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Onishi H, Toh N, Akagi T, Baba K, Kotani Y, Takaki A, Kasahara S, Ito H. Detection of hepatocellular carcinoma during Fontan-associated liver disease follow-up: a report of three cases. Clin J Gastroenterol 2024; 17:148-154. [PMID: 38032452 DOI: 10.1007/s12328-023-01892-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
We herein demonstrate three patients diagnosed with early hepatocellular carcinoma (HCC) during follow-up for Fontan-associated liver disease (FALD). Case 1: Twenty-one years after undergoing the Fontan procedure, a 26-year-old female was diagnosed with FALD. At the initial consultation, her serum alpha-fetoprotein (AFP) levels were markedly elevated, and dynamic enhanced computed tomography (CT) revealed HCC measuring 40 mm in diameter. She underwent partial hepatectomy. Ten months later, she underwent conventional transcatheter arterial chemoembolization (cTACE) for recurrent HCC near the resected hepatic stump as a curative treatment. Case 2: Twenty-one years after undergoing the Fontan procedure, a 25-year-old male was diagnosed with FALD and underwent HCC surveillance every 6 months. Thirteen months after the initial consultation, dynamic enhanced CT revealed HCC measuring 10 mm in diameter. He received cTACE as a curative treatment. Case 3. Twenty-eight years after undergoing the Fontan procedure, a 37-year-old male was diagnosed with FALD and underwent HCC surveillance every 3 months. Fourteen months later, abdominal ultrasonography (US) revealed HCC measuring 13 mm in diameter. He received radiofrequency ablation. These cases showed that HCC surveillance using abdominal US and AFP measurements in patients with FALD enables the detection of HCC and increases the chance of a cure.
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Affiliation(s)
- Hideki Onishi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kenji Baba
- Department of Pediatric Cardiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akinobu Takaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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2
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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3
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Kehar M, Jimenez-Rivera C. Care Pattern for Fontan-Associated Liver Disease by Academic Pediatric Hepatologists in Canada. JPGN REPORTS 2022; 3:e207. [PMID: 37168648 PMCID: PMC10158345 DOI: 10.1097/pg9.0000000000000207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/04/2022] [Indexed: 05/13/2023]
Abstract
Fontan-Associated Liver Disease (FALD) is a common extracardiac complication seen in patients following the Fontan procedure. There are no consensus guidelines on screening and management of children with FALD. Objective The current study aims to determine academic pediatric hepatologists' practices and identify variability in management provided to children with FALD in Canada. Methods Using the infrastructure of the Canadian Pediatric Hepatology Research Group, a nationwide survey was distributed electronically to all pediatric hepatologists practicing in university-affiliated hospitals. Results Twelve pediatric hepatologists from 12 of 13 academic centers (92%) responded to the survey. The institutions of only 2 (17%) physicians offer post-Fontan care with a multidisciplinary team, both from different provinces. The screening for other comorbidities, use of noninvasive modality, and timing of liver biopsy for estimation of liver fibrosis and screening for esophageal varices differ from program to program. The frequency of outpatient clinic follow-up varies significantly. Education and counseling concerning liver health are generally used as treatment; only 58% of academic centers have a formal adult care transition plan. Conclusions Significant discrepancies exist in the care provided to children with FALD by hepatologists practicing in academic centers across Canada. Future study is needed to develop a standardized protocol for managing and following children and youth with FALD.
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Affiliation(s)
- Mohit Kehar
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Carolina Jimenez-Rivera
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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4
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Suzuki H, Niizeki T, Shirono T, Koteda Y, Kinjyo Y, Mizukami N, Koda M, Ota S, Nakano M, Okamura S, Iwamoto H, Shimose S, Noda Y, Kamachi N, Kajiwara A, Suda K, Akiba J, Yano H, Kuromatsu R, Koga H, Torimura T. Robust Effect of Hepatic Arterial Infusion Chemotherapy and Radiation Therapy on Hepatocellular Carcinoma Arising from Fontan-associated Liver Disease. Intern Med 2022; 61:1145-1150. [PMID: 34565776 PMCID: PMC9107970 DOI: 10.2169/internalmedicine.8154-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/01/2021] [Indexed: 11/06/2022] Open
Abstract
Fontan-associated liver disease (FALD) caused by long-term systemic venous congestion following the Fontan procedure may eventually lead to hepatocellular carcinoma (HCC). Treatment strategies for HCC due to FALD (FALD-HCC) remain unclear. We herein report a 35-year-old man with FALD-HCC that was well controlled by 3 cycles of continuous infusion of 5-fluorouracil and low-dose cisplatin (low-dose FP therapy) combined with 60 Gy of radiation therapy. However, the patient ultimately died of extrahepatic metastases. A pathological autopsy revealed more than 90% necrosis in the primary HCC lesion. This case suggests that low-dose FP therapy might be effective in FALD-HCC.
