response rates and very few side effects has drastically changed the management of hepatitis C virus infection. The impact of direct‐acting antiviral exposure on hepatocellular carcinoma recurrence after a first remission in patients with advanced fibrosis remains to be clarified.