Beatrice L. Madrazo

Liver transplantation for hepatocellular carcinoma in the model for end-stage liver disease era.

BACKGROUND Since March 2002, the United Network for Organ Sharing liver allocation policy has given extra priority to patients with hepatocellular carcinoma (HCC) who meet specific medical criteria. This study reviews our experience with liver transplantation for HCC under this system. STUDY DESIGN Between March 2002 and April 2009, 244 patients with HCC underwent primary liver or liver-kidney transplantation under the current allocation system at the University of Miami. Outcomes including HCC recurrence-free survival (RFS) and patient survival (PS) were assessed retrospectively. Clinical variables that predicted outcomes were analyzed. RESULTS The median time from listing to transplantation was 48 days. The median follow-up was 27.4 months, with an observed recurrence rate of 10.7%. The RFS rates at 1, 3, and 5 years after transplantation were 96.0%, 89.0%, and 83.6%, respectively. The PS rates at 1, 3, and 5 years after transplantation were 86.3%, 71.5%, and 61.7%, respectively. Among patients diagnosed with T2 HCC, a trend toward improved RFS was observed for those who received preoperative ablative therapy; PS was similar (p > 0.05). Outcomes (RFS and PS) for patients with T3 HCC were similar to those in patients with T2 HCC (p > 0.05). Patients with an alpha-fetoprotein >100 ng/mL had an RFS that was inferior to that in patients with an alpha-fetoprotein < or =100 ng/mL (p < 0.0001). CONCLUSIONS Under the current allocation system, transplantation for HCC results in excellent RFS; PS depends on factors other than HCC; the value of preoperative ablative therapy for patients with T2 HCC is uncertain; the current criteria could be expanded to include selected patients with T3 HCC; and an elevated AFP level is associated with an increased risk of HCC recurrence after transplantation.

Innominate Artery Occlusive Disease: Sonographic Findings

OBJECTIVE The objective of this study was to report the sonographic abnormalities in a group of patients with angiographically proven innominate artery stenosis and occlusion. MATERIALS AND METHODS A review of all cerebrovascular sonograms at our institutions was undertaken to identify patients with complete or partial flow reversal in the right vertebral artery and reversal or midsystolic deceleration of flow in any one of the three major segments of the right carotid system (common, internal, or external carotid artery). The distribution and appearance of these abnormalities was evaluated, and the presence or absence of tardus-parvus waveforms was noted in any segment of the right carotid artery. Additionally, a left to right common carotid peak systolic velocity ratio (LCCA/RCCA) was calculated and compared to published normal values. All patients had correlative contrast or MR angiography. Correlation was made between the severity of stenosis as determined by angiographic images and waveform aberrations as well as the more objective LCCA/RCCA ratios. RESULTS Twelve patients were identified as having the abnormalities described above in the right vertebral and carotid arteries. Doppler waveforms from the right vertebral artery revealed that eight of the 12 patients had complete reversal of flow at rest. Bidirectional flow was found in the remaining four as manifested by the presence of marked midsystolic deceleration. In the carotid arteries, one patient had complete reversal of flow in all segments of the right carotid system. Waveforms with midsystolic deceleration were identified in at least one of the carotid arteries of the remaining 11 patients: common carotid artery (8/11 = 73%), internal carotid artery (10/11 = 91%), external carotid artery (3/11 = 27%). The average LCCA/RCCA was 3.1 with a range of 1.7 to 5.7 (normal = 0.7-1.3). All patients had severe innominate artery disease (from 70% to occlusion) by contrast angiography or MR angiography. There was no correlation between the angiographically determined degree of stenosis and the Doppler findings. CONCLUSION A distinctive pattern of hemodynamic alterations occurs in the right vertebral and carotid arteries of patients with severe innominate artery disease. Findings include reversed or bidirectional flow in the right vertebral artery, the presence of midsystolic deceleration in any of the branches of the right carotid system, and elevated LCCA/RCCA ratio.

