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Mostafa A, Abramson Z, Ghbrial M, Biswas S, Chan S, Darji H, Gartrell J, Karol SE, Li Y, Mulrooney DA, Patni T, Zaghloul TM, McCarville MB. Contrast enhanced ultrasound of liver lesions in patients treated for childhood malignancies. Cancer Imaging 2024; 24:115. [PMID: 39210481 PMCID: PMC11360734 DOI: 10.1186/s40644-024-00750-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 07/24/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Patients treated for cancer have a higher incidence of focal liver lesions than the general population and there is often concern for a malignant etiology. This can result in patient, caregiver and physician anxiety and is managed by a "wait and watch" approach, or immediate additional imaging, or biopsy, depending on the degree of clinical concern. Because it is a low-cost, easily accessible, radiation and sedation free modality, we investigated the value of contrast enhanced ultrasound (CEUS) to accurately distinguish benign from malignant liver lesions in patients treated for childhood malignancies. METHODS We performed an IRB approved retrospective study of 68 subjects who were newly diagnosed, on treatment or off treatment for a pediatric malignancy and had liver lesions discovered on CT, MRI or non-contrast ultrasound and subsequently underwent CEUS between September 2013 and September 2021. Two experienced pediatric radiologists and a radiology trainee, blinded to the etiology of the liver lesions, independently reviewed the CEUS examinations and categorized lesions as benign, indeterminate, or malignant. The reference standard was biopsy for 19 lesions and clinical follow-up for 49. The sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of CEUS were calculated using only the benign and malignant CEUS classifications. Inter-reviewer agreement was assessed by Cohen's kappa statistic. RESULTS There were 26 males and 42 females, mean age, 14.9 years (range, 1-52 years). Fifty subjects were off therapy, twelve receiving treatment, and six with newly diagnosed cancer. By the reference standard, 59 (87%) lesions were benign and 9 (13%) were malignant. Sensitivities of CEUS for the three reviewers ranged from 83 to 100% (95% CI, 35.9-100%), specificities from 93.1 to 96.0% (95% CI, 83.5-99.6%), PPV 60.0-71.4% (95% CI, 29.0-96.3%), NPV 98.0-100% (95% CI, 89.2-100%) and accuracy from 93.8 to 94.6% (95% CI, 85.1-99.7%). The kappa statistic for agreement between the two experienced radiologists was moderate at 0.58. CONCLUSIONS CEUS is highly accurate in distinguishing benign from malignant etiologies of liver lesions in patients treated for pediatric malignancies.
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Affiliation(s)
- Ayatullah Mostafa
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital MS 220, 262 Danny Thomas Place, Memphis, TN, 38105, USA.
- Rutgers New Jersey Medical School , Newark, USA.
| | - Zachary Abramson
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital MS 220, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Mina Ghbrial
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital MS 220, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Som Biswas
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital MS 220, 262 Danny Thomas Place, Memphis, TN, 38105, USA
- Pediatric Radiology Department, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Sherwin Chan
- Department of Radiology, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO, 64108, USA
| | - Himani Darji
- Department of Surgery, MS 133, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
- Quantitative Sciences Unit, Stanford University, 3180 Porter Drive, Palo Alto, CA, 94304, USA
| | - Jessica Gartrell
- Department of Oncology, MS 260, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN, 38105, USA
| | - Seth E Karol
- Department of Oncology, MS 260, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN, 38105, USA
| | - Yimei Li
- Department of Biostatistics , St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Daniel A Mulrooney
- Department of Oncology, MS 260, St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN, 38105, USA
| | - Tushar Patni
- Department of Biostatistics , St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Tarek M Zaghloul
- Department of Surgery, MS 133, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
- Quantitative Sciences Unit, Stanford University, 3180 Porter Drive, Palo Alto, CA, 94304, USA
- Department of Surgery, National Cancer Institute, Cairo University, Cairo, Egypt
| | - M Beth McCarville
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital MS 220, 262 Danny Thomas Place, Memphis, TN, 38105, USA.
