Imaging the liver

What Is the Optimal Time on a Low-Calorie Diet Prior to Laparoscopic Anti-reflux Surgery? A Prospective Case-Controlled Study

INTRODUCTION

A very low-calorie diet (VLCD) or low-calorie diet (LCD) is often used prior to laparoscopic surgery to optimize access to the hiatus. Much debate exists in the literature regarding the required duration for a VLCD or LCD, and how to evaluate the presence of a fatty liver. The aim of our study was to determine the optimal amount of time on an LCD to achieve maximal liver volume reduction, and to assess the accuracy of the InBody 230® vs. bedside ultrasonography vs. magnetic resonance imaging (MRI) in the measurement of liver volume.

METHODS

Seventeen consecutive patients undergoing laparoscopic anti-reflux surgery were recruited into the study. Each patient underwent body composition analysis with the InBody® 230, liver ultrasound, and liver MRI. Patients then began an LCD with a weekly ultrasound assessment until the day before surgery when they underwent repeat body composition analysis, liver ultrasound, and MRI.

RESULTS

The mean age was 54 years (range 21, 74). Maximal liver volume loss was noted within 3 weeks for 88% of participants, with 47% achieving their maximal liver volume reduction after the first week of an LCD. The mean reduction in liver volume was 16%, 18.6%, and 19% for MRI, ultrasound, and body composition analysis, respectively.

CONCLUSION

Close to 90% of patients require 3 weeks or less on an LCD to achieve maximal liver volume loss prior to laparoscopic anti-reflux surgery. Body composition analysis and bedside ultrasonography were both as accurate as the gold standard MRI in the assessment of liver volume.

Noninvasive Detection of Ischemic Vascular Damage in a Pig Model of Liver Donation After Circulatory Death

BACKGROUND AND AIMS

Liver graft quality is evaluated by visual inspection prior to transplantation, a process highly dependent on the surgeon's experience. We present an objective, noninvasive, quantitative way of assessing liver quality in real time using Raman spectroscopy, a laser-based tool for analyzing biomolecular composition.

APPROACH AND RESULTS

A porcine model of donation after circulatory death (DCD) with normothermic regional perfusion (NRP) allowed assessment of liver quality premortem, during warm ischemia (WI) and post-NRP. Ten percent of circulating blood volume was removed in half of experiments to simulate blood recovery for DCD heart removal. Left median lobe biopsies were obtained before circulatory arrest, after 45 minutes of WI, and after 2 hours of NRP and analyzed using spontaneous Raman spectroscopy, stimulated Raman spectroscopy (SRS), and staining. Measurements were also taken in situ from the porcine liver using a handheld Raman spectrometer at these time points from left median and right lateral lobes. Raman microspectroscopy detected congestion during WI by measurement of the intrinsic Raman signal of hemoglobin in red blood cells (RBCs), eliminating the need for exogenous labels. Critically, this microvascular damage was not observed during WI when 10% of circulating blood was removed before cardiac arrest. Two hours of NRP effectively cleared RBCs from congested livers. Intact RBCs were visualized rapidly at high resolution using SRS. Optical properties of ischemic livers were significantly different from preischemic and post-NRP livers as measured using a handheld Raman spectrometer.

CONCLUSIONS

Raman spectroscopy is an effective tool for detecting microvascular damage which could assist the decision to use marginal livers for transplantation. Reducing the volume of circulating blood before circulatory arrest in DCD may help reduce microvascular damage.

Liver findings in patients with Carney complex, germline PRKAR1A pathogenic variants, and link to cardiac myxomas

This study aimed to evaluate liver involvement in patients with Carney complex (CNC) based on a large cohort and to analyze any germline PRKAR1A genotype-phenotype association of liver disease. The study included 83 patients with CNC, followed between 1995 and 2018 at a tertiary research center. We reviewed liver images, recorded types and number of lesions and analyzed per genotype: all patients were sequenced for the PRKAR1A gene. A total of 29/83 patients (24.0%) had liver radiological findings. Patients with liver lesion had a significantly higher rate of pathogenic variants detected in the PRKAR1A gene (72.4 vs 38.9%, P = 0.005, respectively). Patients with a pathogenic variant detected on germline PRKAR1A analysis had a higher risk for having a liver lesion compared with patients with wild-type (WT) PRKAR1A alleles (21/42 (50.0%) vs 8/41 (19.5%), respectively, P = 0.004). Among patients with liver lesions, those with a nonsense PRKAR1A pathogenic-variant had more liver lesions (7/7) than among those with other pathogenic-variant types (8/22, P = 0.001). In multivariable analysis, detection of liver lesion(s) was associated with an odds ratio of 5.2 for cardiac myxomas (95% CI 1.55-17.49, P = 0.008). In conclusion, patients with CNC, particularly with a PRKAR1A pathogenic variant, have a higher rate of liver lesions. Additionally, liver lesions are associated with a high risk for cardiac myxomas in this population.

'Hepato-diaphragmatic fat interposition' and 'increased right hemi-diaphragmatic thickness': new imaging signs for early diagnosis of hepatic cirrhosis on routine CT abdomen

BACKGROUND

Cirrhosis of liver is often a silent disease and need early diagnosis for effective treatment strategy.

OBJECTIVES

The present article aims to describe new imaging signs for early diagnosis of cirrhosis on routine CT. These are 'hepato-diaphragmatic fat interposition' (HDFI) and 'increased right hemi-diaphragmatic thickness' (increased r-DT sign).

MATERIALS AND METHODS

This was a retrospective study based on the presence or absence of cirrhosis of liver (n = 100). 'HDFI sign' was labeled as positive if F is more than 50% of D; where F is the medio-lateral extent of the intra-abdominal fat along the postero-medial margin of liver and D is the distance from the lateral vertebral margin to the medial margin of the outer-most rib in the same axial image. Increased 'r-DT sign' is labeled when the dimension on right side exceeds left side by at least 0.2 cm. Pearson χ² was performed to calculate the p value. A p value of < 0.05 was considered to indicate a significant difference.

RESULTS

There was a significant difference between cirrhotic and normal group, The sensitivity, specificity, positive predictive value and the negative predictive value of HDFI sign was found to be 94%, 62%, 71.21% and 91.17%, while that of increased r-DT sign was found to be 96%,52%, 66.66% and 92.85%. The area under the ROC curve for the HDFI sign was found to be 0.78 as compared to 0.74 for the increased r-DT sign.

CONCLUSION

Both these new signs should be used as additional imaging signs for early diagnosis of cirrhosis.

