Rong Qin Zheng

Diagnostic Accuracy of Imaging for Liver Cirrhosis Compared to Histologically Proven Liver Cirrhosis

Objective: To evaluate the diagnostic accuracy of liver cirrhosis by imaging modalities, including CT, MRI and US, compared to results obtained from histopathological diagnoses of resected specimens. Materials and Methods: CT, MRI and US examinations of 142 patients with chronic liver disease who underwent surgery for complicated hepatocellular carcinoma (<3 cm in diameter) in 10 institutions were blindly reviewed in a multicenter study by three radiologists experienced in CT, MRI and US. The images were evaluated for five imaging parameters (irregular or nodular liver surface, blunt liver edge, liver parenchymal abnormalities, liver morphological changes and manifestations of portal hypertension) using a severity scale. The diagnostic imaging impression score was also calculated. Patients were histologically classified into chronic hepatitis (CH; n = 54), liver cirrhosis (LC; n = 71) and pre-cirrhosis (P-LC; n = 17) by three pathologists, independently, who reviewed the resected liver specimens. The results of the three imaging methods were compared to those from histological diagnoses, and a multivariate analysis (stepwise forward logistic regression analysis) was performed to identify independent predictive signs of cirrhosis. The diagnostic efficacies for LC and early cirrhosis were also compared among CT, MRI and US using a receiver-operating characteristic (ROC) curve analysis. Results: The differences in the five imaging parameters evaluated by CT, MRI and US between LC and CH were statistically significant (p < 0.001) except for the manifestations of portal hypertension on US. Irregular or nodular surface, blunt edge or morphological changes in the liver were selected as the best predictive signs for cirrhosis on US whereas liver parenchymal abnormalities, manifestations of portal hypertension and morphological changes in the liver were the best predictive signs on MRI and CT by multivariate analysis. The predictive diagnostic accuracy, sensitivity and specificity in discriminating LC from CH based on the best predictive signs were 71.9, 77.1 and 67.6% by CT; 67.9, 67.5 and 68.3% by MRI, and 66.0, 38.4 (lower than CT and MRI, p =0.001) and 88.8% (higher than CT and MRI, p =0.001)by US. According to the imaging impression scoring system, diagnostic accuracy, sensitivity and specificity were 67.0, 84.3 and 52.9% by CT; 70.3, 86.7 and 53.9% by MRI, and 64.0, 52.4 (lower than CT and MRI, p =0.0001) and 73.5% (higher than CT and MRI, p < 0.003) by US. ROC analysis showed that MRI and CT were slightly superior to US in the diagnosis of LC but no statistically significant difference was found between them. For the pathological diagnosis of P-LC, cirrhosis was diagnosed in 59.5, 46.7 and 41.7% of the P-LC cases by US, CT and MRI, respectively, with no significant difference among these methods. Conclusion: US, CT and MRI had different independent predictive signs for the diagnosis of LC. MRI and CT were slightly superior to US in predicting cirrhosis, especially regarding sensitivity. Noninvasive imaging techniques play an important role in the diagnosis of cirrhosis, especially in the evaluation of P-LC.

Transient portal vein thrombosis caused by radiofrequency ablation for hepatocellular carcinoma