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Yang F, Peng W, Chen S, Wan L, Zhao R, Liu X, Ye F, Zhang H. Hepatic focal nodular hyperplasia during follow-up of patients after cyclophosphamide- or oxaliplatin-based chemotherapy: differentiation from liver metastasis. Insights Imaging 2024; 15:215. [PMID: 39186145 PMCID: PMC11347512 DOI: 10.1186/s13244-024-01793-7] [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: 04/23/2024] [Accepted: 08/02/2024] [Indexed: 08/27/2024] Open
Abstract
OBJECTIVES Newly detected hepatic nodules during follow-up of cancer survivors receiving chemotherapy may pose a diagnostic dilemma. We investigated a series of hepatic focal nodular hyperplasia (FNH) diagnosed by either typical MRI features and follow-up or pathology in cancer survivors. METHODS This retrospective study evaluated 38 patients with tumours who developed new hepatic FNH after cyclophosphamide-based (n = 19) and oxaliplatin-based (n = 19) chemotherapies. The main tumour types were breast cancer (n = 18) and colorectal cancer (n = 17). MRI findings, clinical features, and temporal evolution of all target hepatic lesions (n = 63) were reported. In addition, the two chemotherapy drug groups were compared. RESULTS The median interval between chemotherapy completion and FNH detection was 30.4 months (12.9, 49.4). Six patients underwent biopsy or surgery, while the remaining patients were diagnosed based on typical MRI features and long-term follow-up. Among the patients, 60.5% (23/38) presented with multiple nodules and 63 target lesions were detected. The median size of target lesions was 11.5 mm (8.4, 15.1). The median follow-up time was 32.5 months (21.2, 48.6), and 15 patients experienced changes in their lesions during the follow-up period (11 increased and 4 decreased). The cyclophosphamide-based treatment group had a younger population, a greater proportion of females, and a shorter time to discovery than the oxaliplatin-based chemotherapy group (all p ≤ 0.016). CONCLUSIONS FNH may occur in cancer survivors after cyclophosphamide- or oxaliplatin-based chemotherapy. Considering a patient's treatment history and typical MRI findings can help avoid misdiagnosis and unnecessary invasive treatment. CLINICAL RELEVANCE STATEMENT When cancer survivors develop new hepatic nodules during follow-up, clinicians should think of the possibility of focal nodular hyperplasia in addition to liver metastasis, especially if the cancer survivors were previously treated with cyclophosphamide or oxaliplatin. KEY POINTS Cancer survivors, after chemotherapy, can develop hepatic focal nodular hyperplasia. Cyclophosphamide and oxaliplatin are two chemotherapeutic agents that predispose to focal nodular hyperplasia development. Focal nodular hyperplasia occurs at shorter intervals in patients treated with cyclophosphamide.
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Affiliation(s)
- Fan Yang
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021, Beijing, China
| | - Wenjing Peng
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021, Beijing, China
| | - Shuang Chen
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021, Beijing, China
| | - Lijuan Wan
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021, Beijing, China
| | - Rui Zhao
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021, Beijing, China
| | - Xiangchun Liu
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021, Beijing, China
| | - Feng Ye
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021, Beijing, China
| | - Hongmei Zhang
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021, Beijing, China.
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Appearance of Focal Nodular Hyperplasia after Chemotherapy in Two Patients during Follow-Up of Colon Carcinoma. Case Rep Surg 2021; 2021:6676109. [PMID: 33880199 PMCID: PMC8046561 DOI: 10.1155/2021/6676109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/17/2022] Open
Abstract
Surgical liver resection is a treatment option in patients with resectable colorectal liver metastases. We present two cases of focal nodular hyperplasia (FNH) development after treatment with oxaliplatin during follow-up of colon carcinoma. The first case was a 40-year-old male patient who developed multiple liver lesions suspect for metastatic disease four years after he had undergone laparoscopic right-sided hemicolectomy and adjuvant chemotherapy (capecitabine and oxaliplatin). He underwent a metastasectomy of segments three and four and microwave ablation (MWA) of the lesion in segment one. Pathological analysis demonstrated FNH. The second patient was a 21-year-old woman who presented with multiple liver lesions during follow-up for colon carcinoma. She underwent a laparoscopic right-sided hemicolectomy and was adjuvantly treated with capecitabine and oxaliplatin three years ago. Magnetic resonance imaging (MRI) was performed, and the lesions showed no signs of metastatic disease but were classified as FNH. Therefore, the decision was made to follow up the patient. In conclusion, the development of benign liver lesions could occur during follow-up of colon carcinoma and might be caused by oxaliplatin-induced changes to the liver parenchyma. Hence, it is important to distinguish these from metastatic liver disease.
