CT features of hepatic venoocclusive disease and hepatic graft-versus-host disease in patients after hematopoietic stem cell transplantation

Review of imaging findings in hepatic veno-occlusive disease

Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), is a potentially life-threatening complication of hematopoietic stem cell transplantation. Patients present with right upper-quadrant abdominal pain, jaundice, weight gain, and conjugated hyperbilirubinemia. Early diagnosis of VOD is essential to promptly initiate defibrotide therapy, which has been demonstrated to enhance survival and achieve complete resolution of disease in some patients. Historically, VOD was diagnosed by the modified Seattle or Baltimore criteria, which are both based on clinical symptoms. Alongside advancements in medical imaging over the last 40 years, the diagnosis of VOD has evolved to include the use of ultrasound, elastography, cross-sectional imaging, and image guided biopsy. Identification and interpretation of findings of VOD across imaging modalities is now a critical aspect of post-HSCT care. This review will outline the imaging findings and recommendations for the use of imaging in the management of VOD including gray-scale, color and spectral Doppler ultrasound, ultrasound elastography, CT, MRI, and liver biopsy.

Primary Budd-Chiari syndrome versus sinusoidal obstruction syndrome: a review

Budd-Chiari syndrome (BCS) and sinusoidal obstruction syndrome (SOS) are two major vascular disorders of the liver, of which both can cause portal hypertension related complications, but their locations of obstruction are different. BCS refers to the obstruction from the hepatic vein to the junction between the inferior vena cava and right atrium, which is the major etiology of post-sinusoidal portal hypertension; by comparison, SOS is characterized as the obstruction at the level of hepatic sinusoids and terminal venulae, which is a cause of sinusoidal portal hypertension. Both of them can cause hepatic congestion with life-threatening complications, especially acute liver failure and chronic portal hypertension, and share some similar features in terms of imaging and clinical presentations, but they have heterogeneous risk factors, management strategy, and prognosis. Herein, this paper reviews the current evidence and then summarizes the difference between primary BCS and SOS in terms of risk factors, clinical features, diagnosis, and treatment.

Cancer Therapy-related Hepatic Injury in Children: Imaging Review from the Pediatric LI-RADS Working Group

The liver is the primary organ for the metabolism of many chemotherapeutic agents. Treatment-induced liver injury is common in children undergoing cancer therapy. Hepatic injury occurs due to various mechanisms, including biochemical cytotoxicity, hepatic vascular injury, radiation-induced cytotoxicity, and direct hepatic injury through minimally invasive and invasive surgical treatments. Treatment-induced liver injury can be seen contemporaneous with therapy and months to years after therapy is complete. Patients can develop a combination of hepatic injuries manifesting during and after treatment. Acute toxic effects of cancer therapy in children include hepatitis, steatosis, steatohepatitis, cholestasis, hemosiderosis, and vascular injury. Longer-term effects of cancer therapy include hepatic fibrosis, chronic liver failure, and development of focal liver lesions. Quantitative imaging techniques can provide useful metrics for disease diagnosis and monitoring, especially in treatment-related diffuse liver injury such as hepatic steatosis and steatohepatitis, hepatic iron deposition, and hepatic fibrosis. Focal liver lesions, including those developing as a result of treatment-related vascular injury such as focal nodular hyperplasia-like lesions and hepatic perfusion anomalies, as well as hepatic infections occurring as a consequence of immune suppression, can be anxiety provoking and confused with recurrent malignancy or hepatic metastases, although there often are imaging features that help elucidate the correct diagnosis. Radiologic evaluation, in conjunction with clinical and biochemical screening, is integral to diagnosing and monitoring hepatic complications of cancer therapy in pediatric patients during therapy and after therapy completion for long-term surveillance. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material See the invited commentary by Ferraciolli and Gee in this issue.

Role of Multiparametric Ultrasound in Evaluating Hepatic Acute Graft-versus-Host Disease: An Animal Study

OBJECTIVE

Hepatic acute graft-versus-host disease (aGVHD) is a serious complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT) and is one of the leading causes of early non-recurrent death. The current diagnosis is based mainly based on clinical diagnosis, and there is a lack of non-invasive quantitative diagnosis methods. We propose a multiparametric ultrasound (MPUS) imaging method and explore its effectiveness in evaluating hepatic aGVHD.