branch of the left portal vein. Dynamic CT showed the lesion to be an inhomogeneous enhancement during the arterial phase, with slightly hyperto low-attenuation during the portal venous phase and delayed phase, respectively, with no invasion into the portal vein (Fig. 1). Contrast-enhanced harmonic US with intravenous administration of Levovist (SHU-508, Schering, Germany) and hepatic angiography all demonstrated a hypervascular mass with dense tumor stain. A diagnosis of HCC was made on the basis of the clinical data and imaging findings. Because of his advanced age and liver dysfunction, the patient underwent US-guided percutaneous RFA. The treatment was performed by using an RF generator (RTC 2000; Radiotherapeutic, Sunny Vale, CA, USA) and a LeVeen (Radiotherapeutic, Sunny Vale, CA, USA) needle (15-gauge, 25-cm-long insulated cannula, containing ten individual hook-shaped electrode tines with an array diameter of 3.5 cm). The needle was inserted first into the deep and then into the middle and superficial parts of the tumor under the guidance of real-time US. The initial emission power was set at 50 W, and then gradually increased to 90W and lasted until the tissue impedance value was up to 100%. Dynamic CT scan performed 6 days later showed a complete response, with a coagulation area about 5cm in diameter. In addition, there was a small hypodense area within the first branch of the left portal vein during the portal venous phase (Fig. 2), suggesting the formation of portal vein thrombosis. Considering that the patient appeared to have no symptoms after treatment, no special medical treatment was given to the patient. On a follow-up CT scan performed 3 months after RFA, the portal vein thrombosis had disappeared spontaneously (Fig. 3). The patient is doing well. Portal vein thrombosis is usually a complication of pre-existing cirrhosis, abdominal malignancy, or abdominal inflammation.3 It was also reported as a complication following splenectomy, which might be caused by Radiofrequency ablation (RFA) is an effective and safe treatment option for patients with focal liver tumors. Procedure-related complications were minimal1 and mild. Pleural effusion, subcapsular and subcutaneous hematoma, and perihepatic abscess have been reported as complications of RFA.1,2 However, portal vein thrombosis caused by RFA is rarely reported, because heat injury to the vessel is believed to have a minimal risk due to the cooling effect of RFA. Herein, we present details of a patient with transient portal vein thrombosis that followed RFA treatment for hepatocellular carcinoma (HCC) and disappeared spontaneously. A 78-year-old man was admitted to our hospital for further examination and treatment of a liver mass detected by follow-up abdominal computed tomography (CT) scan for hepatitis C-related cirrhosis in October 2000. There were no special abnormal findings on physical examination. Laboratory tests showed leukopenia (white blood cell count, 2100/μl), with mild anemia (red blood cell count, 3.47 106/μl; hemoglobin, 11.8 g/dl) and decreased platelet count (5.9 104/μl); and a low level of serum total protein (5.8 g/dl) with mild elevation of serum total bilirubin (1.7mg/dl) and γ-glutamyl transpeptidase (γ GTP; 126IU/l). Coagulation test results were normal. Serum levels of protein induced by vitamin K absence (PIVKA-II) were elevated (2390 mAU/ml; normal range, 40 mAU/ml). Values of alpha-fetoprotein (AFP) and lens culinaris agglutinin AFP (AFP-L3) were within normal ranges. Serum antibodies for hepatitis C were positive. The patient had had a history of hepatitis C-related cirrhosis for about 10 years. Abdominal ultrasonography (US) revealed a hypoechoic lesion 3 cm in diameter in the medial segment of the left liver lobe (segment 4) near the first

Hepatocellular Carcinoma with Nodule-in-Nodule Appearance: Demonstration by Contrast-Enhanced Coded Phase Inversion Harmonic Imaging

Objective: A nodule-in-nodule hemodynamic pattern, namely a vascular spot in a hypovascular nodule, is specific for the diagnosis of early-stage hepatocellular carcinoma (HCC). The purpose of this study was to assess whether this unique hemodynamic pattern can be detected by contrast-enhanced coded phase inversion harmonic imaging (PIHI). Methods:159 consecutive patients with HCC who underwent contrast-enhanced coded PIHI were retrospectively reviewed. Cases with nodule-in-nodule patterns were selected, and findings were compared with those on computed tomography (CT) angiography (CTA) and intraarterial contrast-enhanced ultrasonography (US angiography). Results: Contrast-enhanced coded PIHI successfully displayed the nodule-in-nodule hemodynamic pattern in two cases of histologically proven HCC and the hemodynamic transition in one of the two cases, which corresponded well with findings on CTA and US angiography. Conclusions: Contrast-enhanced coded PIHI can demonstrate the special nodule-in-nodule hemodynamic pattern. It is useful in the diagnosis and follow-up of early-stage HCC or suspected nodules because of its noninvasiveness and easy performance.

Multiple tuberculous abscesses of the liver and the brain in a patient with acute leukemia.

1. Takahashi T, Gamboa-Dominguez A, Gomez-Mendez TJ, Remes JM, Rembis V, Martinez-Gonzalez D, et al. Fulminant amebic colitis: analysis of 55 cases. Dis Colon Rectum 1997;40:1362–7. 2. Takenaka A. Ameobic dysentery: a relapsing case by cancer chemotherapy (in Japanese with English abstract). Kansenshogaku Zasshi 1989;63:162–5. 3. Eckmann L, Reed SL, Smith JR, Kagnoff MF. Entamoeba histolytica trophozoites induce an inflammatory cytokine response by cultured human cells through the paracrine action of cytolytically released interleukin-1α. J Clin Invest 1995;96:1269–79. 4. Jung HC, Eckmann L, Yang SK, Panja A, Fierer J, MorzyckaWroblewska E, et al. A distinct array of proinflammatory cytokines is expressed in human colon epithelial cells in response to bacterial invasion. J Clin Invest 1995;95:55–65.