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Diagnosis of Focal Nodular Hyperplasia (FNH) after Liver Transplantation. Case Rep Transplant 2020; 2020:8824099. [PMID: 33083085 PMCID: PMC7556100 DOI: 10.1155/2020/8824099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/09/2020] [Accepted: 09/17/2020] [Indexed: 11/29/2022] Open
Abstract
Following liver transplantation (LT), recipients can develop benign and malignant hepatic masses just like any other patient. Patients transplanted for hepatocellular carcinoma (HCC) undergo surveillance imaging, and any new mass seen on imaging must be carefully evaluated to rule out recurrent cancer. Focal nodular hyperplasia (FNH) is a benign tumor of the liver that most often occurs in women and is rarely symptomatic. It is important to distinguish FNH from more serious etiologies, such as recurrent HCC and other malignancies, since the treatments differ greatly. To date, there have been very few reports of FNH occurring in a liver allograft. We present a case of a patient with a history of a carcinoid tumor who underwent LT for HCC. Several years posttransplant, the patient was found to have a liver mass with classic features of HCC on imaging. The liver biopsy revealed the unexpected diagnosis of FNH. This finding avoided unnecessary treatment for HCC, which is associated with morbidity, especially in the posttransplant setting. We present our diagnostic approach, discuss the clinicopathologic and imaging findings of FNH, and review the literature on FNH in the posttransplant setting.
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Cattoni A, Rovelli A, Prunotto G, Bonanomi S, Invernizzi P, Perego R, Mariani AM, Balduzzi A. Hepatic focal nodular hyperplasia after pediatric hematopoietic stem cell transplantation: The impact of hormonal replacement therapy and iron overload. Pediatr Blood Cancer 2020; 67:e28137. [PMID: 31889398 DOI: 10.1002/pbc.28137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 11/16/2019] [Accepted: 12/02/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The advent of techniques for the assessment of iron overload (liver T2*-MRI) has led to the awareness that focal nodular hyperplasia (FNH) represents a possible incidental finding after hematopoietic stem cell transplantation (HSCT), though its pathogenesis is still unclear. METHODS We performed a retrospective analysis of the liver T2*-MRI scans performed between 2013 and 2018 in a single pediatric HSCT Unit and recorded the number of patients with FNH (group A). Patients incidentally diagnosed with FNH at imaging performed for different clinical indications were included in group B. RESULTS Nine of 105 (8.6%) patients from group A were diagnosed with FNH. Group B included three patients. Overall, 12 patients were diagnosed 4.4 ± 3.1 years after HSCT. At univariate analysis, female gender (odds ratio [OR] 3.77, P = .03), moderate-to-severe iron overload (OR 6.97, P = .01), and hormone replacement therapy (HRT) administered for at least 6 months (OR 18.20, P = .0002) exposed patients to a higher risk of developing FNH. The detrimental effect of HRT was significant also at multivariate analysis (OR 7.93, P = .024). MRI-T2* values in affected patients were statistically lower than healthy controls (P < .001). CONCLUSIONS We confirm the high incidence of FNH among transplanted pediatric patients and demonstrate the potential pathogenic role of HRT and iron overload.
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Affiliation(s)
- Alessandro Cattoni
- Clinica Pediatrica, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
| | - Attilio Rovelli
- Clinica Pediatrica, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
| | - Giulia Prunotto
- Clinica Pediatrica, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
| | - Sonia Bonanomi
- Clinica Pediatrica, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
| | - Pietro Invernizzi
- Gastroenterologia, Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | - Rosangela Perego
- Radiologia, Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | - Anna Maria Mariani
- Radiologia, Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | - Adriana Balduzzi
- Clinica Pediatrica, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
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Gologorsky R, Wong V, Holmes W, Haider A. Liver lesions in children post-oncologic therapy: Review of case reports and institutional observation. INTERNATIONAL JOURNAL OF CANCER THERAPY AND ONCOLOGY 2015. [DOI: 10.14319/ijcto.0302.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Gong Y, Chen L, Qiao ZW, Ma YY. Focal nodular hyperplasia coexistent with hepatoblastoma in a 36-d-old infant. World J Gastroenterol 2015; 21:1028-1031. [PMID: 25624742 PMCID: PMC4299321 DOI: 10.3748/wjg.v21.i3.1028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 07/03/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023] Open
Abstract
Focal nodular hyperplasia (FNH) is a benign hepatic tumor characterized by hepatocyte hyperplasia and a central stellate scar. The association of FNH with other hepatic lesions, such as adenomas, hemangiomas and hepatocellular carcinoma, has been previously reported, but FNH associated with another hepatic tumor is rare in infants. Here we report a case of FNH coexistent with hepatoblastoma in a 36-d-old girl. Computed tomography (CT) imaging showed an ill-delineated, inhomogeneous enhanced mass with a central star-like scar in the right lobe of the liver. The tumor showed early mild enhancement at the arterial phase (from 40HU without contrast to 52HU at the arterial phase), intense enhancement at the portal phase (87.7HU) and 98.1HU in the 3-min delay scan. A central scar in the tumor presented as low density on non-contrast CT and slightly enhanced at delayed contrast-enhanced scanning. This infant underwent surgical resection of the tumor. Histopathology demonstrated typical FNH coexistent with a focal hepatoblastoma, which showed epithelioid tumor cells separated by proliferated fibrous tissue.
