Romain Breguet

Autologous bone marrow mononuclear cell transplantation in patients with decompensated alcoholic liver disease: a randomized controlled trial.

Objective Impaired liver regeneration is associated with a poor outcome in patients with decompensated alcoholic liver disease (ALD). We assessed whether autologous bone marrow mononuclear cell transplantation (BMMCT) improved liver function in decompensated ALD. Design 58 patients (mean age 54 yrs; mean MELD score 19, all with cirrhosis, 81% with alcoholic steatohepatitis at baseline liver biopsy) were randomized early after hospital admission to standard medical therapy (SMT) alone (n = 30), including steroids in patients with a Maddrey’s score ≥32, or combined with G-CSF injections and autologous BMMCT into the hepatic artery (n = 28). Bone marrow cells were harvested, isolated and reinfused the same day. The primary endpoint was a ≥3 points decrease in the MELD score at 3 months, corresponding to a clinically relevant improvement in liver function. Liver biopsy was repeated at week 4 to assess changes in Ki67+/CK7+ hepatic progenitor cells (HPC) compartment. Results Both study groups were comparable at baseline. After 3 months, 2 and 4 patients died in the BMMCT and SMT groups, respectively. Adverse events were equally distributed between groups. Moderate alcohol relapse occurred in 31% of patients. The MELD score improved in parallel in both groups during follow-up with 18 patients (64%) from the BMMCT group and 18 patients (53%) from the SMT group reaching the primary endpoint (p = 0.43 (OR 1.6, CI 0.49–5.4) in an intention to treat analysis. Comparing liver biopsy at 4 weeks to baseline, steatosis improved (p<0.001), and proliferating HPC tended to decrease in both groups (−35 and −33%, respectively). Conclusion Autologous BMMCT, compared to SMT is a safe procedure but did not result in an expanded HPC compartment or improved liver function. These data suggest either insufficient regenerative stimulation after BMMCT or resistance to liver regenerative drive in patients with decompensated alcoholic cirrhosis. Trial Registration Controlled-Trials.com ISRCTN83972743.

Cone Beam Computed Tomography (CBCT) in the Field of Interventional Oncology of the Liver

Cone beam computed tomography (CBCT) is an imaging modality that provides computed tomographic images using a rotational C-arm equipped with a flat panel detector as part of the Angiography suite. The aim of this technique is to provide additional information to conventional 2D imaging to improve the performance of interventional liver oncology procedures (intraarterial treatments such as chemoembolization or selective internal radiation therapy, and percutaneous tumor ablation). CBCT provides accurate tumor detection and targeting, periprocedural guidance, and post-procedural evaluation of treatment success. This technique can be performed during intraarterial or intravenous contrast agent administration with various acquisition protocols to highlight liver tumors, liver vessels, or the liver parenchyma. The purpose of this review is to present an extensive overview of published data on CBCT in interventional oncology of the liver, for both percutaneous ablation and intraarterial procedures.

Respiratory-Gated MRgHIFU in Upper Abdomen Using an MR-Compatible In-Bore Digital Camera

Objective. To demonstrate the technical feasibility and the potential interest of using a digital optical camera inside the MR magnet bore for monitoring the breathing cycle and subsequently gating the PRFS MR thermometry, MR-ARFI measurement, and MRgHIFU sonication in the upper abdomen. Materials and Methods. A digital camera was reengineered to remove its magnetic parts and was further equipped with a 7 m long USB cable. The system was electromagnetically shielded and operated inside the bore of a closed 3T clinical scanner. Suitable triggers were generated based on real-time motion analysis of the images produced by the camera (resolution 640 × 480 pixels, 30 fps). Respiratory-gated MR-ARFI prepared MRgHIFU ablation was performed in the kidney and liver of two sheep in vivo, under general anaesthesia and ventilator-driven forced breathing. Results. The optical device demonstrated very good MR compatibility. The current setup permitted the acquisition of motion artefact-free and high resolution MR 2D ARFI and multiplanar interleaved PRFS thermometry (average SNR 30 in liver and 56 in kidney). Microscopic histology indicated precise focal lesions with sharply delineated margins following the respiratory-gated HIFU sonications. Conclusion. The proof-of-concept for respiratory motion management in MRgHIFU using an in-bore digital camera has been validated in vivo.

Magnetic resonance-guided shielding of prefocal acoustic obstacles in focused ultrasound therapy: application to intercostal ablation in liver.

ObjectivesThe treatment of liver cancer is a major public health issue because the liver is a frequent site for both primary and secondary tumors. Rib heating represents a major obstacle for the application of extracorporeal focused ultrasound to liver ablation. Magnetic resonance (MR)–guided external shielding of acoustic obstacles (eg, the ribs) was investigated here to avoid unwanted prefocal energy deposition in the pathway of the focused ultrasound beam. Materials and MethodsEx vivo and in vivo (7 female sheep) experiments were performed in this study. Magnetic resonance–guided high-intensity focused ultrasound (MRgHIFU) was performed using a randomized 256-element phased-array transducer (f∼1 MHz) and a 3-T whole-body clinical MR scanner. A physical mask was inserted in the prefocal beam pathway, external to the body, to block the energy normally targeted on the ribs. The effectiveness of the reflecting material was investigated by characterizing the efficacy of high-intensity focused ultrasound beam reflection and scattering on its surface using Schlieren interferometry. Before high-intensity focused ultrasound sonication, the alignment of the protectors with the conical projections of the ribs was required and achieved in multiple steps using the embedded graphical tools of the MR scanner. Multiplanar near real-time MR thermometry (proton resonance frequency shift method) enabled the simultaneous visualization of the local temperature increase at the focal point and around the exposed ribs. The beam defocusing due to the shielding was evaluated from the MR acoustic radiation force impulse imaging data. ResultsBoth MR thermometry (performed with hard absorber positioned behind a full-aperture blocking shield) and Schlieren interferometry indicated a very good energy barrier of the shielding material. The specific temperature contrast between rib surface (spatial average) and focus, calculated at the end point of the MRgHIFU sonication, with protectors vs no protectors, indicated an important reduction of the temperature elevation at the ribs’ surface, typically by 3.3 ± 0.4 in vivo. This was translated into an exponential reduction in thermal dose by several orders of magnitude. The external shielding covering the full conical shadow of the ribs was more effective when the protectors could be placed close to the ribs’ surface and had a tendency to lose its efficiency when placed further from the ribs. Hepatic parenchyma was safely ablated in vivo using this rib-sparing strategy and single-focus independent sonications. ConclusionsA readily available, MR-compatible, effective, and cost-competitive method for rib protection in transcostal MRgHIFU was validated in this study, using specific reflective strips. The current approach permitted safe intercostal ablation of small volumes (0.7 mL) of liver parenchyma.

