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Kutaiba N, Chung W, Goodwin M, Testro A, Egan G, Lim R. The impact of hepatic and splenic volumetric assessment in imaging for chronic liver disease: a narrative review. Insights Imaging 2024; 15:146. [PMID: 38886297 PMCID: PMC11183036 DOI: 10.1186/s13244-024-01727-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 05/26/2024] [Indexed: 06/20/2024] Open
Abstract
Chronic liver disease is responsible for significant morbidity and mortality worldwide. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) can fully visualise the liver and adjacent structures in the upper abdomen providing a reproducible assessment of the liver and biliary system and can detect features of portal hypertension. Subjective interpretation of CT and MRI in the assessment of liver parenchyma for early and advanced stages of fibrosis (pre-cirrhosis), as well as severity of portal hypertension, is limited. Quantitative and reproducible measurements of hepatic and splenic volumes have been shown to correlate with fibrosis staging, clinical outcomes, and mortality. In this review, we will explore the role of volumetric measurements in relation to diagnosis, assessment of severity and prediction of outcomes in chronic liver disease patients. We conclude that volumetric analysis of the liver and spleen can provide important information in such patients, has the potential to stratify patients' stage of hepatic fibrosis and disease severity, and can provide critical prognostic information. CRITICAL RELEVANCE STATEMENT: This review highlights the role of volumetric measurements of the liver and spleen using CT and MRI in relation to diagnosis, assessment of severity, and prediction of outcomes in chronic liver disease patients. KEY POINTS: Volumetry of the liver and spleen using CT and MRI correlates with hepatic fibrosis stages and cirrhosis. Volumetric measurements correlate with chronic liver disease outcomes. Fully automated methods for volumetry are required for implementation into routine clinical practice.
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Affiliation(s)
- Numan Kutaiba
- Department of Radiology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
- The University of Melbourne, Parkville, Melbourne, VIC, Australia.
| | - William Chung
- The University of Melbourne, Parkville, Melbourne, VIC, Australia
- Department of Gastroenterology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Mark Goodwin
- Department of Radiology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Adam Testro
- The University of Melbourne, Parkville, Melbourne, VIC, Australia
- Department of Gastroenterology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Gary Egan
- Monash Biomedical Imaging, Monash University, Clayton, VIC, 3800, Australia
| | - Ruth Lim
- Department of Radiology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- The University of Melbourne, Parkville, Melbourne, VIC, Australia
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Yoo J, Joo I, Jeon SK, Park J, Yoon SH. Utilizing fully-automated 3D organ segmentation for hepatic steatosis assessment with CT attenuation-based parameters. Eur Radiol 2024:10.1007/s00330-024-10660-4. [PMID: 38393403 DOI: 10.1007/s00330-024-10660-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/22/2023] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES To investigate the clinical utility of fully-automated 3D organ segmentation in assessing hepatic steatosis on pre-contrast and post-contrast CT images using magnetic resonance spectroscopy (MRS)-proton density fat fraction (PDFF) as reference standard. MATERIALS AND METHODS This retrospective study analyzed 362 adult potential living liver donors with abdominal CT scans and MRS-PDFF. Using a deep learning-based tool, mean volumetric CT attenuation of the liver and spleen were measured on pre-contrast (liver(L)_pre and spleen(S)_pre) and post-contrast (L_post and S_post) images. Agreements between volumetric and manual region-of-interest (ROI)-based measurements were assessed using the intraclass correlation coefficient (ICC) and Bland-Altman analysis. Diagnostic performances of volumetric parameters (L_pre, liver-minus-spleen (L-S)_pre, L_post, and L-S_post) were evaluated for detecting MRS-PDFF ≥ 5% and ≥ 10% using receiver operating characteristic (ROC) curve analysis and compared with those of ROI-based parameters. RESULTS Among the 362 subjects, 105 and 35 had hepatic steatosis with MRS-PDFF ≥ 5% and ≥ 10%, respectively. Volumetric and ROI-based measurements revealed ICCs of 0.974, 0.825, 0.992, and 0.962, with mean differences of -4.2 HU, -3.4 HU, -1.2 HU, and -7.7 HU for L_pre, S_pre, L_post, and S_post, respectively. Volumetric L_pre, L-S_pre, L_post, and L-S_post yielded areas under the ROC curve of 0.813, 0.813, 0.734, and 0.817 for MRS-PDFF ≥ 5%; and 0.901, 0.915, 0.818, and 0.868 for MRS-PDFF ≥ 10%, comparable with those of ROI-based parameters (0.735-0.818; and 0.816-0.895, Ps = 0.228-0.911). CONCLUSION Automated 3D segmentation of the liver and spleen in CT scans can provide volumetric CT attenuation-based parameters to detect and grade hepatic steatosis, applicable to pre-contrast and post-contrast images. CLINICAL RELEVANCE STATEMENT Volumetric CT attenuation-based parameters of the liver and spleen, obtained through automated segmentation tools from pre-contrast or post-contrast CT scans, can efficiently detect and grade hepatic steatosis, making them applicable for large population data collection. KEY POINTS • Automated organ segmentation enables the extraction of CT attenuation-based parameters for the target organ. • Volumetric liver and spleen CT attenuation-based parameters are highly accurate in hepatic steatosis assessment. • Automated CT measurements from pre- or post-contrast imaging show promise for hepatic steatosis screening in large cohorts.