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Affiliation(s)
- Hiroyuki Suzuki
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Takashi Niizeki
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Tomotake Shirono
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Yusuke Koteda
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Japan
| | - Yoshinao Kinjyo
- Department of Pathology, Kurume University School of Medicine, Japan
| | | | - Makoto Koda
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Satoshi Ota
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Masahito Nakano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Shusuke Okamura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Hideki Iwamoto
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
- Iwamoto Internal Medicine Clinic, Japan
| | - Shigeo Shimose
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Yu Noda
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Naoki Kamachi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Akira Kajiwara
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Kenji Suda
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Japan
| | - Jun Akiba
- Department of Pathology, Kurume University School of Medicine, Japan
| | - Hirohisa Yano
- Department of Pathology, Kurume University School of Medicine, Japan
| | - Ryoko Kuromatsu
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Hironori Koga
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Takuji Torimura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
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5
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Naganuma A, Suzuki Y, Hoshino T, Yasuoka H, Tamura Y, Naruse H, Tanaka H, Hirai K, Sakamoto I, Ogawa T, Hatanaka T, Kakizaki S. A case of conversion hepatectomy for huge ruptured hepatocellular carcinoma after transarterial embolization and lenvatinib therapy. Clin J Gastroenterol 2021; 15:177-184. [PMID: 34811701 DOI: 10.1007/s12328-021-01558-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/10/2021] [Indexed: 12/09/2022]
Abstract
We herein report a successfully treated case of huge ruptured hepatocellular carcinoma (HCC) by conversion hepatectomy after transarterial embolization (TAE) and lenvatinib therapy. A 33-year-old male patient with right hypochondralgia and liver tumor was referred to our hospital. He had a history of surgery for heart malformation. The tumor at the right lobe was 15 cm in diameter with bloody ascites. Right atrial thrombus 4.5 cm in diameter and marked cardiac dilatation were observed. TAE with ethanol suspended in lipiodol and gelatin sponge achieved hemostasis of the ruptured HCC. Although viable HCC remained after TAE, surgical treatment was abandoned because of abdominal wall invasion and his heart function. Lenvatinib and rivaroxaban were then initiated for HCC and atrial thrombus, respectively. Lenvatinib treatment resulted in a reduction in tumor marker levels and the tumor size. First, we planned conversion hepatectomy after 5 months of lenvatinib. However, recurrence of atrial thrombus prompted us to put off the surgery, and lenvatinib was re-administered. After improvement of atrial thrombus, we finally performed conversion hepatectomy 10 months after starting lenvatinib administration. The tumor was completely removed by combined resection of the diaphragm, and the patient has been doing well without any signs of recurrence.
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Affiliation(s)
- Atsushi Naganuma
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Yuhei Suzuki
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Takashi Hoshino
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Hidetoshi Yasuoka
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Yuki Tamura
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Hiroaki Naruse
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Hiroshi Tanaka
- Department of Surgery, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Keitaro Hirai
- Department of Surgery, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Ichiro Sakamoto
- Department of Surgery, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Tetsushi Ogawa
- Department of Surgery, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Takeshi Hatanaka
- Department of Gastroenterology, Gunma Saiseikai Maebashi Hospital, 564-1 Kamishindenmachi, Maebashi, Gunma, 371-0821, Japan
| | - Satoru Kakizaki
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan. .,Department of Clinical Research, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan.
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Téllez L, Rodríguez de Santiago E, Albillos A. Fontan-Associated Liver Disease: Pathophysiology, Staging, and Management. Semin Liver Dis 2021; 41:538-550. [PMID: 34399435 DOI: 10.1055/s-0041-1732355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fontan-associated liver disease is the term used to encompass the disorders arising from abnormal hemodynamic alterations and systemic venous congestion after the Fontan procedure. The histological changes produced in the liver are similar but not equivalent to those seen in other forms of cardiac liver disease. While the natural history of this form of liver disease is poorly established, many Fontan patients ultimately develop portal hypertension-related complications such as ascites, esophageal varices, malnutrition, and encephalopathy. Fontan survivors also show an elevated risk of hepatocellular carcinoma. Adequate staging of the liver damage is essential to anticipate screening strategies and improve global management.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
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Gasparrini F, Lenci I, Gagliardi MG, Spada M, Salimei F, Orlacchio A. Repeated TACE in HCC after Fontan surgery and situs viscerum inversus: A case report. Radiol Case Rep 2021; 16:2564-2569. [PMID: 34306288 PMCID: PMC8283149 DOI: 10.1016/j.radcr.2021.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 12/12/2022] Open
Abstract
We describe the case of a 32-year-old man who developed a liver neoplasm due to previous Fontan surgery (FS) for a single ventricle anomaly and situs viscerum inversus. He was admitted to our hospital for suspected hepatocellular carcinoma during an Ultrasound (US) follow up. Computed tomography (CT) showed features of chronic liver disease and 7 cm hepatic nodule with arterial enhancement. Laboratory analyses documented preserved liver function and increased levels of alpha-fetoprotein. Trans-arterial-chemoembolization (TACE) was performed obtaining complete necrosis at 4 weeks of follow up and significant reduction of alpha-fetoprotein. The patient is currently in follow-up, being evaluated for further treatments and/or combined liver-heart transplantation. TACE is a therapeutic option for the treatment of patients with unresectable hepatocellular carcinoma (HCC) and with severe heart disease, like those submitted to FS and with also other vascular abnormalities like those correlated to situs viscerum inversus.