A Rare Nonhepatocytic Primary Liver Neoplasm with an Unusual Presentation: Ossifying Malignant Mixed Epithelial and Stromal Tumor

We present a case of a rare liver neoplasm – Ossifyimg malignant mixed epithelial and stromal tumor. This entity has well-delineated morphological and immunohistochemical features, and so can be easily diagnosed, even with core biopsy tissue. Our patient was a middle-aged male, which is unheard of in the literature of this disease. He had a bad recurrence of the disease after surgical removal of the tumor, unlike the previously reported cases with the same diagnosis, where the patients lived for almost a decade after surgery without recurrence. This neoplasticdisease can thus take a destructive course, and a change in treatment methods such as neoadjuvant or adjuvant chemotherapy should be thought of, to make it more beneficial and effective.

Rapid switching kVp dual energy CT: Value of reconstructed dual energy CT images and organ dose assessment in multiphasic liver CT exams

PURPOSE

Clinical applications of dual energy computed tomography (DECT) have been widely reported; however, the importance of the different image reconstructions and radiation organ dose remains a relevant area of investigation, particularly considering the different commercially available DECT equipment. Therefore, the purpose of this study was to assess the image reliability and compare the information content between several image reconstructions in a rapid-switching DECT (rsDECT), and assess radiation organ dose between rsDECT and conventional single-energy computed tomography (SECT) exams.

MATERIALS AND METHODS

This Institutional Review Board-approved retrospective study included 98 consecutive patients who had a history of liver cancer and underwent multiphasic liver CT exams with rsDECT applied during the late arterial phase between June 2015 and December 2015. Virtual monochromatic 70 keV, material density images (MDI) iodine (-water) and virtual unenhanced (VUE) images were generated. Radiation dose analysis was performed in a subset of 44 patients who had also undergone a multiphasic SECT examination within 6 months of the rsDECT. Four board-certified abdominal radiologists reviewed 24-25 patients each, and a fifth radiologist re-evaluated all the scans to reach a consensus. The following imaging aspects were assessed by the radiologists: (a) attenuation measurements were made in the liver and spleen in VUE and true unenhanced (TUE) images; (b) subjective evaluation for lesion detection and conspicuity on MDI iodine (-water)/VUE images compared with the virtual monochromatic images/TUE images; and (c) overall image quality using a five-point Likert scale. The radiation dose analyses were evaluated in the subset of 44 patients regarding the following parameters: CTDIvol, dose length product, patient's effective diameter and organ dose using a Monte Carlo-based software, VirtualDose™ (Virtual Phantoms, Inc.) to 21 organs.

RESULTS

On average, image noise on the TUE images was 49% higher within the liver (p < 0.0001) and 48% higher within the spleen (p < 0.0001). CT numbers for the spleen were significantly higher on VUE images (p < 0.0001). Twenty-eight lesions in 24/98 (24.5%) patients were not observed on the VUE images. The conspicuity of vascular anatomy was considered better on MDI iodine (-water) Images 26.5% of patients. Using the Likert scale, the rsDECT image quality was considered to be satisfactory. Considering the subset of 44 patients with recent SECT, the organ dose was, on average, 37.4% less with rsDECT. As the patient's effective diameter decreased, the differences in dose between the rsDECT and SECT increased, with the total average organ dose being less by 65.1% when rsDECT was used.

CONCLUSION

VUE images in the population had lower image noise than TUE images; however, a few small and hyperdense findings were not characterized on VUE images. Delineation of vascular anatomy was considered better in around a quarter of patients on MDI iodine (-water) images. Finally, radiation dose, particularly organ dose, was found to be lower with rsDECT, especially in smaller patients.

Universal Liver Extraction Algorithm: An Improved Chan–Vese Model

Liver segmentation is important to speed up liver disease diagnosis. It is also useful for detection, recognition, and measurement of objects in liver images. Sufficient work has been carried out until now, but common methodology for segmenting liver image from CT scan, MRI scan, PET scan, etc., is not available. The proposed methodology is an effort toward developing a general algorithm to segment liver image from abdominal computerized tomography (CT) scan and magnetic resonance imaging (MRI) scan images. In the proposed algorithm, pixel intensity range of the liver portion is obtained by cropping a random section of the liver. Using its histogram, threshold values are calculated. Further, threshold-based segmentation is performed, which separates liver from abdominal CT scan image/abdominal MRI scan image. Noise in the liver image is reduced using median filter, and the quality of the image is improved by sigmoidal function. The image is then converted into binary image. The Chan–Vese (C–V) model demands an initial contour, which evolves outward. A novel algorithm is proposed to identify the initial contour inside the liver without user intervention. This initial contour propagates outward and continues until the boundary of the liver is identified accurately. This process terminates by itself when the entire boundary of the liver is detected. The method has been validated on CT images and MRI images. Results on the variety of images are compared with existing algorithms, which reveal its robustness, effectiveness, and efficiency.

Which Criteria Applied in Multi-Phasic CT Can Predict Early Tumor Response in Patients with Hepatocellular Carcinoma Treated Using Conventional TACE: RECIST, mRECIST, EASL or qEASL?

PURPOSE

Our study aimed to evaluate quantitative tumor response assessment (quantitative EASL-[qEASL]) on computed tomography (CT) images in patients with hepatocellular carcinoma (HCC) treated using conventional transarterial chemoembolization (cTACE), compared to existing 1-dimensional and 2-dimensional methods (RECIST, mRECIST, EASL).

MATERIALS AND METHODS

In this IRB-approved, single-institution retrospective cohort study, 52 consecutive patients with intermediate-stage HCC were consecutively included. All patients underwent contrast-enhanced CT scan at baseline and 4 weeks after cTACE.

RESULTS

Median follow-up period was 13.5 months (range 1.2-54.1). RECIST, mRECIST and EASL identified progression in 2 (4%), 1 (2%) and 1 (2%) patients, respectively, whereas qEASL identified 10 (19%) patients. qEASL was the only tumor response method able to predict survival among different tumor response groups (P < 0.05), whereas RECIST, mRECIST and EASL did not (P > 0.05). Both EASL and qEASL were able to identify responders and non-responders and were predictive of survival (P < 0.05). Multivariate analysis showed that progression was an independent predictor of overall survival with hazard ratio of 1.9 (P = 0.025). Patients who demonstrated progression with qEASL had significantly shorter survival than those with non-progression (7.6 vs. 20.4 months, P = 0.012). Similar multivariate analysis using RECIST, mRECIST and EASL could not be performed because too few patients were categorized as progressive disease.

CONCLUSION

qEASL could be applied on CT images to assess tumor response following cTACE and is a more sensitive biomarker to predict survival and identify tumor progression than RECIST, mRECIST and EASL at an early time point.

LEVEL OF EVIDENCE

Level 2a, retrospective cohort study.