Hepatic lymphatics: anatomy and related diseases.

The liver normally produces a large amount of lymph. It is estimated that between 25% and 50% of the lymph received by the thoracic duct comes from the liver. In normal conditions, hepatic lymphatics are not depicted on cross-sectional imaging. They are divided in lymphatics of deep system (lymphatics following the hepatic veins and the portal tract) and those of superficial system (convex surface and inferior surface). A variety of diseases may affect hepatic lymphatics and in general they manifest as lymphedema, lymphatic mass, or cystic lesions. Abnormal distended lymphatics are especially seen in periportal spaces as linear hypoattenuations on CT or strong linear hyperintensities on heavily T2-weighted MR imaging. Lymphatic tumor spread as in lymphoma and lymphangitic carcinomatosis manifests as periportal masses and regional lymph node enlargement. Lymphatic disruption after trauma or surgery is depicted as perihepatic fluid collections of lymph (lymphocele). Lymphatic malformation such as lymphangioma is seen on imaging as cystic spaces of variable size.

Acute Hand Ischemia after Unintentional Intraarterial Injection of Drugs: Is Catheter-Directed Thrombolysis Useful?

Unintentional intraarterial injections are rare but may have devastating consequences. No consensus on treatment has been established owing to the wide variety of possible injected substances, incomplete understanding of the underlying pathophysiology, and the absence of case-controlled, prospective human studies. The aim of the present study and literature review was to evaluate the benefit of intraarterial thrombolysis combined with systemic anticoagulation therapy when an artery of the upper extremity is accidentally punctured and ischemia of the hand ensues.

Emergency Computed Tomography: What is Missed at First Reading?

Objectives The aim of this study was to evaluate the accuracy of preliminary computed tomography (CT) interpretations made by radiology residents in the emergency department. Methods For 4 periods of 20 consecutive days, attending radiologists prospectively recorded any disparities between their own CT interpretations (reference standard) and the preliminary interpretations of emergency radiology residents. Misinterpretations were defined as major when related to a potentially life-threatening pathology if not immediately managed after CT. The rate of disparities was calculated for all CT examinations, separately for body and neuroradiological cases, and for working and on-call hours. Results A total of 3044 emergency CT examinations were performed during the survey: 1568 (51%) body scans and 1476 (49%) neurological scans. Disparities were reported in 145 (4.8%) of all CT examinations, with 0.8% (24/3044) defined as major misinterpretations. There were 100 (6.3%) of 1568 disparities in body CT versus 45 (3.0%) of 1476 in neurological CT examinations (P = 0.001). No significant differences were found between disparities recorded during regular working hours (47/1083 [4.3%]) versus on-call hours (98/1961 [5.0%], P = 0.47). Conclusions There were typically more disparities between resident and attending interpretations in emergency body CT. Major disparities represented only a small proportion of all misinterpretations. The detailed analysis of our data enables benchmarking over time and offers a reference for optimizing the training of residents in emergency radiology.

Hereditary haemorrhagic telangiectasia: to transplant or not to transplant – is there a right time for liver transplantation?

Hereditary haemorrhagic telangiectasia is characterized by arterio‐venous malformations (AVM). It frequently involves the liver without clinical symptoms, but may lead to biliary ischaemia, portal hypertension, or fatal high‐output heart failure. The indication of liver transplantation is controversial.

Portal Vein Embolization Before Extended Hepatectomy in a Toddler With Mesenchymal Hamartoma.

Portal vein embolization is widely used to induce hypertrophy of the future liver remnant before extended hepatectomy, decreasing the risk of postoperative liver failure. However, this percutaneous procedure has not been previously reported in a young child. The present report describes the case of a 14-month-old patient with a large multifocal mesenchymal hamartoma of the entire right liver, successfully resected after induction of future liver remnant hypertrophy by portal vein embolization.

Colovesical fistula causing an uncommon reason for failure of computed tomography colonography: a case report

IntroductionComputed tomography colonography, or virtual colonoscopy, is a good alternative to optical colonoscopy. However, suboptimal patient preparation or colon distension may reduce the diagnostic accuracy of this imaging technique.Case presentationWe report the case of an 83-year-old Caucasian woman who presented with a five-month history of pneumaturia and fecaluria and an acute episode of macrohematuria, leading to a high clinical suspicion of a colovesical fistula. The fistula was confirmed by standard contrast-enhanced computed tomography. Optical colonoscopy was performed to exclude the presence of an underlying colonic neoplasm. Since optical colonoscopy was incomplete, computed tomography colonography was performed, but also failed due to inadequate colon distension. The insufflated air directly accumulated within the bladder via the large fistula.ConclusionsClinicians should consider colovesical fistula as a potential reason for computed tomography colonography failure.