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Key Words
- CM, Contrast Medium
- CT, Computed Tomography, EDVi, End- Diastolic Volume index, EF, Ejection Fraction
- Cardiac cirrhosis
- Congenital heart disease
- FALD, Fontan-associated liver disease
- Fontan surgery
- HCC, hepatocellular carcinoma
- HR, Heart Rate
- IVC-PA, Inferior Vena Cava-Pulmonary Artery
- MRI, Magnetic Resonance Imaging
- SI, Situs inversus
- SMA, Superior Mesenteric Artery
- Situs viscerum inversus
- TACE, Trans Arterial ChemoEmbolization
- TACE, trans-arterial-chemoembolization
- US, Ultrasound
- bpm, beats per minute
- ceCT, Contrast Enhanced CT
- ceCT, contrast enhanced Computed Tomography
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Affiliation(s)
- Fulvio Gasparrini
- Department of Diagnostic and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| | - Ilaria Lenci
- Liver Unit, University Hospital Tor Vergata, Rome, Italy
| | - Maria Giulia Gagliardi
- Department of Cardiology, Division of Grow Up Congenital Heart, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Marco Spada
- Department of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fabio Salimei
- Department of Diagnostic and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| | - Antonio Orlacchio
- Department of Diagnostic and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
- Corresponding author: Viale Oxford, 81 - 00133 Rome, Italy.
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Perucca G, de Lange C, Franchi-Abella S, Napolitano M, Riccabona M, Ključevšek D, Toso S, Herrmann J, Stafrace S, Darge K, Damasio MB, Bruno C, Woźniak MM, Lobo L, Ibe D, Smets AM, Petit P, Ording Müller LS. Surveillance of Fontan-associated liver disease: current standards and a proposal from the European Society of Paediatric Radiology Abdominal Task Force. Pediatr Radiol 2021; 51:2598-2606. [PMID: 34654967 PMCID: PMC8599216 DOI: 10.1007/s00247-021-05173-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/08/2021] [Accepted: 07/31/2021] [Indexed: 12/16/2022]
Abstract
Since Francis Fontan first introduced the eponymous technique, the Fontan procedure, this type of surgical palliation has allowed thousands of children affected by specific heart malformations to reach adulthood. Nevertheless, abdominal, thoracic, lymphatic and neurologic complications are the price that is paid by these patients. Our review focuses on Fontan-associated liver disease; the purpose is to summarize the current understanding of its physiopathology, the aim of follow-up and the specific radiologic follow-up performed in Europe. Finally, we as members of the Abdominal Task Force of the European Society of Paediatric Radiology propose a consensus-based imaging follow-up algorithm.
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Affiliation(s)
- Giulia Perucca
- Department of Pediatric Radiology, Regina Margherita Children’s Hospital, Turin, Italy
| | - Charlotte de Lange
- Department of Radiology and Clinical Physiology, Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Stéphanie Franchi-Abella
- Pediatric Radiology Department, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Marcello Napolitano
- Department of Paediatric Radiology and Neuroradiology, V. Buzzi Children’s Hospital, Milan, Italy
| | - Michael Riccabona
- Department of Radiology, Division of Pediatric Radiology, Medical University Graz and University Hospital LKH, Graz, Austria
| | - Damjana Ključevšek
- Department of Radiology, University Children’s Hospital Ljubljana, Ljubljana, Slovenia
| | - Seema Toso
- Department of Pediatric Radiology, University Hospital of Geneva, Geneva, Switzerland
| | - Jochen Herrmann
- Department of Pediatric Radiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Samuel Stafrace
- Department of Diagnostic Imaging, Sidra Medicine, Doha, Qatar ,Weill Cornell Medicine, Doha, Qatar
| | - Kassa Darge
- Department of Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA USA
| | | | - Costanza Bruno
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata Verona (AOUI), Verona, Italy
| | | | - Luisa Lobo
- Serviço de Imagiologia Geral, Hospital de Santa Maria–Centro Hospitalar Universitário Lisboa, Norte (CHULN), Lisbon, Portugal
| | - Donald Ibe
- Department of Radiology, Silhouette Diagnostic Consultants, Abuja, Nigeria
| | - Anne M. Smets
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Philippe Petit
- Aix Marseille Université, AP-HM, Equipe d’Accueil 3279 - IFR 125, Hôpital Timone Enfants, Service d’Imagerie Pédiatrique et Prénatale, Marseille, France
| | - Lil-Sofie Ording Müller
- Unit for Paediatric Radiology, Department of Radiology, Oslo University Hospital, Rikshospitalet, PB 4950 Nydalen, 0424 Oslo, Norway.
