Noncirrhotic portal hypertension due to peripheral T-cell lymphoma, not otherwise specified: A case report

BACKGROUND

Peripheral T-cell lymphoma (PTCL), an aggressive and rare disease that belongs to a heterogeneous group of mature T-cell lymphomas, develops rapidly and has a poor prognosis. Early detection and treatment are essential to improve patient cure and survival rates. Here, we report a rare case of PTCL with clinical presentation of noncirrhotic portal hypertension, which provides a basis for early vigilance of lymphomas in the future.

CASE SUMMARY

A 65-year-old Chinese woman was admitted to our hospital because of abdominal distension for 3 months and pitting oedema of both lower limbs for 2 months. Physical examinations and associated auxiliary examinations showed the presence of hepatosplenomegaly, and her hepatic venous pressure gradient was 10 mmHg. Immunohistochemical analysis of the liver biopsy confirmed the diagnosis of PTCL. The patient underwent combination therapy with dexamethasone, VP-16, and chidamide. Unfortunately, after 41 days of chemotherapy, the patient died of multiple organ failure.

CONCLUSION

PCTL accompanied by noncirrhotic portal hypertension is rarely reported. This case report discusses the diagnosis of a patient according to the literature.

Conspicuousness and recurrence related factors of ultrasound-guided microwave ablation in the treatment of benign thyroid nodules

Objective

Microwave ablation (MWA) is a minimally invasive technique for the treatment of benign thyroid nodules. The purpose of this study was to evaluate efficacy and safety of ultrasound-guided MWA in the treatment of benign thyroid nodules, and to find out the recurrence related factors, so as to provide reference for future clinical work.

Methods

This study retrospectively analyzed the patients who received ultrasound-guided MWA for benign thyroid nodules in our hospital from October 2018 to March 2020. A total of 214 patients were included in the study. We assessed thyroid volume changes (represented by volume reduction ratio VRR), the energy per 1 mL reduction in nodular volume (represented by energy volume ratio ΔE), the serum levels of free triiodide thyroid hormone (FT3), free thyroxine (FT4), thyrotropin (TSH) and complications after MWA treatment.

Results

There were a total of 306 nodules in 214 patients, including 183 (85.51%) females and 31 (14.49%) males. The median diameter and volume of the nodule were 33 mm and 8.01 mL. The VRR at 1 month, 3 months, 6 months and 12 months were 40.79%, 60.37%, 74.59% and 85.60%, respectively. In addition, MWA had a better ablation effect for small nodules (initial volume ≤ 10 mL). In recurrent studies, we found that ΔE was an independent risk factor for benign thyroid nodules (P < 0.05).

Conclusions

Ultrasound-guided MWA is effective and safe in the treatment of benign thyroid nodules. In addition, it has little damage to surrounding tissues and no effect on thyroid function. Especially, the nodules with smaller initial volume, the treatment is better. On the other hand, the energy per 1 mL reduction ΔE in nodular volume may be associated with nodular recurrence, which requires further follow-up for longer periods. At this stage, we consider that ultrasound-guided MWA can be used as one of the main clinical treatment methods for benign thyroid nodules.

Diagnostic Accuracy of CEUS LI-RADS for the Characterization of Liver Nodules 20 mm or Smaller in Patients at Risk for Hepatocellular Carcinoma

