Value of computed tomography and magnetic resonance imaging for assessing severity of liver cirrhosis secondary to viral hepatitis

A hemodynamic study of the relationship between the left and right liver volumes and the blood flow distribution in portal vein branches

BACKGROUND

Cirrhosis patients often exhibit clinical symptoms such as right liver atrophy, portal hypertension, spleen enlargement and increased blood supply, which exhibit considerable variation between the left and right liver sections. These differences are hypothesized to stem from disparities in blood flow within the left and right portal vein (PV) branches. However, rigorous quantitative evidence remains scarce.

PURPOSE

We mainly aim at quantitatively revealing the relationship between the blood flow rates of two PV branches and liver volumes, and providing quantitative evidence and theoretical support for the diagnosis and treatment of cirrhosis from the perspective of hemodynamics.

METHODS

Five cirrhotic patients and two healthy volunteers from Beijing Friendship Hospital are investigated. Their PV blood flow models are established based on computed tomography (CT) images and finite volume simulations. The volume of the left and right liver lobes are measured in 3-matic. The distributions of blood source in the PV branches are tracked by streamline analysis. The blood flow rates are quantitatively counted by integrating the blood source velocities. Linear analysis is performed to build the relationship between liver volumes and PV blood flow distributions.

RESULTS

Streamline analysis reveals significant differences in blood distribution between the left and right PV branches. The majority of blood from the superior mesenteric vein (SMV) flowed into the right portal vein (RPV), while most blood from the splenic vein (SV) entered the left portal vein (LPV). The main PV pressure drop linearly increases with the SV blood velocity for all PV structures of patients and healthy volunteers. The flow rate ratio QRPV/QLPV demonstrates an increase in tandem with the volume ratio VR/VL, exhibiting a linear correlation with the Pearson correlation coefficient being 0.93.

CONCLUSION

The differences in the blood distributions are consistent with the clinicians' knowledge and validate our simulations. We demonstrated a linear increase in PV pressure with elevated SV blood velocity. Additionally, the volumes of the left and right hepatic lobes exhibited a positive correlation with blood flow rates in the corresponding PV branches.

Lower Ratio of Liver Volume and Body Weight Is a Negative Predictor of Survival after Transjugular Intrahepatic Portosystemic Shunt

Transjugular intrahepatic portosystemic shunt (TIPS) is the most effective measure to treat complications of portal hypertension. However, liver function may deteriorate after TIPS. Predictors of liver function and outcome after TIPS are therefore important for management of TIPS patients. The study aimed to evaluate the impact of liver volume on transplant-free survival (TFS) after TIPS, as well as the evolution of liver volume and its relationship with liver function after TIPS. A retrospective analysis of all consecutive patients who underwent TIPS in a tertiary care university liver center between 2012 and 2017 (n = 216) was performed; n = 72 patients with complete prior and follow-up (FU) computed tomography (CT) imaging studies were included in the study. Volumetry of the liver was performed by a semi-automatic 9-lobe image segmentation algorithm at baseline and FU (FU 1: 90–180 d; FU 2: 180–365 d; FU 3: 365–545 d; FU 4: 545–730 d; FU 5: >730 d). Output variables were total liver volume (TLV, cm³), left liver volume (LLV, cm³), right liver volume (RLV, cm³) and TLV/body weight ratio. CT derived liver volumes were correlated with liver function tests, portosystemic pressure gradient (PPG) measurements and survival. To assess predictors of liver volume change over time we fitted linear mixed models. Kaplan–Meier analysis was performed and validated by matched pair analysis followed by Cox regression to determine independent prognostic factors for survival. The median TLV at baseline was 1507.5 cm³ (773.7–3686.0 cm³). Livers with higher baseline liver volumes and larger TLV/weight ratios retained their volume after an initial loss while smaller livers continuously lost volume after TIPS. At the first follow-up period (90–180 d post-TIPS) lower liver volumes and TLV/weight ratios were associated with higher bilirubin levels. Within the final multivariable model containing time (days since TIPS), baseline INR and baseline TLV, the average loss of liver volume was 0.74 mL per day after TIPS. Twelve-month overall transplant-free survival was 89% and median overall TFS was 33 months. The median TFS for a baseline TLV/body weight ratio > 20 was significantly higher compared with ≤20 (40.0 vs. 27.0 months, p = 0.010) while there were no differences regarding the indication for TIPS or etiology of liver disease in the matched pair analysis. Lower TLV/weight ratios before TIPS were associated with shorter TFS and should therefore be critically considered when selecting patients for TIPS. In addition, this study provides first evidence of an effect of TIPS on subsequent liver volume change and associated liver function.

Porto-sinusoidal vascular disease with portal hypertension versus liver cirrhosis: differences in imaging features on CT and hepatobiliary contrast-enhanced MRI

PURPOSE

To differentiate the computed tomography (CT) and magnetic resonance imaging (MRI) features of porto-sinusoidal vascular disease (PSVD) and liver cirrhosis (LC).

METHODS

In this retrospective case-control study of patients with PSVD matched in a 1:3 ratio with LC patients according to liver function, initial diagnosis and time to final diagnosis were analyzed. Imaging features on CT and the parenchymal enhancement on hepatobiliary phase of hepatobiliary agent-enhanced MRI (HBA-MRI) were compared using a generalized linear mixed model. Focal hepatic lesions in the PSVD group were analyzed.

