Application of ultrasonography in the diagnosis and treatment tracing of hepatocellular carcinoma-associated arteriovenous fistulas

An exploration of radiological signs in post-intervention liver complications

The advent and progression of radiological techniques in the past few decades have revolutionized the diagnostic and therapeutic landscape for liver diseases. These minimally invasive interventions, ranging from biopsies to complex therapeutic procedures like transjugular intrahepatic portosystemic shunt placement and transarterial embolization, offer substantial benefits for the treatment of patients with liver diseases. They provide accurate tissue diagnosis, allow real-time visualization, and render targeted treatment for hepatic lesions with enhanced precision. Despite their advantages, these procedures are not without risks, with the potential for complications that can significantly impact patient outcomes. It is imperative for radiologists to recognize the signs of these complications promptly to mitigate further health deterioration. Ultrasound, CT, and MRI are widely utilized examinations for monitoring the complications. This article presents an overarching review of the most commonly encountered hepatobiliary complications post-radiological interventions, emphasizing their imaging characteristics to improve patient post-procedure management.

Objective Tumor Response of Hepatocellular Carcinoma Obtained by Transarterial Radioembolization with Iodine-131-Lipiodol Versus Transarterial Chemoembolization for Patients with and without Portal Venous Thrombosis: A Controlled Interventional Trial

RATIONALE AND OBJECTIVES

Hepatocellular carcinoma (HCC) treatment often requires transarterial chemoembolization (TACE). However, TACE efficacy is controversial in the presence of portal vein thrombosis (PVT). Although transarterial radioembolization (TARE) benefit was previously documented in PVT, neither the objective tumor response (OTR) after TARE with Iodine-131-lipiodol (131I-lipiodol) nor the PVT effect on the results of locoregional therapies was accurately measured in prospective clinical trials. The aim of this study was to compare OTR and survival obtained by TARE with 131I-lipiodol versus TACE in patients with cirrhosis and HCC, as well as between those with and without PVT.

MATERIALS AND METHODS

33 patients were included, from whom 38 tumors were assessed. OTR was quantified by a special algorithm to measure hypervascular HCC tissue.

RESULTS

19 tumors received each therapy. Nine subjects (27%) had PVT, most of them in the TARE group (p = 0.026). Mean OTR according to the tumor volumes was 24.2% ± 56% after TARE and 32.8% ± 48.9% after TACE, with no difference between the treatments (p = 0.616). Similar values were also observed between those with and without PVT (p = 0.704). Mean survival was 340 days and did not differ between the two treatments (p = 0.596), but was 194 days in PVT cases (p = 0.007).

CONCLUSIONS

This is the first study in which OTR obtained by TARE with 131I-lipiodol is accurately measured. Additionally, PVT impact on survival after TARE and TACE was precisely documented. Although the TARE group had more PVT subjects (who had shorter survival), TARE and TACE achieved similar OTR and OS rates.

Evaluation of efficacy of transcatheter arterial chemoembolization for hepatocellular carcinoma using magnetic resonance diffusion-weighted imaging

Although the efficacy of transcatheter arterial chemoembolization (TACE) has been recommended as first-line therapy for nonsurgical patients with hepatocellular carcinoma (HCC), it is difficult to accurately predict the efficacy of TACE. Therefore, this study evaluated the efficacy of TACE for HCC using magnetic resonance (MR) diffusion-weighted imaging (DWI). A total of 84 HCC patients who received initial TACE were selected and assigned to the stable group (n=39) and the progressive group (n=45). Before TACE treatment, a contrast-enhanced MR scan and DWI (b=300, 600, and 800 s/mm²) were performed on all patients. The modified response evaluation criteria in solid tumors were used for evaluation of tumor response. Receiver operating characteristic curve was employed to predict the value of apparent diffusion coefficient (ADC) for TACE efficacy. The ADC values of HCC patients in the progressive group were higher than those in the stable group at different b-values (b=300, 600, and 800 s/mm²) before TACE treatment. The area under the curve of ADC values with b-values of 300, 600, and 800 s/mm² were 0.693, 0.724, and 0.746; the threshold values were 1.94×10^-3 mm²/s, 1.28×10^-3 mm²/s, and 1.20×10^-3 mm²/s; the sensitivity values were 55.6%, 77.8%, and 73.3%; and the specificity values were 82.1%, 61.5%, and 71.8%, respectively. Our findings indicate that the ADC values of MR-DWI may accurately predict the efficacy of TACE in the treatment of HCC patients.

