Marcelo Facciuto

Hepatocellular carcinoma: short-term reproducibility of apparent diffusion coefficient and intravoxel incoherent motion parameters at 3.0T.

To evaluate short‐term test–retest and interobserver reproducibility of IVIM (intravoxel incoherent motion) diffusion parameters and ADC (apparent diffusion coefficient) of hepatocellular carcinoma (HCC) and liver parenchyma at 3.0T.

Stereotactic body radiation therapy in hepatocellular carcinoma and cirrhosis: evaluation of radiological and pathological response.

Loco‐regional therapies for cirrhotic patients with hepatocellular carcinoma (HCC) who are awaiting liver transplantation (OLT) attempt to prevent tumor progression. However, there is limited data regarding the efficacy of stereotactic body radiation therapy (SBRT) as loco‐regional treatment.

An integrated approach to intestinal failure: results of a new program with total parenteral nutrition, bowel rehabilitation, and transplantation.

Intestinal failure can be treated with bowel rehabilitation, total parenteral nutrition, or intestinal transplantation. Little has been done to integrate these therapies for patients with intestinal insufficiency or failure and to develop an algorithm for appropriate use and timing. We established a multidisciplinary program using bowel rehabilitation, total parenteral nutrition, or intestinal transplantation as appropriate in a large population. Evaluation included clinical, pathlogic, and psychosocial assessments and assignment to therapy based on the results of this evaluation. Of 59 patients evaluated for life-threatening complications of intestinal failure, 68% were considered appropriate candidates for transplantation, 10% were managed with rehabilitation, and 17% were maintained on optimized long-term parenteral nutrition. Nineteen transplants were performed, with 78% patient survival and 66% graft survival. Patient survival among isolated intestine recipients was 90%. All patients managed with rehabilitation were weaned from parenteral nutrition within 6 months. Long-term management with parenteral nutrition resulted in a significant number of deaths both among patients waiting for a transplant and those who were poor candidates for transplant. Intestinal rehabilitation, when successful, is optimal. For patients with irreversible intestinal failure, isolated intestinal transplantation holds particular promise. Parenteral nutrition is plagued by high failure rates among this population of debilitated patients compared with the general parenteral nutrition population. Integration of these therapies, with individualization of care based on a multidisciplinary approach and perhaps with earlier isolated intestinal transplantation for patients with irreversible intestinal failure, should optimize survival.

Ischemia time impacts recurrence of hepatocellular carcinoma after liver transplantation

Although experimental evidence has indicated that ischemia‐reperfusion (I/R) injury of the liver stimulates growth of micrometastases and adhesion of tumor cells, the clinical impact of I/R injury on recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) has not been fully investigated. To study this issue, we conducted a retrospective review of the medical records of 391 patients from two transplant centers who underwent LT for HCC. Ischemia times along with other tumor/recipient variables were analyzed as risk factors for recurrence of HCC. Subgroup analysis focused on patients with HCC who had pathologically proven vascular invasion (VI) because of the associated increased risk of micrometastasis. Recurrence occurred in 60 patients (15.3%) with median time to recurrence of 0.9 years (range, 40 days‐4.6 years). Cumulative recurrence curves according to cold ischemia time (CIT) at 2‐hour intervals and warm ischemia time (WIT) at 10‐minute intervals showed that CIT >10 hours and WIT >50 minutes were associated with significantly increased recurrence (Pu2009=u20090.015 and 0.036, respectively). Multivariate Coxs regression analysis identified prolonged cold (>10 hours; Pu2009=u20090.03; hazard ratio [HR]u2009=u20091.9) and warm (>50 minutes; Pu2009=u20090.003; HRu2009=u20092.84) ischemia times as independent risk factors for HCC recurrence, along with tumor factors, including poor differentiation, micro‐ and macrovacular invasion, exceeding Milan criteria, and alpha‐fetoprotein >200 ng/mL. Prolonged CIT (Pu2009=u20090.04; HRu2009=u20092.24) and WIT (Pu2009=u20090.001; HRu2009=u20095.1) were also significantly associated with early (within 1 year) recurrence. In the subgroup analysis, prolonged CIT (Pu2009=u20090.01; HRu2009=u20092.6) and WIT (Pu2009=u20090.01; HRu2009=u20093.23) were independent risk factors for recurrence in patients with VI, whereas there was no association between ischemia times and HCC recurrence in patients with no VI. Conclusion: Reducing ischemia time may be a useful strategy to decrease HCC recurrence after LT, especially in those with other risk factors. (Hepatology 2015;61:895–904)