RESULTS

In total, 43 PSVD patients and 129 LC patients were included. Among PSVD patients, 72.1% were initially misdiagnosed with LC. PSVD patients had a longer diagnostic delay than LC patients (32 months vs. 4 months; p < 0.001). Liver surface nodularity was less common in the PSVD group than in the LC group (16.3% vs. 89.2%, p < 0.001). Increased caudate-to-right lobe ratio, heterogeneous parenchymal enhancement, and portal vein abnormalities were more frequently noted in the PSVD group than in the LC group (all p < 0.001). The grade of portal hypertension was significantly higher in the PSVD group than in the LC group (p < 0.001), and they also had brighter parenchymal enhancement during the hepatobiliary phase of HBA-MRI (p < 0.001). In the PSVD group, 14% patients had at least one focal hepatic lesion, primarily a focal nodular hyperplasia (FNH)-like nodule.

CONCLUSIONS

Some imaging features on CT and HBA-MRI can distinguish PSVD from LC. Benign focal lesions, most commonly FNH-like nodules, can develop in PSVD.

CT and MR imaging findings of the livers in adults with Fontan palliation: an observational study

PURPOSE

To describe liver imaging findings and complications on computed tomography (CT) or magnetic resonance imaging (MRI) in adults with Fontan palliation and investigate whether imaging features show correlations with clinical and physiological parameters.

METHODS

Our Institutional Review Board approved this retrospective study. Two blinded abdominal radiologists reviewed abdominal CT (n = 21) and MRI (n = 16) images between September 2011 and October 2017 in 37 adults (median age 27 years, interquartile range 21-36 years, 14 males [38%]) with a Fontan palliation (median post-Fontan duration 22 years, interquartile range 19-28 years). Correlation between CT/MRI findings and clinical parameters including laboratory results within 6 months of CT/MRI examinations was assessed by Spearman's rank correlation coefficient.

RESULTS

Lobulated hepatic surface and blunt hepatic edge were seen in 92% (34/37) and 95% (35/37) of patients, respectively. Surface nodularity was noted in 32% (12/37). In 7 patients, there were 11 hepatic nodules which showed arterial-phase hyperenhancement and washout. Among them, 2 were biopsy-proven hepatocellular carcinomas (HCCs), and the remaining 9 were focal nodular hyperplasia (FNH)-like nodules. Suprahepatic inferior vena cava (IVC) diameter showed positive correlations with post-Fontan duration (p < 0.01), serum gamma-glutamyl transferase (p < 0.01), and total bilirubin (p < 0.01).

CONCLUSION

The livers in post-Fontan adults show a unique morphology of blunt edge and lobulating surface with occasional nodularity. There is a diagnostic challenge in distinguishing HCCs from FNH-like nodules in post-Fontan population due to overlapping imaging findings. Suprahepatic IVC diameter is a potentially useful imaging marker that reflects hepatic dysfunction in Fontan palliation.

Liver volume index predicts the risk of esophageal variceal hemorrhage in cirrhotic patients on propranolol prophylaxis

BACKGROUND/AIMS

Non-selective β-blockers (NSBBs) are used for primary prevention of esophageal variceal hemorrhage (VH) in patients with portal hypertension, but a significant number of patients develop VH while on NSBB therapy. In this study, we sought to determine whether liver volume can predict the risk of primary prophylaxis failure in cirrhotic patients on NSBB therapy.

METHODS

A retrospective cohort of 309 patients on prophylactic propranolol was analyzed. Liver volume was measured in portal venous phase images of multidetector computed tomography. Predictors of VH were assessed using a Cox proportional hazards model with competing-risks analysis. A nomogram was developed for estimation of the risk of primary prophylaxis failure.

RESULTS

During a median follow-up of 36 months, 37 patients on propranolol developed VH. Liver volume index, the ratio of measured-to-expected liver volume, was an independent predictor of VH (adjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.37 to 5.33; p = 0.004) as were the presence of large varices and the absence of ascites. A nomogram-based volume score of > 0.6 was predictive of prophylaxis failure (HR, 7.54; 95% CI, 2.88 to 19.73; p < 0.001). Time-dependent receiver operating characteristic curve analysis revealed that a nomogram-based risk score had significantly better discriminatory power than the North Italian Endoscopy Club index in predicting prophylaxis failure at 6 and 8 years.

CONCLUSION

Liver volume index is an independent predictor of first VH and a nomogram-based volume score stratifies the VH risk in cirrhotic patients on propranolol prophylaxis.

Importance of Multislice Computed Tomography in Determining the Severity of Chronic Liver Disease State

BACKGROUND

In the present study, we aimed to put forward the relationship between multidetector computed tomography findings and scores for liver function evaluation.

METHOD

Included in the study were 51 patients with liver cirrhosis. Preoperative creatinine levels, international normalized ratio and alpha-fetoprotein values, albumin and sodium levels, the presence of ascites and varices, Model for End-Stage Liver Disease (MELD) scores, MELD-Sodium (MELD-Na) scores, and Child-Turcotte-Pugh Classification, the presence of ascites and varices, the size of liver, the size and diameter of the spleen, portal vein diameter, splenic artery diameter, and proper hepatic and right hepatic artery diameter were all determined.

