Matthanja Bieze

Diagnostic Accuracy of MRI in Differentiating Hepatocellular Adenoma From Focal Nodular Hyperplasia: Prospective Study of the Additional Value of Gadoxetate Disodium

OBJECTIVE The purpose of this article is to prospectively determine the sensitivity of hepatobiliary phase gadoxetate disodium-enhanced MRI combined with standard MRI in differentiating focal nodular hyperplasia (FNH) from hepatocellular adenoma (HCA). SUBJECTS AND METHODS Patients suspected of having FNH or HCA larger than 2 cm underwent gadoxetate disodium-enhanced MRI. Standard MRI was evaluated separately from the additional hepatobiliary phase by two blinded radiologists. For the largest lesion in each patient, findings were compared with histologic diagnosis. Sensitivity, positive predictive value (PPV), and distinctive features were analyzed using McNemar and analysis of variance tests. RESULTS Fifty-two patients completed the study. Histologic diagnosis revealed 24 HCAs and 28 FNHs. Characterization on standard MRI was inconclusive in 40% (21/52) and conclusive in 60% (31/52) of lesions. The sensitivity of standard MRI for HCA was 50% (12/24) with a PPV of 100% (12/12). The sensitivity for FNH was 68% (19/28) with a PPV of 95% (18/19). After review of hepatobiliary phase, the sensitivity for HCA improved to 96% (23/24) with a PPV of 96% (23/24). The sensitivity for FNH improved to 96% (27/28) with a PPV of 96% (27/28). Features with significant predictive value for diagnosis in HCA included bleeding (p < 0.001), fat (p = 0.010), and glycogen (p = 0.024). The presence of a central scar was predictive for FNH (p < 0.001). CONCLUSION This study shows high sensitivity of gadoxetate disodium-enhanced MRI when standard series are combined with the hepatobiliary phase for differentiation of FNH and HCA in lesions larger than 2 cm.

Risk factors for bleeding in hepatocellular adenoma.

Hepatocellular adenoma (HCA) is a benign hepatic lesion that may be complicated by bleeding, although the risk of bleeding is ill‐defined. The aim of this study was to assess risk factors for bleeding in patients diagnosed with HCA.

Management of giant liver hemangiomas: an update

Liver hemangiomas are the most common benign liver tumors and are usually incidental findings. Liver hemangiomas are readily demonstrated by abdominal ultrasonography, computed tomography or magnetic resonance imaging. Giant liver hemangiomas are defined by a diameter larger than 5 cm. In patients with a giant liver hemangioma, observation is justified in the absence of symptoms. Surgical resection is indicated in patients with abdominal (mechanical) complaints or complications, or when diagnosis remains inconclusive. Enucleation is the preferred surgical method, according to existing literature and our own experience. Spontaneous or traumatic rupture of a giant hepatic hemangioma is rare, however, the mortality rate is high (36–39%). An uncommon complication of a giant hemangioma is disseminated intravascular coagulation (Kasabach–Merritt syndrome); intervention is then required. Herein, the authors provide a literature update of the current evidence concerning the management of giant hepatic hemangiomas. In addition, the authors assessed treatment strategies and outcomes in a series of patients with giant liver hemangiomas managed in our department.

Diagnostic accuracy of 18F‐methylcholine positron emission tomography/computed tomography for intra‐ and extrahepatic hepatocellular carcinoma

Diagnosis of hepatocellular carcinoma (HCC) primarily involves imaging. The aim of this study was to assess the accuracy of 18F‐fluorocholine (18F‐FCH) positron emission tomography (PET) for detection of HCC and evaluation of extent of disease. Patients with HCC >1 cm were included between 2009 and July 2011, and follow‐up closed in February 2013. Diagnosis was based on American Association for the Study of Liver Diseases criteria, and all patients underwent 18F‐FCH PET/computed tomography (CT) at baseline before treatment, 6 underwent a second PET/CT posttreatment, and 1 a third during follow‐up. Whole‐body PET and low‐dose CT imaging were performed 15 minutes after 18F‐FCH injection. Evaluation of imaging was done with standardized uptake value (SUV) ratios: SUV maximum of the lesion divided by the SUV mean of surrounding tissue. Statistical analyses included descriptive analyses, receiver operating characteristic curve, McNemars test, and Kaplan‐Meiers test at 5% level of significance. Twenty‐nine patients revealed 53 intrahepatic lesions. In 48 of 53 lesions, 18F‐FCH PET was positive (SUVratio, 1.95 ± 0.66; sensitivity, 88%; specificity, 100%). PET/CT showed uptake in 18 extrahepatic lesions and no uptake in 3 lesions affirmed non‐HCC lesions; all lesions were confirmed with additional investigation (accuracy, 100%). In 17 of 29 patients, additional lesions were found on PET/CT imaging, with implications for treatment in 15 patients. Posttreatment PET/CT showed identical results, compared with standard treatment evaluation. Conclusion: This study shows additional value of 18F‐FCH PET/CT for patients with HCC. 18F‐FCH PET/CT has implications for staging, management, and treatment evaluation because of accurate assessment of extrahepatic disease. (Hepatology 2014;59:996–1006)

Outcomes of liver resection in hepatocellular adenoma and focal nodular hyperplasia.