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Rodriguez De Santiago E, Téllez L, Guerrero A, Albillos A. Hepatocellular carcinoma after Fontan surgery: A systematic review. Hepatol Res 2021; 51:116-134. [PMID: 33037858 DOI: 10.1111/hepr.13582] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023]
Abstract
AIM Fontan surgery is often the procedure of choice for patients with congenital single effective ventricle. In the long term, elevated systemic venous pressure and chronic ischemia following this procedure could lead to advanced chronic liver disease and there is also a risk of hepatocellular carcinoma (HCC). This review systematically summarizes the characteristics and outcomes of this rare condition. METHODS PubMed and Embase databases were searched from inception to January 2020 for studies reporting on HCC after Fontan surgery. The factors analyzed were clinical presentation, histology, imaging findings, treatments, and survival. Our primary analysis was based on biopsy-proven HCC. RESULTS The records selected were 26 observational studies (19 case reports/case series and seven cohort studies) including 65 biopsy-proven HCC. Age at the time of HCC diagnosis ranged from 12 to 52 years, and 62% of the patients were female. Only one case occurred earlier than 10 years after Fontan surgery. Twenty patients had no imaging or histological evidence of liver cirrhosis and 78.3% had elevated α-fetoprotein levels. Advanced stage was the most common at diagnosis. The most frequent treatments were transarterial chemoembolization (n = 18) and surgery (n = 12). One-year survival was 50% and only four patients (6.2%) were under liver imaging surveillance. We also analyzed 17 patients with non-biopsy-proven HCC. CONCLUSIONS After Fontan surgery, HCC usually occurs at least 10 years later and can develop in the absence of cirrhosis. Biopsy is mandatory to confirm the diagnosis. Patients were diagnosed at a late stage and survival outcomes were poor, highlighting a need for liver surveillance.
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Affiliation(s)
- Enrique Rodriguez De Santiago
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Luis Téllez
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Antonio Guerrero
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
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Fontan-associated liver disease and hepatocellular carcinoma in adults. Sci Rep 2020; 10:21742. [PMID: 33303924 PMCID: PMC7728791 DOI: 10.1038/s41598-020-78840-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/20/2020] [Indexed: 02/07/2023] Open
Abstract
The Fontan operation creates a unique circulation, and is a palliative therapy for patients with single-ventricle congenital heart disease. Increased venous pressure and decreased cardiac output and hepatic venous drainage result in sinusoidal dilatation around the central veins. This causes congestion and hypoxia in the liver, leading to Fontan-associated liver disease (FALD). Non-invasive and invasive markers enable diagnosis and evaluation of the fibrosis status in chronic liver disease; however, these markers have not been validated in FALD. Additionally, regenerative nodules such as focal nodular hyperplasia (FNH) are frequently found. The severity of fibrosis correlates with the duration of the Fontan procedure and the central venous pressure. Cirrhosis is a risk factor for hepatocellular carcinoma (HCC), the annual risk of which is 1.5–5.0%. HCC is frequently difficult to diagnose and treat because of cardiac complications, coagulopathy, and congenital abnormalities. The mortality rate of FALD with liver cirrhosis and/or FALD-HCC was increased to ~ 29.4% (5/17 cases) in a nationwide survey. Although there is no consensus on the surveillance of patients with FALD, serial monitoring of the alpha fetoprotein level and imaging at 6-month intervals is required in patients with cirrhosis.
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Possner M, Gordon-Walker T, Egbe AC, Poterucha JT, Warnes CA, Connolly HM, Ginde S, Clift P, Kogon B, Book WM, Walker N, Wagenaar LJ, Moe T, Oechslin E, Kay WA, Norris M, Dillman JR, Trout AT, Anwar N, Hoskoppal A, Broering DC, Bzeizi K, Veldtman G. Hepatocellular carcinoma and the Fontan circulation: Clinical presentation and outcomes. Int J Cardiol 2020; 322:142-148. [PMID: 32828959 DOI: 10.1016/j.ijcard.2020.08.057] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/16/2020] [Accepted: 08/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fontan-associated liver disease (FALD) is universal in patients with a Fontan circulation. Hepatocellular carcinoma (HCC) is one of its severe expressions, and, though rare, frequently fatal. The purpose of this study was to describe the clinical presentation, risk factors, and outcomes of HCC in patients with a Fontan circulation. METHODS A multicenter case series of Fontan patients with a diagnosis of HCC formed the basis of this study. The case series was extended by published cases and case reports. Clinical presentation, tumor characteristics, laboratory and hemodynamic findings as well as treatment types and outcomes, were described. RESULTS Fifty-four Fontan patients (50% female) with a diagnosis of HCC were included. Mean age at HCC diagnosis was 30 ± 9.4 years and mean duration from Fontan surgery to HCC diagnosis was 21.6 ± 7.4 years. Median HCC size at the time of diagnosis was 4 cm with a range of 1 to 22 cm. The tumor was located in the right hepatic lobe in 65% of the patients. Fifty-one percent had liver cirrhosis at the time of HCC diagnosis. Fifty percent of the patients had no symptoms related to HCC and alpha-fetoprotein was normal in 26% of the cases. Twenty-six patients (48%) died during a median follow-up duration of 10.6 (range 1-50) months. CONCLUSIONS HCC in Fontan patients occurs at a young age with a 1-year survival rate of only 50%. Meticulous liver surveillance is crucial to detect small tumors in the early stage.
