Yoji Maetani

Expansion of selection criteria for patients with hepatocellular carcinoma in living donor liver transplantation

In the present study, the results of living donor liver transplantation (LDLT) for 125 hepatocellular carcinoma (HCC) patients were analyzed to determine optimal criteria exceeding the Milan criteria (MC) but still with predictably good outcomes. On the basis of pretransplant imaging studies, 70 patients met the MC, and 55 patients did not. Patients who exceeded the MC but presented with ≤10 tumors all ≤5 cm in diameter (n = 30) displayed 5‐year recurrence rates (7.3%) similar to those of patients within the MC (9.7%, P = 0.8787). According to the results of multivariate analysis of risk factors for recurrence among preoperative tumor variables, we have defined the new criteria, namely ≤10 tumors all ≤5 cm in diameter and protein induced by vitamin K absence or antagonist‐II (PIVKA‐II) ≤400 mAU/mL. The 78 patients who met the new criteria showed significantly lower 5‐year recurrence rates (4.9%) than the 40 patients who exceeded them (60.5%, P < 0.0001). Similarly, 5‐year survival rates significantly differed between these groups (86.7% versus 34.4%, respectively; P < 0.0001). In conclusion, selection criteria for patients with HCC undergoing LDLT may be safely extended to ≤10 tumors all ≤5 cm in diameter and PIVKA‐II ≤400 mAU/mL with acceptable outcomes. Liver Transpl 13: 1637–1644, 2007.

Noninvasive evaluation of graft steatosis in living donor liver transplantation

Background. Hepatic steatosis affects graft function as well as postoperative recovery of donors in living donor liver transplantation. Liver macrovesicular steatosis in living donors was assessed using quantitative X-ray computed tomography (CT) analysis and histological examination of intraoperative liver biopsy. Methods. A total of 266 living donors with complete pretransplant CT data and intraoperative “time 0” biopsy were included in the study. Liver biopsy specimen obtained during donor operation was examined for macrovesicular steatosis and was classified as none; mild (<30%); moderate (30%–60%); or severe (>60%). Liver-to-spleen CT attenuation values ratio (L/S ratio) on noncontrast-CT was evaluated for its usefulness as an index of hepatic steatosis in comparison with other parameters including body mass index (BMI) and serum liver function tests (gamma-glutamyl transpeptidase, alanine aminotransferase, aspartate aminotransferase, cholinesterase, and total cholesterol) using receiver operating characteristic (ROC) analysis. Results. Histological grade of macrovesicular steatosis was none in 198 patients (74.4%), mild in 50 (18.8%), moderate in 15 (5.7%), and severe in 3 (1.1%). The median L/S ratios for the respective histological grades were 1.20 (range: 1.00–1.46), 1.12 (0.83–1.37), 1.01 (0.74–1.21), and 0.90 (0.70–0.99) (P<0.0001). The ROC curve for L/S ratio was located closest to the upper left corner, and the area under the curve of L/S ratio was significantly larger than that of any other preoperative variables. Conclusion. L/S ratio calculated from preoperative CT can be a useful tool to discriminate hepatic macrovesicular steatosis. Based on the present results, the optimal cut-off value for L/S ratio to exclude more than moderate steatosis would be 1.1.

Living donor liver transplantation as a second‐line therapeutic strategy for patients with hepatocellular carcinoma