Application of Real-Time 3D Navigation System in CT-Guided Percutaneous Interventional Procedures: A Feasibility Study

Introduction

To evaluate the accuracy of a quantitative 3D navigation system for CT-guided interventional procedures in a two-part study.

Materials and Methods

Twenty-two procedures were performed in abdominal and thoracic phantoms. Accuracies of the 3D anatomy map registration and navigation were evaluated. Time used for the navigated procedures was recorded. In the IRB approved clinical evaluation, 21 patients scheduled for CT-guided thoracic and hepatic biopsy and ablations were recruited. CT-guided procedures were performed without following the 3D navigation display. Accuracy of navigation as well as workflow fitness of the system was evaluated.

Results

In phantoms, the average 3D anatomy map registration error was 1.79 mm. The average navigated needle placement accuracy for one-pass and two-pass procedures, respectively, was 2.0 ± 0.7 mm and 2.8 ± 1.1 mm in the liver and 2.7 ± 1.7 mm and 3.0 ± 1.4 mm in the lung. The average accuracy of the 3D navigation system in human subjects was 4.6 mm ± 3.1 for all procedures. The system fits the existing workflow of CT-guided interventions with minimum impact.

Conclusion

A 3D navigation system can be performed along the existing workflow and has the potential to navigate precision needle placement in CT-guided interventional procedures.

Imaging of Neuroendocrine Tumors: Indications, Interpretations, Limits, and Pitfalls

Imaging is critical in the diagnosis, prognosis, and management of neuroendocrine tumors (NETs). NETs share common imaging features, but each type exhibits unique features. Computed tomography scans or MRI of the abdomen is used to assess tumor burden routinely. Functional imaging with octreotide scan or gallium-68 somatostatin analog PET is used selectively to confirm diagnosis and guide therapy. Clinicians and radiologists should be familiar with the indications and interpretations of imaging modalities. Novel functional imaging modalities likely will be developed to detect small NETs, predict prognosis, guide therapeutic choices, and design novel therapies.

Resection of Colorectal Liver Metastases: Current Perspectives

BACKGROUND

Metastases to the liver is the leading cause of death in patients with colorectal cancer.

METHODS

The authors review the data on diagnosis and management of this clinical problem, and they discuss management options that can be considered.

RESULTS

Complete surgical resection of metastases from colorectal cancer that are localized to the liver results in 5-year survival rates ranging from 26% to 40%.

CONCLUSIONS

By adding modalities such as targeted systemic therapy and other "local" treatments for liver metastases, further gains in survival are anticipated.

Intrahepatic Biliary Metastasis of Colonic Adenocarcinoma: A Case Report With Immunohistochemical Analysis

Although intrabiliary metastasis of carcinoma in the liver is unusual, intraductal and/or intraepithelial spread of cancer cells along intrahepatic bile ducts is now well recognized as hepatic metastasis. However, several clinical and laboratory findings, including images, lead us to differentially diagnose from primary intrahepatic cholangiocarcinoma. We report here on a case of colonic adenocarcinoma that metastasized to the liver with spread along with the intrahepatic bile duct of S5/6 area. The patient was a 51-year-old man and clinically diagnosed liver metastasis of sigmoid colon cancer (tub2, pMP, ly1, v0, n0), which was diagnosed and treated by sigmoidectomy 7 years ago. The right hepatic lobectomy was performed in March 2016 and histopathological examination revealed that moderately differentiated adenocarcinoma proliferated along the epithelium of intrahepatic bile ducts. Immunohistochemistry (IHC) showed that cancer cells in the intrahepatic bile ducts were positive for CK20, CDX2, CK17 and CK19, but negative for CK7, MUC-5AC, MUC-2 and CA19-9. The findings were almost the same as those of the sigmoid colon cancer removed in July 2009. We finally diagnosed the liver tumor as intrahepatic biliary metastasis of sigmoid colon cancer. Patients with liver metastasis of cancer are hard to be detected biliary invasion and spread on diagnostic image examination. Knowledge of distinctive morphological and IHC features can help to accurately diagnose this rare intrahepatic biliary metastasis of colonic cancer in routine pathological diagnostic procedures.

Impact of Modified Anisotropic Diffusion-based Enhancement Method in Computer-Aided Classification of Focal Liver Lesions

This work is presented with the objective to assess quantitatively the impact of modified anisotropic diffusion-based enhancement method of Mittal et al. in computer-aided classification of focal liver lesions. This assessment was made before and after enhancement of clinically acquired ultrasound images with the comparison of (a) discrimination capability of radiologically important texture contrast feature using box plot and p-value statistics and (b) test results of designed computer-aided classification schemes to detect/classify focal liver tissues using receiver operating characteristic curves. The results reveal that the application of enhancement method on clinically acquired ultrasound image may effectively improve the confidence of clinicians/radiologists in computer-aided diagnostic solutions to detect and classify focal liver lesions.

Computer-aided Characterization and Diagnosis of Diffuse Liver Diseases Based on Ultrasound Imaging: A Review

Diffuse liver diseases, such as hepatitis, fatty liver, and cirrhosis, are becoming a leading cause of fatality and disability all over the world. Early detection and diagnosis of these diseases is extremely important to save lives and improve effectiveness of treatment. Ultrasound imaging, a noninvasive diagnostic technique, is the most commonly used modality for examining liver abnormalities. However, the accuracy of ultrasound-based diagnosis depends highly on expertise of radiologists. Computer-aided diagnosis systems based on ultrasound imaging assist in fast diagnosis, provide a reliable "second opinion" for experts, and act as an effective tool to measure response of treatment on patients undergoing clinical trials. In this review, we first describe appearance of liver abnormalities in ultrasound images and state the practical issues encountered in characterization of diffuse liver diseases that can be addressed by software algorithms. We then discuss computer-aided diagnosis in general with features and classifiers relevant to diffuse liver diseases. In later sections of this paper, we review the published studies and describe the key findings of those studies. A concise tabular summary comparing image database, features extraction, feature selection, and classification algorithms presented in the published studies is also exhibited. Finally, we conclude with a summary of key findings and directions for further improvements in the areas of accuracy and objectiveness of computer-aided diagnosis.