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Affiliation(s)
- Mathias Possner
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Timothy Gordon-Walker
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; The University of Edinburgh, Edinburgh, United Kingdom
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Carole A Warnes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul Clift
- Department of Cardiology, New Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Brian Kogon
- Department of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Egleston, Emory University, Atlanta, GA, USA
| | - Wendy M Book
- Division of Cardiology, Department of Medicine, Emory University Department of Medicine, Atlanta, GA, USA
| | - Niki Walker
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Lodewijk J Wagenaar
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente Hospital, Enschede, the Netherlands
| | - Tabitha Moe
- Division of Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Erwin Oechslin
- Toronto Congenital Cardiac Centre for Adults, University Health Network / Peter Munk Cardiac Centre, and University of Toronto, Toronto, Ontario, Canada
| | - W Aaron Kay
- Section of Pediatric Cardiology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA; Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mark Norris
- Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Gastroenterology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Arvind Hoskoppal
- Department of Pediatrics, University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Dieter C Broering
- Department of Liver Transplantation, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khalid Bzeizi
- Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gruschen Veldtman
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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12
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A patient with post-Fontan operation underwent left hepatectomy and caudate lobectomy for hepatocellular carcinoma: a case report. Surg Case Rep 2020; 6:104. [PMID: 32430849 PMCID: PMC7237549 DOI: 10.1186/s40792-020-00866-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/08/2020] [Indexed: 12/17/2022] Open
Abstract
Background The Fontan procedure has been widely accepted for children with single ventricle physiology and guarantees survival rates of approximately 80% at age 20 years. However, there have been cases of Fontan-associated liver disease (FALD) caused due to congestion, along with recent reports of the development of hepatocellular carcinoma (HCC) in younger patients with FALD. The literature consists of only five previous case reports of patients who underwent hepatectomy for HCC due to poorer cardiac function and liver cirrhosis caused due to congestion. Case presentation The patient was a 37-year-old woman who presented with epigastralgia. Computed tomography (CT) revealed a liver tumor, 8 cm in diameter, in the caudate lobe. Liver damage was A, with an indocyanine green retention rate of 6% at 15 min. The levels of alpha-fetoprotein (AFP) and protein induced by vitamin K antagonists-II (PIVKA-II) were elevated to 81,663 ng/ml (normal < 10 ng/ml) and 238 mAU/ml (normal < 40 mAU/ml), respectively. Left ventricular ejection fraction was 56%, and central venous pressure (CVP) was 12 mmHg. Left hepatectomy and caudate lobe resection were successfully performed in the reverse Trendelenburg position which reduced the CVP. The total operation duration was 450 min, with a total blood loss of 3200 ml. The patient’s postoperative course was uneventful, and she is still alive 16 months after surgery. Conclusions First left hepatectomy with caudate lobectomy during reverse Trendelenburg position which reduced the CVP was performed in a patient with HCC and FALD.
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Wilson TG, Iyengar AJ, Hardikar W, Sood S, d'Udekem Y. Prevalence of hepatocellular carcinoma in the entire Fontan population of Australia and New Zealand. JTCVS Tech 2020; 2:128-130. [PMID: 34317777 PMCID: PMC8298915 DOI: 10.1016/j.xjtc.2020.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/09/2020] [Accepted: 03/08/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Thomas G Wilson
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Faculty of Medicine, Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Ajay J Iyengar
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Winita Hardikar
- Faculty of Medicine, Department of Paediatrics, The University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, The Royal Children's Hospital, Melbourne, Australia
| | - Siddharth Sood
- Department of Gastroenterology and Hepatology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Yves d'Udekem
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Faculty of Medicine, Department of Paediatrics, The University of Melbourne, Melbourne, Australia.,Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
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Komatsu H, Inui A, Kishiki K, Kawai H, Yoshio S, Osawa Y, Kanto T, Fujisawa T. Liver disease secondary to congenital heart disease in children. Expert Rev Gastroenterol Hepatol 2019; 13:651-666. [PMID: 31131680 DOI: 10.1080/17474124.2019.1621746] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Hepatic fibrosis and hepatocellular carcinoma (HCC) can develop in children with congenital heart disease. Although hepatic fibrosis and HCC are prone to develop after the Fontan operation, they can also develop in patients suffering from congenital heart disease who have not undergone Fontan operation. Area covered: The history of cardiac hepatopathy including Fontan-associated liver disease is described. Patient characteristics, liver histology, imaging examinations and blood tests are reviewed to elucidate the mechanism of cardiac hepatopathy. In addition, a flowchart for the follow-up management of cardiac hepatopathy in children with congenital heart disease is proposed. Expert opinion: Congestion and low cardiac output are the main causes of cardiac hepatopathy. Advanced hepatic fibrosis is presumed to be associated with HCC. HCC can develop in both adolescents and young adults. Regardless of whether the Fontan operation is performed, children with a functional single ventricle and chronic heart failure should be regularly examined for cardiac hepatopathy. There is no single reliable laboratory parameter to accurately detect cardiac hepatopathy; hepatic fibrosis indices and elastography have shown inconsistent results for detection of this disease. Further studies using liver specimen-confirmed patients and standardization of evaluation protocols are required to clarify the pathogenesis of cardiac hepatopathy.
