Giuseppe Brancatelli

Budd-Chiari Syndrome: Spectrum of Imaging Findings

OBJECTIVE The objective of our study was to illustrate the imaging findings of Budd-Chiari syndrome, including CT, MRI, sonographic, and angiographic findings. CONCLUSION The key imaging findings in Budd-Chiari syndrome are occlusion of the hepatic veins, inferior vena cava, or both; caudate lobe enlargement; inhomogeneous liver enhancement; and the presence of intrahepatic collateral vessels and hypervascular nodules. Awareness of these findings is important for early diagnosis and appropriate treatment.

Peliosis Hepatis: Spectrum of Imaging Findings

OBJECTIVE It is important to recognize the imaging characteristics of peliosis hepatis because peliotic lesions may mimic several different types of focal hepatic lesions CONCLUSION We illustrate the spectrum of imaging findings of peliosis hepatis, including sonography, CT, MR, and angiography.

Three-dimensional multislice helical computed tomography with the volume rendering technique in the detection of vascular complications after liver transplantation.

Background. Hepatic artery stenosis and thrombosis are common complications in liver transplant patients. Digital subtraction angiography (DSA) has served as the gold standard to make this diagnosis. More recently, three-dimensional helical computed tomographic arteriography (3D CTA) with maximum intensity projection and shaded surface display techniques has been compared with DSA. The purpose of this study was to determine whether 3D CTA with the volume rendering technique is a useful and accurate tool in the detection of vascular complications after liver transplantation. Methods. Thirty-five consecutive liver transplant patients underwent 3D CTA with volume rendering technique. The standard of reference was DSA for 20 patients and imaging and clinical follow-up for 15 patients. Two blinded reviewers evaluated the axial and 3D CTA images in consensus. Results. 3D CTA with volume rendering technique detected 10 hepatic artery stenoses, six hepatic artery thromboses, two hepatic artery pseudoaneurysms, two splenic artery aneurysms, two portal vein stenoses, and four redundant hepatic arteries. In one case computed tomography (CT) detected a moderate hepatic artery stenosis, while conventional angiography showed a normal artery. The sensitivity of CT for detecting vascular lesions was 100%, specificity was 89% (8 of 9), accuracy was 95% (19 of 20), positive predictive value was 92% (11 of 12), and negative predictive value was 100% (8 of 8). Conclusions. 3D CTA is a useful and accurate noninvasive technique for detection of vascular complications in liver transplant patients.

Percutaneous radiofrequency ablation for hepatocellular carcinoma before liver transplantation : A prospective study with histopathologic comparison

OBJECTIVE The aims of this study were to determine the feasibility and efficacy of percutaneous radiofrequency ablation in patients with hepatocellular carcinoma waiting for liver transplantation and to compare the radiologic and pathologic findings. SUBJECTS AND METHODS Twenty-six patients with 35 hepatocellular carcinomas were addressed for transplantation. Complications of the procedures were recorded. Primary and secondary technique effectiveness and causes of exclusion from the waiting list were assessed. After transplantation, tumor recurrence was evaluated for at least 1 year in all patients. Radiologic-pathologic comparison of the explant was performed. RESULTS Percutaneous radiofrequency ablation was performed in 21 (81%) patients for 28 tumors. Both minor and major complications occurred in three patients (10% each per session). The rates of primary technique effectiveness, secondary technique effectiveness for percutaneous radiofrequency ablation alone (seven tumors), and combined percutaneous radiofrequency ablation and transcatheter arterial chemoembolization (three tumors) were 56%, 76%, and 86%, respectively. After a mean follow-up of 11.9 months, 16 patients (76%) received transplants, whereas five patients were excluded from the waiting list because of distant tumor progression (n =3, 14%) or other causes (n = 2, 10%). After transplantation, tumor recurred in one (6%) of 16 patients. Histopathologic examinations were performed for 13 (81%) of 16 patients and showed complete necrosis and satellite nodules in, respectively, 12 (75%) and seven (44%) of 16 tumors. CONCLUSION Percutaneous radiofrequency ablation can be performed on hepatocellular carcinoma patients waiting for transplantation, allows most patients to undergo transplantation, and does not impair posttransplantation outcomes. The procedure produces complete necrosis of the treated tumor in most cases but is associated with a high rate of satellite nodules.

Natural history of untreatable hepatocellular carcinoma: A retrospective cohort study