RESULTS

Although the correlation between the spleen diameter and the MELD scores (P <.001) and MELD-Na scores (P = .02) was strong, there was no association with the Child-Turcotte-Pugh Classification (P = .08). Despite the correlations between portal vein diameter (P = .04) and splenic artery diameter (P = .04) and MELD scores, no association was detected with MELD-Na scores and the Child-Pugh scores. Even though a negative correlation between proper hepatic artery diameter (P = .18) and MELD-Na scores was noted, no statistically significant correlation could be identified with any scoring systems. In the multivariate linear regression analyses, the correlation between the portal vein diameter and MELD scores was significant as a radiologic finding. In the multiple linear regression analyses, the negative correlation between the right hepatic artery and MELD-Na scores diameter was statistically significant. In the multiple linear regression analyses, there was no statistically significant correlation between preoperative radiologic findings and Child-Turcotte-Pugh Classification.

CONCLUSION

We believe that preoperative multislice computed tomography imaging in patients with chronic liver disease may contribute to the diagnosis of disease, the determination of vascular anomalies, and the grading of the severity of the disease.

Assessing liver function: diagnostic efficacy of parenchymal enhancement and liver volume ratio of Gd-EOB-DTPA-enhanced MRI study during interstitial and hepatobiliary phase

AIM

To assess the efficacy of signal intensity in interstitial and hepatobiliary phase normalized for liver volume, on gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) study, for the evaluation of liver function through the comparison with Child-Pugh (CP), model for end-stage liver disease (MELD), and biochemical tests.

METHODS

All dynamic Gd-EOB-DTPA MRI studies performed in patients with suspected liver lesions were retrospectively reviewed. The rate of liver-to-muscle ratio on T1 sequence 70 s (interstitial phase) and 20 min (hepatobiliary phase) after injection of Gd-EOB-DTPA was calculated for each MRI study and then normalized for liver volume (irINTnorm and irHEPnorm). Pearson correlation coefficient was computed to assess the correlation among these values and CP and MELD scores, and biochemical tests.

RESULTS

A total of 303 MRI studies, performed on 221 patients, were included. Mean age was 63.8 years ± 12.9 with a majority of male patients (186; 61.4%). A total of 186 out of 303 (61.4%) were cirrhotic patients. The irHEPnorm was significantly lower in cirrhotic than non-cirrhotic patients (0.0004 ± 0.0002 to 0.0005 ± 0.0003, p = 0.010). This value had a moderate, significant correlation with Child-Pugh and MELD scores (R = - 0.292, p < 0.0001 and R = - 0.192, p = 0.010, respectively). In particular, irHEPnorm progressively decreased from Child-Pugh A to C (0.0004-0.0002, p < 0.0001) and from MELD ≤ 10 to 19-24 (0.0004-0.0003, p = 0.018). Among biochemical parameters, total bilirubin, GOT, and albumin had the strongest correlation with irHEPnorm (R = - 0.258, - 0.291, and 0.262, p < 0.0001, respectively). No correlations were found between irINTnorm and CP and MELD scores.

CONCLUSION

irHEPnorm value derived from Gd-EOB-DTPA-enhanced MRI is a reliable, non-invasive, useful tool to quantify liver function and to assess the degree of cirrhosis, offering a strict relationship with clinical scores and biochemical parameters. This could help surgeons in clinical decision-making, allowing them to choose the more suitable surgical approach for cirrhotic patients.

Precision analysis of a quantitative CT liver surface nodularity score

PURPOSE

To evaluate precision of a software-based liver surface nodularity (LSN) score derived from CT images.

METHODS

An anthropomorphic CT phantom was constructed with simulated liver containing smooth and nodular segments at the surface and simulated visceral and subcutaneous fat components. The phantom was scanned multiple times on a single CT scanner with adjustment of image acquisition and reconstruction parameters (N = 34) and on 22 different CT scanners from 4 manufacturers at 12 imaging centers. LSN scores were obtained using a software-based method. Repeatability and reproducibility were evaluated by intraclass correlation (ICC) and coefficient of variation. Using abdominal CT images from 68 patients with various stages of chronic liver disease, inter-observer agreement and test-retest repeatability among 12 readers assessing LSN by software- vs. visual-based scoring methods were evaluated by ICC.

RESULTS

There was excellent repeatability of LSN scores (ICC:0.79-0.99) using the CT phantom and routine image acquisition and reconstruction parameters (kVp 100-140, mA 200-400, and auto-mA, section thickness 1.25-5.0 mm, field of view 35-50 cm, and smooth or standard kernels). There was excellent reproducibility (smooth ICC: 0.97; 95% CI 0.95, 0.99; CV: 7%; nodular ICC: 0.94; 95% CI 0.89, 0.97; CV: 8%) for LSN scores derived from CT images from 22 different scanners. Inter-observer agreement for the software-based LSN scoring method was excellent (ICC: 0.84; 95% CI 0.79, 0.88; CV: 28%) vs. good for the visual-based method (ICC: 0.61; 95% CI 0.51, 0.69; CV: 43%). Test-retest repeatability for the software-based LSN scoring method was excellent (ICC: 0.82; 95% CI 0.79, 0.84; CV: 12%).