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Affiliation(s)
- Haruki Komatsu
- a Department of Pediatrics , Toho University, Sakura Medical Center , Chiba , Japan
| | - Ayano Inui
- b Department of Pediatric Hepatology and Gastroenterology , Eastern Yokohama Hospital , Kanagawa , Japan
| | - Kanako Kishiki
- c Department of Pediatric Cardiology , Sakakibara Heart Institute , Tokyo , Japan
| | - Hironari Kawai
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Sachiyo Yoshio
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Yosuke Osawa
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Tatsuya Kanto
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Tomoo Fujisawa
- b Department of Pediatric Hepatology and Gastroenterology , Eastern Yokohama Hospital , Kanagawa , Japan
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15
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Kim TH, Yang HK, Jang HJ, Yoo SJ, Khalili K, Kim TK. Abdominal imaging findings in adult patients with Fontan circulation. Insights Imaging 2018; 9:357-367. [PMID: 29623675 PMCID: PMC5991003 DOI: 10.1007/s13244-018-0609-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/04/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract The Fontan procedures, designed to treat paediatric patients with functional single ventricles, have markedly improved the patient’s survival into adulthood. The physiology of the Fontan circuit inevitably increases systemic venous pressure, which may lead to multi-system organ failure in the long-term follow-up. Fontan-associated liver disease (FALD) can progress to liver cirrhosis with signs of portal hypertension. Focal nodular hyperplasia-like nodules commonly develop in FALD. Imaging surveillance is often performed to monitor the progression of FALD and to detect hepatocellular carcinoma, which infrequently develops in FALD. Other abdominal abnormalities in post-Fontan patients include protein losing enteropathy and pheochromocytoma/paraganglioma. Given that these abdominal abnormalities are critical for patient management, it is important for radiologists to become familiar with the abdominal abnormalities that are common in post-Fontan patients on cross-sectional imaging. Teaching points • Fontan procedure for functional single ventricle has improved patient survival into adulthood. • Radiologists should be familiar with unique imaging findings of Fontan-associated liver disease. • Focal nodular hyperplasia-like nodules commonly develop in Fontan-associated liver disease. • Hepatocellular carcinoma, protein-losing enteropathy, pheochromocytoma/paraganglioma may develop. Electronic supplementary material The online version of this article (10.1007/s13244-018-0609-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tae-Hyung Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongnogu, Seoul, 03080, South Korea
| | - Hyun Kyung Yang
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Hyun-Jung Jang
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Shi-Joon Yoo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5J2L4, Canada
| | - Korosh Khalili
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Tae Kyoung Kim
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
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16
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Wells ML, Hough DM, Fidler JL, Kamath PS, Poterucha JT, Venkatesh SK. Benign nodules in post-Fontan livers can show imaging features considered diagnostic for hepatocellular carcinoma. Abdom Radiol (NY) 2017; 42:2623-2631. [PMID: 28785785 DOI: 10.1007/s00261-017-1181-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To describe the imaging appearance of hyperenhancing nodules arising in post-Fontan patients and to identify specific features best correlated with malignancy. METHODS Hyperenhancing hepatic nodules visible on CT and/or MRI in post-Fontan patients were identified retrospectively and reviewed by subspecialty radiologists. Nodules with characteristic imaging findings of focal nodular hyperplasia (FNH) were defined as typical, the remainder were defined as atypical, described in detail according to LIRADS criteria, and length of stability over time was recorded. Clinical data, alpha fetoprotein levels (AFP), central venous pressures (CVP), and histopathology were recorded. RESULTS 245 hyperenhancing nodules (215 typical, 30 atypical) were evaluated in 30 patients. Twenty-nine atypical nodules showed washout (portal phase in 6, delayed phase in 29), 0 showed pseudocapsule, 1 showed threshold growth, 1 showed tumor in vein, and 5 showed ancillary features favoring malignancy. Pathology confirmed hepatocellular carcinoma (HCC) in 3 atypical nodules and FNH-like histology in 3 atypical and 4 typical nodules. 2 atypical nodules were present in a patient with clinical diagnosis of HCC. 20 nodules (7 typical, 13 atypical due to washout) were studied with hepatobiliary contrast agent and all showed homogenous hepatobiliary phase retention. Atypical nodules were significantly more likely to be HCC than biopsy-proven FNH-like or stable ≥24 months when showing portal phase washout (P < 0.001), mosaic architecture (P = 0.020) or in the presence of cirrhosis (P = 0.004) or elevated AFP (P = 0.004). Atypical nodules that were HCC had higher median CVP than those that were FNH-like (19, range 16-27 vs. 13, range 12-16 mmHg, P = 0.0003), there was not a significant difference based on median patient age (HCC 30, range 10-41 vs. FNH-like 40 range 10-41, P = 0.244). CONCLUSIONS Benign hyperenhancing masses in Fontan patients may demonstrate washout and be mistaken for HCC by imaging criteria. Portal phase washout, mosaic architecture, elevated AFP and higher CVP were associated with HCC in the atypical nodules found in this population.