AIM To investigate the clinical course of untreatable hepatocellular carcinoma (HCC) identified at any stage and to identify factors associated with mortality. METHODS From January 1999 to December 2010, 320 out of 825 consecutive patients with a diagnosis of HCC and not appropriate for curative or palliative treatments were followed and managed with supportive therapy. Cirrhosis was diagnosed by histological or clinical features and liver function was evaluated according to Child-Pugh score. The diagnosis of HCC was performed by Ultra-Sound guided biopsy or by multiphasic contrast-enhanced computed tomography or gadolinium-enhanced magnetic resonance imaging. Data were collected for each patient including all clinical, laboratory and imaging variables necessary for the outcome prediction staging systems considered. HCC staging was performed according Barcelona Clinic Liver Cancer (BCLC) and Cancer of the Liver Italian Program scores. Follow-up time was defined as the number of months from the diagnosis of HCC to death. Prognostic baseline variables were analyzed by multivariate Cox analysis to identify the independent predictors of survival. RESULTS Seventy-five per cent of patients had hepatitis C. Ascites was present in 169 patients (53%), while hepatic encephalopathy was present in 49 patients (15%). The Child-Pugh score was class A in 105 patients (33%), class B in 142 patients (44%), and class C in 73 patients (23%). One hundred patients (31%) had macroscopic vascular invasion and/or extra-hepatic spread of the tumor. A single lesion > 10 cm was observed in 34 patients (11%), while multinodular HCC was present in 189 patients (59%). Thirty nine patients (12%) were BCLC early (A) stage, 55 (17%) were BCLC intermediate (B) stage, 124 (39%) were BCLC advanced (C) stage, and 102 (32%) were end-stage BCLC (D). At the time of this analysis (July 2011), 28 (9%) patients were still alive. Six (2%) patients who were lost during follow-up were censored at the last visit. The overall median survival was 6.8 mo, and the 1-year survival was 32%. The 1-year survival according to BCLC classes was 100%, 79%, 12% and 0%, for BCLC A, B, C and D, respectively. There was a significant difference in survival between each BCLC class. The median survival of patients of BCLC stages A, B, C and D was 33, 17.4, 6.9, and 1.8 mo, respectively (P < 0.05 for comparison between stages). The median survival of Child-Pugh A, B and C classes were 9.8 mo (range 6.4-13), 6.1 (range 4.9-7.3), and 3.7 (range 1.5-6), respectively (P < 0.05 for comparison between stages). By univariate analysis, the variables significantly associated to an increased liklihood of mortality were Eastern Cooperative Oncology Group performance status (PS), presence of ascites, low level of albumin, elevated level of bilirubin, international normalized ratio (INR) and Log-[(α fetoprotein (AFP)]. At multivariate analysis, mortality was independently predicted by bad PS (P < 0.0001), high INR values (P = 0.0001) and elevated Log-(AFP) levels (P = 0.009). CONCLUSION This study confirms the heterogeneous behavior of untreated HCC. BCLC staging remains an important prognostic guide and may be important in decision-making for palliative treatment.

Predicting survival in patients with hepatocellular carcinoma treated by transarterial chemoembolisation

Aliment Pharmacol Ther 2011; 34: 196–204

Hepatic capsular retraction: spectrum of benign and malignant etiologies

AbstractRetraction of the liver capsule may be associated with a diverse spectrum of benign and malignant hepatic abnormalities. These include primary malignant neoplasms (epithelioid hemangioendothelioma, hepatocellular carcinoma, cholangiocarcinoma), secondary malignant neoplasms before and after treatment, and hepatic hemangioma, especially in cirrhotic livers. Other etiologies include confluent fibrosis in cirrhotic livers, chronic biliary obstruction (as can be seen in primary sclerosing cholangitis), and traumatic hepatic injury (iatrogenic and noniatrogenic). Because several recent studies have incorrectly reported hepatic capsular retraction as a specific sign of hepatic malignancy, it is important to understand the imaging appearances of the various etiologies associated with this sign to avoid misdiagnosis that may adversely affect the therapeutic approach.

CT and MR imaging evaluation of hepatic adenoma.

Abstract: Hepatic adenoma is a rare benign epithelial tumor that is usually encountered in young women who use oral contraceptives. It is clinically significant because of the risk of hemorrhage and of its low-grade malignancy potential. Adenomas usually are mildly hypervascular at contrast-enhanced CT and MR imaging, and heterogeneous due to the presence of hemorrhage, necrosis, calcifications and fat. The objective of our study was to illustrate the CT and MR imaging findings of hepatic adenoma.

Focal nodular hyperplasia: typical and atypical MRI findings with emphasis on the use of contrast media

Focal nodular hyperplasia is a benign hypervascular hepatic tumour, frequently detected in asymptomatic patients undergoing imaging studies for unrelated reasons. Magnetic resonance imaging (MRI) generally allows a confident differential diagnosis with other hypervascular liver lesions, either benign or malignant. In addition, due to the recent development of hepatospecific MRI contrast agents, MRI concomitantly enables functional and morphological information to be obtained, thus providing important clues for the detection and characterization of focal nodular hyperplasia lesions.

Hepatocellular-cholangiocarcinoma: helical computed tomography findings in 30 patients.

Objective To report the helical multiphasic computed tomography (CT) findings in 30 patients with hepatocellular-cholangiocarcinoma. Method We evaluated age, gender, tumor risk factors, serum tumor markers, symptoms, and tumor morphology and enhancement on helical multiphasic CT in 30 patients. Results Twenty-six of 30 patients (86%) were men. Patients had an age range of 27–78 years (mean = 58 years). Abdominal signs or symptoms were present in 21 of 30 patients, and 25 of 30 (83%) had chronic liver disease. Helical CT demonstrated a well-defined tumor in all patients with signs of malignancy such as hepatic hypervascularity (63%), biliary obstruction (17%), satellite lesions (40%), and lymphadenopathy (27%). Portions of the tumor were hyperattenuated on arterial-phase imaging and hypoattenuated on all other phases, whereas other portions showed delayed persistent enhancement, sometimes (27%) with hepatic capsular retraction, findings that have been reported to be characteristic of hepatocellular carcinoma and cholangiocarcinoma, respectively. Conclusion The diagnosis of hepatocellular-cholangiocarcinoma should be considered when a hepatic tumor has CT features of both hepatocellular carcinoma and cholangiocarcinoma. Radiologists should be aware of this tumor type so that the biopsy is performed properly to allow sufficient tissue sampling.