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Affiliation(s)
- Jeongin Yoo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
- Institute of Radiation Medicine, Seoul National University Medical Research Center Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Sun Kyung Jeon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Junghoan Park
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- MEDICALIP. Co. Ltd., Seoul, Korea
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Jeon SK, Joo I, Park J, Kim JM, Park SJ, Yoon SH. Fully-automated multi-organ segmentation tool applicable to both non-contrast and post-contrast abdominal CT: deep learning algorithm developed using dual-energy CT images. Sci Rep 2024; 14:4378. [PMID: 38388824 PMCID: PMC10883917 DOI: 10.1038/s41598-024-55137-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/20/2024] [Indexed: 02/24/2024] Open
Abstract
A novel 3D nnU-Net-based of algorithm was developed for fully-automated multi-organ segmentation in abdominal CT, applicable to both non-contrast and post-contrast images. The algorithm was trained using dual-energy CT (DECT)-obtained portal venous phase (PVP) and spatiotemporally-matched virtual non-contrast images, and tested using a single-energy (SE) CT dataset comprising PVP and true non-contrast (TNC) images. The algorithm showed robust accuracy in segmenting the liver, spleen, right kidney (RK), and left kidney (LK), with mean dice similarity coefficients (DSCs) exceeding 0.94 for each organ, regardless of contrast enhancement. However, pancreas segmentation demonstrated slightly lower performance with mean DSCs of around 0.8. In organ volume estimation, the algorithm demonstrated excellent agreement with ground-truth measurements for the liver, spleen, RK, and LK (intraclass correlation coefficients [ICCs] > 0.95); while the pancreas showed good agreements (ICC = 0.792 in SE-PVP, 0.840 in TNC). Accurate volume estimation within a 10% deviation from ground-truth was achieved in over 90% of cases involving the liver, spleen, RK, and LK. These findings indicate the efficacy of our 3D nnU-Net-based algorithm, developed using DECT images, which provides precise segmentation of the liver, spleen, and RK and LK in both non-contrast and post-contrast CT images, enabling reliable organ volumetry, albeit with relatively reduced performance for the pancreas.
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Affiliation(s)
- Sun Kyung Jeon
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
- Institute of Radiation Medicine, Seoul National University Medical Research Center Seoul National University Hospital, Seoul, Korea.