Living donor liver transplantation (LDLT) has evolved to represent an important surgical strategy for patients with hepatocellular carcinoma (HCC). However, due to disadvantages, including donor risks and higher rates of perioperative complications, LDLT has been considered as a second‐line treatment in Japan. The present study retrospectively evaluated clinical outcomes for 93 patients with HCC who underwent LDLT at our institute, including 44 patients who exceeded Milan criteria (MC). A total of 73 patients (78%) displayed a history of previous treatment for HCC using various nontransplant methods. Median follow‐up was 24 months (range, 1–76 months). At 4 years after LDLT, overall patient survival rate was 64%, with similar rates for within‐MC and over‐MC groups (68% vs. 59%, respectively; P = 0.6548). However, cumulative recurrence rate was significantly higher in the over‐MC group than in the within‐MC group (35% vs. 15%, P = 0.0190). Regarding history of conventional treatment for HCC before LDLT, patients who had received only 1–2 previous treatments showed significantly lower recurrence rates than patients with ≥3 treatments (9% vs. 37%, P = 0.0411). In conclusion, LDLT may constitute an optional treatment with a chance of cure for patients with otherwise uncontrolled disease. However, repeated nontransplant treatments for recurrent HCC prior to LDLT may increase the risk of recurrence and impair the survival advantages conferred by LDLT. Liver Transpl 12:912–919, 2006.

Cholangitis and Liver Abscess after Percutaneous Ablation Therapy for Liver Tumors: Incidence and Risk Factors

PURPOSE To determine the risk factors of cholangitis and liver abscess occurring after percutaneous ablation therapy for liver tumors. MATERIALS AND METHODS Between October 1995 and September 2002, 358 patients with 455 liver tumors underwent a total of 683 ablation procedures, such as percutaneous ethanol injection (PEI), percutaneous microwave coagulation (PMC), and radiofrequency (RF) ablation therapy. With a retrospective review of medical records, the rates and outcomes of cholangitis and/or liver abscess occurring after ablation therapy were evaluated. The relationship between cholangitis and/or liver abscess and multiple variables (age, disease, Child-Pugh class, size of nodules, multiplicity of nodules, history of transcatheter arterial embolization, presence of bilioenteric anastomosis, and lack of prophylactic antibiotics administration) were statistically analyzed. RESULTS Cholangitis and/or liver abscess occurred in 10 sessions (1.5%) in 10 patients: six sessions after PEI, three sessions after PMC, and one session after RF ablation. Both cholangitis and liver abscess were noted in seven sessions, cholangitis was noted in two, and liver abscess was noted in one. Six patients recovered, but two developed recurrent cholangitis and liver abscess, one developed lung abscess complicated with liver abscess, and one died of septic shock associated with cholangitis. On stepwise regression analysis, bilioenteric anastomosis was the sole significant predictor of cholangitis and/or liver abscess formation (P <.001; odds ratio = 36.4; 95% CI = 9.67-136.9). CONCLUSION Bilioenteric anastomosis strongly correlated with the development of cholangitis and/or liver abscess after percutaneous ablation therapy. Close posttreatment attention should be paid to this subgroup of patients.

MRI Artifact Reduction and Quality Improvement in the Upper Abdomen with PROPELLER and Prospective Acquisition Correction (PACE) Technique

OBJECTIVE The purpose of this study was to evaluate the effectiveness of the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER [BLADE in the MR systems from Siemens Medical Solutions]) with a respiratory compensation technique for motion correction, image noise reduction, improved sharpness of liver edge, and image quality of the upper abdomen. SUBJECTS AND METHODS Twenty healthy adult volunteers with a mean age of 28 years (age range, 23-42 years) underwent upper abdominal MRI with a 1.5-T scanner. For each subject, fat-saturated T2-weighted turbo spin-echo (TSE) sequences with respiratory compensation (prospective acquisition correction [PACE]) were performed with and without the BLADE technique. Ghosting artifact, artifacts except ghosting artifact such as respiratory motion and bowel movement, sharpness of liver edge, image noise, and overall image quality were evaluated visually by three radiologists using a 5-point scale for qualitative analysis. The Wilcoxons signed rank test was used to determine whether a significant difference existed between images with and without BLADE. A p value less than 0.05 was considered to be statistically significant. RESULTS In the BLADE images, image artifacts, sharpness of liver edge, image noise, and overall image quality were significantly improved (p < 0.001). CONCLUSION With the BLADE technique, T2-weighted TSE images of the upper abdomen could provide reduced image artifacts including ghosting artifact and image noise and provide better image quality.