Outcomes of Radioembolization in the Treatment of Hepatocellular Carcinoma with Portal Vein Invasion: Resin versus Glass Microspheres

PURPOSEnTo compare outcomes of yttrium-90 radioembolization performed with resin-based ((90)Y-resin) and glass-based ((90)Y-glass) microspheres in the treatment of hepatocellular carcinoma (HCC) with associated portal vein invasion.nnnMATERIALS AND METHODSnA single-center retrospective review (January 2005-September 2014) identified 90 patients ((90)Y-resin, 21; (90)Y-glass, 69) with HCC and ipsilateral portal vein thrombosis (PVT). Patients were stratified according to age, sex, ethnicity, Child-Pugh class, Eastern Cooperative Oncology Group status, α-fetoprotein > 400 ng/mL, extent of PVT, tumor burden, and sorafenib therapy. Outcome variables included clinical and laboratory toxicities (Common Terminology Criteria Adverse Events, Version 4.03), imaging response (modified Response Evaluation Criteria in Solid Tumors), time to progression (TTP), and overall survival (OS).nnnRESULTSnGrade 3/4 bilirubin and aspartate aminotransferase toxicities developed at a 2.8-fold (95% confidence interval [CI], 1.3-6.1) and 2.6-fold (95% CI, 1.1-6.1) greater rate in the (90)Y-resin group. The disease control rate was 37.5% in the (90)Y-resin group and 54.5% in the (90)Y-glass group (P = .39). The median (95% CI) TTP was 2.8 (1.9-4.3) months in the (90)Y-resin group and 5.9 (4.2-9.1) months in the (90)Y-glass group (P = .48). Median (95% CI) survival was 3.7 (2.3-6.0) months in the (90)Y-resin group and 9.4 (7.6-15.0) months in the (90)Y-glass group (hazard ratio, 2.6; 95% CI, 1.5-4.3, P < .001). Additional multivariate predictors of improved OS included age < 65 years, Eastern Cooperative Oncology Group status < 1, α-fetoprotein ≤ 400 ng/mL, and unilobar tumor distribution.nnnCONCLUSIONSnImaging response of (90)Y treatment in patients with HCC and PVT was not significantly different between (90)Y-glass and (90)Y-resin groups. Lower toxicity and improved OS were observed in the (90)Y-glass group.

Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk.

Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.

Comparison of gadoxetic acid to gadobenate dimeglumine for assessment of biliary anatomy of potential liver donors

PurposeTo compare MRI using gadobenate dimeglumine (Gd-BOPTA) vs. gadoxetic acid disodium (Gd-EOB-DTPA) for the assessment of biliary anatomy of potential liver donors.Methods76 potential liver donors (39xa0M/37xa0F, mean 38xa0years) who underwent 1.5T MRI using Gd-BOPTA (nxa0=xa037) or Gd-EOB-DTPA (nxa0=xa039) were retrospectively evaluated. T2 cholangiogram (T2 MRC) and delayed hepatobiliary phase (HBP) T1 cholangiogram (T1 MRC) (performed during HBP 20xa0min after injection of Gd-EOB-DTPA and 1–2xa0h after Gd-BOPTA injection) were obtained in addition to MR angiogram/venogram. Two independent observers evaluated image quality (IQ) and conspicuity scores (CS) of the biliary system. Biliary anatomy was assessed in 3 reading sessions (T2 MRC, T1 MRC, and combined T2/T1 MRC). Reference standard consisted of consensus reading of two separate observers of all image sets, clinical/surgical information and intraoperative cholangiogram when available. Datasets were compared using the Mann–Whitney U test or Chi-squared test.ResultsThere was no difference in IQ for T1 MRC using either contrast agent or T2 MRC vs. T1 MRC for both observers (all p values >0.07). There was superior CS for T2 MRC vs. Gd-BOPTA T1 MRC for both observers and T2 MRC vs. Gd-EOB for one observer (pxa0<xa00.001). No difference was found for biliary variant detection for T1 MRC (with either contrast agent) vs. T2 MRC. Combined T2/T1 MRC demonstrated improved sensitivity for biliary variant detection using Gd-BOPTA for both observers (pxa0<xa00.004) and Gd-EOB-DTPA for one observer (pxa0<xa00.001).ConclusionEquivalent image quality was found for T1 MRC obtained with Gd-BOPTA or Gd-EOB-DTPA and T2 MRC. T1 MRC is equivalent to T2 MRC for detection of variant biliary anatomy, and the combination of sequences may have added value.