| | - Junghoan Park
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | | | | | - Soon Ho Yoon
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
- MEDICALIP. Co. Ltd., Seoul, Korea
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Yang C, Tan J, Chen Y, Wang Y, Qu Y, Chen J, Jiang H, Song B. Prediction of late recurrence after curative-intent resection using MRI-measured spleen volume in patients with hepatocellular carcinoma and cirrhosis. Insights Imaging 2024; 15:31. [PMID: 38302787 PMCID: PMC10834928 DOI: 10.1186/s13244-024-01609-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/08/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Late recurrence of hepatocellular carcinoma (HCC) after liver resection is regarded as a de novo tumor primarily related to the severity of underlying liver disease. We aimed to investigate risk factors, especially spleen volume, associated with late recurrence in patients with HCC and cirrhosis. METHODS We retrospectively analyzed 301 patients with HCC and cirrhosis who received curative resection and preoperative MRI. Patients were followed for late recurrence for at least 2 years. Spleen volume was automatically measured on MRI with artificial intelligence techniques, and qualitative MRI imaging features reflecting tumor aggressiveness were evaluated. Uni- and multivariable Cox regression analyses were performed to identify independent predictors and a risk score was developed to predict late recurrence. RESULTS Eighty-four (27.9%) patients developed late recurrence during follow-up. Preoperative spleen volume was independently associated with late recurrence, and patients with a volume > 370 cm3 had significantly higher recurrence risk (hazard ratio 2.02, 95%CI 1.31-3.12, p = 0.002). Meanwhile, no qualitative imaging features were associated with late recurrence. A risk score was developed based on the APRI score, spleen volume, and tumor number, which had time-dependent area under the curve ranging from 0.700 to 0.751. The risk score at a cutoff of 0.42 allowed for the identification of two risk categories with distinct risk of late recurrence. CONCLUSIONS Preoperative spleen volume on MRI was independently associated with late recurrence after curative-intent resection in patients with HCC and cirrhosis. A risk score was proposed for individualized risk prediction and tailoring of postoperative surveillance strategies. CRITICAL RELEVANCE STATEMENT Spleen volume measured on MRI with the aid of AI techniques was independently predictive of late HCC recurrence after liver resection. A risk score based on spleen volume, APRI score, and tumor number was developed for accurate prediction of late recurrence. KEY POINTS • Preoperative spleen volume measured on MRI was independently associated with late recurrence after curative-intent resection in patients with HCC and cirrhosis. • Qualitative MRI features reflecting tumor aggressiveness were not associated with late recurrence. • A risk score based on spleen volume was developed for accurate prediction of late recurrence and risk stratification.
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Affiliation(s)
- Chongtu Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jia Tan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yidi Chen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yanshu Wang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yali Qu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jie Chen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hanyu Jiang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Bin Song
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China.
- Department of Radiology, Sanya People's Hospital, Sanya, Hainan, China.
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Nasr P, Forsgren M, Balkhed W, Jönsson C, Dahlström N, Simonsson C, Cai S, Cederborg A, Henriksson M, Stjernman H, Rejler M, Sjögren D, Cedersund G, Bartholomä W, Rydén I, Lundberg P, Kechagias S, Leinhard OD, Ekstedt M. A rapid, non-invasive, clinical surveillance for CachExia, sarcopenia, portal hypertension, and hepatocellular carcinoma in end-stage liver disease: the ACCESS-ESLD study protocol. BMC Gastroenterol 2023; 23:454. [PMID: 38129794 PMCID: PMC10734181 DOI: 10.1186/s12876-023-03093-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Liver cirrhosis, the advanced stage of many chronic liver diseases, is associated with escalated risks of liver-related complications like decompensation and hepatocellular carcinoma (HCC). Morbidity and mortality in cirrhosis patients are linked to portal hypertension, sarcopenia, and hepatocellular carcinoma. Although conventional cirrhosis management centered on treating complications, contemporary approaches prioritize preemptive measures. This study aims to formulate novel blood- and imaging-centric methodologies for monitoring liver cirrhosis patients. METHODS In this prospective study, 150 liver cirrhosis patients will be enrolled from three Swedish liver clinics. Their conditions will be assessed through extensive blood-based markers and magnetic resonance imaging (MRI). The MRI protocol encompasses body composition profile with Muscle Assement Score, portal flow assessment, magnet resonance elastography, and a abbreviated MRI for HCC screening. Evaluation of lifestyle, muscular strength, physical performance, body composition, and quality of life will be conducted. Additionally, DNA, serum, and plasma biobanking will facilitate future investigations. DISCUSSION The anticipated outcomes involve the identification and validation of non-invasive blood- and imaging-oriented biomarkers, enhancing the care paradigm for liver cirrhosis patients. Notably, the temporal evolution of these biomarkers will be crucial for understanding dynamic changes. TRIAL REGISTRATION Clinicaltrials.gov, registration identifier NCT05502198. Registered on 16 August 2022. Link: https://classic. CLINICALTRIALS gov/ct2/show/NCT05502198 .