Fatty liver index as a simple predictor of incident diabetes from the KoGES-ARIRANG study

The fatty liver index (FLI), calculated from serum triglyceride, body mass index, waist circumference, and gamma-glutamyltransferase, is considered a surrogate marker of nonalcoholic fatty liver disease (NAFLD). We investigated whether FLI predicts the development of diabetes mellitus (DM) and assessed the predictive ability of FLI for new onset of DM in a prospective population-based cohort study.We analyzed a total of 2784 adults (944 men and 1840 women) aged 40 to 70 years without DM at baseline. Participants were classified according to FLI values into 3 groups: FLI < 30, no NAFLD; 30 ≤ FLI ≤ 59, intermediate NAFLD; and FLI ≥ 60, participants with NAFLD. The area under the receiver-operating characteristic curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to determine whether FLI improved DM risk prediction.During a mean of 2.6 years follow-up, 88 (3.16%) participants developed DM. The odds ratio analyzed from multivariable-adjusted models (95% confidence interval [CI]) for new onset of DM increased in a continuous manner with increased FLI (<30 vs 30-59 vs ≥60 = 1 vs 1.87 [95% CI 1.05-3.33] vs 2.84 [95% CI 1.4-5.75], respectively). The AUC significantly increased when FLI was added to the conventional DM prediction model (0.835, 95% CI: 0.789-0.881, P = 0.0289 vs traditional DM prediction model). The category-free NRI was 0.417 (95% CI: 0.199-0.635) and the IDI was 0.015 (95% CI: 0.003-0.026) for overall study participants.We found that FLI, a surrogate marker of hepatic steatosis, resulted in significant improvement in DM risk prediction. Our finding suggests that FLI may have clinical and prognostic information for incident DM among the Korean adult population.

Hepatic myelolipoma in two Goeldi's monkeys from South America held captive

Two cases of hepatic myelolipoma in Goeldi's monkeys from South America are described. One was a female evaluated due progressive abdominal distension. Ultrasound and computed tomography detected hepatic mass. Partial hepatectomy was performed, but the monkey died after surgery. Case 2 was a male that died suddenly, showing non-specific clinical signs.

Ultrasound Accuracy of Liver Length Measurement with Cadaveric Specimens

The liver is one of the principal organs of our body involved in over 500 physiological functions related to metabolism, digestion, immunity, and storage of nutrients, which makes it an essential organ to preserve life. Given that there are a number of approaches to measure liver length through diagnostic 2D sonography, this work aims to determine the most accurate measurement of this organ. Cadaveric specimens (n = 21) were employed to assess measurements in midclavicular line (MCL) and midaxillary line (MAL). Each measurement was calculated in anteroposterior (AP) and craniocaudal (CC) planes. In addition, in situ measurements were obtained by accessing the organ through the anterior thoracoabdominal wall. Statistical differences were detected between MCL and MAL measurements (p < 0.05), a positive correlation between MAL CC and in situ anterior measurements were noted (r = 0.97). Liver size, as assessed through in situ measurements, varied as a funtion of BMI and waist circumference (p < 0.05). It is concluded that CC measurement of the RLL in MAL from the uppermost right hemi-diaphragm to the inferior tip of the right lobe through a horizontal line parallel to the anterior liver wall is the most accurate measurement of the organ by sonography.

Development of nanotheranostics against metastatic breast cancer--A focus on the biology & mechanistic approaches

Treatment for metastatic breast cancer still remains to be a challenge since the currently available diagnostic and treatment strategies fail to detect the micro-metastasis resulting in higher mortality rate. Moreover, the lack of specificity to target circulating tumor cells is also a factor. In addition, currently available imaging modalities to identify the secondaries vary with respect to various metastatic anatomic areas and size of the tumor. The drawbacks associated with the existing clinical management of the metastatic breast cancer demands the requirement of multifunctional nanotheranostics, which could diagnose at macro- and microscopic level, target the solid as well as circulating tumor cells and control further progression with the simultaneous evaluation of treatment response in a single platform. However, without the understanding of the biology as well as preferential homing ability of circulating tumor cells at distant organs, it is quite impossible to address the existing challenges in the present diagnostics and therapeutics against the breast cancer metastasis. Hence this review outlines the severity of the problem, basic biology and organ specificity with the sequential steps for the secondary progression of disease followed by the various mechanistic approaches in diagnosis and therapy at different stages.

T2-weighted four dimensional magnetic resonance imaging with result-driven phase sorting

PURPOSE

T2-weighted MRI provides excellent tumor-to-tissue contrast for target volume delineation in radiation therapy treatment planning. This study aims at developing a novel T2-weighted retrospective four dimensional magnetic resonance imaging (4D-MRI) phase sorting technique for imaging organ/tumor respiratory motion.

METHODS

A 2D fast T2-weighted half-Fourier acquisition single-shot turbo spin-echo MR sequence was used for image acquisition of 4D-MRI, with a frame rate of 2-3 frames/s. Respiratory motion was measured using an external breathing monitoring device. A phase sorting method was developed to sort the images by their corresponding respiratory phases. Besides, a result-driven strategy was applied to effectively utilize redundant images in the case when multiple images were allocated to a bin. This strategy, selecting the image with minimal amplitude error, will generate the most representative 4D-MRI. Since we are using a different image acquisition mode for 4D imaging (the sequential image acquisition scheme) with the conventionally used cine or helical image acquisition scheme, the 4D dataset sufficient condition was not obviously and directly predictable. An important challenge of the proposed technique was to determine the number of repeated scans (NR) required to obtain sufficient phase information at each slice position. To tackle this challenge, the authors first conducted computer simulations using real-time position management respiratory signals of the 29 cancer patients under an IRB-approved retrospective study to derive the relationships between NR and the following factors: number of slices (NS), number of 4D-MRI respiratory bins (NB), and starting phase at image acquisition (P0). To validate the authors' technique, 4D-MRI acquisition and reconstruction were simulated on a 4D digital extended cardiac-torso (XCAT) human phantom using simulation derived parameters. Twelve healthy volunteers were involved in an IRB-approved study to investigate the feasibility of this technique.

RESULTS

4D data acquisition completeness (Cp) increases as NR increases in an inverse-exponential fashion (Cp = 100 - 99 × exp(-0.18 × NR), when NB = 6, fitted using 29 patients' data). The NR required for 4D-MRI reconstruction (defined as achieving 95% completeness, Cp = 95%, NR = NR,95) is proportional to NB (NR,95 ∼ 2.86 × NB, r = 1.0), but independent of NS and P0. Simulated XCAT 4D-MRI showed a clear pattern of respiratory motion. Tumor motion trajectories measured on 4D-MRI were comparable to the average input signal, with a mean relative amplitude error of 2.7% ± 2.9%. Reconstructed 4D-MRI for healthy volunteers illustrated clear respiratory motion on three orthogonal planes, with minimal image artifacts. The artifacts were presumably caused by breathing irregularity and incompleteness of data acquisition (95% acquired only). The mean relative amplitude error between critical structure trajectory and average breathing curve for 12 healthy volunteers is 2.5 ± 0.3 mm in superior-inferior direction.

CONCLUSIONS

A novel T2-weighted retrospective phase sorting 4D-MRI technique has been developed and successfully applied on digital phantom and healthy volunteers.

