Hepatobiliary phase liver MR imaging findings after Oxaliplatin-based chemotherapy in cancer patients

Imaging features facilitate diagnosis of porto-sinusoidal vascular disorder

OBJECTIVES

Porto-sinusoidal vascular disorder (PSVD) is a recently defined vascular liver disease. Since diagnosis remains challenging, we aimed to evaluate radiological features that are distinct between PSVD and cirrhosis.

METHODS

Clinical, laboratory, and radiological parameters (CT/MRI) of patients with histologically-confirmed PSVD vs. cirrhosis vs. non-cirrhotic parenchymal liver disease were retrospectively evaluated.

RESULTS

Sixty-three PSVD, 155 cirrhosis, and 41 non-cirrhotic patients were included. As compared to cirrhosis, PSVD patients were younger and had lower HVPG, liver stiffness, and MELD. Routine clinical and imaging findings indicative of portal hypertension were similarly common. Intrahepatic portal tract abnormalities (49% vs. 15%; p < 0.001), FNH-like lesions (30% vs. 1%; p < 0.001), and abnormal liver morphology defined as peripheral parenchymal atrophy and compensatory hypertrophy of central segments (32% vs. 7%; p < 0.001) were significantly more common in PSVD patients. Hypertrophy of segment I (70% vs. 84%; p = 0.019), atrophy of segment IV (24% vs. 47%; p = 0.001), and nodular liver surface (22% vs. 89%; p < 0.001) were more common in patients with cirrhosis. In patients with gadoxetic acid-enhanced MRI, we identified the distinct imaging feature of "periportal hyperintensity" in the hepatobiliary phase (HBP) in 42% of patients with PSVD (14/33) vs. 1% in cirrhosis (1/95) vs. 0% in non-cirrhotic controls (0/41); p < 0.001).

CONCLUSIONS

Diagnosis of PSVD must be considered in younger patients presenting with clinical features of portal hypertension, portal tract abnormalities, and FNH-like lesions on CT/MRI. 'Periportal hyperintensity' in the HBP of gadoxetic acid-enhanced MRI was identified as a specific radiological feature of PSVD.

KEY POINTS

• Cross-sectional imaging can provide essential information to identify patients with porto-sinusoidal vascular disorder (PSVD). • Intrahepatic portal tract abnormalities, FNH-like lesions, and abnormal liver morphology are common in PSVD patients. • Periportal hyperintensity on the hepatobiliary phase of gadoxetic acid-enhanced MRI seems to be specific for patients with PSVD.

Multiparametric MRI with MR elastography findings in patients with sinusoidal obstruction syndrome after oxaliplatin-based chemotherapy

Objective

To evaluate the magnetic resonance elastography (MRE)-derived liver stiffness measurement (LSM), T1 and T2 relaxation times, and hepatobiliary phase images in patients, who developed sinusoidal obstruction syndrome (SOS) after oxaliplatin-based chemotherapy.

Methods

Thirty-four patients (M/F:22/12) who underwent liver MRI-MRE and received oxaliplatin for colorectal, gastric, and pancreas cancer were included in the study. SOS was diagnosed by Gd-EOB-DTPA-enhanced MRI in 18 patients. MRE-LSM and T1–T2 maps were evaluated. Patients with SOS were grouped according to the amount of reticular hypointensity on the hepatobiliary phase images.

Results

The mean MRE-LSM in the patients with SOS was 3.14 ± 0.45 kPa, and the control group was 2.6 ± 0.5 kPa (p = 0.01). The mean-corrected T1 (cT1) relaxation time was 1181 ± 151 ms in the SOS group and 1032 ± 129 ms in the control group (p = 0.005). The mean T2 relaxation time was 50.29 ± 3.6 ms in the SOS group and 44 ± 3.9 ms in the control group (p = 0.01). Parenchymal stiffness values were 2.8 ± 0.22 kPa, 3 ± 0.33 kPa, and 3.65 ± 0.28 kPa in patients with mild, moderate, and advanced SOS findings, respectively (p = 0.002). Although cT1 and T2 relaxation times increased with increasing SOS severity, no statistical significance was found.

Conclusions

We observed increased MRE-LSM in patients with SOS after chemotherapy compared to control group. T1 and T2 relaxation times were also useful in diagnosing SOS but were found inadequate in determining SOS severity. MRE is effective in diagnosing SOS and determining SOS severity in patients who cannot receive contrast agents, and it may be useful in the follow-up evaluation of these patients.