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Affiliation(s)
- Patrik Nasr
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Wallenberg Centre for Molecular Medicine, Linköping University, Linköping, Sweden
| | - Mikael Forsgren
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
- AMRA Medical AB, Linköping, Sweden
| | - Wile Balkhed
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Cecilia Jönsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Nils Dahlström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Christian Simonsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Shan Cai
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Anna Cederborg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Henriksson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Henrik Stjernman
- Department of Internal Medicine, Ryhov Hospital Jönköping, Jönköping, Sweden
| | - Martin Rejler
- Department of Medicine, Höglandssjukhuset Eksjö, Region Jönköping County Council, Jönköping, Sweden
- The Jönköping Academy for Improvement of Health and Welfare, Hälsohögskolan, Jönköping University, Jönköping, Sweden
| | - Daniel Sjögren
- Department of Medicine, Höglandssjukhuset Eksjö, Region Jönköping County Council, Jönköping, Sweden
| | - Gunnar Cedersund
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
- School of Medical Sciences and Inflammatory Response and Infection Susceptibility Centre (iRiSC), Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Wolf Bartholomä
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Ingvar Rydén
- Department of Research, Region Kalmar County, Kalmar, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Peter Lundberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Stergios Kechagias
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Olof Dahlqvist Leinhard
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
- AMRA Medical AB, Linköping, Sweden
| | - Mattias Ekstedt
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.
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Yoo J, Cho H, Lee DH, Cho EJ, Joo I, Jeon SK. Prognostic role of computed tomography analysis using deep learning algorithm in patients with chronic hepatitis B viral infection. Clin Mol Hepatol 2023; 29:1029-1042. [PMID: 37822214 PMCID: PMC10577347 DOI: 10.3350/cmh.2023.0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/08/2023] [Accepted: 08/27/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND/AIMS The prediction of clinical outcomes in patients with chronic hepatitis B (CHB) is paramount for effective management. This study aimed to evaluate the prognostic value of computed tomography (CT) analysis using deep learning algorithms in patients with CHB. METHODS This retrospective study included 2,169 patients with CHB without hepatic decompensation who underwent contrast-enhanced abdominal CT for hepatocellular carcinoma (HCC) surveillance between January 2005 and June 2016. Liver and spleen volumes and body composition measurements including subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and skeletal muscle indices were acquired from CT images using deep learning-based fully automated organ segmentation algorithms. We assessed the significant predictors of HCC, hepatic decompensation, diabetes mellitus (DM), and overall survival (OS) using Cox proportional hazard analyses. RESULTS During a median follow-up period of 103.0 months, HCC (n=134, 6.2%), hepatic decompensation (n=103, 4.7%), DM (n=432, 19.9%), and death (n=120, 5.5%) occurred. According to the multivariate analysis, standardized spleen volume significantly predicted HCC development (hazard ratio [HR]=1.01, P=0.025), along with age, sex, albumin and platelet count. Standardized spleen volume (HR=1.01, P<0.001) and VAT index (HR=0.98, P=0.004) were significantly associated with hepatic decompensation along with age and albumin. Furthermore, VAT index (HR=1.01, P=0.001) and standardized spleen volume (HR=1.01, P=0.001) were significant predictors for DM, along with sex, age, and albumin. SAT index (HR=0.99, P=0.004) was significantly associated with OS, along with age, albumin, and MELD. CONCLUSION Deep learning-based automatically measured spleen volume, VAT, and SAT indices may provide various prognostic information in patients with CHB.