A model for effects of adaptive immunity on tumor response to chemotherapy and chemoimmunotherapy

Complete clinical regressions of solid tumors in response to chemotherapy are difficult to explain by direct cytotoxicity alone, because of low growth fractions and obstacles to drug delivery. A plausible indirect mechanism that might reconcile this is the action of the immune system. A model for interaction between tumors and the adaptive immune system is presented here, and used to examine controllability of tumors through the interplay of cytotoxic, cytostatic and immunogenic effects of chemotherapy and the adaptive immune response. The model includes cytotoxic and helper T cells, T regulatory cells (Tregs), dendritic cells, memory cells, and several key cytokines. Nearly all parameter estimates are derived from experimental and clinical data. Individual tumors are characterized by two parameters: growth rate and antigenicity, and regions of tumor control are identified in this parameter space. The model predicts that inclusion of the immune response significantly expands the region of tumor control for both cytostatic and cytotoxic chemotherapies. Moreover, outside the control zone, tumor growth is delayed significantly. An optimal fractionation schedule is predicted, for a fixed cumulative dose. The model further predicts expanded regions of tumor control when several forms of immunotherapy (adoptive T cell transfer, Treg depletion, and dendritic cell vaccination) are combined with chemotherapy. Outcomes depend greatly on tumor characteristics, the schedule of administration, and the type of immunotherapy chosen, suggesting promising opportunities for personalized medicine. Overall, the model provides insight into the role of the adaptive immune system in chemotherapy, and how scheduling and immunotherapeutic interventions might improve efficacy.

Association between the Fatty Liver Index and Risk of Type 2 Diabetes in the EPIC-Potsdam Study

The fatty liver index (FLI) predicts fatty liver by using BMI, waist circumference, γ-glutamyltransferase and triglycerides. We investigated the association between the FLI and the risk of type 2 diabetes and evaluated to what extent single FLI components contribute to the diabetes risk. We analysed a case-cohort study (random sub-cohort: 1922; incident cases: 563) nested within the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study. The proportion of exposure effect (PEE) explained by single FLI components was evaluated and effect decomposition using inverse probability weighting (IPW) was applied. Women and men with a FLI ≥60 compared to those with a FLI <30 had a multivariable-adjusted Hazard Ratio (HR) of 17.6; 95% confidence interval (CI) 11.1-28.0 and HR: 10.9; 95% CI 6.22-19.2, respectively. Adjustment for BMI or waist circumference attenuated this association in men [PEE_BMI (95% CI) = 53.8% (43.9%-65.8%); PEE_waist (95% CI) = 54.8% (44.2%-68.8%)]. In women, adjustment for waist circumference attenuated the association to a lesser degree than in men [PEE_waist (95% CI) = 31.1%; (21.9%-43.1%)] while BMI had no appreciable effect [PEE_BMI (95% CI) = 11.0% (2.68%-21.0%)]. γ-glutamyltransferase and triglycerides showed only a small attenuation in women [PEE_GGT(95% CI) = 3.11% (-0.72%-4.48%); PEE_TG (95% CI) = 6.36% (3.81%-9.92%)] and in men [PEE_GGT = 0%; PEE_TG (95% CI) = 6.23% (2.03%-11.8%)]. In women, the total effect was decomposed into a direct effect and 4 indirect effects (HR_BMI = 1.10; HR_waist = 1.28; HR_GGT = 0.97 and HR_TG = 1.03). In men, the 4 indirect effects were HR_BMI = 1.25; HR_waist = 1.29; HR_GGT = 0.97 and HR_TG = 0.99. These data suggest that the FLI, as a proxy for fatty liver, is associated with risk of type 2 diabetes. This association is only partly explained by standard estimates of overall and abdominal body fatness, particularly among women.

Evaluation of contrast Sonazoid-enhanced ultrasonography for the detection of hepatic metastases in breast cancer

Background

The present study was aimed to evaluate the usefulness of contrast Sonazoid-enhanced ultrasonography (US) for the detection of hepatic metastases in breast cancer patients and compare the clinical efficacy and sensitivity of this technique with conventional contrast unenhanced B-mode US in follow-up examinations of breast cancer patients with liver metastasis.

Methods

We assessed a total of 84 hepatic tumors from 24 patients diagnosed with or suspected of having metastatic cancer. These hepatic nodules were diagnosed through imaging, including dynamic magnetic resonance imaging (MRI), contrast-enhanced computed tomography (CECT) scan, B-mode US or contrast Sonazoid-enhanced US (SEUS). Differences in the sensitivity between US and SEUS were compared using MR imaging, CECT, and follow-up imaging.

Results

A total of 79 nodules were diagnosed as metastatic tumors. The remaining nodules were diagnosed as benign tumors (hepatic hemangioma: n = 3; local fatty change: n = 2). SEUS precisely detected the presence or absence of hepatic tumors in the 24 patients examined, showing a sensitivity of 98.8 % (83 of 84 lesions) for total imaged solid liver lesions, with an accuracy of 98.7 % (78 of 79 lesions) for total metastatic breast cancer lesions. In contrast, conventional B-mode US imaging revealed hepatic tumor lesions at a sensitivity of 66.7 % (56 of 84 lesions) and an accuracy of 64.6 % (51 of 79 lesions), respectively. Furthermore, the false positive and false negative rates were, respectively, 6.33 and 29.1 % for B-mode US and 0 and 1.3 % for SEUS. Moreover, twenty-seven metastatic tumors and five benign lesions (3 hemangiomas and 2 focal fatty changes/sparings) were imaged using SEUS but not conventional B-mode US. Significant differences in diagnostic accuracy rates between contrast Sonazoid-enhanced US and conventional B-mode US were observed (Wilcoxon signed rank test: p = 0.0009). No severe adverse events occurred during SEUS after the administration of Sonazoid, except for a grade 1 skin reaction and nausea in one patient.

Conclusion

These results suggested that Sonazoid could be safely administrated to breast cancer patients with liver metastatic disease. Thus, contrast Sonazoid-enhanced US is a feasible and more effective method than B-mode US for the detection of hepatic metastasis, particularly for small metastatic breast cancer lesions less than 14 mm in diameter, showing significant high sensitivity and accuracy.

Potential role of FDG PET/CT in evaluating patients with hepatic incidentalomas

This review article is focused on the role of FDG PET/CT in diagnosing and characterizing hepatic incidentalomas. A large variety of unsuspected lesions can be detected in the liver both with ultrasound and CT performed for other reasons; the prevalence of liver incidentalomas increases in patients with chronic liver disease or preexisting oncologic history. The major challenge is to discriminate benign from malignant lesions. There is a large body of literature indicating that FDG PET/CT is a useful tool to this purpose even if it is unspecific (ie, it cannot differentiate a primary tumor from a secondary lesion). Occasionally, FDG PET/CT can be useful for biopsy guidance.