METHODS

In this study, 48 female Wistar rats were used as receptors and 12 male Fischer 344 rats were used as donors for allo-HSCT to establish aGVHD models. After transplantation, 8 rats were randomly selected for ultrasonic examination weekly, including color Doppler ultrasound, contrast-enhanced ultrasound (CEUS) and shear wave dispersion (SWD) imaging. The values of nine ultrasonic parameters were obtained. Hepatic aGVHD was subsequently diagnosed by histopathological analysis. A classification model for predicting hepatic aGVHD was established using principal component analysis and support vector machines.

RESULTS

According to the pathological results, the transplanted rats were categorized into the hepatic aGVHD and non-GVHD (nGVHD) groups. All parameters obtained by MPUS differed statistically between the two groups. The first three contributing percentages of principal component analysis results were resistivity index, peak intensity and shear wave dispersion slope, respectively. The accuracy of classifying aGVHD and nGVHD using support vector machines reached 100%. The accuracy of the multiparameter classifier was significantly higher than that of the single parameter.

CONCLUSION

The MPUS imaging method has proven to be useful in detecting hepatic aGVHD.

Clinical Features and CT Imaging Analysis of Hepatic Sinuscase-Syndrome and Budd–Chiari Syndrome

Objective

This study aimed to analyze the clinical features and computed tomography (CT) manifestations of hepatic sinusoidal obstruction syndrome (HSOS) induced by Gynura segetum, a Chinese herbal medicine, so as to improve the clinical understanding and diagnosis of the disease.

Methods

Relevant clinical and laboratory parameters and CT imaging data of 20 patients with HSOS confirmed by liver biopsy were retrospectively analyzed and compared with 16 patients with Budd-Chiari syndrome (BCS).

Results

Levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and glutamyl transpeptidase increased significantly (p < 0.05) in HSOS patients compared to the BCS patients, while the albumin level and prothrombin time, which are indicators of liver synthesis function, decreased and prolonged significantly, respectively. All 20 patients with HSOS had manifestations of ascites and heterogeneous hypoattenuation on CT, including 18 cases (90%) with heterogeneous enhancement (characteristic map-like enhancement), 17 (85%) with hepatomegaly, 18 (90%) with gallbladder wall oedema, and 16 (80%) with stenosis of main hepatic veins and characteristic “clover-like” enhancement at the second porta hepatis.

Conclusion

Both HSOS and BCS are post-sinusoidal portal hypertension, but have different etiologies and durations. Although they both cause liver congestion, the clinical manifestation of HSOS is acute liver injury. The CT manifestations are characterized by ascites, map-like enhancement and heterogeneous hypoattenuation of the liver parenchyma, and stenosis of the main hepatic veins. BCS is often found in the stage of decompensated liver cirrhosis, resulting in liver shrinkage, splenomegaly, and ascites.

Imaging of the chemotherapy-induced hepatic damage: Yellow liver, blue liver, and pseudocirrhosis

The liver is the major drug-metabolizing and drug-detoxifying organ. Many drugs can cause liver damage through various mechanisms; however, the liver response to injury includes a relatively narrow spectrum of alterations that, regardless of the cause, are represented by phlogosis, oxidative stress and necrosis. The combination of these alterations mainly results in three radiological findings: vascular alterations, structural changes and metabolic function reduction. Chemotherapy has changed in recent decades in terms of the drugs, protocols and duration, allowing patients a longer life expectancy. As a consequence, we are currently observing an increase in chemotherapy-associated liver injury patterns once considered unusual. Recognizing this form of damage in an early stage is crucial for reconsidering the therapy regimen and thus avoiding severe complications. In this frontier article, we analyze the role of imaging in detecting some of these pathological patterns, such as pseudocirrhosis, “yellow liver” due to chemotherapy-associated steatosis-steatohepatitis, and “blue liver”, including sinusoidal obstruction syndrome, veno-occlusive disease and peliosis.

Gd-EOB-DTPA-enhanced MR findings in chemotherapy-induced sinusoidal obstruction syndrome in colorectal liver metastases

Background

We assessed the clinical presentations, biomarkers, and Gd-EOB-DTPA-enhanced MRI features that were associated with oxaliplatin-induced sinusoidal obstruction syndrome (SOS) to detect chemotherapy-associated SOS in a timely manner.

Methods

Fifty-seven patients who underwent oxaliplatin-based chemotherapy and Gd-EOB-DTPA-enhanced MRI were included. Post-oxaliplatin heterogeneity in liver parenchyma was scored on a grading scale of 0 to 3. Abnormal clinical findings, including splenomegaly, hepatomegaly, gall bladder wall thickening, and hepatic vein narrowing, were also assessed. Additionally, alanine transaminase (ALT) levels, aspartate aminotransferase (AST) levels, and platelet counts were measured.

