Pauline Kane

Accuracy of radiology in detection of hepatocellular carcinoma before liver transplantation

BACKGROUND/AIMS Recurrence of hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT) depends on tumor size and number; the accuracy of radiology in detecting HCC is uncertain. This study compared tumor size at radiological and pathological examination in 30 patients with HCC who underwent OLT. METHODS Pre-OLT radiology included ultrasonography (US), computerized tomography (CT), and hepatic angiography (HA). Sensitivity of radiology was calculated by comparison with pathology. RESULTS Radiology missed HCC in two patients but showed five with small (< 4 cm) and eight with large (> 4 cm) lesions. Multicentricity was shown in 15 cases at radiological examination and 24 at pathological examination, including one incidental and 4 of 5 radiologically small HCC. Mean tumor bulk was 3.4, 74, 338, and 1375 cm3, respectively, in patients with incidental, small, large, and multicentric HCC at radiology. Sensitivities of US, CT, and HA in detection of HCC (and multicentricity) were 80% (16.6%), 86.6% (58.3%), and 90% (58.3%). No recurrence was found in patients with incidental or small HCC; even when multicentric. CONCLUSIONS US, CT, and HA identified patients with small or large tumor bulk, but sensitivity in detecting satellites was poor; their finding in patients with radiologically small or incidental tumors does not affect outcome. The failure of US, CT, and HA to detect satellites must be considered in patients undergoing partial hepatectomy for HCC.

Mixed phenotype hepatocellular carcinoma after transarterial chemoembolization and liver transplantation.

We investigated the phenotype of hepatocellular carcinoma (HCC) in livers removed during transplantation after local ablation therapy by transarterial chemoembolization (TACE). This study involved 80 HCC nodules (40 treated with TACE and 40 not treated with local ablation before transplantation) observed in 64 explanted livers and included clinicopathological evaluations as well as single and double immunohistochemistry and reverse‐transcription polymerase chain reaction (RT‐PCR) for cytokeratin 19 (CK19), epithelial cell adhesion molecule (EpCAM), neural cell adhesion molecule (NCAM), and CD133. HCCs with complete necrosis post‐TACE without viable tumors were excluded from the analysis. Cholangiolar, glandular, or spindle cell areas suggestive of a mixed hepatocholangiocellular phenotype were seen in 14 post‐TACE HCCs and in none of the non‐TACE HCCs (P < 0.001). According to single‐epitope immunohistochemistry of post‐TACE HCCs, CD133, CK19, EpCAM, and NCAM were expressed in 14 (35%), 8 (20%), 12 (30%), and 8 (20%), respectively. Only EpCAM was detected in 4 non‐TACE HCC cases (10%). RT‐PCR experiments using tissues obtained by laser microdissection showed that 4 of 5 investigated post‐TACE HCCs expressed at least 1 of the markers, which were coexpressed in 3 of 5 tumors, whereas CD133 and EpCAM were individually expressed in 2 non‐TACE HCCs. Double immunostaining showed that CD133+ cells frequently coexpressed CK19, EpCAM, or NCAM. Interestingly, the recurrence rate for patients with CD133+ post‐TACE HCC was significantly higher than the rate for patients with CD133− post‐TACE HCC (P = 0.025). In conclusion, HCC with the combined hepatocholangiocellular phenotype appears to be more frequent in post‐TACE HCC versus untreated HCC. Further studies are needed to investigate the potential relationships between TACE and HCC subpopulations with a chemoembolization‐resistant phenotype and their clinical significance. Liver Transpl 17:943–954, 2011.

Liver transplantation for neonatal haemochromatosis.

Two cases of neonatal haemochromatosis, a rare and often fatal metabolic disorder, presenting with acute liver failure, are reported. Both presented in the first week of life with hypoglycaemia, jaundice, and coagulopathy, with rapid deterioration of liver function. Both received a transplantation using reduced liver grafts. One child was well 18 months later. Few survivors have been reported and despite the difficult perioperative management, liver transplantation is the best treatment for neonatal haemochromatosis.