The Preoperative Assessment of Hepatic Tumours: Evaluation of UK Regional Multidisciplinary Team Performance

Introduction. In the UK, patients where liver resection is contemplated are discussed at hepatobiliary multidisciplinary team (MDT) meetings. The aim was to assess MDT performance by identification of patients where radiological and pathological diagnoses differed. Materials and Methods. A retrospective review of a prospectively maintained database of all cases undergoing liver resection from March 2006 to January 2012 was performed. The presumed diagnosis as a result of radiological investigation and MDT discussion is recorded at the time of surgery. Imaging was reviewed by specialist gastrointestinal radiologists, and resultswereagreedonby consensus. Results. Four hundred and thirty-eight patients were studied. There was a significant increase in the use of preoperative imaging modalities (P ≤ 0.01) but no change in the rate of discrepant diagnosis over time. Forty-two individuals were identified whose final histological diagnosis was different to that following MDT discussion (9.6%). These included 30% of patients diagnosed preoperatively with hepatocellular carcinoma and 25% with cholangiocarcinoma of a major duct. Discussion. MDT assessment of patients preoperatively is accurate in terms of diagnosis. The highest rate of discrepancies occurred in patients with focal lesions without chronic liver disease or primary cancer, where hepatocellular carcinoma was overdiagnosed and peripheral cholangiocarcinoma underdiagnosed, where particular care should be taken. Additional care should be taken in these groups and preoperative multimodality imaging considered.

Contrast-enhanced high-frequency ultrasound imaging of early stage liver metastasis in a preclinical mouse model

Monitoring angiogenesis is potentially an effective strategy for the early detection of cancer. In this study, early detection was achieved by evaluating blood vessel density in the liver using a three-dimensional contrast-enhanced high-frequency ultrasound (CE-HFUS) system and Sonazoid microbubbles. Three-dimensional CE-HFUS detected an increase in blood vessel density in the liver after intrasplenic injection of breast tumor cells into mice. The results were in agreement with immunohistochemical analysis of blood vessel density. Three-dimensional CE-HFUS using microbubbles is an attractive, novel approach for the early detection of liver metastases through quantification of new, pathological vascular growth (i.e. tumor angiogenesis).

Colorectal liver metastasis with intrabiliary growth: case report and review of the literature

Colorectal liver metastases with intrabiliary growth are uncommon and difficult to characterize by radiology alone. We present the case of a 61-year-old woman previously operated on for a left colon cancer who developed a metacronous lesion at liver segment II-III. Radiologic workup was indicative for cholangiocarcinoma. Thus, the patient underwent an anatomical left lateral hepatectomy. Pathology showed instead a colorectal metastases with intrabiliary growth. We suggest that in cases of radiological uncertainty between an intrabiliary growth metastasis and a cholangiocarcinoma, the correct surgical strategy should always be an anatomical liver resection without preoperative biopsy because it would not change the operative planning and instead it may increase the risk of dissemination.

Characterization of hepatic tumors using [11C]metomidate through positron emission tomography: comparison with [11C]acetate

Background

Using positron emission tomography (PET), we compared two tracers, [¹¹C]metomidate ([¹¹C]MTO) and [¹¹C]acetate ([¹¹C]ACE), for the characterization of hepatic tumors.

Methods

Thirty-three patients underwent PET with [¹¹C]MTO and [¹¹C]ACE and magnetic resonance imaging (MRI). Based on the histology of the tumor biopsy, 14 patients had hepatocellular carcinoma (HCC), 9 patients had focal nodular hyperplasia (FNH), and 10 patients had other types of hepatic tumors. Tumor uptake was evaluated by calculating the maximum and mean standardized uptake value and tumor-to-liver ratio.

Results

Altogether, 120 hepatic lesions (59 HCC, 18 FNH, 30 metastases of different primaries, 9 adenomas, and 4 regenerating nodules of liver cirrhosis) were detected by MRI. The overall tumor detection rate was slightly higher for [¹¹C]MTO (39%) than for [¹¹C]ACE (33%). [¹¹C]ACE was more sensitive for HCC detection (50% versus 43%, respectively), whereas [¹¹C]MTO was more sensitive for FNH detection (78% versus 44%, respectively). In HCC patients, the tumor grade correlated with [¹¹C]ACE, but not with [¹¹C]MTO. All of the patients with liver metastases, from various primary tumors (n = 10), were negative for both tracers.

Conclusions

Due to low sensitivity, [¹¹C]MTO and [¹¹C]ACE PET have only limited value in diagnosing hepatic tumors.

Fluorodeoxyglucose positron emission tomography response and normal tissue regeneration after stereotactic body radiotherapy to liver metastases

PURPOSE

To characterize changes in standardized uptake value (SUV) in positron emission tomography (PET) scans and determine the pace of normal tissue regeneration after stereotactic body radiation therapy (SBRT) for solid tumor liver metastases.

METHODS AND MATERIALS

We reviewed records of patients with liver metastases treated with SBRT to ≥40 Gy in 3-5 fractions. Evaluable patients had pretreatment PET and ≥1 post-treatment PET. Each PET/CT scan was fused to the planning computed tomography (CT) scan. The maximum SUV (SUV(max)) for each lesion and the total liver volume were measured on each PET/CT scan. Maximum SUV levels before and after SBRT were recorded.

RESULTS

Twenty-seven patients with 35 treated liver lesions were studied. The median follow-up was 15.7 months (range, 1.5-38.4 mo), with 5 PET scans per patient (range, 2-14). Exponential decay curve fitting (r=0.97) showed that SUV(max) declined to a plateau of 3.1 for controlled lesions at 5 months after SBRT. The estimated SUV(max) decay half-time was 2.0 months. The SUV(max) in controlled lesions fluctuated up to 4.2 during follow-up and later declined; this level is close to 2 standard deviations above the mean normal liver SUV(max) (4.01). A failure cutoff of SUV(max) ≥6 is twice the calculated plateau SUV(max) of controlled lesions. Parenchymal liver volume decreased by 20% at 3-6 months and regenerated to a new baseline level approximately 10% below the pretreatment level at 12 months.

CONCLUSIONS

Maximum SUV decreases over the first months after SBRT to plateau at 3.1, similar to the median SUV(max) of normal livers. Transient moderate increases in SUV(max) may be observed after SBRT. We propose a cutoff SUV(max) ≥6, twice the baseline normal liver SUV(max), to score local failure by PET criteria. Post-SBRT values between 4 and 6 would be suspicious for local tumor persistence or recurrence. The volume of normal liver reached nadir 3-6 months after SBRT and regenerated within the next 6 months.