Results

For SOS, 21 patients were scored grade 0, 24 were grade 1, seven were grade 2, and five were grade 3. Hepatomegaly, splenomegaly, gall bladder wall thickening, and hepatic vein narrowing were significantly correlated with the grade for non-tumorous hepatic parenchymal heterogeneity. For laboratory findings, ALT and AST levels, the AST-to-platelet ratio index score, and platelet counts were significantly associated with a high grade (≥2) of non-tumorous hepatic parenchymal heterogeneity.

Conclusions

We assessed the clinical presentations, biomarkers, and Gd-EOB-DTPA-enhanced MRI features that were associated with oxaliplatin-induced sinusoidal obstruction syndrome (SOS) to detect chemotherapy-associated SOS in a timely manner. Additionally, specific laboratory findings were significantly associated with a high grade (≥2).

Imaging in Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome

Veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication of hematopoietic cell transplantation. Early diagnosis and, subsequently, earlier intervention have been shown to be beneficial to clinical outcomes. Diagnostic criteria from the European Society for Blood and Marrow Transplantation include recommendations on the use of imaging for diagnosis. This review discusses evidence on the use of imaging in the management of VOD/SOS and how imaging biomarkers can contribute to earlier diagnosis/treatment.

Liver stiffness and perfusion changes for hepatic sinusoidal obstruction syndrome in rabbit model

BACKGROUND

Hepatic sinusoidal obstruction syndrome (SOS) is caused by damage to hepatic sinusoidal endothelial cells that results in fibrous obliteration of intrahepatic venules and necrosis of hepatocytes. Currently the diagnosis is primarily based on nonspecific clinical features and invasive liver biopsy. Therefore, noninvasive imaging methods are required for the early diagnosis and severity assessment of hepatic SOS.

AIM

To determine the effectiveness of supersonic shear wave imaging (SSI) and dual energy computed tomography (DECT) for diagnosing hepatic SOS using a rabbit model.

METHODS

Among nine New Zealand white rabbits (3-4 kg, male), three in control group ingested normal saline for 20 d and six in the SOS group ingested 6-thioguanine (5 mg/kg/d) for 20 d. Liver stiffness was measured using SSI on days 0, 3, 10, and 20. On the same days, liver perfusion was evaluated from virtual monochromatic images of 55 keV and iodine map using DECT. Morphologic changes in the liver were assessed using CT. Final pathology scores were compared between the two groups. Liver stiffness and perfusion parameters were compared according to the groups, days, and pathology scores.

RESULTS

Final pathology scores were significantly higher in the SOS than the control group (median 22 vs 2, P = 0.024). No gross morphologic changes were seen in livers. Liver stiffness, Hounsfield Unit values, and iodine concentrations were higher in the SOS compared to the control group on days 10 and 20 (all, P ≤ 0.007). Compared to day 0, liver stiffness and perfusion parameters were higher on day 20 in the SOS group (all, P ≤ 0.001). Correlation coefficients for liver stiffness (r = 0.635), Hounsfield Unit values (r = 0.587), and iodine concentration (r = 0.611) with final pathology scores were positive without significance (all, P > 0.05).

CONCLUSION

Liver stiffness and perfusion parameters were significantly increased in the livers of a rabbit SOS model. SSI and DECT might aid in early diagnosis of hepatic SOS.

Clinical characteristics, CT signs, and pathological findings of Pyrrolizidine alkaloids-induced sinusoidal obstructive syndrome: a retrospective study

BACKGROUND

One major etiology of hepatic sinusoidal obstruction syndrome (HSOS) in China is the intake of pyrrolizidine alkaloids (PAs). Since PAs-induced HSOS is a rare disease that has not been clearly characterized until now, the aim of this study was to investigate clinical characteristics, CT features, and pathological findings of PA-induced HSOS.

METHODS

This retrospective cohort study included 116 patients with PAs-induced HSOS and 68 patients with Budd-Chiari syndrome from Jan 2006 to Sep 2016. We collected medical records of the patients, and reviewed image features of CT, and analyzed pathological findings.