Developmental intrahepatic shunts of childhood: radiological features and management

The purpose of this study was to evaluate the role of radiological techniques in the diagnosis and management of developmental intrahepatic shunts. Hepatic vascular fistulae are recognised sequelae of liver trauma and intrahepatic tumours. However, there are rare developmental malformations which may present in childhood or later life and which may carry life-threatening complications. Retrospective analysis of clinical and radiological data was carried out in 24 patients. Anomalies evaluated were: (a) direct communication between hepatic artery and hepatic veins; (b) congenital hepatoportal arteriovenous malformations; and (c) congenital portocaval anastomosis with persistent flow through the ductus venosus. Although rare, the prompt recognition of these vascular anomalies allows early surgical or radiological intervention and reversal of the haemodynamic complications.

Interventional Radiology in Liver Transplantation

Radiology is a key specialty within a liver transplant program. Interventional techniques not only contribute to graft and recipient survival but also allow appropriate patient selection and ensure that recipients with severe liver decompensation, hepatocellular carcinoma or portal hypertension are transplanted with the best chance of prolonged survival. Equally inappropriate selection for these techniques may adversely affect survival. Liver transplantation is a dynamic field of innovative surgical techniques with a requirement for interventional radiology to parallel these developments. This paper reviews the current practice within a major European center for adult and pediatric transplantation.

Safety and efficacy of Mangafodipir trisodium in patients with liver lesions and cirrhosis

Abstract.Mangafodipir trisodium (Mn-DPDP, Teslascan) is a well-tolerated liver contrast agent. Although the enhancement characteristics of the cirrhotic liver after Mangafodipir trisodium administration have been studied, at present there is no published data on the impact that cirrhosis might have on the safety and efficacy profiles of this agent. Our objective is to evaluate by means of a retrospective comparison the safety and efficacy of Mangafodipir trisodium in patients with underlying cirrhosis who were examined for suspicion of focal liver lesions. A total of 923 patients received Mangafodipir trisodium (5 µmol/kg) in 11 prospective randomized European clinical trials. Adverse events and discomfort were recorded and graded in all patients. The efficacy analyses were performed on the subsets consisting of 617 patients with independent lesion counts (detection), and on the subset with 399 patients with independent and onsite final lesion diagnosis (characterization). Of the 399 patients, 149 had histologic confirmation. One hundred eighty of 923 patients (19.5%) had cirrhosis. There were no main differences between cirrhotic and non-cirrhotic patients. Adverse events were observed in 64 patients (6.9%), 6.7% in the cirrhotic group and 7.0% in the non-cirrhotic group, a non-significant difference. Adverse events in most patients were mild or moderate. The presence and intensity of the events did not differ between groups. Discomfort was recorded in 79 patients (8.6%), equally distributed in cirrhotic (6.1%) and non-cirrhotic (9.2%) patients. Regarding lesion count, significantly more lesions were found in the post- than in the precontrast images in both the cirrhotic and non-cirrhotic groups (p<0.0001). This increase was not influenced by the presence of liver cirrhosis (p=0.94). Lesion characterization was significantly improved in cirrhotic patients after administration of Mangafodipir trisodium (p=0.002) but not in non-cirrhotic patients (p=0.13). Mangafodipir trisodium is a safe and well-tolerated useful contrast agent in patients with cirrhosis.

Vanishing liver tumours

Spontaneous resolution of liver tumours is a rare, but recognized entity that has been reported to occur within the spectrum of benign and malignant liver tumours occurring in both adult and paediatric population. The aetiology of this unusual phenomenon is not clearly understood. In this article we present case examples of various benign and malignant liver tumours that have regressed spontaneously without treatment together with a review of the literature, and a summary of the current understanding of the pathogenesis of these tumours.

Prevalence of symptoms in patients with multiple myeloma: a systematic review and meta‐analysis

Multiple myeloma (MM) is an incurable haematological disease. Due to novel agents, overall survival has improved in this group, yet there are no systematic reviews to understand the symptom profiles resulting from disease and treatment‐related toxicities. We aimed to synthesise data on the prevalence of symptoms in patients with MM.