CONCLUSION

The software-based LSN score is a quantitative CT imaging biomarker with excellent repeatability, reproducibility, inter-observer agreement, and test-retest repeatability.

Prognostic nomogram for acute-on-chronic hepatitis B liver failure

Background & Aims

To establish an effective prognostic nomogram for acute-on-chronic hepatitis B liver failure (ACHBLF).

Materials and Methods

The nomogram was based on clinical data of 203 ACHBLF patients who admitted to the First Affiliated Hospital of Fujian Medical University from 2009 to 2014. The area under the receiver-operating characteristic curve (AUC) and calibration curve were carried out to verify the predictive accuracy ability of the nomogram. The result was validated in internal and external validation cohorts. Kaplan-Meier survival curve was used in survival analysis.

Results

We developed a new prognostic nomogram to predict 3-month mortality based on risk factors selected by multivariate analysis. This nomogram consisted three independent factors: age, liver to abdominal area ratio (LAAR) and model for end-stage liver disease (MELD) score. The AUC of this nomogram for survival prediction was 0.877 (95% CI 0.831–0.923), which was higher than that of MELD score, MELD-Na and Child-Turcotte-Pugh (CTP). Good agreement of calibration plot for the probability of survival at 3-month was shown between the prediction by nomogram and actual observation. These results were supported by internal and external validation studies.

Conclusions

The ACHBLF nomogram could predict the short-term survival for ACHBLF patients.

New formula for predicting standard liver volume in Chinese adults

AIM

To obtain a reference range of morphological indices and establish a formula to accurately predict standard liver volume (SLV) in Chinese adults.

METHODS

Computed tomography (CT)-estimated total liver volume (CTLV) was determined in 369 Chinese adults. Age, sex, body weight, body height, body mass index, and body surface area (BSA) were recorded using CT. Total splenic volume, portal venous diameter (PVD), splenic venous diameter (SVD), and portal venous cross-sectional area (PVCSA) were also measured by CT. Stepwise multiple linear regression analysis was performed to evaluate the impact of each parameter on CTLV and to develop a new SLV formula. The accuracy of the new formula was compared with the existing formulas in a validation group.

RESULTS

The average CTLV was 1205.41 ± 257.53 cm³ (range, 593.80-2250.10 cm³). The average of PVD, SVD and PVCSA was 9.34 ± 1.51 mm, 7.40 ± 1.31 mm and 173.22 ± 48.11 mm², respectively. The CT-estimated splenic volume of healthy adults varied markedly (range, 46.60-2892.30 cm³). Sex, age, body height, body weight, body mass index, and BSA were significantly correlated with CTLV. BSA showed the strongest correlation (r = 0.546, P < 0.001), and was used to establish a new model for calculating SLV: SLV (cm³) = 758.259 × BSA (m²)-124.272 (R² = 0.299, P < 0.001). This formula also predicted CTLV more accurately than the existing formulas, but overestimated CTLV in elderly subjects > 70 years of age, and underestimated liver volume when CTLV was > 1800 cm³.

CONCLUSION

Our new BSA-based formula is more accurate than other formulas in estimating SLV in Chinese adults.

3-Dimensional liver volume assessment in patients with hepatitis B virus-related liver cirrhosis during long-term oral nucleos(t)ide analogues therapy

AIM

To assess the effect of long-term oral nucleos(t)ide analogues (NUCs) therapy on liver volume change in patients with suppress hepatitis B virus (HBV)-related liver cirrhosis.

METHODS

We reviewed the data of naïve patients with HBV-related liver cirrhosis, who had taken oral NUCs therapy, between 2003 and 2007 at Chonbuk University Hospital. We analyzed two consecutive sets of abdominal computerized tomography scans-one at the time of treatment initiation and another at the second-year follow-up. Liver volume was calculated by 3-dimensional liver extraction volumetry program.

RESULTS

A total of 55 patients (34 males) were included. There was 114.3 mL ± 167.8 mL (12.9% ± 17.9%) of increase in liver volume during the two years of NUCs therapy (993.8 mL ± 242.8 mL at baseline vs 1108.1 mL ± 263.3 mL at two-year follow-up, P < 0.001). The ratio of the measured baseline liver volume to the estimated standard liver volume was improved from 70.8% to 78.0%. An increase in liver volume was shown not only in patients with compensated cirrhosis (P = 0.046) but also in those with decompensated cirrhosis (P < 0.001). Significant factors for volume increases were Child-Turcotte-Pugh grade and model for end-stage liver disease score improvement without virological breakthrough. In multiple linear regression analysis, delta albumin and delta alanine aminotransferase levels showed a significant association with the increase in liver volume (P = 0.002 and 0.005, respectively).

CONCLUSION

Long-term oral NUCs therapy in patients with HBV-related liver cirrhosis lead to significant increase in liver volume assessed with 3-dimensional liver extraction volumetry program.