RESULTS

Common clinical manifestations of PAs-induced HSOS were abdominal distention (98.26%), ascites (100%), jaundice (52.94%), abdominal pain (36.36%). Abnormal liver function was observed in most of PAs-induced HSOS. On CT scan, common findings included: ascites, hepatomegaly, the thickening of gallbladder wall, pleural effusion, patchy liver enhancement, and heterogeneous hypoattenuation. Most of the patients had a low ascitic total protein (< 25 g/L) and a high SAAG (≥ 11.0 g/L). In acute stage, pathologic features were massive sinusoidal dilatation, sinusoidal congestion, the extravasation of erythrocytes, hepatocellular necrosis, the accumulation of macrophages, the deposition of hemosiderin. In subacute stage, complete loss of pericentral hepatocytes, sinusoidal dilatation, the deposition of pigment granules were observed.

CONCLUSIONS

The PAs-induced HSOS patients displayed distinct clinical characteristics, imaging features, and pathological findings, which provided some evidences for the diagnosis of PAs-induced HSOS.

TRIAL REGISTRATION

ChiCTR-DRD-17010709.

Noninvasive imaging diagnosis of sinusoidal obstruction syndrome: a pictorial review

Sinusoidal obstruction syndrome (SOS) is a rare liver disorder due to hepatic vascular injury. Its rapid and accurate diagnosis is crucial for patient survival. SOS is often established clinically, based on Baltimore, modified Seattle, or European Society for Blood and Marrow Transplantation (EBMT) criteria. Unfortunately, such criteria are not highly specificity and fail to provide a timely, reliable differential diagnosis. The use of noninvasive imaging techniques, such as ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), has recently grown in this setting, some key imaging features offering diagnostic improvement. This review provides a synopsis of current noninvasive imaging techniques used for this purpose, summarizing accurate and reliable diagnostic features of SOS.

Hepatic disorders associated with exogenous sex steroids: MR imaging findings

OBJECTIVE

To describe the MRI findings of the effects of exogenous sex steroids on the liver.

FINDINGS

Estrogens, progesterone and synthetic testosterone are exogenous sex steroids that may result in a variety of liver diseases, including tumour formation and vascular disorders. These hormones are mainly administered in the form of the oral contraceptive pill (OCP) and anabolic steroids. Both are implicated in hepatic adenoma formation. The HNF-1α-mutated and inflammatory adenoma subgroups are more commonly seen in association with the OCP whereas there is an increased incidence of the β-catenin positive subtype with anabolic steroid use. Furthermore, anabolic steroids are associated with hepatocellular carcinoma resulting from malignant transformation of β-catenin positive adenomas. The oral contraceptive pill may also induce vascular disorders within the liver, some of which are related to the prothrombotic effect of the hormones, such as hepatic and portal vein thrombosis. Other hepatic vascular abnormalities resulting from exogenous sex steroids include veno-occlusive disease and peliosis hepatis.

Role of imaging techniques in liver veno-occlusive disease diagnosis: recent advances and literature review

Veno-occlusive-disease (VOD), known also as sinusoidal-obstruction-syndrome (SOS), is one of the main complications of haematopoietic stem cell transplantation and is related to the treatment with pyrrolizidine alkaloids or other toxic agents (chemotherapy for liver-metastasis). Clinical diagnosis using the recent criteria from the European Society for Blood and Marrow Transplantation, is the reference for VOD/SOS diagnosis. However, increasing evidence suggests the emerging role of several imaging methods that could help the clinician in VOD/SOS assessment. Areas covered: This review evaluates the current literature on the various imaging techniques used in VOD/SOS diagnosis in several clinical scenarios. Literature searches were performed using several keywords on MEDLINE/Ovid/In-Process/Cochrane Library/EMBASE and PubMed up to July 2018. Expert commentary: Hepatic-gradient-measurement (HVPG) and contextual transjugular-liver-biopsy are invasive and should always be considered in unclear cases. The main studies revolve around ultrasound with Doppler evaluation, identifying numerous findings suggestive of VOD/SOS. However, their accuracy and validation are still suboptimal and controversial. CT-Scan and MRI have shown encouraging data in other contexts in which VOD/SOS can develop, but studies on the post-HSCT patient are lacking. Elastography techniques measuring liver stiffness (LSM) represent the most recent and promising approach for an accurate and early diagnosis of VOD/SOS. In our view, a multidisciplinary approach to the VOD/SOS diagnosis should be highly encouraged.

Imaging manifestations of hepatic sinusoidal obstruction syndrome

Hepatic sinusoidal obstruction syndrome (HSOS), previously known as hepatic veno-occlusive disease, is a kind of vascular disorder of the liver. HSOS is caused by toxic destruction of hepatic sinusoidal endothelial cells. Major etiologies of HSOS include hematopoietic stem cell transplantation, oxaliplatin-containing chemotherapy, intake of pyrrolizidine alkaloid-containing herbal remedies, etc. There have been many studies on the imaging manifestations of HSOS in recent years. This paper summarizes the imaging manifestations of HSOS by reviewing the latest literature and our work.

