J. Ashley Guthrie

Superparamagnetic iron oxide (SPIO) enhancement in the cirrhotic liver: a comparison of two doses of ferumoxides in patients with advanced disease

The aim of this study was to establish whether enhancement of the liver by the MRI contrast agent ferumoxides could be effectively achieved at a reduced dose of 7.5 micromol/kg in patients with advanced liver cirrhosis. Forty-two liver transplant candidates with end-stage cirrhosis underwent SPIO-enhanced MRI at 1.5T, using either 15 micromol/kg or 7.5 micromol/kg ferumoxides. The lower dose of ferumoxides was also used in 21 non-cirrhotic patients with colorectal liver metastases who acted as a control group. The percentage signal intensity loss (PSIL) after SPIO was measured in all patients, and in those patients with tumors the post-SPIO contrast-to-noise ratio (CNR) was measured. The median PSIL after SPIO in the high dose cirrhotic (HDLC), low dose non-cirrhotic (LDNC) and low dose cirrhotic (LDLC) patients was 86.3%, 74.6%, and 64.2% respectively. These differences were significant using the Mann-Whitney U test. Tumors were found in 8 patients in the high dose cirrhotic group, 9 in the low dose cirrhotic group, and all 21 of the control group. No significant differences were found between the CNR values after SPIO in the 3 groups (median values HDLC 15.1, LDNC 23.7, LDLC 19.5). In patients with late-stage cirrhosis the PSIL after SPIO was significantly less at 7.5 micromol/kg than at 15 micromol/kg, but both doses produced a substantial loss of signal. Lesion to liver CNR was not adversely affected by using the lower dose, so when imaging at 1.5T the authors would recommend using 7.5 micromol/kg in patients with liver cirrhosis.

Portal Vein Arterialization as a Salvage Procedure During Left Hepatic Trisectionectomy for Hilar Cholangiocarcinoma

d h c r s urgical resection for hilar cholangiocarcinoma (HCCA) emains a challenge for surgeons aiming to maximize paients’ chances for longterm survival. Since 1984, it has een accepted that standard bile duct resection should be ombined with an additional major hepatic resection to btain improved oncological clearance and increase quanity and quality of survival. This aggressive approach was nitially criticized, but today a consensus exists that perorming such extended resections is the treatment of choice or HCCA.There is strong evidence of better survival when 0 resection is performed. The extended resections that nable a better oncological clearance have become achievble as a result of the major advances in surgical techniques nd preoperative and postoperative care, which have reuced morbidity and mortality after major liver resection. Recent studies suggest that portal vein resection with econstruction can increase the chance for cure in some atients with advanced HCCA who were previously hought to have inoperable disease. Because perineual invasion correlates with poorer outcomes, theoretically, esection of the hepatic artery with its nerve sheath will uarantee an even better oncological result. Arterial resecion and reconstruction can be technically problematic and ometimes unachievable, with very few cases reported in he literature. To overcome this, a recent study rom Japan by Kondo and colleagues has reported 10 cases f portal vein arterialization (PVA) after hepatic artery reection for biliary cancers, with some accompanied by mall hepatic resections. We report a case where PVA was used with good result as salvage technique during left hepatic trisectionectomy nd a second case where the same technique was used to

Role of quantification of hepatic steatosis and future remnant volume in predicting hepatic dysfunction and complications after liver resection for colorectal metastases: a pilot study.

OBJECTIVES Accurate prediction of safe remnant liver volume to minimize complications following liver resection remains challenging. The aim of this study was to assess whether quantification of steatosis improved the predictive value of preoperative volumetric analysis. METHODS Thirty patients undergoing planned right or extended right hemi-hepatectomy for colorectal metastases were recruited prospectively. Magnetic resonance imaging was used to assess the level of hepatic steatosis and future remnant liver volume. These data were correlated with data on postoperative hepatic insufficiency, complications and hospital stay. Correlations of remnant percentage, remnant mass to patient mass and remnant mass to body surface area with and without steatosis measurements were assessed. RESULTS In 10 of the 30 patients the planned liver resection was altered. Moderate-severe postoperative hepatic dysfunction was seen in 17 patients. Complications arose in 14 patients. The median level of steatosis was 3.8% (range: 1.2-17.6%), but was higher in patients (n= 10) who received preoperative chemotherapy (P= 0.124), in whom the median level was 4.8% (range: 1.5-17.6%). The strongest correlation was that of remnant liver mass to patient mass (r= 0.77, P < 0.001). However, the addition of steatosis quantification did not improve this correlation (r= 0.76, P < 0.001). CONCLUSIONS This is the first study to combine volumetric with steatosis quantifications. No significant benefit was seen in this small pilot. However, these techniques may be useful in operative planning, particularly in patients receiving preoperative chemotherapy.

Investigation of abdominal pain to detect pancreatic cancer.

When a patient presents with abdominal pain, which investigations should clinicians use to establish whether the pain results from pancreatic cancer?

Staging and Follow-Up of Colorectal Cancer

The prognosis of any neoplasm is dependant upon its extent of dissemination at the time of initial treatment and the efficacy of available therapies to eliminate all sites of disease. Staging and post-operative surveillance have the common goals of determining the extent of dissemination of the cancer so as to direct treatment. Staging is performed at presentation with the aim of giving a measure of the extent of local and metastatic disease and is now a fundamental part of oncological practice. Post-operative surveillance is performed for two purposes, firstly to identify metachronous tumours for which the patient is at increased risk and secondly to detect residual or recurrent cancer from the original tumour. The latter is much more contentious and is performed to compensate for failures of initial treatment and staging techniques with the intention of initiating further treatment. An understanding of the sites and mechanism of spread is useful in considering both staging and surveillance. The role of radiology for staging and post-operative surveillance of colorectal cancer will be examined. Follow-up to identify second primary tumours is usually performed by colonoscopy and will not be discussed in detail.