The value of intraoperative ultrasound and preoperative imaging, individually and in combination, in liver resection for metastatic colorectal cancer

INTRODUCTION

Liver resection is proved to offer potential long-term survival for colorectal liver metastases (CRLM). Accurate radiological assessment is vital to enable an appropriate surgical approach. The role of intraoperative ultrasound (IOUS) has been controversial. This study was designed to analyse the accuracy of IOUS compared with that of preoperative imaging (POI) in these patients.

MATERIALS AND METHODS

A prospective analysis of 51 consecutive patients who underwent liver resection for CRLM was undertaken. The accuracy of POI and IOUS were correlated and compared with histopathological analysis. Statistical analyses included t-tests, to compare continuous variables, and chi-square and Fisher's exact tests to compare categorical variables. p<0.05 was considered significant

RESULTS

POI correlated with histology in 35 patients (68.6%). The sensitivity and specificity were 82.4% and 86.3% respectively. IOUS correlated with histology in 31 (60.8%) patients. The sensitivity and specificity were 84.3% and 76.5% respectively. There was no difference in accuracy between modalities. The accuracy of POI combined with IOUS correlated with histology in 40 patients (78.4%). The sensitivity and specificity were 88.2% and 84.3% respectively. The accuracy of combined modalities was significantly greater than IOUS or POI alone.

CONCLUSIONS

POI combined with IOUS may significantly increase the diagnostic accuracy of patients undergoing liver resection for CRLM.

Utility of preoperative imaging in evaluating colorectal liver metastases declines over time

OBJECTIVES

Reports on the sensitivity and accuracy of contrast-enhanced helical computed tomography (HCT) in the preoperative evaluation of colorectal liver metastases (CLM) have been conflicting. Few studies have controlled for and reported on the time interval between HCT and eventual surgery.

METHODS

A multi-institution, retrospective review of consecutive patients who underwent hepatic resection for CLM from January 1999 to September 2004 was conducted. Data regarding lesion characteristics and resectability were extracted from radiology reports, operative findings and histopathological records. Findings in HCT were evaluated according to their sensitivity for detecting CLM and ability to predict resectability.

RESULTS

A total of 217 consecutive patients who underwent hepatic resection for CLM were identified. The overall sensitivity of HCT for detection of CLM was 83.2%. Prolonged time between imaging and surgery was a negative predictor for HCT sensitivity in univariate and multivariate analysis (P < 0.001). In predicting resectability, preoperative HCT was accurate 77.0% of the time. The time interval to surgery was negatively correlated with HCT prediction accuracy in univariate and multivariate analyses (P < 0.001).

CONCLUSIONS

The utility of HCT as a preoperative tool to evaluate CLM is inversely proportional to the time interval between imaging and surgery. This may explain conflicting reports of the accuracy of HCT in the current literature.

Morphological and functional MDCT: problem-solving tool and surrogate biomarker for hepatic disease clinical care and drug discovery in the era of personalized medicine

This article explains the significant role of morphological and functional multidetector computer tomography (MDCT) in combination with imaging postprocessing algorithms served as a problem-solving tool and noninvasive surrogate biomarker to effectively improve hepatic diseases characterization, detection, tumor staging and prognosis, therapy response assessment, and novel drug discovery programs, partial liver resection and transplantation, and MDCT-guided interventions in the era of personalized medicine. State-of-the-art MDCT depicts and quantifies hepatic disease over conventional CT for not only depicting lesion location, size, and extent but also detecting changes in tumor biologic behavior caused by therapy or tumor progression before morphologic changes. Color-encoded parameter display provides important functional information on blood flow, permeability, leakage space, and blood volume. Together with other relevant biomarkers and genomics, the imaging modality is being developed and validated as a biomarker to early response to novel, targeted anti-VEGF(R)/PDGFR or antivascular/angiogenesis agents as its parameters correlate with immunohistochemical surrogates of tumor angiogenesis and molecular features of malignancies. MDCT holds incremental value to World Health Organization response criteria and Response Evaluation Criteria in Solid Tumors in liver disease management. MDCT volumetric measurement of future remnant liver is the most important factor influencing the outcome of patients who underwent partial liver resection and transplantation. MDCT-guided interventional methods deliver personalized therapies locally in the human body. MDCT will hold more scientific impact when it is fused with other imaging probes to yield comprehensive information regarding changes in liver disease at different levels (anatomic, metabolic, molecular, histologic, and other levels).

Laparoscopic intra-operative ultrasound in liver and pancreas resection: Analysis of 93 cases

INTRODUCTION

Laparoscopic inspection before pancreatic and liver surgery is a widely accepted approach and has changed the surgical strategy in a growing number of patients for the last 10 years. The addition of intra-operative ultrasound to laparoscopy has further refined surgical judgments. The aim of this study was to evaluate the impact of open (IOUS) or laparoscopic (LIOUS) ultrasound in patients undergoing hepatic or pancreatic resection for benign or malignant lesions.

MATERIALS AND METHODS

In the years 2005-2008, 45 patients (aged 42-75 years) were selected for liver resection, and 48 others (aged 14-72 years) were selected for partial pancreatic resection. Intra-operative ultrasound was performed for surgical staging. An Aloka SSD-5500 scanner (Aloka, Tokyo, Japan) was used with a flexible laparoscopic multifrequency linear and an electronic T-shaped linear probe.

RESULTS

LIOUS prevented useless laparotomies in six patients (13.3%) with liver tumors and, coupled with IOUS, revealed previously undetected tumors that required a change in the surgical strategy in 5 others (11.1%). In patients with pancreatic disease, LIOUS excluded the possibility of radical surgery in 7 patients (14.4%) due to the presence of mesenteric vein infiltration, involvement of the celiac or para-aortic nodes, or the presence of liver or peritoneal micro-metastases. In 11 patients with benign lesions, it defined the lesions' relation to the Wirsung duct and splenic vessels, and in 6 others it provided guidance for aspiration of fluid for chemical and cytologic analysis.

CONCLUSIONS

LIUOS and IOUS can play fundamental roles in selecting patients for resective surgery and in planning the surgical approach. They provided information that affected surgical strategies in 11 patients with liver disease (24.4%) and 13 with pancreas disease (27%).