Imaging Evaluation of the Inferior Vena Cava

The inferior vena cava (IVC) is an essential but often overlooked structure at abdominal imaging. It is associated with a wide variety of congenital and pathologic processes and can be a source of vital information for referring clinicians. Initial evaluation of the IVC is most likely to occur at computed tomography performed for another indication. Many routine abdominal imaging protocols may result in suboptimal evaluation of the IVC; however, techniques to assist in specific evaluation of the IVC can be used. In this article, the authors review the spectrum of IVC variants and pathologic processes and the relevant findings from magnetic resonance imaging, angiography, sonography, and positron emission tomography. Embryologic development of the IVC and examples of congenital IVC variants, such as absence, duplication, left-sided location, azygous or hemiazygous continuation, and web formation, are described. The authors detail IVC involvement in Wilms tumor, leiomyosarcoma, adrenal cortical carcinoma, testicular carcinoma, hepatocellular carcinoma, renal cell carcinoma, and other neoplasms, as well as postsurgical, traumatic, and infectious entities (including filter malposition, mesocaval shunt, and septic thrombophlebitis). The implications of these entities for patient treatment and instances in which specific details should be included in the dictated radiology report are highlighted. Furthermore, the common pitfalls of IVC imaging are discussed. The information provided in this review will allow radiologists to detect and accurately characterize IVC abnormalities to guide clinical decision making and improve patient care.

A Case of a Ruptured Sclerosing Liver Hemangioma

Hemangiomas are the most common benign tumors found in the liver, typically asymptomatic, solitary, and incidentally discovered. Although vascular in nature, they rarely bleed. We report a case of a 52-year-old woman with a previously stable hemangioma who presented to our hospital with signs and symptoms indicative of spontaneous rupture. We review the literature, focusing on diagnosis and management of liver hemangiomas.

Recurrent Cardiac Tamponade: An Unusual Presentation of Intrahepatic Cholangiocarcinoma.

A 48-year-old Egyptian woman presented with 8 months of sharp right upper chest pain and weight loss. She was discovered to have an enlarged cardiac silhouette on chest x-ray, and an echocardiogram revealed a large pericardial effusion with diastolic right atrial collapse. Pericardial window was done, and epithelial membrane antigen-positive neoplastic cells were identified in the pericardial fluid. Computed tomography showed a 6-cm hypermetabolic lesion on the liver segment IV, confirmed on biopsy to be a moderately differentiated adenocarcinoma consistent with intrahepatic cholangiocarcinoma.

Focal nodular hyperplasia within accessory liver: imaging findings at computed tomography and magnetic resonance imaging.

Accessory liver tissue is a rare but probably underreported entity that may harbor the same spectrum of pathology as that of the parent organ. The rarity and aberrant locations of such lesions cause confusion and may lower diagnostic confidence despite otherwise classic radiographic appearances. Focal nodular hyperplasia (FNH) is the most common non-hemangiomatous benign hepatic tumor, but to our knowledge, ectopic FNH has been reported only once before in the gastroenterology literature. We present the first case of ectopic FNH in the radiology literature.

Color Doppler ultrasound of the genitourinary tract

This paper discusses the role of color Doppler ultrasonography (CDU) as it applies to the genitourinary tract. CDU is beneficial in evaluating both the native and allograft kidney in the diagnosis of renal arterial and venous stenosis, arteriovenous fistulas, pseudoaneurysms, arterial and venous thrombosis, and in the characterization and staging of renal masses. CDU has redefined the role of ultrasonography in the evaluation of the scrotum as it relates to testicular torsion, inflammatory disorders and varicoceles. Early results of CDU in prostate carcinoma and benign prostate hypertrophy have shown limited success. Identifying and assessing the neurovascular bundle may have an impact on the staging of prostate carcinoma. It is hoped that the future addition of ultrasound contrast agents will further establish the role of color Doppler in the diagnosis of a variety of genitourinary diseases and disorders.