Laparoscopic versus open splenectomy and devascularization for massive splenomegaly due to portal hypertension

Although the clinical benefit of laparoscopic splenectomy and devascularization (LSD) has been elaborated in many studies, its application in massive splenomegaly remains controversial. We conducted a retrospective research to assess the curative efficacy of LSD for massive splenomegaly due to portal hypertension. Forty-seven patients with massive splenomegaly due to portal hypertension were enrolled in this study, and divided into two groups. Twenty-one patients underwent open splenectomy and devascularization (OSD) from June 2010 to October 2012 (OSD group). From March 2013 to February 2015, LSD was performed on 26 patients (LSD group). Perioperative variables were analyzed. Compared to OSD, LSD was associated with less blood loss (241.9±110.0 mL vs. 319.0±139.5 mL, P<0.05), more rapid resumption of oral diet (2.46±0.95 days vs. 3.76±1.09 days, P<0.05), and shorter postoperative hospital stay (5.35±1.65 days vs. 7.24±1.55 days, P<0.05). It was concluded that for patients with massive splenomegaly due to portal hypertension, LSD is feasible and as safe as OSD.

Diffusion-weighted imaging (DWI) of the liver in assessing chronic liver disease: effects of the presence and the degree of ascites on ADC values

PURPOSE

The aim of this study was to determine the correlation between the liver and spleen apparent diffusion coefficient (ADC) values of patients with chronic liver disease and the presence and the degree of ascites.

MATERIALS AND METHOD

In this retrospective study, we assessed 107 patients with chronic liver disease and 39 control subjects who underwent upper abdominal MR imaging including echo-planar diffusion-weighted imaging (DWI). Among the 107 cirrhotic patients, 56 were classified as group 1, 25 as group 2, and 26 as group 3 according to the absence, the presence of minimal, and the presence of massive ascites, respectively. The scores of model for end-stage liver disease (MELD) were matched between groups as the standard reference. The liver ADC, spleen ADC, and normalized liver ADC values were compared between the control group and patients' groups.

RESULTS

Patients with massive ascites had significantly higher MELD score compared with the other groups. The MELD score was also significantly higher in patient groups than in control group. The liver and normalized liver ADCs of patients' groups were significantly lower than that of the control group. With some overlap among groups, the measured ADC values decreased as the amount of the ascites increased, and these relationships were statistically significant. Furthermore, compared to control group, patients with massive ascites had significantly higher spleen ADCs.

CONCLUSION

Our results indicate that the ADC value of the liver and spleen correlates with the presence and the degree of ascites in patients with chronic liver disease, and merits further study.

Noninvasive fibrosis marker can predict recurrence of hepatocellular carcinoma after radiofrequency ablation

BACKGROUND/AIMS

Tumor recurrence after curative therapy is common for patients with hepatocellular carcinoma (HCC). As fibrosis and chronic inflammation contribute to the progression of HCC, we aimed to identify the predictive value of inflammatory and fibrosis markers for HCC recurrence after curative therapy using radiofrequency ablation (RFA).

MATERIALS AND METHODS

We retrospectively reviewed the records of patients with HCC treated with RFA between October 2005 and September 2013. The median duration of follow-up was 40 months (4-95 months). Inflammatory and fibrosis markers and demographic and clinical data were analyzed by Cox proportional hazards model using univariate and multivariate analyses and longitudinal analysis.

RESULTS

A total of 98 patients were included for analysis. There were 54 cases of HCC recurrence (55.1%). The aspartate aminotransferase-to-platelet ratio index (APRI; 2.3 ± 1.8 vs. 1.3 ± 1.4, P = 0.018) was significantly higher in the recurrence group than in the recurrence-free group. In multivariate analysis, APRI (hazard ratio, 2.64; confidence interval, 1.488-4.714; P = 0.001) was an independent risk factor for tumor recurrence. In particular, patients with APRI >1.38 showed a higher recurrence rate than patients with APRI ≤ 1.38 (P < 0.001). Longitudinal analysis showed persistently higher APRI values when assessed 12 months after RFA in patients who developed recurrence during follow-up than those who remained recurrence-free.

CONCLUSIONS

These findings show that a high APRI value is associated with HCC recurrence after RFA. Therefore, APRI could play an important role in predicting HCC recurrence after RFA.

Impact of liver cirrhosis due to chronic hepatitis C viral infection on the outcome of ovarian cancer: a prospective study

BACKGROUND

This study was designed to investigate the impact of liver cirrhosis due to chronic hepatitis C virus (HCV) infection on the disease-free and overall survival of ovarian cancer patients undergoing a standard primary operation followed by standard chemotherapy. Attainment of the operative goals, intra- and postoperative events, possible complications under chemotherapy necessitating the termination of treatment, and the impact of ovarian cancer treatment on liver function were assessed.

METHODS

This was a prospective observational study that included only patients with primary epithelial ovarian cancer. Only patients with Child-Turcotte-Pugh classification class A disease were recruited. Patients were divided into two groups according to whether they had liver cirrhosis. All the patients underwent primary debulking surgery followed by 6 cycles of chemotherapy, and were followed-up for 24 months after chemotherapy was completed.

RESULTS

We recruited 77 patients, 19 of whom had liver cirrhosis. There were no significant differences between patients with or without liver cirrhosis with respect to tumor stage, histopathological type, tumor grade, or optimal operative debulking. There was no registered liver dysfunction-related mortality in the follow-up period, and there were no statistically significant differences between the groups with respect to disease-free or overall survival (p = 0.719 and p = 0.524, respectively).