Focal nodular hyperplasia after oxaliplatin-based chemotherapy: A diagnostic challenge

Chemotherapy could induce benign liver alterations presenting as diffuse or focal lesions mimicking metastases. Oxaliplatin-induced vascular liver injury is described in literature, but the association with FNH-like lesions has been reported in a limited number of cases. We herewith describe the case of a 67-year-old male, who had laparoscopic right-sided hemicolectomy, 8 years ago, because of colonic adenocarcinoma (pT3N0M0) and subsequent adjuvant chemotherapy (capecitabine + oxaliplatin), who referred to the ultrasound service of our Radiology Unit because of abdominal pain. Five-years follow-up was negative for metastases. Ultrasound examination showed 2 small hypoechoic hepatic nodules, in segment VIII and VII, confirmed at CT, suspected for metastases. FDG-PET was negative, and blood tumor markers were within normal ranges. For further evaluation we performed gadoxetic acid (Gd-EOB-DTPA)-enhanced MRI that showed hyperintensity of the nodules in the hepatobiliary phase with central small hypointensity due to a central scar. Considering the previous oxaliplatin-based chemotherapy the findings were compatible with FNHlike lesions and the diagnostic suspicion was confirmed at ultrasound-guided core needle biopsy. Knowledge of the possible occurrence of FNH-like lesions in oncologic setting, along with the detection of typical MRI appearance, is important for appropriate management and may avoid unnecessary biopsy or surgery and reduce patients’ anxiety.

Newly detected liver nodules with a history of colorectal cancer: are they metastatic? Review of 2,632 cases in a single center

Background

The diagnosis of newly detected liver nodules in patients with colorectal cancer (CRC) is crucial for determining prognosis and treatment. Accurate identification of benign nodules can help avoid unnecessary therapy. The aim of our study was to retrospectively review patients with CRC who underwent liver resection for benign liver nodules misdiagnosed as CRC metastasis (CRLM) in our institution.

Methods

We reviewed all patients with a history of CRC who underwent liver resection from January 2012 to December 2019 in our institution. We specifically focused on nodules pathologically confirmed as benign. The pathology was rechecked by an independent pathologist. The clinicopathological characteristics of these patients were collected. Preoperative imaging examinations, including ultrasound (US), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET-CT) were reviewed.

Results

From 2012 to 2019, a total of 2,632 patients with CRC who were preoperatively diagnosed CRLM received liver resection, among which 2,584 (98.2%) cases were proven to be malignant, and 48 (1.8%) cases were benign. Among these 48 cases, 24 were pathologically confirmed as focal nodular hyperplasia (FNH), 9 were peliosis, 10 were inflammatory lesions, and 5 were hemangioma. At least one preoperative imaging examination indicated CRLM, with a median size of 2.0 cm (range, 0.4–8.0 cm). Before liver resection, ten patients received chemotherapy after the discovery of liver nodules.

Conclusions

It should be noted that newly detected liver nodules in patients with a history of CRC could be benign. Accurate diagnosis of liver nodules in CRC is necessary to avoid overtreatment and to identify cost-effective medication.

Hepatocyte-specific contrast-enhanced MRI findings of focal nodular hyperplasia-like nodules in the liver following chemotherapy in pediatric cancer patients

PURPOSE

We aimed to assess the MRI findings and follow-up of multiple focal nodular hyperplasia (FNH)- like lesions in pediatric cancer patients diagnosed by imaging findings.

METHODS

We retrospectively analyzed clinical data and MRI examinations of 16 pediatric patients, who had been scanned using gadoxetate disodium (n=13) and gadobenate dimeglumine (n=3). Hepatic nodules were reviewed according to their number, size, contour, T1- and T2-weighted signal intensities, arterial, portal, delayed and hepatobiliary phase enhancement patterns. Follow-up images were evaluated for nodule size, number, and appearance.

RESULTS

All 16 patients received chemotherapy in due course. Time interval between the initial diagnosis of cancer and detection of the hepatic nodule was 2-14 years. Three patients had a single lesion, 13 patients had multiple nodules. The median size of the largest nodules was 19.5 mm (range, 8-41 mm). Among 16 patients that received hepatocyte-specific agents, FNH-like nodules appeared hyperintense in 11 and isointense in 5 on the hepatobiliary phase. During follow-up, increased number and size of the nodules were seen in 4 patients. The nodules showed growth between 6-15 mm.

CONCLUSION

Liver MRI using hepatocyte-specific agents is a significant imaging method for the diagnosis of FNH-like lesions, which can occur in a variety of diseases. Lesions can increase in size and number in pediatric patients.

T1 Mapping on Gd-EOB-DTPA-Enhanced MRI for the Prediction of Oxaliplatin-Induced Liver Injury in a Mouse Model

BACKGROUND

Oxaliplatin-induced liver injury (OILI) not only impairs hepatic regeneration but also increases postoperative morbidity and mortality. Therefore, noninvasive, accurate, and early diagnosis of OILI is mandatory.