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Affiliation(s)
- Jeongin Yoo
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Heejin Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Ju Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Sun Kyung Jeon
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
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Liang YF, Wang SQ, Pan ZY, Deng ZH, Xie WR. Differentiation between alcohol-associated cirrhosis and hepatitis B-associated cirrhosis based on hepatic complications and psychological symptoms. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2023; 28:37. [PMID: 37213447 PMCID: PMC10199369 DOI: 10.4103/jrms.jrms_187_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/27/2022] [Accepted: 02/16/2023] [Indexed: 05/23/2023]
Abstract
Background The prognosis of and occurrence of complications in patients with different clinical features of cirrhosis differ, and cirrhosis with different etiologies has varying clinical characteristics. The aim of this study was to describe the liver function markers, hepatic complications, and psychological features differentiating patients with hepatitis B virus (HBV) infection-related and alcohol-related cirrhosis. Materials and Methods This was a retrospective and observational study that analyzed the medical data of inpatients with alcohol-related or HBV infection-related cirrhosis from May 2014 to May 2020. Markers of liver function, portal hypertension, and psychological symptoms were compared between the two groups. Results Patients with alcohol-related cirrhosis showed higher Self-Rating Anxiety Scale scores and prevalence of hypoproteinemia, fatty liver, and depression than those with HBV infection-related cirrhosis (all P < 0.05). After adjustment for potential confounders, patients with alcohol-related cirrhosis also showed higher risks of increased total cholesterol (odds ratio [OR] =2.671, 95% confidence interval [CI]: 1.160-6.151, P = 0.021), increased high-density lipoprotein-cholesterol (OR = 2.714, 95% CI: 1.009-7.299, P = 0.048), and fatty liver (OR = 2.713, 95% CI: 1.002-7.215, P = 0.048); however, splenomegaly and splenectomy were significantly associated with HBV infection-related cirrhosis (OR = 2.320, 95% CI: 1.066-5.050, P = 0.034). Conclusion Patients with alcohol-related cirrhosis were more likely to develop hyperlipidemia, fatty liver, and psychological symptoms, whereas those with HBV-related cirrhosis had a higher risk of splenomegaly.
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Affiliation(s)
- Yun-Fang Liang
- Department of Nursing, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Si-Qi Wang
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Zhao-Yu Pan
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Zhi-He Deng
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Wen-Rui Xie
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
- Address for correspondence: Prof. Wen-Rui Xie, Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglinxia Road, Yuexiu, Guangzhou 510000, Guangdong Province, China. E-mail:
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Yu Q, Xu C, Li Q, Ding Z, Lv Y, Liu C, Huang Y, Zhou J, Huang S, Xia C, Meng X, Lu C, Li Y, Tang T, Wang Y, Song Y, Qi X, Ye J, Ju S. Spleen volume-based non-invasive tool for predicting hepatic decompensation in people with compensated cirrhosis (CHESS1701). JHEP Rep 2022; 4:100575. [PMID: 36204707 PMCID: PMC9531280 DOI: 10.1016/j.jhepr.2022.100575] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/14/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background & Aims Non-invasive stratification of the liver decompensation risk remains unmet in people with compensated cirrhosis. This study aimed to develop a non-invasive tool (NIT) to predict hepatic decompensation. Methods This retrospective study recruited 689 people with compensated cirrhosis (median age, 54 years; 441 men) from 5 centres from January 2016 to June 2020. Baseline abdominal computed tomography (CT), clinical features, and liver stiffness were collected, and then the first decompensation was registered during the follow-up. The spleen-based model was designed for predicting decompensation based on a deep learning segmentation network to generate the spleen volume and least absolute shrinkage and selection operator (LASSO)-Cox. The spleen-based model was trained on the training cohort of 282 individuals (Institutions I–III) and was validated in 2 external validation cohorts (97 and 310 individuals from Institutions IV and V, respectively) and compared with the conventional serum-based models and the Baveno VII criteria. Results The decompensation rate at 3 years was 23%, with a 37.6-month median (IQR 21.1–52.1 months) follow-up. The proposed model showed good performance in predicting decompensation (C-index ≥0.84) and outperformed the serum-based models (C-index comparison test p <0.05) in both the training and validation cohorts. The hazard ratio (HR) for decompensation in individuals with high risk was 7.3 (95% CI 4.2–12.8) in the training and 5.8 (95% CI 3.9–8.6) in the validation (log-rank test, p <0.05) cohorts. The low-risk group had a negligible 3-year decompensation risk (≤1%), and the model had a competitive performance compared with the Baveno VII criteria. Conclusions This spleen-based model provides a non-invasive and user-friendly method to help predict decompensation in people with compensated cirrhosis in diverse healthcare settings where liver stiffness is not available. Lay summary People with compensated cirrhosis with larger spleen volume would have a higher risk of decompensation. We developed a spleen-based model and validated it in external validation cohorts. The proposed model might help predict hepatic decompensation in people with compensated cirrhosis when invasive tools are unavailable. Spleen volume is a predictor for decompensation by rapid risk increasement after spleen volume >364 cm3. The spleen-based model revealed incremental prognostic improvement (C-index >0.84). Low-risk patients identified by the spleen-based model had a negligible 3-year risk (≤1%) of decompensation.