Stage IV hepatocellular carcinoma with portal venous tumor thrombus: complete response after combined therapy of repeated arterial chemoembolization and radiofrequency ablation.

monic angio technique after intravenous administration of Levovist (Schering Co., Berlin, Germany) showed a hypervascular mass. Plain CT revealed a slightly hypodense lesion, During the arterial phase of dynamic CT, the lesion appeared inhomogeneous and hyperdense with irregular streaky enhancement in the first branch of the left portal vein (Fig. 1a,b), and it became hypodense in the portal venous phase and the delayed phase. A wedge-shaped irregular lowattenuation area near the tumor was shown in the portal venous phase (Fig. 1c). A hypodense area in the medial branch and first branch of the left portal vein was also clearly revealed in the delayed phase (Fig. 1d), suggesting PVTT (VP3)1 with arterioportal (A–P) shunting. Magnetic resonance imaging (MRI) revealed inhomogeneous hypoand hyperintensity on T1and T2-weighted images, respectively. On Feridex (Tanabe Co., Osaka, Japan) enhanced MRI, the lesion showed heterogeneous hyperintensity compared with the surrounding liver parenchyma, suggesting that there were no Kupffer cells within the tumor. Digital subtraction angiography (DSA) showed a hypervascular mass with tumor vessels and tumor stain. In the light of the imaging findings and the markedly elevated levels of tumor markers, a diagnosis of stage IV-A HCC with PVTT was confirmed according to the HCC staging criteria proposed by the Liver Cancer Study Group of Japan.1 Owing to the advanced stage of HCC, resection of the tumor was not advocated. The patient underwent TACE, through the proper hepatic artery, using Lipiodol (3 ml/once) mixed with an anticancer drug (Farmorubicin, 30mg/once) and gelatin sponges, two times, at an interval of 3 weeks. RFA was performed once between the two sessions of TACE for the purpose of mass reduction for intraarterial chemotherapy. No major complications occurred in the patient. CT scans performed 1 month after the last TACE showed that the tumor size and the PVTT were obviously reduced (Fig. 2a,b), with Lipiodol accumulating in the Although great achievements have been made in the treatment of small hepatocellular carcinoma (HCC), management of advanced-stage HCC remains difficult and challenging. We report a patient with stage IV HCC with portal venous tumor thrombus (PVTT) in whom complete response and disappearance of PVTT for more than 2/2 years was achieved after combined therapy of repeated transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA). A 69-year-old man was referred to our hospital for further investigation and treatment of a liver mass detected by abdominal computed tomography (CT). This patient had been diagnosed as having chronic hepatitis C 3 years previously. He had a history of alcohol intake for more than 10 years, and impaired liver function was pointed out during hospitalization for an accidental injury 9 years previously. On physical examination, there were palmar erythema, vascular spider, and hepatomegaly. No jaundice, splenomegaly, ascites, or edema were detected. Liver function tests showed no remarkable abnormalities, except for mild elevation of serum aspartate aminotransferase (AST; 92IU/l) and alanine aminotransferase (ALT; 40IU/l). Test for hepatitis C antibody was positive. Serum levels of tumor markers, including alpha-fetoprotein (AFP), protein induced by vitamin K antagonist-II (PIVKA-II), and lens culinaris agglutinin-reactive AFP (AFP-L3) were all markedly elevated (AFP, 5435ng/ml [normal range, 10 ng/ml]; PIVKA-II, 6830mAU/ml [normal range, 40 mAU/ ml]; AFP-L3, 77.8% [normal range, 10%]). Abdominal ultrasonography (US) and color Doppler imaging revealed a hypoechoic lesion 5cm in diameter in the medial segment of the left liver lobe (segment 4) with pulsatile blood signal within the tumor. Contrastenhanced harmonic US performed by the coded har-

Imaging findings of biliary hamartomas (von Meyenburg complexes)