Unintended Consequences of Systemic and Ablative Oncologic Therapy in the Abdomen and Pelvis

Human cancers are genetically complex and diverse. Although advances in oncologic therapy aim to define and target unique steps in carcinogenesis, oncologists often rely on less discriminate anticancer therapies that have consequences for normal tissues. Even many of the so-called targeted therapies currently employed can adversely affect normal cells, leading to complications that necessitate dose reductions or cessation of specific therapies. This article explores the unintended consequences of currently employed systemic and ablative anticancer therapies that might manifest at imaging examinations of the abdomen and pelvis, including cytotoxic, molecular targeted, and immunologic agents; ablation; and hematopoietic stem cell transplant. Each of these treatments can have both major and minor unintended effects in the targeted organ(s), in local or adjacent structures, or at distant sites. Timely detection and reporting of adverse consequences of anticancer therapies by the astute imager can result in critical treatment modifications and/or lifesaving interventions; therefore, knowledge of these unintended effects is paramount for radiologists interpreting the results of imaging examinations in cancer patients. ^©RSNA, 2018.

Imaging of pathology involving the space around the hepatic veins: "perivenous pattern"

We aimed to illustrate diseases involving the potential space around the hepatic veins. Perivenous halo sign can be seen in patients with congestive heart failure or fluid overload. Perivenous involvement can be observed in patients with alcoholic fatty liver disease, which can be focal or diffuse. Metastasis and primary liver tumor spread can also involve this space most likely due to involvement of lymphatics around hepatic veins.

CT Features of Hepatic Veno-occlusive Disease: A Meta-analysis

RATIONALE AND OBJECTIVE

The computed tomography (CT) features of hepatic veno-occlusive disease (HVOD) could play a role in its diagnosis. We aimed to perform a meta-analysis of studies examining the CT features of HVOD.

METHODS

Relevant studies published up to May 3, 2017 were searched in major electronic databases. The extracted data included the proportion of various CT features in patients with HVOD. The meta-analysis was conducted using R 3.3.3 with the "meta" package.

RESULTS

Eleven studies were included. The studies involved 326 patients with a mean age range of 50.2-58.9 years, and the proportion of female patients ranged from 20% to 57.5%. The meta-analysis showed the pooled proportion of CT features: hepatic parenchyma with heterogeneous hypoattenuation (81.05%, 95% confidence interval [CI]: 56.97%-93.25%), patchy enhancement in the portal venous phase (87.09%, 95% CI: 75.15%-93.77%) with or without a narrow or invisible hepatic vein (71.02% 95% CI: 42.09%-89.20%), gallbladder wall edema (65.51%, 95% CI: 28.98%-89.84%), and patchy heterogeneous enhancement in the arterial phase (44.36%, 95% CI: 29.98%-59.76%) with or without slightly enlarged hepatic artery (56.61%, 95% CI: 40.62%-71.33%).

CONCLUSION

Hepatic parenchyma with heterogeneous hypoattenuation and patchy enhancement with or without narrowing or an invisible hepatic vein in the portal venous or equilibrium phase may be the most important CT feature for diagnosing HVOD.

Diagnostic performance of contrast-enhanced CT-scan in sinusoidal obstruction syndrome induced by chemotherapy of colorectal liver metastases: Radio-pathological correlation

PURPOSE

Sinusoidal obstruction syndrome (SOS) is a likely side effect of colorectal liver metastases (CRLM) chemotherapy. This study aimed to assess computed tomography scan (CT-scan) performance for SOS diagnosis for patients receiving neoadjuvant chemotherapy (NC) prior to CRLM surgery, comparing obtained results with pathological gold standard.

METHODS

Preoperative CT-scans of 67 patients who had received a NC prior to liver resection for CRLM from 2011 to 2016 were retrospectively analysed. Positive diagnosis and severity of SOS were established after consensual review of the slides by three pathologists. Preoperative CT-scans were separately interpreted by two radiologists and evocative signs of SOS were sought, defined according to a literature review and operators experience. In order to identify SOS predictors, univariate analysis and multivariate logistic regression were used to study CT-scan signs and pathological results correlation.