CONCLUSION

From the results of this study, we conclude that compensated liver cirrhosis (Child-Turcotte-Pugh class A) due to chronic HCV infection affects neither the disease-free nor the overall survival of ovarian cancer patients, regardless of their stage. This study shows that it is possible to treat ovarian cancer patients with cirrhosis caused by HCV infection the same as any other patient; treatment does not have to be adjusted as long as the patients have Class A disease.

Platelet count combined with right liver volume and spleen volume measured by magnetic resonance imaging for identifying cirrhosis and esophageal varices

AIM: To determine whether the combination of platelet count (PLT) with spleen volume parameters and right liver volume (RV) measured by magnetic resonance imaging (MRI) could predict the Child-Pugh class of liver cirrhosis and esophageal varices (EV).

METHODS: Two hundred and five cirrhotic patients with hepatitis B and 40 healthy volunteers underwent abdominal triphasic-enhancement MRI and laboratory examination of PLT in 10⁹/L. Cirrhotic patients underwent endoscopy for detecting EV. Spleen maximal width (W), thickness (T) and length (L) in mm together with spleen volume (SV) and RV in mm³ were measured by MRI, and spleen volume index (SI) in mm³ was obtained by W × T × L. SV/PLT, SI/PLT and RV × PLT/SV (RVPS) were calculated and statistically analyzed to assess cirrhosis and EV.

RESULTS: SV/PLT (r = 0.676) and SI/PLT (r = 0.707) increased, and PLT (r = -0.626) and RVPS (r = -0.802) decreased with the progress of Child-Pugh class (P < 0.001 for all). All parameters could determine the presence of cirrhosis, distinguish between each class of Child-Pugh class, and identify the presence of EV [the areas under the curve (AUCs) = 0.661-0.973]. Among parameters, RVPS could best determine presence and each class of cirrhosis with AUCs of 0.973 and 0.740-0.853, respectively; and SV/PLT could best identify EV with an AUC of 0.782.

CONCLUSION: The combination of PLT with SV and RV could predict Child-Pugh class of liver cirrhosis and identify the presence of esophageal varices.

Albumin and magnetic resonance imaging-liver volume to identify hepatitis B-related cirrhosis and esophageal varices

AIM: To investigate whether liver lobe volume and albumin (ALB) could predict the presence and severity of liver cirrhosis, and esophageal varices.

METHODS: Seventy-one cirrhotic patients with hepatitis B and 21 healthy individuals were enrolled in this study. All the participants underwent abdominal enhanced magnetic resonance imaging to measure each liver lobe volume, and biochemical workup for testing ALB and Child-Pugh class. All cirrhotic patients underwent upper gastrointestinal endoscopy to show the presence of cirrhotic esophageal varices. Right liver lobe volume (RV), left medial liver lobe volume (LMV), left lateral liver lobe volume (LLV), and caudate lobe volume (CV) were measured using enhanced magnetic resonance imaging. The ratios of RV to ALB (RV/ALB), LMV to ALB (LMV/ALB), LLV to ALB (LLV/ALB) and CV to ALB (CV/ALB) were calculated. Statistical analyses were performed to determine whether and how the combination of liver lobe volume measured using magnetic resonance imaging and albumin could predict the presence and severity of liver cirrhosis, and the presence of esophageal varices.

RESULTS: RV, LMV, LLV and CV decreased (r = -0.51-0.373; all P < 0.05), while RV/ALB increased (r = 0.424; P < 0.05), with the progress of Child-Pugh class of liver cirrhosis. RV, LMV, CV, LLV/ALB and CV/ALB could identify presence of liver cirrhosis; LLV and LMV could distinguish Child-Pugh class A from B; RV, LMV, LLV, CV, RV/ALB and LLV/ALB could distinguish class A from C; RV and LLV/ALB could differentiate B from C; and RV, RV/ALB and CV/ALB could identify presence of esophageal varices (all P < 0.05). Among these parameters, CV/ALB could best identify the presence of liver cirrhosis, with an area under receiver operating characteristic curve (AUC) of 0.860, a sensitivity of 82.0% and a specificity of 83.0%. LLV could best distinguish class A from B, with an AUC of 0.761, a sensitivity of 74.4% and a specificity of 73.1%. RV could best distinguish class A from C, with an AUC of 0.900, a sensitivity of 90.3% and a specificity of 84.5%. LLV/ALB could best distinguish class B from C, with an AUC of 0.900, a sensitivity of 93.8% and a specificity of 81.5%. RV/ALB could best identify esophageal varices, with an AUC of 0.890, a sensitivity of 80.0% and a specificity of 83.5%.

CONCLUSION: The combination of liver lobe volume and ALB has potential to identify presence and severity of cirrhosis, and presence of esophageal varices.

Modified laparoscopic splenectomy and azygoportal disconnection combined with cell salvage is feasible and might reduce the need for blood transfusion

AIM: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy and azygoportal disconnection (MLSD) with intraoperative autologous cell salvage.

METHODS: We retrospectively evaluated outcomes in 79 patients admitted to the Clinical Medical College of Yangzhou University with cirrhosis, portal hypertensive bleeding and secondary hypersplenism who underwent MLSD without (n = 46) or with intraoperative cell salvage and autologous blood transfusion, including splenic blood and operative hemorrhage (n = 33), between February 2012 and January 2014. Their intraoperative and postoperative variables were compared. These variables mainly included: operation time; estimated intraoperative blood loss; volume of allogeneic blood transfused; visual analog scale for pain on the first postoperative day; time to first oral intake; initial passage of flatus and off-bed activity; perioperative hemoglobin (Hb) concentration; and red blood cell concentration.