Background American College of Radiology contrast agent-enhanced US Liver Imaging Reporting and Data System (CEUS LI-RADS) was developed to improve the accuracy of hepatocellular carcinoma (HCC) diagnosis at contrast agent-enhanced US. However, to the knowledge of the authors, the diagnostic accuracy of the system in characterization of liver nodules 20 mm or smaller has not been fully evaluated. Purpose To evaluate the diagnostic accuracy of CEUS LI-RADS in diagnosing HCC in liver nodules 20 mm or smaller in patients at risk for HCC. Materials and Methods Between January 2015 and February 2018, consecutive patients at risk for HCC presenting with untreated liver nodules 20 mm or less were enrolled in this retrospective double-reader study. Each nodule was categorized according to the CEUS LI-RADS and World Federation for Ultrasound in Medicine and Biology (WFUMB)-European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) criteria. Diagnostic performance of CEUS LI-RADS and WFUMB-EFSUMB characterization was evaluated by using tissue histologic analysis, multiphase contrast-enhanced CT and MRI, and imaging follow-up as reference standard and compared by using McNemar test. Results The study included 175 nodules (mean diameter, 16.1 mm ± 3.4) in 172 patients (mean age, 51.8 years ± 10.6; 136 men). The sensitivity of CEUS LR-5 versus WFUMB-EFSUMB criteria in diagnosing HCC was 73.3% (95% confidence interval [CI]: 63.8%, 81.5%) versus 88.6% (95% CI: 80.9%, 94%), respectively (P < .001). The specificity of CEUS LR-5 versus WFUMB-EFSUMB criteria was 97.1% (95% CI: 90.1%, 99.7%) versus 87.1% (95% CI: 77%, 94%), respectively (P = .02). No malignant lesions were found in CEUS LR-1 and LR-2 categories. Only two nodules (of 41; 5%, both HCC) were malignant in CEUS LR-3 category. The incidences of HCC in CEUS LR-4, LR-5, and LR-M were 48% (11 of 23), 98% (77 of 79), and 75% (15 of 20), respectively. Two of 175 (1.1%) histologic analysis-confirmed intrahepatic cholangiocarcinomas were categorized as CEUS LR-M by CEUS LI-RADS and misdiagnosed as HCC by WFUMB-EFSUMB criteria. Conclusion The contrast-enhanced US Liver Imaging Reporting and Data System (CEUS LI-RADS) algorithm was an effective tool for characterization of small (≤20 mm) liver nodules in patients at risk for hepatocellular carcinoma (HCC). Compared with World Federation for Ultrasound in Medicine and Biology-European Federation of Societies for Ultrasound in Medicine and Biology criteria, CEUS LR-5 demonstrated higher specificity for diagnosing small HCCs with lower sensitivity. Published under a CC BY 4.0 license. See also the editorial by Crocetti in this issue.

The preliminary application of liver imaging reporting and data system (LI-RADS) with contrast-enhanced ultrasound (CEUS) on small hepatic nodules (≤ 2cm)

To evaluate the diagnostic accuracy of liver imaging reporting and data system (LI-RADS) with contrast-enhanced ultrasound (CEUS) for patients at risk for hepatocellular carcinoma with hepatic nodules (≤2cm). We retrospectively evaluated 56 CEUS exam records of hepatic nodules (≤2cm) performed between January 2015 and July 2016 at West China hospital. Each nodule was classified into a LI-RADS-CEUS category by two radiologists according to imaging features. The ultimate CEUS categories were then compared with pathological reports and their correlation was then calculated. Inter-observer agreement for LI-RADS between reader A and B was κ, 0.690, illustrating good consistency. The diagnostic accuracy of LR-5 on hepatocellular carcinoma (HCC) was 86.49% but 11.11% for LR-M. LI-RADS-CEUS is a potential standardized categorization system for high-risk HCC patients but might also increase the false-negative diagnosis of nodules of less than 2cm.

Comparison of three cut-offs to diagnose clinically significant portal hypertension by liver stiffness in chronic viral liver diseases: a meta-analysis

BACKGROUND

Transient elastography-based liver stiffness value (TE-LSV) has been investigated for assessing clinically significant portal hypertension (CSPH). The aetiology of CSPH is an important factor determining TE-LSV. There is insufficient evidence for selecting cut-off values.

AIMS

This study performed a meta-analysis to compare the three most widely used cut-off values (around 13.6 kPa, 18 kPa and 22kPa) of TE-LSV for the diagnosis of CSPH in patients with chronic viral liver disease.

METHODS

The PubMed, Ovid, Web of Science and Cochrane Library databases were searched. Diagnostic data for cut-off values around 13.6 kPa, 18 kPa and 22 kPa in each included study were extracted. The bivariate model was performed to estimate pooled sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-).