RESULTS

Twenty-nine patient (43%) had an SOS, 22 (33%) were low-grade and 7 (10%) were high-grade. All patient had received a median of 6 cures (3-27) containing Oxaliplatin for 53 (79%) of them. In univariate analysis, hepatic heterogeneity (p<0.001), puddle-like or micronodular appearance (p<0.001), peripheral distribution of heterogeneity (p=0.085), clover-like sign (p=0.02), splenomegaly (p=0.0026), spleen volume increase ≥30% (p=0.04) or splenic length increase ≥15% (p=0.04), as well as the subjective impression of the observer (P<0.001) were significantly associated with SOS diagnosis. In multivariate analysis, clover-like sign (OR 1.87, 95% CI 1.18-2.95, p=0.0081), increase in spleen volume ≥30% (OR 1.29, 95% CI 1.01-1.64, p=0.04), and the peripheral distribution of heterogeneity (OR 1.53, 95% CI 1.21-1.94, p<0.001) were independent SOS predictors. The area under the ROC curve was 0.804. The inter-observer agreement for SOS diagnosis was moderate (Kappa=0.546).

CONCLUSION

CT-scan can detect suggestive signs of SOS in patients receiving chemotherapy for CRLM. By integrating clinical and biological information into CT-scan data, it may be fruitful to create a positive diagnostic and severity score for chemotherapy-induced SOS.

Imaging of Abdominal and Pelvic Manifestations of Graft-Versus-Host Disease After Hematopoietic Stem Cell Transplant

OBJECTIVE

Graft-versus-host disease (GVHD) is a common complication of hematopoietic stem cell transplant (HSCT). GVHD predominantly affects the skin, gastrointestinal system and hepatobiliary systems. Imaging findings in the gastrointestinal tract include bowel wall thickening with mucosal enhancement, mesenteric edema, and vascular engorgement. In the hepatobiliary system, hepatosplenomegaly, periportal edema, bile duct dilatation, and gallbladder and biliary wall thickening are seen. Although the imaging findings of GVHD are nonspecific, with a known history of HSCT, GVHD should be considered.

CONCLUSION

GVHD is a serious complication of HSCT, which involves multiple organ systems, with imaging manifestations most commonly seen in the gastrointestinal tract and hepatobiliary system. Knowledge of the imaging manifestations of GVHD, which alone may be relatively nonspecific, taken in conjunction with clinical history including the timing and type of HSCT, laboratory values, stool studies, and dermatologic findings can increase radiologist confidence in suggesting this diagnosis.

Hepatic Lesions that Mimic Metastasis on Radiological Imaging during Chemotherapy for Gastrointestinal Malignancy: Recent Updates

During chemotherapy in patients with gastrointestinal malignancy, the hepatic lesions may occur as chemotherapy-induced lesions or tumor-associated lesions, with exceptions for infectious conditions and other incidentalomas. Focal hepatic lesions arising from chemotherapy-induced hepatopathies (such as chemotherapy-induced sinusoidal injury and steatosis) and tumor-associated eosinophilic abscess should be considered a mimicker of metastasis in patients with gastrointestinal malignancy. Accumulating evidence suggests that chemotherapy for gastrointestinal malignancy in the liver has roles in both the therapeutic effects for hepatic metastasis and injury to the non-tumor bearing hepatic parenchyma. In this article, we reviewed the updated concept of chemotherapy-induced hepatopathies and tumor-associated eosinophilic abscess in the liver, focusing on the pathological and radiological findings. Awareness of the causative chemo-agent, pathophysiology, and characteristic imaging findings of these mimickers is critical for accurate diagnosis and avoidance of unnecessary exposure of the patient to invasive tissue-based diagnosis and operations.

Diagnostic performance of Contrast-enhanced CT in Pyrrolizidine Alkaloids-induced Hepatic Sinusoidal Obstructive Syndrome

Hepatic sinusoidal obstruction syndrome (HSOS) can be caused by pyrrolizidine alkaloids(PAs)-containing herbals. Since PAs exposure is obscure and clinical presentation of HSOS is unspecific, it is challenge to establish the diagnosis of PAs-induced HSOS. Gynura segetum is one of the most wide-use herbals containing PAs. The aim of our study is to describe the features of contrast-enhanced computed tomography (CT) in gynura segetum-induced HSOS, and then determine diagnostic performance of radiological signs. We retrospectively analyzed medical records and CT images of HSOS patients (71 cases) and the controls (222 cases) enrolled from January 1, 2008, to Oct 31, 2015. The common findings of contrast CT in PAs-induced HSOS included: ascites (100%), hepatomegaly (78.87%), gallbladder wall thickening (86.96%), pleural effusion (70.42%), hepatic vein narrowing (87.32%), patchy liver enhancement (92.96%), and heterogeneous hypoattenuation (100%); of these signs, patchy enhancement and heterogeneous hypoattenuation were valuable features. Then, the result of diagnostic performance demonstrated that contrast CT possessed better performance in diagnosing PAs-induced HSOS compared with various parameters of Seattle criteria. In conclusion, the patients with PAs-induced HSOS display distinct radiologic features at CT-scan, which reveals that contrast-enhanced CT provides an effective noninvasive method for diagnosing PAs-induced HSOS.