Living Donor Liver Transplantation for Patients with HCC Exceeding the Milan Criteria: A Proposal of Expanded Criteria

Background: Optimal indications for living donor liver transplantation (LDLT) for patients with hepatocellular carcinoma (HCC) have yet not been established. The aim of the present study was to determine optimal criteria including categories outside the Milan criteria (MC) and still with a predictably good outcome. Patients and Methods: Between February 1999 and December 2007, 136 patients with HCC underwent LDLT. Based on preoperative imaging studies, 74 patients met the MC and 62 did not. Results: Overall patient survival rate at 5 years was 70%. Patients who exceeded MC but presented with ≤10 tumors and all ≤5 cm in diameter (n = 33) displayed similar 5-year recurrence rate to those within MC (7 vs. 10%). Based on the results of multivariate analysis of risk factors for recurrence, we defined new criteria as n ≤10 and all ≤5 cm and PIVKA-II ≤400 mAU/ml. The 5-year recurrence rate for the 83 patients who met the new criteria was significantly lower than for the 44 patients who exceeded them (5 vs. 61%, p < 0.0001). Similarly, patients who met the new criteria showed a significantly better 5-year survival rate (87 vs. 37%, p < 0.0001). Conclusion: The selection criteria may be safely extended up to n ≤10 and all ≤5 cm in diameter and PIVKA-II ≤400 mAU/ml with acceptable outcomes.

Evaluation of motion correction effect and image quality with the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) (BLADE) and parallel imaging acquisition technique in the upper abdomen

To evaluate motion correction effect and image quality in the upper abdomen with the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) (BLADE) and parallel imaging acquisition technique.

Diffusion tensor imaging of kidneys with respiratory triggering: Optimization of parameters to demonstrate anisotropic structures on fraction anisotropy maps

To demonstrate the feasibility of diffusion tensor imaging (DTI) of kidneys with respiratory triggering, and determine the optimal imaging parameters for fraction anisotropy (FA) maps.

Background and clinical impact of tissue congestion in right-lobe living-donor liver grafts: a magnetic resonance imaging study.

Background. Although right‐lobe liver grafts from living donors have been widely accepted as an option for adult patients, impact of middle hepatic vein (MHV) deprivation is a recent controversy. Methods. Fifty recipients of right‐lobe living‐donor liver grafts without MHV or drainage reconstruction in anterior segment were evaluated for posttransplant tissue congestion with T2‐weighted magnetic resonance imagings. Age of recipients and donors ranged from 19 to 69 (median 50) and 19 to 64 (46) years, respectively. Graft‐to‐recipient weight ratio ranged from 0.74% to 1.66% (1.06%). Cavoplasty was provided during right hepatic vein reconstruction to avoid anastomotic stricture. Results. Congestion was observed in 88% of segments V and 85% of segments VIII in the first month. Congestion positively correlated with anatomic dependency on MHV. Also, donors were significantly older in age in grafts with more congestion. However, congestion improved within several months in most grafts. Graft congestion was associated neither with morbidities nor with graft loss except for temporary correlation with ascites production in the third and fourth posttransplant weeks. Conclusion. A significant proportion of right‐lobe liver grafts without MHV experience morphologic congestion of the anterior segment in the early phase after transplantation, which is dependent on venous anatomy and donor age. However, the congestion spontaneously resolves in most cases. These results suggest that reconstruction of drainage vein(s) from the anterior segment is not necessary for all grafts provided good outflow through compensatory routes is secured. Additional reconstruction may be indicated in grafts with marginal size, anatomy, and quality.

MRI of the female pelvis at 3T compared to 1.5T: Evaluation on high‐resolution T2‐weighted and HASTE images

To evaluate the feasibility of MRI of the female pelvis using high‐resolution T2‐weighted imaging (T2WI) and the half‐Fourier acquisition single‐shot turbo spin‐echo (HASTE) technique at 3 Tesla (T) compared to 1.5T, while focusing on the uterine body and cervical anatomy.