Size reduction of small bowels from adult cadaveric donors to alleviate the scarcity of pediatric size-matched organs an anatomical and feasibility study

BACKGROUND Small bowel transplantation in children weighing less than 10 kg is hindered by the lack of size-matched donors. The ability to create reduced size small bowel grafts from adult cadaveric donors suitable for use in young children has been studied. METHODS Volumetric assessment of computed tomography scans were used to evaluate abdominal cavity and small bowel volumes in children. Small bowels were retrieved from adult cadaveric donors and reduced in size. RESULTS Computed tomography studies of the abdominal cavity showed that the mean volume available for a small bowel graft was 260 ml in children less than 5 kg (n = 5) and 460 ml in children weighing 5-10 kg (n = 5). Fifteen small bowels were successfully reduced to provide an ileal graft of one meter while keeping the whole length of the superior mesenteric artery and vein after their dissection in the proximal part of the mesentery. The mean volume of the grafts created was 270 ml in seven thin patients (body mass index [BMI] <25), 390 ml in five preobese patients (25< BMI<30), and 490 ml in three obese patients (BMI>30). Mesenteric transillumination in thin donors allowed safe dissection and complete hemostasis. No diameter reduction was required. Technical modifications permitted the creation of two grafts, one ileal and the other jejunal from a single donor. Volumetric and surgical data show that implantation of up to two meters of ileum from a thin adult weighing up to 80 kg is feasible in children weighing less than 10 kg. CONCLUSION Size reduction of adult cadaveric small bowels can provide suitable grafts for children of less than 10 kg and could expand the potential pool of donors for these patients.

Graft positioning at liver transplantation in situs inversus

Situs inversus (SI) totalis is a rare congenital anomaly. In the past it was considered an absolute contraindication to liver transplantation (LT) because of associated malformations, and difficulty achieving accurate graft positioning. We describe successful outcome following LT in a 41-year-old with alcoholrelated chronic liver disease and complete SI using a novel technique (Fig. 1). Recipient hepatectomy was uncomplicated. A donor whole liver was implanted using a piggyback technique. Reduced space in the right upper quadrant from the stomach and spleen resulted in 40% clockwise graft rotation. To attenuate this effect, the left diaphragm was plicated and a Sengstaken-Blakemore tube was inserted percutaneously into the left upper quadrant (LUQ). The gastric balloon was inflated with 400 ml of normal saline to support the left lobe (Fig. 2). The donor remnant falciform ligament was fixed to the recipient diaphragmatic surface to effect long-term optimal positioning. Abdominal CT scan on day 7 demonstrated the gastric balloon elevating and supporting the graft (Figure 3). On day 12, 200 ml of normal saline was aspirated with gradual balloon deflation over the next 3 days, and removal of the Sengstaken-Blakemore tube on day 15. Serial Doppler ultrasonography demonstrated normal hepatic venous flow. An abdominal CT scan at 3 months demonstrated no change in graft position (Figure 4A). The hepatic veins, portal vein and hepatic artery appeared patent (Figure 4B). The patient remains well 17 months following LT with normal graft function. Abdominal SI is described in association with the polysplenia syndrome with inferior vena caval absence, preduodenal portal vein, midgut malrotation, aberrant hepatic arterial anatomy, and portal vein hypoplasia. Anatomic anomalies result in a more complex recipient hepatectomy. Consideration has to be given to correct donor graft positioning, and additional vascular reconstruction. However, LT has been performed successfully using modified surgical techniques. Most cases are in the paediatric population in whom graft displacement and hepatic venous pedicle torsion are less due to a smaller abdominal cavity when even split and reduced grafts are typically large-for-size, and greater use of caval replacement techniques. Cadaveric segmental and living related left lateral segment grafts have been successfully placed with suitable orientation for hilar vessel anastomoses. However, in adults following recipient hepatectomy, a large empty space exists in the LUQ predisposing to lateral displacement with supero-lateral graft rotation and torsion of the hepatic venous pedicle particularly with a piggyback technique. Split, reduced, and right lobe living related LT have been performed successfully. Technical modifications with an intact recipient cava include piggyback implantation over the right suprahepatic vein with orthotopic graft position, and graft rotation by 90°. In our patient, only partial volume reduction of the left hepatic fossa was achieved by diaphragmatic plication. Due to its large size, filling the defect with omentum and mobilized hepatic flexure would have been inadequate. The use of a Sengstaken-Blakemore tube represents an innovative and simple technique to provide effective graft support, and reduce the risk of outflow obstruction. Subsequent peri-hepatic adhesion formation and migration of bowel loops into the LUQ would be expected to provide longterm graft fixation.