Multiscale model of liver DCE-MRI towards a better understanding of tumor complexity

The use of quantitative imaging for the characterization of hepatic tumors in magnetic resonance imaging (MRI) can improve the diagnosis and therefore the treatment of these life-threatening tumors. However, image parameters remain difficult to interpret because they result from a mixture of complex processes related to pathophysiology and to acquisition. These processes occur at variable spatial and temporal scales. We propose a multiscale model of liver dynamic contrast-enhanced (DCE) MRI in order to better understand the tumor complexity in images. Our design couples a model of the organ (tissue and vasculature) with a model of the image acquisition. At the macroscopic scale, vascular trees take a prominent place. Regarding the formation of MRI images, we propose a distributed model of parenchymal biodistribution of extracellular contrast agents. Model parameters can be adapted to simulate the tumor development. The sensitivity of the multiscale model of liver DCE-MRI was studied through observations of the influence of two physiological parameters involved in carcinogenesis (arterial flow and capillary permeability) on its outputs (MRI images at arterial and portal phases). Finally, images were simulated for a set of parameters corresponding to the five stages of hepatocarcinogenesis (from regenerative nodules to poorly differentiated HepatoCellular Carcinoma).

Detection of focal liver lesions: from the subjectivity of conventional ultrasound to the objectivity of volume ultrasound

PURPOSE

This study was undertaken to establish the reliability of automated volumetric liver scans in detecting focal liver lesions by evaluating the degree of agreement between conventional and volume ultrasound (US) examinations.

MATERIALS AND METHODS

Over a period of 3 months, we prospectively studied 100 consecutive patients (36 men and 64 women; age range 15-87 years; mean age 63 years) referred to our institute for US imaging of the liver. Volumetric acquisition of the liver was achieved with a 3D transducer (2.0-5.0 MHz) and a Logiq 9 US scanner. All patients underwent both 2- and 3D US studies performed by two expert radiologists. Volumetric acquisitions were subsequently reviewed by the second radiologist, who was blinded to the first radiologist's report. Three categories were established: 1=presence of focal liver lesions; 2=doubtful finding; 3=absence of focal liver lesions. Concordance between volume US and conventional US was calculated by using the k statistic.

RESULTS

Out of 100 patients examined, 39 were found to be affected by focal liver lesions. All volume US examinations were technically adequate, allowing exploration of all hepatic sectors, except for five cases that were marred by major respiratory motion artefacts. Conventional and volume US identified the same number of focal liver lesions, with the exception of four cases of doubtful findings at volume US. Concordance between automated volume US and conventional US of the liver was high (k=0.92).

CONCLUSIONS

The identification of focal liver lesions on automated volume US is possible, and the examination shows a high level of concordance with conventional US.

Imaging approach for evaluation of focal liver lesions

Focal liver lesions are common in the general population. Radiology (imaging) plays a pivotal role for the diagnosis, staging, treatment planning, and follow-up of focal liver lesions. To maximize lesion detection and characterization, imaging needs to be performed with appropriate equipment by using protocols carefully designed on the basis of the underlying clinical context. In addition, the decision of an imaging modality cannot be based on the diagnostic accuracy of an imaging test solely but must also consider patient safety and cost-effectiveness.

Receiver operating characteristic analysis of diffusion-weighted magnetic resonance imaging in differentiating hepatic hemangioma from other hypervascular liver lesions

PURPOSE

To evaluate the role of diffusion-weighted imaging in differentiating between hepatic hemangiomas, both typical and atypical, and other hypervascular liver lesions.

METHODS

Retrospective review of 182 hypervascular liver lesions in 117 patients was performed. Diffusion and contrast-enhanced magnetic resonance imaging were performed using a 1.5-T unit. Imaging protocol consisted of T2-weighted fast spin-echo images, breath-hold diffusion-weighted echo-planar images, and breath-hold unenhanced and contrast-enhanced T1-weighted 3-dimensional fat-suppressed spoiled gradient-echo images in the arterial phase (20 seconds) and portal venous phase (60 seconds). Signal intensity changes and apparent diffusion coefficient (ADC) values were evaluated for all lesions. Unpaired t test was used to compare the mean ADC values for different lesions, and statistical significance was set at P < 0.01. Receiver operating characteristic analysis was used to determine the accuracy of diffusion-weighted imaging in differentiating hemangiomas from other hypervascular liver lesions.

RESULTS

Lesions included typical and atypical hemangioma (n = 38), hepatocellular carcinoma (HCC; n = 58), focal nodular hyperplasia (FNH; n = 22), and neuroendocrine tumor metastasis (NET; n = 64) with a mean tumor size of 5.3 cm. Mean ADC value for hemangioma, HCC, FNH, and NET was 2.29 x 10(-3), 1.55 x 10(-3), 1.65 x 10(-3), and 1.43 x 10(-3) mm2/s, respectively. There was a statistically significant difference in the ADC value of hemangioma compared with that of FNH (P < 0.001), HCC (P < 0.001), and NET (P < 0.001), respectively. The area under the receiver operating characteristic curve was 0.91.

CONCLUSIONS

Diffusion-weighted magnetic resonance imaging and ADC maps can provide rapid quantifiable information to differentiate typical and atypical hemangiomas from other hypervascular liver lesions.

Treatment of diffuse large B-cell lymphoma of the liver with yttrium-90 microsphere embolization

BACKGROUND

A 41-year-old male with a 4-year history of chronic hepatitis C presented with a 1-month history of abdominal pain, fatigue, weight loss, and night sweats.

INVESTIGATIONS

Laboratory examinations, chest, abdomen, and pelvic CT scans, PET-CT scans, ultrasound-guided needle biopsies of liver lesions, bone-marrow biopsy, flow cytometry, and immunohistochemical staining for B-cell markers including CD20.

DIAGNOSIS

Chemoresistant diffuse large B-cell lymphoma, with gradual loss of CD20 antigen expression.

MANAGEMENT

Embolization of hepatic tumors using yttrium-90 microspheres (Therasphere, Theragenics Corporation, Buford, GA).

Neoplasias hepáticas: caracterização por métodos de imagem

Uma grande variedade de tumores benignos e malignos ocorre no fígado. Embora a caracterização de lesões hepáticas focais possa ser um desafio para o radiologista, a maioria das lesões se apresenta com características de imagem que permitem o seu diagnóstico. O objetivo deste trabalho é o de rever os principais aspectos de imagem dos tumores hepáticos benignos e malignos mais comumente encontrados no fígado adulto.

Factors that influence treatment strategies in advanced colorectal cancer

This review focuses on the factors that now influence our treatment strategies designed to increase the pool of patients with colorectal liver metastases for whom curative treatment may be possible. These strategies include improved preoperative staging techniques, new standards for surgical resection, novel surgical strategies, the application of modern systemic chemotherapy in a neoadjuvant setting, an emerging role for ablative therapies and an emphasis on the collaborative, a reappraisal of staging advanced disease, multidisciplinary management, and defining the role of the patient in managing their disease. It is now clear that an aggressive multi-disciplinary approach to the management of this problem will lead to nearly one third of these patients being considered for treatment that even if not achieving complete cure, offers significant long-term survival.