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Affiliation(s)
- Qian Yu
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chuanjun Xu
- Department of Radiology, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Qinyi Li
- Department of Radiology, The Affiliated Third Hospital of Jiangsu University, Zhenjiang, China
| | - Zhimin Ding
- Department of Radiology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Yan Lv
- Department of Medical Imaging, Subei People’s Hospital, Medical School of Yangzhou University, Yangzhou, China
| | - Chuan Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yifei Huang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jiaying Zhou
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Shan Huang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Cong Xia
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiangpan Meng
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chunqiang Lu
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yuefeng Li
- Department of Radiology, The Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Tianyu Tang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yuancheng Wang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Song
- MR Scientific Marketing, Siemens Healthineers Ltd., Shanghai, China
| | - Xiaolong Qi
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jing Ye
- Department of Medical Imaging, Subei People’s Hospital, Medical School of Yangzhou University, Yangzhou, China
| | - Shenghong Ju
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Corresponding author. Address: Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China. Tel.: +86-83272121.
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9
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Gadoxetic acid-enhanced MRI-derived functional liver imaging score (FLIS) and spleen diameter predict outcomes in ACLD. J Hepatol 2022; 77:1005-1013. [PMID: 35525337 DOI: 10.1016/j.jhep.2022.04.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Functional liver imaging score (FLIS) - derived from gadoxetic acid-enhanced MRI - correlates with liver function and independently predicts liver-related mortality in patients with chronic liver disease (CLD), while splenic craniocaudal diameter (SCCD) is a marker of portal hypertension. The aim of this study was to investigate the accuracy of a combination of FLIS and SCCD for predicting hepatic decompensation, acute-on-chronic liver failure (ACLF), and mortality in patients with advanced CLD (ACLD). METHODS We included 397 patients with CLD who underwent gadoxetic acid-enhanced liver MRI. The FLIS was calculated by summing the points (0-2) of 3 hepatobiliary-phase features: hepatic enhancement, biliary excretion, and portal vein signal intensity. Patients were stratified into 3 groups according to liver fibrosis severity and presence/history of hepatic decompensation: non-ACLD, compensated ACLD (cACLD), and decompensated ACLD (dACLD). RESULTS SCCD showed excellent intra- and inter-reader agreement. Importantly, SCCD was an independent risk factor for hepatic decompensation in patients with cACLD (per cm; adjusted hazard ratio [aHR] 1.13; 95% CI 1.04-1.23; p = 0.004). Patients with cACLD and a FLIS of 0-3 points and/or a SCCD of >13 cm were at increased risk of hepatic decompensation (aHR 3.07; 95% CI 1.43-6.59; p = 0.004). In patients with dACLD, a FLIS of 0-3 was independently associated with an increased risk of ACLF (aHR 2.81; 95% CI 1.16-6.84; p = 0.02), even after adjusting for other prognostic factors. Finally, a FLIS and SCCD-based algorithm was independently predictive of transplant-free mortality and stratified the probability of transplant-free survival (TFS) in ACLD (p <0.001): FLIS 4-6 and SCCD ≤13 cm (5-year TFS of 84%) vs. FLIS 4-6 and SCCD >13 cm (5-year TFS of 70%) vs. FLIS 0-3 (5-year TFS of 24%). CONCLUSION The FLIS and SCCD are simple imaging markers that provide complementary information for risk stratification in patients with compensated and decompensated ACLD. LAY SUMMARY Magnetic resonance imaging (MRI) can be used to assess the state of the liver. Previously the functional liver imaging score, which is based on MRI criteria, was developed as a measure of liver function and to predict the risk of liver-related complications or death. By combining this score with a measurement of spleen diameter, also using MRI, we generated an algorithm that could predict the risk of adverse liver-related outcomes in patients with advanced chronic liver disease.