PURPOSE

To evaluate the potential of T₁ mapping on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI for assessing OILI in a mouse model.

STUDY TYPE

Case control, animal model.

ANIMAL MODEL

Thirty oxaliplatin-treated mice and 10 control mice were included.

FIELD STRENGTH

Volumetric interpolated breath-hold examination sequence: 3T scanner with a phased-array animal 8-channel coil. T₁ mapping before and at hepatobiliary phase (HBP) after injection of Gd-EOB-DTPA were undertaken.

ASSESSMENT

T₁ relaxation times of the liver parenchyma were measured and the reduction rate (ΔT₁ %) was calculated. Histological findings were used as a standard reference.

STATISTICAL TESTS

The Kruskal-Wallis test with pairwise comparisons using the Mann-Whitney U-test were applied to compare the parameters across groups. Spearman's rank correlation test and receiver operating characteristics (ROC) analyses were performed. Areas under the curves (AUCs) were compared using the DeLong method.

RESULTS

Histologically, mice were classified as normal (n = 10), hepatocellular degeneration without fibrosis (n = 16), and hepatocellular degeneration with fibrosis (n = 14). HBP T₁ relaxation time increased with the severity of OILI (rho = 0.60, P < 0.05), and ΔT₁ % decreased with the severity of OILI (rho = -0.78, P < 0.05). AUC was 0.92 for ΔT₁ % in differentiating hepatocellular degeneration without fibrosis from normal liver, but HBP T₁ relaxation time could not distinguish them (P = 0.09). AUCs were 0.96 and 0.95 for HBP T₁ relaxation time, and 0.90 and 0.84 for ΔT₁ % in discriminating OILI with fibrosis from normal liver and OILI without fibrosis.

DATA CONCLUSION

HBP T₁ relaxation time and ΔT₁ % of Gd-EOB-DTPA enhanced MRI was useful for assessing OILI. ΔT₁ % may be more sensitive than HBP T₁ relaxation time in detecting early stage of liver injury.

LEVEL OF EVIDENCE

2.

TECHNICAL EFFICACY STAGE

5.

Current state of the art imaging approaches for colorectal liver metastasis

One of the most common cancers worldwide, colorectal cancer (CRC) has been associated with significant morbidity and mortality and therefore represents an enormous burden to the health care system. Recent advances in CRC treatments have provided patients with primary and metastatic CRC a better long-term prognosis. The presence of synchronous or metachronous metastasis has been associated, however, with worse survival. The most common site of metastatic disease is the liver. A variety of treatment modalities aimed at targeting colorectal liver metastases (CRLM) has been demonstrated to improve the prognosis of these patients. Loco-regional approaches such as surgical resection and tumor ablation (operative and percutaneous) can provide patients with a chance at long-term disease control and even cure in select populations. Patient selection is important in defining the most suitable treatment option for CRLM in order to provide the best possible survival benefit while avoiding unnecessary interventions and adverse events. Medical imaging plays a crucial role in evaluating the characteristics of CRLMs and disease resectability. Size of tumors, proximity to adjacent anatomical structures, and volume of the unaffected liver are among the most important imaging parameters to determine the suitability of patients for surgical management or other appropriate treatment approaches. We herein provide a comprehensive overview of current-state-of-the-art imaging in the management of CRLM, including staging, treatment planning, response and survival assessment, and post-treatment surveillance. Computed tomography (CT) scan and magnetic resonance imaging (MRI) are two most commonly used techniques, which can be used solely or in combination with functional imaging modalities such as positron emission tomography (PET) and diffusion weighted imaging (DWI). Providing up-to-date evidence on advantages and disadvantages of imaging modalities and tumor assessment criteria, the current review offers a practice guide to assist providers in choosing the most suitable imaging approach for patients with CRLM.

Diagnostic value/performance of radiological liver imaging during chemoterapy for gastrointestinal malignancy: a critical review

This article reviews the main toxic effect, complications and relative imaging findings of the liver that may appear during the oncologic follow up among patients affected by gastrointestinal malignancy. Awareness of the causative chemotherapeutic agent and regimens, pathophysiology and relative characteristic imaging findings of hepatic injuries is critical in order to obtain an accurate diagnosis especially when these parenchymal lesions are focal. An accurate synergic radiological diagnosis with Computed Tomography (CT) and Magnetic Resonance (MR) techniques may induce a potential termination of ineffective/toxic chemotherapy during early phases of treatment, changing the therapeutic plan in order to avoid first unnecessary liver biopsy and then invasive treatment as hepatic resection if not required.