Paul D. Russ

Impact of pretransplant diagnosis of hepatocellular carcinoma on cadveric liver allocation in the era of MELD

The allocation system based on the Model for End‐stage Liver Disease (MELD) has led to more patients diagnosed with hepatocellular carcinoma (HCC) being transplanted. We hypothesized that more patients misdiagnosed with HCC are also being transplanted, leading to inappropriate organ allocation. Therefore, we retrospectively analyzed all liver transplants at our center from July 14, 2000, to October 22, 2002 (N = 172; 129 pre‐MELD, 43 post‐MELD), comparing pretransplant HCC diagnosis to explant histology. Thirty patients met the United Network for Organ Sharing (UNOS) diagnostic criteria for pretransplant HCC diagnosis. There were 25 men (median age, 52.5 yr), and 80% had hepatitis C. The proportion of patients transplanted who had an HCC diagnosis increased from 12% (15/129) pre‐MELD to 35% (15/43) post‐MELD implementation (P < 0.01). Three of 15 (20%) transplanted pre‐MELD and 5 of 15 (33%) transplanted post‐MELD lacked HCC in the explant (P = 0.10). Of the three false‐positives pre‐MELD, one was Status 2B already, and two received living‐donor livers. Of the 5 false‐positives post‐MELD, three had score upgrades that led to early transplantation (13 to 29, 20 to 29, and 9 to 24) while two had MELD scores of 35 and 36 already. The percentage of organs that could have gone to patients with more advanced liver disease without HCC increased from 0% (0/129) pre‐MELD to 7% (3/43) post‐MELD (P < 0.01). Since the implementation of MELD, the proportion of patients transplanted who had an HCC diagnosis nearly tripled, and a small but significant proportion of organs are now going to patients misdiagnosed with HCC. More stringent HCC diagnostic criteria will be required to decrease the effect that misdiagnosis has on organ allocation. (Liver Transpl 2004;10:42–48.)

Dandy-walker syndrome: a review of fifteen cases evaluated by prenatal sonography

Fifteen cases of the Dandy-Walker syndrome evaluated by prenatal sonography were reviewed retrospectively. A posterior fossa cyst communicating with the fourth ventricle was a feature in each case. Hydrocephalus was present in 53% of fetuses. Extracranial congenital malformations were documented in 60% of cases. Cardiac, genitourinary, gastrointestinal, and skeletal anomalies were noted. Of 12 available karyotypes, 4 (33%) were abnormal, including two cases of trisomy 18. Excluding terminated pregnancies, there was an overall mortality of 55%. Associated congenital defects contributed to 83% of the postnatal deaths. The Dandy-Walker syndrome can be accurately diagnosed in utero by sonographic demonstration of characteristic morphologic changes in the fetal posterior fossa. The prenatal examination should include an evaluation of associated supratentorial and extracranial defects. Coexisting structural and chromosomal anomalies occur frequently and adversely affect survival.

Correlation of high-resolution breast MR imaging with histopathology; validation of a technique

A high‐resolution three‐dimensional surface gradient coil set was used to obtain magnetic resonance (MR) images of breast specimens, using a gradient‐echo pulse sequence (TR/TE 1000/8 msec, flip angle 75°), with 117 μm in‐plane resolution and 1 mm slice thickness. Breast tissues were obtained from one autopsy and three surgical specimens. High‐resolution breast MR images and histopathology sections (7 μm thickness) were acquired in the same anatomical plane. Radiographs were acquired of the sliced specimens (approximately 5 mm thick) so that images from all three methods could be correlated. It was found that in vitro high‐resolution breast MRI correlated well with low‐resolution microscopic histology, demonstrating normal anatomy (lobules, ducts, connective tissue strands, blood vessels) and pathology (tumor content, margins, and presence of microcalcifications) of the breast more clearly than conventional pre‐gadolinium breast MRI. High‐resolution breast MRI may improve specificity, when added to a conventional breast MRI protocol. J. Magn. Reson. Imaging 2000;11:601–606.