To evaluate the imaging findings of biliary hamartomas (von Meyenburg complexes, vMCs) and discuss their differential diagnosis from other related diseases, imaging findings of biliary hamartomas on ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and hepatobiliary scintigraphy were prospectively analyzed in six patients. On ultrasound images, five of the six cases showed multiple small hyper- and hypoechoic lesions with comet-tail echoes, especially when magnified using the zoom function. In all six cases, multiple tiny hypodense lesions less than 10 mm in diameter were scattered throughout the liver with no enhancement on CT. These tiny lesions were demonstrated to be hyper- and hypointense on T2- and TI-weighted images, respectively, in three patients who underwent MRI examinations. MRCP was performed in two patients, and it clearly showed multiple tiny round and irregular-shaped hyperintense lesions. MRCP and hepatobiliary scintigraphy showed normal appearances of intra- and extrahepatic bile ducts in two and one patients, respectively. Imaging modalities are useful in the diagnosis and differential diagnosis of vMCs. A correct diagnosis might be obtained when typical imaging findings present even without histological confirmation.

Hepatic angiomyolipoma: identification of an efferent vessel as a hepatic vein by contrast-enhanced harmonic sonography.

Two cases of hepatic angiomyolipoma were studied by contrast-enhanced harmonic sonography. The special tumor hemodynamics, namely the efferent blood flow of the hepatic angiomyolipoma draining into the hepatic vein, were clearly shown on harmonic imaging, and they corresponded well with those seen on angiography and computed tomography during angiography. Benign hepatic tumors were diagnosed preoperatively in both cases according to the hemodynamic findings. Hepatic angiomyolipoma was finally identified histologically. The special tumor hemodynamics might be one of the important characteristics of hepatic angiomyolipoma. Contrast-enhanced harmonic sonography is useful for the detection of special tumor hemodynamics and may facilitate the differential diagnosis from other hepatic tumors, especially malignant liver tumors.

Hemodynamic and morphologic changes of peripheral hepatic vasculature in chronic liver disease : a preliminary study by contrast-enhanced coded phase-inversion harmonic sonography

To investigate whether observing the morphology of the peripheral hepatic vasculature and the hemodynamics of microbubble arrival time in these vessels can provide useful information for the diagnosis of liver disease, Five normal volunteers and 16 patients were studied by contrast-enhanced coded phase-inversion harmonic sonography. Vessel images of the peripheral vessels were observed in real time after intravenous injection of Levovist. The time when the microbubbles appeared in the peripheral vessels was measured. Three patterns of morphologic change of the peripheral hepatic vasculature were seen, marked, slight, and no abnormal changes. The microbubble arrival times at the peripheral vessels were all shorter in patients with cirrhosis than chronic hepatitis or normal subjects. Marked, slight, and no abnormal morphologic changes of the peripheral hepatic vasculature in patients with liver cirrhosis were found in five, one and zero of the six patients, respectively. Those patients with chronic hepatitis, were found in one, six and three of the ten patients, respectively. There was a significant difference among the different groups (P < 0.001). Evaluating the hemodynamics and morphology by contrast-enhanced coded pulse-inversion harmonic sonography may offer useful information in the diagnosis of liver disease.

Hepatobiliary and pancreatic: Inflammatory pseudotumor of the liver

Contributed by Rong Qin Zheng and Masatoshi Kudo, Department of Gastroenterology and Hepatology, Kinki University School of Medicine, 377–2, Ohno-Higashi, Osaka-Sayama, Osaka 589–8511, Japan. Contributions to the Images of Interest Section are welcomed and should be submitted to Professor IC Roberts-Thomson, Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville South, South Australia 5011, Australia.

Spontaneous regurgitation of portal blood flow normalized by meal intake in a patient with alcoholic liver cirrhosis

We report a case with spontaneous regurgitation of portal blood flow (SRPBF) that was normalized by meal intake. A 41-year-old man with long-term alcohol abuse was admitted with a chief complaint of general fatigue. He was diagnosed as having alcoholic liver cirrhosis since his laboratory tests showed the abnormal liver function. Dynamic computed tomography detected numerous portosystemic shunts. Hepatic arterial portography showed the portal vein was narrow and irregular. Color Doppler imaging portrayed the direction of the blood flows in the branches of the portal vein to be retrograde. However, 30 min after meal intake on the same day, color Doppler study showed the direction of the blood flow in the first branch of right and left portal vein became normal. Color Doppler imaging is a useful technique to detect SRPBF and hemodynamic change in portal venous system after meal intake in patient under a completely physiologic condition.