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10
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Xiao L, Hu C, Cui H, Li R, Hong C, Li Q, Huang C, Dong Z, Zhu H, Liu L. Splenomegaly in predicting the survival of patients with advanced primary liver cancer treated with immune checkpoint inhibitors. Cancer Med 2022; 11:4880-4888. [PMID: 35599583 PMCID: PMC9761067 DOI: 10.1002/cam4.4818] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/06/2022] [Accepted: 04/25/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND & AIMS Immune checkpoint inhibitors (ICIs) play an increasingly important role in the treatment of primary liver cancer (PLC). Some patients with PLC experience symptoms of splenomegaly. Splenomegaly may affect the efficacy of ICIs due to an imbalance of the immune microenvironment. Currently, there is a lack of evidence on the relationship between splenomegaly and prognosis in patients with PLC treated with ICIs. This study analyzed the relationship between splenomegaly and prognosis in patients with PLC treated with ICIs. METHODS In this retrospective cohort study of 161 patients with PLC treated with ICIs, splenomegaly was diagnosed using computed tomography or magnetic resonance imaging and the impact of splenomegaly on patient survival was analyzed. RESULTS Through univariate and multivariate Cox regression analyses, we determined that splenomegaly was associated with shortened overall survival (p = 0.002) and progression-free survival (p = 0.013) in patients with PLC treated with ICIs. Kaplan-Meier analysis further validated our results. The overall survival and progression-free survival of patients with splenomegaly were significantly shorter than those of patients without splenomegaly (p < 0.01 and p = 0.02, respectively). CONCLUSIONS We concluded that splenomegaly was a predictor of prognosis in patients with PLC treated with ICIs. This is the first study to report this important finding.
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Affiliation(s)
- Lu‐Shan Xiao
- Big Data Center, Nanfang HospitalSouthern Medical UniversityGuangzhouChina,Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Cheng‐Yi Hu
- Big Data Center, Nanfang HospitalSouthern Medical UniversityGuangzhouChina,Department of Infectious Diseases, Guangzhou First People's HospitalSchool of Medicine, South China University of TechnologyGuangzhouChina
| | - Hao Cui
- Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Rui‐Ning Li
- Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Chang Hong
- Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Qi‐Mei Li
- Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Chao‐Yi Huang
- Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Zhong‐Yi Dong
- Department of Radiation Oncology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Hong‐Bo Zhu
- Department of Oncology, The First Affiliated Hospital, Hengyang Medical SchoolUniversity of South ChinaHengyangChina
| | - Li Liu
- Big Data Center, Nanfang HospitalSouthern Medical UniversityGuangzhouChina,Department of Infectious Diseases, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
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11
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Renzulli M, Dajti E, Ierardi AM, Brandi N, Berzigotti A, Milandri M, Rossini B, Clemente A, Ravaioli F, Marasco G, Azzaroli F, Carrafiello G, Festi D, Colecchia A, Golfieri R. Validation of a standardized CT protocol for the evaluation of varices and porto-systemic shunts in cirrhotic patients. Eur J Radiol 2021; 147:110010. [PMID: 34801322 DOI: 10.1016/j.ejrad.2021.110010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of the present study was to propose and validate a standardized CT protocol for evaluating all the types of portosystemic collaterals (P-SC), including gastroesophageal varices and spontaneous portosystemic shunts (SPSS), and to evaluate the prognostic role of portal hypertension CT features for the prediction of the hepatic decompensation risk in cirrhotic patients. METHODS A retrospective cohort study of 184 advanced chronic liver disease who underwent CT scan between January 2014 and December 2017. Patients with an interval > 6 months between the imaging, elastometric, endoscopic and biochemical evaluation were excluded, as well as patients with previous transjugular intrahepatic portosystemic shunt (TIPS), liver transplantation (LT) or terminal medical conditions. Data on liver disease history, co-morbidities, endoscopic and radiologic findings were collected. The incidence of hepatic decompensation and other events, such as portal vein thrombosis, HCC, TIPS placement, LT, death, and its cause, were also recorded. The procedure was performed at baseline and after the administration of contrast agent using a multiphasic technique and bolus tracking. Two senior radiologists working in different centres and a non-expert radiologist reviewed all CT examinations, to evaluate both intra-observer and inter-observer variability of the CT protocol and to obtain an external validation. The radiological variables were evaluated using both univariate and adjusted multivariate competing risk regression models. RESULTS Both intra-observer and inter-observer agreement were excellent in detection and measurement of almost all types of P-SC. The presence of SPSS, a spleen diameter > 16 cm, a portal vein diameter > 17 mm and the presence of ascites resulted independent predictors of decompensation-free survival for cirrhotic patients and were incorporated in an easy-to-use score (AUROC = 0.799, p-value = 0.732) which can the risk of decompensation at 5 years, ranking it as low (11.3%), moderate (35.6%) or high (70.8%). CONCLUSIONS The CT protocol commonly performed during the HCC surveillance program for cirrhotic patients is valid for detecting all types of P-SC. The radiological score identified to predict the decompensation-free survival for cirrhotic patients could be an easy-to-use clinical tool.