Herpes simplex in a liver transplant recipient

Fatal hepatitis is a rare complication of disseminated herpes simplex virus (HSV) 1 and 2 infections. In adult transplant recipients, most cases of HSV hepatitis occur with reactivation but may be seen with primary infection. Herein, we present a case of a 57-year-old white female with end-stage liver disease from hepatitis C who underwent transplant of a right lobe of the liver from her daughter and died after contracting HSV 2 hepatitis. Her immunosuppressive regimen included rapamycin, tacrolimus, and prednisone. Due to elevated liver function tests (total bilirubin 14.1, aspartate aminotransferase 287, alanine aminotransferase 138, and alkaline phosphatase 1,246), an abdominal computed tomography scan was performed on day 7 after transplant, showing multiple hepatic microabscesses (Fig. 1). A presumptive diagnosis of disseminated candidiasis was made, and treatment with fluconazole was initiated. Blood cultures were negative for yeast. Due to worsening liver tests, a transjugular liver biopsy was obtained on day 22 after transplant and found to be immunostain-positive for HSV 2 within a necrotizing granuloma with evidence of viral cytopathic changes (Fig. 2). Cultures of the liver tissue were positive for HSV. Serum HSV qualitative polymerase chain reactions were also positive for HSV. The patient was promptly started on intravenous acyclovir 10 mg/kg every 12 hours with dosing adjusted due to concomitant development of acute renal failure. Her liver function tests improved over the next few days, with no further progression of her renal failure. The patient had no cutaneous or genital HSV lesions and, on review of records, did not undergo pretransplant screening for HSV 1 or 2. Her daughter was subsequently found to have antibodies to HSV1 and 2, with no history of HSV genital, mucous membrane, or cutaneous lesions. The patient subsequently required surgical debridement of a wound infection in the operating room. The liver was noted to have numerous vesicles uniformly distributed throughout its surface (Fig. 3). An intraoperative biopsy of the liver was immunostain-positive for herpes simplex within a necrotizing granuloma with no further viral cytopathic changes, consistent with resolving infection. No other manifestations of HSV infection were identified. However, she subsequently developed worsening liver function tests and partial disruption of the bile duct anastomosis due to a multiresistant Pseudomonas aeruginosa infection and ultimately succumbed to persistent Pseudomonas aeruginosa sepsis. At the request of the family, no autopsy was performed.

Multiple myeloma involving the porta hepatis and peritoneum causing biliary obstruction and malignant ascites.

Multiple myeloma is a monoclonal plasma cell neoplasm that usually produces large amounts of a specific immunoglobulin. It typically affects patients over age 50 and has a slight predominance in men and African Americans. The clinical presentation may vary from being asymptomatic to life-threatening spinal cord compression. The most common symptoms are fatigue and bone pain associated with osteolytic lesions. Anemia and hypercalcemia may contribute to fatigue. Nearly half of myeloma patients develop nephropathy from hypercalcemia or precipitation of monoclonal light chains in the collecting tubules (1). Myeloma cells proliferate in the bone marrow and circulate through the bloodstream to create the typical clinical picture. Like benign plasma cells, they circulate through the lymphatics and the reticuloendothelial system; hence spleen, liver, or lymph node lesions are common. Organ involvement may be characterized by diffuse infiltrative disease or by discrete myelomatous masses known as plasmacytomas, which may lead to massive organ distortion and tumorous destruction or microscopic involvement alone. Although less common, aggressive myelomas may invade organs outside the bone marrow, lymphatics, or reticuloendothelial system (2). Such cases are associated with a poor prognosis. The upper respiratory tract and kidney are relatively common sites of implantation, while the gastrointestinal tract, retroperitoneum, and pelvic organs are less common. Diffuse intra-abdominal seeding leading to

Monckeberg's Arteriosclerosis of the Liver and Spleen Demonstrated by Ultrasound

There are three types of arteriosclerosis (hardening of the arteries): atherosclerosis, Monckebergs arteriosclerosis, and arteriolosclerosis. The features of central large-vessel atherosclerosis are familiar and frequently depicted at sonography of the carotid arteries and abdominal aorta. Monckebergs arteriosclerosis is not often encountered during ultrasound examinations. The authors report a case of Monckebergs arteriosclerosis demonstrated by sonography. Its pathogenesis and distinctive imaging findings are described.

Hematoma Mimicking Ruptured Testis After Self-Inflicted Orchiectomy A Case of Munchausen Syndrome

Testicular rupture is a potentially serious sequela of scrotal trauma. Physical examination is often quite limited in these cases. Sonography contributes significantly by directly visualizing the testis and intrascrotal contents. False-positive sonograms can occur, particularly when a hematocele displaces or distorts the testis beyond recognition or when a hematoma is mistaken for a damaged testis. This report describes the ultrasonographic appearance of a hematoma that mimicked a ruptured testis. The testis had actually been removed by the patient himself, who was suffering from a psychiatric disturbance called Munchausen syndrome.

Pancreatic Duct Changes in Patients With Chronic Pancreatitis Treated With Polyethylene and Sof-Flex Material Stents: A Blinded Comparison.

Objectives Pancreatic stenting is used to improve painful, obstructive chronic pancreatitis. Data suggest that polyethylene stents (PESs) cause stent-associated changes (SACs). Whether a stent composed of more flexible material (Sof-Flex stent [SFS]) is associated with less SAC is unknown. Methods This study is a retrospective study of patients who underwent pancreatic duct stenting of at least 1 PES and 1 SFS on separate examinations and had a follow-up pancreatogram at the time of stent removal. The main outcome measurements were assessed for SAC on follow-up pancreatogram and interpreted by 2 radiologists blinded to the clinical data. Results Stent-associated changes were noted with 28% (13/47) of SFS and with 25% (13/52) of PES (P = 0.65). For 10F stent subgroups, SACs were seen with 25% (6/24) of the SFS compared with 50% (2/4) in the PES. Thirty percent (7/23) of the 8.5F SFS subgroup had SACs versus 29% (2/7) in the PES group (P = 0.887) for 8.5F + 10F combined comparison. Conclusions In patients who have had polyethylene or SFSs of varying sizes, approximately 1 in 4 have SACs. Despite the use of a softer stent material for therapeutic stenting, the rate of SACs in the 8.5F and 10F subgroups seems similar between the 2 materials and design.