Role of Ultrasound in Complications of Hematopoetic Stem Cell Transplantation

Hematopoetic stem cell transplantation (HSCT) is an established therapeutic option for both malignant and nonmalignant indications, whose incidence has continued to increase in recent years. Because of its lower cost and lack of radiation exposure, ultrasound examination is often the first-line imaging modality in evaluating patients both before and after HSCT. It is important for radiologists to be aware of sonographic manifestations of the complications that may arise from HSCT. In this study, we will review the basics of HSCT, the role of imaging, and ultrasound examination findings in common and uncommon complications arising from HSCT.

Sonographic Appearance of the Gallbladder in the Allogeneic Hematopoietic Stem Cell Transplant Population

OBJECTIVES

To determine whether gallbladder sonographic findings in hematopoietic stem cell (HSC) transplant patients can distinguish among hepatobiliary complications of HSC transplants (graft-versus-host disease [GVHD] and veno-occlusive disease) and biliary events (cholecystitis, cholangitis, and choledocholithiasis).

METHODS

All HSC transplant patients who underwent gallbladder sonography from 2009 through 2012 were identified. Complications and sonographic findings were recorded.

RESULTS

Of 124 patients, 66 (53.2%) had an event: 33 (50.0%) had GVHD; 22 (33.3%) had veno-occlusive disease; 6 (9.0%) had a biliary event; 4 (6.0%) had veno-occlusive disease and GVHD; and 1 (1.5%) had veno-occlusive disease and a biliary event. Of all patients, 115 (92.7%) had 1 or more sonographic findings in the gallbladder, with sludge being most common in all groups. In patients with veno-occlusive disease, the second and third most common findings were pericholecystic fluid and wall thickening. In patients with GVHD, distension was the second most common. Patients with biliary events all had distension, and half had pericholecystic fluid. Patients with veno-occlusive disease were significantly more likely to have wall thickening than those with GVHD or no event (77.2% versus 36.3%; P= .005; and 77.2% versus 37.9%; P= .002) and more likely to have pericholecystic fluid than patients with GVHD (95.5% versus 45.5%; P = .0001), a biliary event (95.5% versus 50%; P = .02), or no event (95.5% versus 29.3%; P = .0001). The positive predictive value of any finding was low for all groups because findings were common in patients with no event.

CONCLUSIONS

Sonographic abnormalities of the gallbladder after HSC transplants are common in patients with and without HSC transplant complications and in those with biliary events. No sonographic finding is useful to distinguish among complications in HSC transplant patients.

Revised diagnosis and severity criteria for sinusoidal obstruction syndrome/veno-occlusive disease in adult patients: a new classification from the European Society for Blood and Marrow Transplantation

Sinusoidal obstruction syndrome, also known as veno-occlusive disease (SOS/VOD), is a potentially life threatening complication that can develop after hematopoietic cell transplantation. Although SOS/VOD progressively resolves within a few weeks in most patients, the most severe forms result in multi-organ dysfunction and are associated with a high mortality rate (>80%). Therefore, careful attention must be paid to allow an early detection of SOS/VOD, particularly as drugs have now proven to be effective and licensed for its treatment. Unfortunately, current criteria lack sensitivity and specificity, making early identification and severity assessment of SOS/VOD difficult. The aim of this work is to propose a new definition for diagnosis, and a severity-grading system for SOS/VOD in adult patients, on behalf of the European Society for Blood and Marrow Transplantation.

Current Indications, Techniques, and Imaging Findings of Stem Cell Treatment and Bone Marrow Transplant

The role of stem cell therapy in the treatment of hematologic and nonhematologic conditions is ever increasing. A thorough knowledge of the applications of stem cells and transplant physiology is essential for understanding the imaging manifestations. Stem cell imaging includes molecular imaging, and diagnostic and interventional radiology. It is possible to make a diagnosis of various complications and diseases associated with stem cell transplant. This article presents a simplified overview of stem cell applications and techniques with focus on hematopoietic stem cell transplant imaging.