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17
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Cardiac echoparameters (geometry and dimensions), interleukin 6, and anthropometric measurements in Egyptian adolescents with hepatitis C and hepatocellular carcinoma. EGYPTIAN LIVER JOURNAL 2017. [DOI: 10.1097/01.elx.0000526967.41371.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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18
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Oh C, Youn JK, Han JW, Kim GB, Kim HY, Jung SE. Hepatocellular carcinoma after the Fontan procedure in a 16-year-old girl: A case report. Medicine (Baltimore) 2016; 95:e4823. [PMID: 27741102 PMCID: PMC5072929 DOI: 10.1097/md.0000000000004823] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION The Fontan procedure (FP) has become the standard operation for patients with single ventricle physiology. However, a long period of elevated systemic venous pressure and low cardiac output after the procedure result in chronic inflammation and liver cirrhosis, which may eventually lead to the occurrence of hepatocellular carcinoma (HCC). CLINICAL FINDINGS We described the case of a 16-year-old female who developed HCC after the FP. At 21 months, the patient received a lateral tunnel FP, and 14 years later, she began complaining of abdominal distension, telangiectasia, and fatigue. Imaging studies revealed a large hepatic mass involving most of the right lobe and multiple masses in the left lobe. Evidence suggested severe liver cirrhosis, and the presence of ascites, hepatosplenomegaly, paraesophageal gastric varices reflecting the severity of the disease. In addition, tumor thrombosis was found in the right hepatic vein, middle hepatic vein, and inferior vena cava, as well as multiple metastatic nodules in both lungs. The patient received an incisional biopsy and the diagnosis of HCC was pathologically confirmed. After treatment with 1 cycle of systemic chemotherapy, she received ongoing supportive care for disease-related complications, and died 2 months after chemotherapy due to hematemesis. CONCLUSION With the advances in medicine, the incidence of Fontan physiology-related complications is likely to increase, and the incidence of HCC will also increase accordingly. As early diagnosis of HCC results in better patient outcomes, a surveillance guideline for HCC after the FP should be developed.
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Affiliation(s)
| | | | | | - Gi Beom Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Department of Surgery
- Correspondence: Hyun-Young Kim, Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea (e-mail: )
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Josephus Jitta D, Wagenaar LJ, Mulder BJ, Guichelaar M, Bouman D, van Melle JP. Three cases of hepatocellular carcinoma in Fontan patients: Review of the literature and suggestions for hepatic screening. Int J Cardiol 2016; 206:21-6. [DOI: 10.1016/j.ijcard.2015.12.033] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 12/31/2015] [Indexed: 01/08/2023]
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Yamada K, Shinmoto H, Kawamura Y, Wakamatsu H, Kawauchi T, Soga S, Ogata S, Kaji T. Transarterial embolization for pediatric hepatocellular carcinoma with cardiac cirrhosis. Pediatr Int 2015; 57:766-70. [PMID: 26013052 DOI: 10.1111/ped.12619] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 10/27/2014] [Accepted: 12/11/2014] [Indexed: 12/28/2022]
Abstract
We describe the case of a 15-year-old boy with a history of Fontan operation and multiple intrahepatic tumors. Computed tomography showed multiple hepatic nodules with arterial enhancement. Because hepatocellular carcinoma (HCC) was not detected on biopsies and tumor markers were normal, progress was monitored on imaging. One hepatic tumor increased greatly in size during follow up. At 15 years of age, tumor markers rose rapidly, and he had upper abdominal swelling. Therefore, transarterial embolization (TAE) was performed for the largest tumor, suspected to be a HCC due to cardiac cirrhosis. This tumor had not increased at follow up 4 months later. The patient died from hepatic failure at the age of 17 years, and HCC was diagnosed at autopsy. Although pediatric HCC is rare, its incidence is likely to increase. TAE, with or without anticancer agents, is a therapeutic option for unresectable pediatric HCC, as it is for adult HCC.