Comparison of gadoxetic acid and gadopentetate dimeglumine-enhanced MRI for HCC detection: prospective crossover study at 3 T

Background Gadoxetic acid and gadopentetate dimeglumine are gadolinium-based contrast agents (GBCAs) with an established role in HCC detection and characterization. Purpose To compare gadopentetate dimeglumine and gadoxetic acid-enhanced magnetic resonance imaging (MRI) for image quality and hepatocellular carcinoma (HCC) detection/conspicuity. Material and Methods In this IRB approved cross-over pilot prospective study, 12 patients (all men; mean age, 56 years) with chronic liver disease at risk of HCC underwent two repeat MRI examinations using gadopentetate dimeglumine and gadoxetic acid (mean interval between studies, 5 days). Two independent observers analyzed images for image quality and HCC detection/conspicuity. Per-lesion sensitivity, positive predictive value, quantitative enhancement, and lesion-to-liver contrast ratio were calculated for both contrast agents. Results There was no significant difference in image quality scores between both GBCAs (Pu2009=u20090.3). A total of 20 HCCs were identified with reference standard in 12 patients (mean size 2.6u2009cm, range, 1.0–5.0u2009cm). Higher sensitivity was seen for observer 1 for gadoxetic acid-set in comparison with gadopentetate dimeglumine-set (sensitivity increased from 85.7% to 92.8%), while no difference was noted for observer 2 (sensitivity of 78.5%). Lesion conspicuity was significantly higher on hepatobiliary phase (HBP) images compared to arterial phase images with both GBCAs for both observers (Pu2009<u20090.05). Lesion-to-liver contrast ratios were significantly higher for HBP compared to all dynamic phases for both agents (Pu2009<u20090.05). Conclusion Our initial experience suggests that gadoxetic acid-set was superior to gadopentetate dimeglumine-set in terms of HCC detection for one observer, with improved lesion conspicuity and liver-to-lesion contrast on HBP images.

WITHDRAWN: Recurrence prediction of hepatocellular carcinoma after liver transplantation by ischemia time and tumor characteristics.

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Analysis of Preoperative Portal Vein Embolization Outcomes in Patients with Hepatocellular Carcinoma: A Single-Center Experience

PURPOSEnTo analyze outcomes of patients with hepatocellular carcinoma (HCC) undergoing preoperative portal vein embolization (PVE).nnnMATERIALS AND METHODSnA retrospective analysis of survival, recurrence, and complications was performed in 82 patients with HCC undergoing preoperative PVE and surgical treatment with curative intention from June 2006 to Decemberxa02014.nnnRESULTSnRate of major adverse events after PVE was 11% with no mortality. Twenty-eight (34.1%) patients showed radiologic progression of HCC after PVE; 72 patients (87.8%) eventually were accepted as surgical candidates. Median interval between PVE and surgery was 37 days, and 69 patients (84.1%) ultimately underwent surgical resection. At 1 and 3 years, disease-free survival rates were 81.3% and 53.1%, respectively, and overall patient survival rates were 77.5% and 63.1%. Compared with patients accepted as surgical candidates, patients who did not undergo surgery had a higher median number of HCC tumors (1 [range, 1-5] vs 2 [range, 1-4], Pxa0= .031). At 1 and 3 years, patients with disease progression after PVE but who still underwent surgical resection showed similar recurrence-free (90% vs 79.6% and 75% vs 48.6%) and overall (72.2% vs 78.4% and 57.8% vs 64%) survival rates as the rest of the patients who underwent resection.nnnCONCLUSIONSnPVE is a safe technique with good outcomes that potentially increases the number of patients with initially unresectable HCC who can be offered resection. Radiologic progression after PVE should not be seen as a contraindication to offer resection if it is still deemed possible.