RESULTS: There were no significant differences between the groups in terms of duration of surgery, estimated intraoperative blood loss and overall perioperative complication rate. In those receiving salvaged autologous blood, Hb concentration increased by an average of 11.2 ± 4.8 g/L (P < 0.05) from preoperative levels by the first postoperative day, but it had fallen by 9.8 ± 6.45 g/L (P < 0.05) in the group in which cell salvage was not used. Preoperative Hb was similar in the two groups (P > 0.05), but Hb on the first postoperative day was significantly higher in the autologous blood transfusion group (118.5 ± 15.8 g/L vs 102.7 ± 15.6 g/L, P < 0.05). The autologous blood transfusion group experienced significantly fewer postoperative days of temperature > 38.0 °C (P < 0.05).

CONCLUSION: Intraoperative cell salvage during MLSD is feasible and safe and may become the gold standard for liver cirrhosis with portal hypertensive bleeding and hypersplenism.

Quantitative assessment of the presence and severity of cirrhosis in patients with hepatitis B using right liver lobe volume and spleen size measured at magnetic resonance imaging

OBJECTIVE

To determine whether right liver lobe volume (RV) and spleen size measured utilizing magnetic resonance (MR) imaging could identify the presence and severity of cirrhosis in patients with hepatitis B.

METHODS

Two hundred and five consecutive patients with clinically confirmed diagnosis of cirrhosis due to hepatitis B and 40 healthy control individuals were enrolled in this study and underwent abdominal triphasic enhanced scans using MR imaging. Spleen maximal width (W), thickness (T) and length (L), together with RV and spleen volume (SV), were measured utilizing MR imaging. Spleen multidimensional index (SI) was obtained by multiplying previously acquired parameters W×T×L. Then statistical assessment was performed to evaluate the ability of these parameters, including RV, SV, RV/SV and SI, to identify the presence of cirrhosis and define Child-Pugh class of this disease.

RESULTS

SV and SI tended to increase (r = 0.557 and 0.622, respectively; all P<0.001), and RV and RV/SV tended to decrease (r = -0.749 and -0.699, respectively; all P<0.001) with increasing Child-Pugh class of cirrhosis. All the parameters, including RV, SV, RV/SV and SI, might be the indicators used to discriminate the patients with liver cirrhosis from the control group, and to distinguish these patients between Child-Pugh class A and B, between B and C, and between A and C (area under receiver operating characteristic curve [AUC] = 0.609-0.975, all P<0.05). Among these parameters, RV/SV was the best noninvasive factor for the discrimination of liver cirrhosis between Child-Pugh class A and B (AUC = 0.725), between A and C (AUC = 0.975), and between B and C (AUC = 0.876), while SI was the best variable to distinguish the cirrhosis patients from the control group (AUC = 0.960, P<0.05).

CONCLUSION

RV/SV should be used to identify the severity of cirrhosis, while SI can be recommended to determine the presence of this disease.

Are caudate-right lobe ratio and splenic size correlated with the MELD score in cirrhotic patients?

AIM

To determine the relationship between caudate-right lobe ratio (C/R) and model for end-stage liver disease (MELD) score.

METHODS

The study included 50 patients with cirrhosis and a control group of 20 patients. C/R was measured as described by Harbin et al. The size of the spleen was measured on coronal images. The Organ Procurement and Transplantation Network Web site was used for MELD score calculation. Aspartate to alanine aminotranferase (AST/ALT) ratio was calculated.

RESULTS

There was statistically significant difference between the two groups. C/R, the size of the spleen, and AST/ALT values were significantly correlated with MELD score.

CONCLUSIONS

There is a significant relationship between the C/R and MELD score.

Assessment of liver volume variation to evaluate liver function

In order to assess the value of liver volumetry in cirrhosis and acute liver failure (ALF) patients, we explored the correlation between hepatic volume and severity of the hepatic diseases. The clinical data of 48 cirrhosis patients with 60 normal controls and 39 ALF patients were collected. Computed tomography-derived liver volume (CTLV) and body surface area (BSA) of normal controls were calculated to get a regression formula for standard liver volume (SLV) and BSA. Then CTLV and SLV of all patients were calculated and grouped by Child-Turcotte-Pugh classification for cirrhosis patients and assigned according to prognosis of ALF patients for further comparison. It turned out that the mean liver volume of the control group was 1,058 ± 337 cm(3). SLV was correlated with BSA according to the regression formula. The hepatic volume of cirrhosis patients in Child A, B level was not reduced, but in Child C level it was significantly reduced with the lowest liver volume index (CTLV/SLV). Likewise, in the death group of ALF patients, the volume index was significantly lower than that of the survival group. Based on volumetric study, we proposed an ROC (receiver operating characteristic) analysis to predict the prognosis of ALF patients that CTLV/SLV < 83.9% indicates a poor prognosis. In conclusion, the CTLV/SLV ratio, which reflects liver volume variations, correlates well with the liver function and progression of cirrhosis and ALF. It is also a very useful marker for predicting the prognosis of ALF.