RESULTS

Eleven studies assessing 910 patients were included in this meta-analysis. Pooled sensitivities of cut-off values around 13.6 kPa, 18 kPa and 22 kPa were 0.96 (95% CI 0.93-0.97), 0.85 (0.81-0.89) and 0.74 (0.66-0.80), respectively; pooled specificities were 0.60 (0.47-0.75), 0.80 (0.71-0.87) and 0.94 (0.86-0.97), respectively. Pooled LR+ values were 2.4 (1.6-3.7), 4.4 (2.9-6.8) and 11.5 (5.5-23.5) for cut-off values around 13.6 kPa, 18 kPa and 22 kPa, respectively, for pooled LR- values of 0.07 (0.04-0.13), 0.17 (0.12-0.25) and 0.28 (0.22-0.36), respectively.

CONCLUSION

Cut-off values around 13.6 kPa (high sensitivity) and 22 kPa (high specificity) could be used as screening and confirmation tools, respectively, in the diagnosis of CSPH. Overall, the cut-off value around 22 kPa showed the best performance.

KEY POINTS

Transient elastography-based liver stiffness could be used to diagnose portal hypertension. Comparison of certain cut-off values would provide more information for clinical decision-making. Cut-off around 13.6 kPa was able to exclude clinically significant portal hypertension (CSPH) effectively. Cut-off around 22 kPa was able to confirm CSPH effectively.

Delayed hepatic rupture post ultrasound-guided percutaneous liver biopsy: A case report

RATIONALE

Hemorrhage, one of complications after liver biopsy, is often identified immediately after the procedure while delayed liver rupture is relatively rare.

PATIENT CONCERNS

A 45-year-old woman was diagnosed with undetermined liver cirrhosis and abnormal liver function. To determine the etiology and severity of liver cirrhosis, ultrasound-guided liver biopsy was arranged. The patients did not complain any pain during the procedure. Ultrasound examination on postoperative day1 (POD 1) and MRI on POD 3 showed no evidence of hematoma and ascites. On POD 7, however, the patient was taken to the hospital with a sudden onset of pain in the right upper quadrant of the abdomen.

DIAGNOSES

Contrast-enhanced computed tomography revealed liver rupture of right inferior segment of the liver with subcapsular hematoma.

INTERVENTIONS

Patient was treated with infusion of 2-unit red blood cell suspension, fluid and hemostatics.

OUTCOMES

The vital signs of the patient were stabilized after the therapy. The follow-up ultrasound 1 month later showed a shrunken subcapsular hematoma measuring 4.2 × 2.1 cm at the right lobe.

LESSONS

Whenever a liver biopsy procedure is performed, the care should be taken to avoid puncturing those areas that may have liver incisure. Moreover, the patient need to rest for several days and to avoid heavy activities, which is one of the major risk factors for post-procedure bleeding.

Assessment of impact factors on shear wave based liver stiffness measurement

Shear wave based ultrasound elastographies have been implemented as non-invasive methods for quantitative assessment of liver stiffness. Nonetheless, there are only a few studies that have investigated impact factors on liver stiffness measurement (LSM). Moreover, standard examination protocols for LSM are still lacking in clinical practice. Our study aimed to assess the impact factors on LSM to establish its standard examination protocols in clinical practice. We applied shear wave based elastography point quantification (ElastPQ) in 21 healthy individuals to determine the impact of liver location (segments I-VIII), breathing phase (end-inspiration and end-expiration), probe position (sub-costal and inter-costal position) and examiner on LSM. Additional studies in 175 healthy individuals were also performed to determine the influence of gender and age on liver stiffness. We found significant impact of liver location on LSM, while the liver segment V displayed the lowest coefficient of variation (CV 21%). The liver stiffness at the end-expiration was significantly higher than that at the end-inspiration (P=2.1E-05). The liver stiffness was 8% higher in men than in women (3.8 ± 0.7 kPa vs. 3.5 ± 0.4 kPa, P=0.0168). In contrast, the liver stiffness was comparable in the different probe positions, examiners and age groups (P>0.05). In conclusion, this study reveals significant impact from liver location, breathing phase and gender on LSM, while furthermore strengthening the necessity for the development of standard examination protocols on LSM.