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Affiliation(s)
- Kentaro Yamada
- Department of Radiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hiroshi Shinmoto
- Department of Radiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yoichi Kawamura
- Department of Pediatrics, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hajime Wakamatsu
- Department of Pediatrics, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Toshio Kawauchi
- Department of Radiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Shigeyoshi Soga
- Department of Radiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Sho Ogata
- Laboratory Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Tatsumi Kaji
- Department of Radiology, National Defense Medical College, Tokorozawa, Saitama, Japan
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Ohashi K, Iimuro Y, Suzumura K, Hai S, Tanaka S, Hirano T, Sueoka H, Hirota S, Fujimoto J. Development of hepatocellular carcinoma in cardiac congestive liver fibrosis: report of a case. Clin J Gastroenterol 2015; 8:143-7. [PMID: 25855581 DOI: 10.1007/s12328-015-0564-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/24/2015] [Indexed: 01/05/2023]
Abstract
We report an extremely rare case of the development of hepatocellular carcinoma (HCC) in cardiac congestive liver fibrosis. A 62-year-old female presented to our hospital with a complaint of right upper quadrant pain. The patient had undergone cardiac surgery for pulmonary valve insufficiency, pulmonary stenosis and atrial septal defect when she was fifteen years of age. During the subsequent 47 years, she had occasionally suffered from various symptoms associated with right-sided heart failure due to pulmonary stenosis. Computed tomography revealed a liver tumor measuring 63 mm in diameter in segment 5 and other liver tumors in segments 5 (18 mm), 8 (17 mm) and 4 (12 mm), which were diagnosed as HCCs. There was no evidence of stenosis in any hepatic veins or inferior vena cava, and no infectious hepatitis or alcoholic liver damage. Anterior sectionectomy and partial resection of segment 4 was performed, and histological examination showed that these tumors were HCC accompanied by congestive liver fibrosis. Nine months later, multiple recurrent HCCs were detected in segment 6, and transcatheter arterial chemoembolization was employed thereafter. The patient died 40 months after surgery due to advanced recurrence.
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Affiliation(s)
- Koichiro Ohashi
- Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo, 663-8501, Japan,
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Hepatic pathology after Fontan palliation: spectrum of imaging findings. Pediatr Radiol 2013; 43:330-8. [PMID: 23052733 DOI: 10.1007/s00247-012-2531-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 08/26/2012] [Accepted: 08/30/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with congenital heart disease corrected by Fontan palliation have chronic liver congestion that commonly progresses to fibrosis and cirrhosis with resultant complications. OBJECTIVE To define the hepatic imaging characteristics associated with Fontan circulation. MATERIALS AND METHODS A retrospective study was performed in patients who underwent Fontan palliation who had CT or MR examinations including the liver. The liver was evaluated for parenchymal morphology, abnormal enhancement, nodules and imaging findings of fibrosis and cirrhosis. RESULTS MRI or CT examinations including the liver were evaluated in 42 Fontan patients. The most common imaging finding was abnormal parenchymal enhancement, present in 38 patients. Hypervascular nodules were present in 13 patients (31%). Imaging findings of cirrhosis were seen in eight patients (19%). One patient with cirrhosis had a large liver mass, subsequently diagnosed as fibrolamellar hepatocellular carcinoma. CONCLUSION A high percentage of patients had imaging abnormalities of the liver, chiefly abnormal parenchymal enhancement, which became more apparent as the duration of the Fontan circulation increased. The hypervascular nodules sometimes present had imaging characteristics most closely resembling those of focal nodular hyperplasia. The underlying fibrosis and eventual development of cirrhosis raise the risk of developing hepatocellular carcinoma.
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McCabe N, Farris AB, Hon H, Ford R, Book WM. Hepatocellular carcinoma in an adult with repaired tetralogy of fallot. CONGENIT HEART DIS 2012; 8:E139-44. [PMID: 22897884 DOI: 10.1111/j.1747-0803.2012.00700.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2012] [Indexed: 12/13/2022]
Abstract
Liver fibrosis is a growing concern among adults with congenital heart disease, particularly for those who have undergone a Fontan operation. Liver fibrosis leads to cirrhosis, a precursor of hepatocellular carcinoma. A few cases of hepatocellular carcinoma in patients with prior palliative surgery for congenital heart disease have been identified in the literature. The current case reports the first known case of hepatocellular carcinoma in a 45-year-old male with repaired tetralogy of Fallot.
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Affiliation(s)
- Nancy McCabe
- Nell Hodgson Woodruff School, Department of Medicine, Emory University, Atlanta, Ga, USA
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