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Abstract
Abstract
Background: Liver is the most common distant metastasized organ in advanced colon cancer. Surgical resection of metastatic lesions would offer the best chance of a long-term survival. An accurate diagnosis and evaluation of extent of disease is crucial in the management of liver metastasis. Objective: Report a benign hepatic condition mimicking liver metastasis in a colon cancer patient. Case presentation: A 53-year-old male with an early stage sigmoid colon cancer was treated with sigmoidectomy followed by adjuvant chemotherapy consisting of 5-FU, leucovorin, and oxaliplatin for six months. Annual computerized tomography of abdomen at two years after the surgery revealed three hypervascular nodules in the liver. Investigations including MRI of the liver and whole body FDG-F18 PET/CT demonstrated evidence consistent with non-metastatic liver nodules. Liver biopsy of one of the lesions led to the diagnosis of “focal nodular hyperplasia”. Conclusion: The possible etiology, diagnosis, and further management of this benign liver tumor, the focal nodular hyperplasia became clear.
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Shen GHHLG, Zhu JYJHMYF, Yang J, Mei JH, Zhu YF. Insight into congenital absence of the portal vein: Is it rare? World J Gastroenterol 2008; 14:5969-79. [PMID: 18932274 PMCID: PMC2760189 DOI: 10.3748/wjg.14.5969] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Congenital absence of portal vein (CAPV) was a rare event in the past. However, the number of detected CAPV cases has increased in recent years because of advances in imaging techniques. Patients with CAPV present with portal hypertension (PH) or porto-systemic encephalopathy (PSE), but these conditions rarely occur until the patients grow up or become old. The patients usually visit doctors for the complications of venous shunts, hepatic or cardiac abnormalities detected by ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). The etiology of this disease is not clear, but most investigators consider that it is associated with abnormal embryologic development of the portal vein. Usually, surgical intervention can relieve the symptoms and prevent occurrence of complications in CAPV patients. Moreover, its management should be stressed on a case-by-case basis, depending on the type or anatomy of the disease, as well as the symptoms and clinical conditions of the patient.
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Levine DS, Navarro OM, Chaudry G, Doyle JJ, Blaser SI. Imaging the complications of bone marrow transplantation in children. Radiographics 2007; 27:307-24. [PMID: 17374855 DOI: 10.1148/rg.272065088] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Bone marrow transplantation is frequently performed to restore hematologic and immunologic competence after chemotherapy and radiation therapy for a range of childhood malignancies, as well as to treat various congenital conditions in which hematologic and immunologic functions are depressed or absent. Potentially devastating complications may occur during the pre-engraftment period after bone marrow transplantation, when marrow aplasia may supervene for several weeks until engraftment occurs, as well as during the post-engraftment period (the 3 months after engraftment) and in subsequent months and years. Complications of bone marrow transplantation may be classified either according to the time interval between transplantation and the occurrence of the complication or according to the organ system affected. The range of complications that may affect the central nervous system and the rest of the body may be detected with ultrasonography, computed tomography, and magnetic resonance imaging. Neurologic, paranasal sinus, pulmonary, and abdominopelvic complications all may be seen after bone marrow transplantation. Graft-versus-host disease and lymphoproliferative disorders also may occur. The increasing use of bone marrow transplantation mandates that the radiologist be familiar with the full range of potential complications and their imaging appearances.
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Affiliation(s)
- Daniel S Levine
- Department of Diagnostic Imaging, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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