Hepatoportal sclerosis: CT and MRI appearance with histopathologic correlation

OBJECTIVE

The purposes of this study were to describe the spectrum of cross-sectional imaging findings of pathologically proven hepatoportal sclerosis and to compare the features of advanced and nonadvanced hepatoportal sclerosis.

MATERIALS AND METHODS

Eighteen patients with a histopathologic diagnosis of hepatoportal sclerosis who had concurrent MRI or CT images participated in the study. The following imaging features were assessed: presence of liver nodularity and liver lesions, portal vein patency, presence and degree of portal hypertension, liver volume, and caudate-to-right lobe ratio. These features were compared between patients who underwent transplant and those who did not.

RESULTS

The 18 patients (11 men and one boy, six women; mean age, 46.5 years) had hepatoportal sclerosis confirmed with liver biopsy (14 patients) or explant (four patients). Fourteen patients underwent contrast-enhanced MRI, and five underwent CT. The imaging findings were as follows: liver surface nodularity, five patients (all four transplant, one nontransplant) (p = 0.0016); evidence of portal hypertension, 17 patients; increased caudate-to-right lobe ratio, 16 patients; high periportal signal intensity on T2-weighted images, six patients; portal vein occlusion with cavernous transformation, five patients. The transplant patients had smaller pretransplant liver volume than did nontransplant patients (p < 0.04).

CONCLUSION

Hepatoportal sclerosis is characterized by caudate lobe hypertrophy and right hepatic lobe atrophy, preserved liver volume, and lack of the liver nodularity associated with portal hypertension. In advanced cases, liver nodularity and atrophy produce an imaging appearance indistinguishable from that of cirrhosis.

Liver volume variation in patients with virus-induced cirrhosis: findings on MDCT

OBJECTIVE

The objective of our study was to establish a standard liver volume formula and explore the correlation between hepatic lobe variations in patients with virus-induced cirrhosis and the severity of disease by measuring the volume of the whole liver, the left lateral segment, and the caudate lobe using 16-MDCT.

MATERIALS AND METHODS

The volume and per-body surface area (BSA) volume of the whole liver, the left lateral segment, and the caudate lobe were calculated in 113 patients with normal livers and 101 patients with virus-induced cirrhosis who underwent volume CT. The proportion of the left lateral segment volume and the proportion of the caudate lobe volume to the total liver volume, the volume index, and the volume change ratio were also calculated, and these data were grouped by Child-Pugh classification and compared. The standard liver volume formula was constructed from body weight and body height or from BSA.

RESULTS

There was a positive correlation between liver volume (LV) and body height, body weight (BW) [LV (cm3) = 12.90 x BW (kg) + 437.91], and BSA [LV (cm3) = 882.08 x BSA (m2) - 308.12]. The total mean +/- standard error (SE) liver volume of the control group was 1,222.76 +/- 216.96 cm3. The mean volumes of the whole liver and of the left lateral segment were 798.01 +/- 203.64 and 213.04 +/- 74.84 cm3, respectively, for Child-Pugh class C patients, which was significantly smaller than those values for Child-Pugh class A and B patients (p < 0.05). The mean volume of the caudate lobe was 36.83 +/- 22.11 cm3 for Child-Pugh class A patients, which is significantly larger than those values for Child-Pugh class B and C patients (p < 0.05).

CONCLUSION

CT-measured liver volume and standard liver volume formulas were helpful in evaluating liver volume variations. Enlargement of the left lateral segment was absolute in Child-Pugh class A and B patients, but was relative in Child-Pugh class C patients; enlargement of the caudate lobe was absolute in Child-Pugh class A patients, but was relative in Child-Pugh class B and C patients.

Assessment of hepatic functional reserve by cirrhosis grading and liver volume measurement using CT

AIM: To explore a method for quantitative assessment of hepatic functional reserve by combining computed tomography (CT) volumetry with CT grading of liver cirrhosis before liver resection in patients with hepatocellular carcinoma.

METHODS: CT images of 55 patients undergoing liver resection were studied prospectively. The degree of liver cirrhosis was referred as "CT grade" and the percentage of remnant liver volume (PRLV) [PRLV = predicted RLV/predicted total liver volume (PTLV) × 100%; PTLV (mL) = 121.75 + 16.49 × body mass (kg)] were calculated by adding slice by slice of CT liver images. The postoperative RLV, pathologic stages of liver fibrosis in non-tumor area and survival time in these cases were analyzed.

RESULTS: There was a significant difference in survival time between the group with PRLV ≤ 50% and the group with PRLV > 50% (χ² = 4.988, P = 0.026), and between the group with CT grade 0/1 and the group with CT grade 2/3 (χ² = 5.429, P = 0.026). With combination of the both parameters, an oblique line was identified according to the distribution of 32 survivors versus 23 deceased subjects. The mortality rate above the line was 7.1% (1/14), and that below the line was 53.7% (22/41), indicating a significant difference between the two rates (χ² = 9.281, P = 0.002, P < 0.05).

CONCLUSION: PRLV and CT grades are significantly correlated with hepatic functional reserve. The predicted line using these two parameters is useful in candidates undergoing liver resection for judging hepatic functional reserve.