OBJECTIVES The clinical management of hepatocellular adenoma (HCA) and focal nodular hyperplasia (FNH) is still subject to controversy, especially with respect to patient selection for surgery. The aim of this prospective cohort study was to assess the outcomes of surgical intervention. METHODS Between January 2008 and September 2012, patients diagnosed with FNH or HCA based on magnetic resonance imaging or computed tomography were enrolled in this prospective study. Resection was undertaken in patients with HCA of > 5 cm or symptomatic lesions. Lesion characteristics, extent of liver resection (minor: fewer than three segments; major: three or more segments), morbidity (by Dindo-Clavien class), mortality, postoperative length of stay and symptoms [McGill Pain Questionnaire, including a visual analogue scale (VAS)] were evaluated. RESULTS A total of 110 patients (106 female; median age: 39 years) were included; 51 patients had HCA and 59 had FNH. Of the 110 patients, 49 underwent resection (33 HCA patients; 16 FNH patients). Laparoscopic minor resection was performed in five HCA and five FNH patients; open minor resection was performed in 19 HCA and seven FNH patients, and open major resection was performed in nine HCA and four FNH patients. Severe postoperative complications were observed in four patients (Grade III, n = 3; Grade IV, n = 1). Median baseline scores on the VAS were 6 in FNH patients and 7 in HCA patients; the median VAS score after resection was 0 (P = 0.008). CONCLUSIONS If patients with HCA and FNH require surgery, limited resection can be carried out with low morbidity and without mortality. Patients with preoperative symptoms show a high rate of postoperative symptom relief.

The use of 18F-fluoromethylcholine PET/CT in differentiating focal nodular hyperplasia from hepatocellular adenoma: a prospective study of diagnostic accuracy

IntroductionDiagnosis of focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) using conventional imaging techniques can be difficult; however, it is important to differentiate between them as these benign liver tumors require different therapeutic strategies. The aim of our study was to prospectively evaluate the use of PET/computed tomography (CT) with 18F-fluoromethylcholine (18F-FCH) as a novel diagnostic approach in the differentiation between HCA and FNH. Materials and methodsFifty-six consecutive patients with a suspicion of one or multiple HCAs or FNHs larger than 2 cm were prospectively included after written informed consent was obtained from them. All the patients underwent a PET/CT with 18F-FCH. Histopathology of the lesions was the standard of reference. The ratio of the standardized uptake value (SUV) of the lesions compared with normal liver uptake within the same patient was calculated. Statistical tests were evaluated at the 95% confidence interval. ResultsForty-nine patients with 60 lesions and histopathological diagnosis of FNH or HCA completed the study and were analyzed. The mean SUV ratio for FNH was 1.67±0.31 (mean±SD, n=28), resulting in a positive likelihood ratio of 32.3 for PET-positive FNH. The mean SUV ratio for HCA was 0.82±0.17 (n=32), with a likelihood ratio of ∼100 for PET-negative HCA. Receiver operating characteristic curve analysis revealed an optimal SUV ratio cutoff value of 1.13, which reached 100% sensitivity and 97% specificity in differentiating FNH from HCA. ConclusionThis prospective study shows that PET/CT with 18F-FCH can accurately differentiate FNH from HCA and may become a valuable diagnostic tool when conventional imaging techniques fail to do so.

Hepatoblastoma evaluated by 18F-fluoromethyl choline PET/CT

Hepatoblastoma is a rare carcinoma mostly seen in children. Neoadjuvant chemotherapy followed by resection and adjuvant chemotherapy is the optimal treatment. We present the case of an 18-year-old woman who presented with abdominal pain, nausea, bloating, and fatigue. MRI showed 3 hepatic lesions with high signal intensity on arterial phase T1-weighted images and slight washout on the late phase, suggestive for hepatocellular carcinoma. Laboratory examinations revealed plasma α-feto-protein of 114,245 μg/L. Subsequent baseline and posttreatment F-fluoromethyl choline PET/CT were performed to possibly evaluate extent of the disease and assess disease response after neoadjuvant chemotherapy.

Hepatocellular Adenomas Associated with Hepatic Granulomas: Experience in Five Cases

We present five cases in whom two rare entities were simultaneously found within the liver, i.e. hepatocellular adenomas (HCAs) and granulomas. Coexistence of both entities confuses diagnosis. Our aim is to disclose the association between HCA and hepatic granulomas. Five patients presented with HCA for which they underwent resection. During laparotomy or at pathological examination, granulomas were found in tumorous and non-tumorous tissue. No specific cause for the granulomas was found. Immunohistochemistry showed overexpression of C-reactive protein and serum amyloid A in 4/5 patients, classifying these lesions as inflammatory HCA. HCA and especially the inflammatory subtype may cause formation of granulomas in (peri-)tumorous tissue as a local response to persistent inflammation and/or the presence of a tumor. Both HCA and hepatic granulomas have also been associated with oral contraceptive use. In conclusion, HCAs associated with hepatic granulomas derive from a local response to (inflammatory) HCA or neoplasm, chronic use of oral contraceptives, or a combination of these factors.

Von Meyenburg complexes mimicking metastatic disease at laparotomy for focal nodular hyperplasia.

A 44-year-old woman presented with symptoms of fatigue and increasing abdominal discomfort. MRI with the hepatobiliary contrast Gd-EOB-DTPA (Primovist) was performed showing a 6 cm lesion in segment 2/3 of the liver typical for focal nodular hyperplasia (FNH). Because of severe complaints attributed to the lesion, the patient was scheduled for resection. At laparotomy multiple small white lesions were found throughout the liver with enlarged locoregional lymph nodes. Macroscopically, the findings could be consistent with widespread metastases and the surgeon felt compelled to determine the nature of these lesions before continuing resection. Final diagnosis revealed multiple bile duct hamartomas and an FNH lesion as was expected.