Arterio-portal shunts in the cirrhotic liver: perfusion computed tomography for distinction of arterialized pseudolesions from hepatocellular carcinoma

OBJECTIVES

To determine perfusion computed tomography (P-CT) findings for distinction of arterial pseudolesions (APL) from hepatocellular carcinoma (HCC) in the cirrhotic liver.

METHODS

32 APL and 21 HCC in 20 cirrhotic patients (15 men; 65 ± 10 years), who underwent P-CT for evaluation of HCC pre- (N = 9) or post- (N = 11) transarterial chemoembolization, were retrospectively included using CT follow-up as the standard of reference. All 53 lesions were qualitatively (visual) and quantitatively (perfusion parameters) analysed according to their shape (wedge, irregular, nodular), location (not-/adjunct to a fistula), arterial liver perfusion (ALP), portal venous liver perfusion (PLP), hepatic perfusion index (HPI). Accuracy for diagnosis of HCC was determined using receiver operating characteristics.

RESULTS

18/32 (56 %) APL were wedge shaped, 10/32 (31 %) irregular and 4/32 (12 %) nodular, while 11/21 (52 %) HCC were nodular or 10/21 (48 %) irregular, but never wedge shaped. Significant difference between APL and HCC was seen for lesion shape in pretreated lesions (P < 0.001), and for PLP and HPI in both pre- and post-treated lesions (all, P < 0.001). Diagnostic accuracy for HCC was best for combined assessment of lesion configuration and PLP showing an area under the curve of 0.901.

CONCLUSION

Combined assessment of lesion configuration and portal venous perfusion derived from P-CT allows best to discriminate APL from HCC with high diagnostic accuracy.

KEY POINTS

• Arterio-portal shunting is common in the cirrhotic liver, especially after local treatment. • Arterial pseudolesions (APL) due to shunting might mimic hepatocellular carcinoma (HCC). • Perfusion-CT allows for qualitative and quantitative assessment of liver lesions. • Lesion configuration fails to discriminate APL from HCC in locally treated patients. • Integration of quantitative perfusion analysis improves accuracy for diagnosis of HCC.

Primary liver cancer complicated with hepatic arterioportal fistula: Clinical characteristics and risk factors

AIM: To investigate the clinical characteristics of and risk factors for primary liver cancer (PLC) complicated with hepatic arterioportal fistula (HAPF).

METHODS: Clinical and imaging data for 152 patients with PLC who underwent transcatheter arterial chemoembolization (TACE) were analyzed retrospectively. These patients were divided into HAPF group and control group to analyze the clinical characteristics of and risk factors for PLC with HAPF.

RESULTS: The percentages of patients with liver function grade (B+C), upper tract hemorrhage, ascites, or portal vein thrombosis were significantly higher in the HAPF group than in the control group (t = 4.858, 4.522, 4.496, 6.024, all P < 0.05). No statistical differences were noted in liver cirrhosis, disseminated lesions in the liver, and abnormal AFP between two groups (all P > 0.05). HAPF was prone to be present in patients with massive PLC that has rich feeding vessels. Approximately 89.9% of patients had improvement of HAPF and 22.2% had remission of portal hypertension shortly after TACE treatment.

CONCLUSION: PLC complicated with HAPF is possibly associated with factors including massive tumors with rich tumor feeding vessel and portal vein thrombosis, which tend to impair liver function and aggravate portal vein hypertension symptoms. Proper TACE treatment can improve HAPF and portal hypertension symptoms in a short term.