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Affiliation(s)
- Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.
| | - Elton Dajti
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Anna Maria Ierardi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano Milan, Italy
| | - Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Matteo Milandri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Benedetta Rossini
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Alfredo Clemente
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138 Naples, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Francesco Azzaroli
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Gianpaolo Carrafiello
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano Milan, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Antonio Colecchia
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
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12
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Jiang W, Li Y, Zhang S, Kong G, Li Z. Association between cellular immune response and spleen weight in mice with hepatocellular carcinoma. Oncol Lett 2021; 22:625. [PMID: 34267817 PMCID: PMC8258616 DOI: 10.3892/ol.2021.12886] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 05/24/2021] [Indexed: 12/29/2022] Open
Abstract
The spleen is an important site for extramedullary hematopoiesis and tumor immunotolerance. Spleen weight varies with tumor progression and may be a predictor of tumor recurrence. However, to the best of our knowledge, the association between spleen weight and tumor progression remains unclear. The present study revealed a novel role for the spleen in predicting the cellular immune response in tumor-bearing mice. A murine H22 subcutaneous hepatoma model was established. The spleen weight and tumor weight were measured. The proportion of immune cells in peripheral blood and spleen were detected by flow cytometry. The results demonstrated that the spleen weight of tumor-bearing mice at day 21 was higher than that of the controls. In addition, spleen weight was identified to be positively correlated with tumor weight. The percentages of CD4+ and CD8+ T lymphocytes in the spleen were decreased at day 21 after tumor cell inoculation, while those of monocytic-like myeloid-derived suppressor cells (M-MDSCs) and CD11b+F4/80+ macrophages were increased at day 21 after tumor cell inoculation. Similarly, the percentage of polymorphonuclear-like MDSCs (PMN-MDSCs) in the spleen of tumor-bearing mice was increased at days 7, 14 and 21 after tumor cell inoculation. Notably, spleen weight was negatively correlated with the percentages of CD4+ and CD8+ T lymphocytes in the spleen, although spleen and tumor weight were positively correlated with the percentages of M-MDSCs and PMN-MDSCs in the spleen. Similarly, the percentages of CD8+ T lymphocytes in the peripheral blood were decreased, and programmed cell death protein 1 expression on CD8+ T lymphocytes was increased at day 21 after tumor cell inoculation. Furthermore, the percentages of M-MDSCs were increased at day 21 and PMN-MDSCs in the peripheral blood were increased at days 7, 14 and 21 after tumor cell inoculation. Additionally, spleen and tumor weight were also positively correlated with the percentages of M-MDSC and PMN-MDSCs in the peripheral blood of tumor-bearing mice. Collectively, the findings of the present study suggested that spleen weight may be a predictor of tumor prognosis, since it was directly correlated with tumor weight and the percentages of M-MDSC and PMN-MDSCs in tumor-bearing mice.
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Affiliation(s)
- Wei Jiang
- Department of Oncology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China.,National and Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Yu Li
- National and Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China.,Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Shuqun Zhang
- Department of Oncology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Guangyao Kong
- National and Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
| | - Zongfang Li
- Department of Oncology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China.,National and Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China.,Key Laboratory of Environment and Disease-Related Gene Ministry of Education, Xi'an Jiaotong University, Xi'an, Shaanxi 710004, P.R. China
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