Imaging of complications from hematopoietic stem cell transplant

Stem cell transplant has been the focus of clinical research for a long time given its potential to treat several incurable diseases like hematological malignancies, diabetes mellitus, and neuro-degenerative disorders like Parkinson disease. Hematopoietic stem cell transplantation (HSCT) is the oldest and most widely used technique of stem cell transplant. HSCT has not only been used to treat hematological disorders including hematological malignancies, but has also been found useful in treamtent of genetic, immunological, and solid tumors like neuroblastoma, lymphoma, and germ cell tumors. In spite of the rapid advances in stem cell technology, success rate with this technique has not been universal and many complications have also been seen with this form of therapy. The key to a successful HSCT therapy lies in early diagnosis and effective management of complications associated with this treatment. Our article aims to review the role of imaging in diagnosis and management of stem cell transplant complications associated with HSCT.

Hepatic sinusoidal obstruction syndrome caused by herbal medicine: CT and MRI features

Objective

To describe the CT and MRI features of hepatic sinusoidal obstruction syndrome (HSOS) caused by herbal medicine Gynura segetum.

Materials and Methods

The CT and MRI features of 16 consecutive Gynura segetum induced HSOS cases (12 men, 4 women) were analyzed. Eight patients had CT; three patients had MRI, and the remaining five patients had both CT and MRI examinations. Based on their clinical presentations and outcomes, the patients were classified into three categories: mild, moderate, and severe. The severity of the disease was also evaluated radiologically based on the abnormal hepatic patchy enhancement in post-contrast CT or MRI images.

Results

Ascites, patchy liver enhancement, and main right hepatic vein narrowing or occlusion were present in all 16 cases. Hepatomegaly and gallbladder wall thickening were present in 14 cases (87.5%, 14/16). Periportal high intensity on T2-weighted images was present in 6 cases (75%, 6/8). Normal liver parenchymal enhancement surrounding the main hepatic vein forming a clover-like sign was observed in 4 cases (25%, 4/16). The extent of patchy liver enhancement was statistically associated with clinical severity classification (kappa = 0.565).

Conclusion

Ascites, patchy liver enhancement, and the main hepatic veins narrowing were the most frequent signs of herbal medicine induced HSOS. The grade of abnormal patchy liver enhancement was associated with the clinical severity.

Imaging of Abdominal Complications Associated with Hematopoietic Stem Cell Transplantation

Complications associated with hematopoietic stem cell transplantation are common and frequently involve the gastrointestinal tract and other abdominal organs. Imaging is often used to help to confirm or exclude a suspected complication and to facilitate management. In this article, we review the imaging findings of abdominal complications related to hematopoietic stem cell transplantation.

BCSH/BSBMT guideline: diagnosis and management of veno-occlusive disease (sinusoidal obstruction syndrome) following haematopoietic stem cell transplantation

DIAGNOSIS

It is recommended that the diagnosis of veno-occlusive disease (sinusoidal obstruction syndrome) [VOD (SOS)] be based primarily on established clinical criteria (modified Seattle or Baltimore criteria) (1A). Ultrasound imaging may be helpful in the exclusion of other disorders in patients with suspected VOD (SOS) (1C). It is recommended that liver biopsy be reserved for patients in whom the diagnosis of VOD (SOS) is unclear and there is a need to exclude other diagnoses (1C). It is recommended that liver biopsies are undertaken using the transjugular approach in order to reduce the risks associated with the procedure (1C). It is suggested that the role of plasminogen activator inhibitor 1 levels remains an area for further research but that these levels should not form part of the routine diagnostic work-up for VOD (SOS) at present (2C).

RISK FACTORS

It is recommended that patients are assessed for risk factors for VOD (SOS) and that these risk factors are addressed prior to haematopoietic stem cell transplantation (1A).

PROPHYLAXIS

Defibrotide is recommended at a dose of 6.25 mg/kg intravenously four times daily for the prevention of VOD (SOS) in children undergoing allogeneic stem cell transplantation with the following risk factors: pre-existing hepatic disease, second myeloablative transplant, allogeneic transplant for leukaemia beyond second relapse, conditioning with busulfan-containing regimens, prior treatment with gemtuzumab ozogamicin, diagnosis of primary haemophagocytic lymphohistiocytosis, adrenoleucodystrophy or osteopetrosis (1A). Defibrotide is suggested at a dose of 6.25 mg/kg intravenously four times daily for the prevention of VOD (SOS) in adults undergoing allogeneic stem cell transplantation with the following risk factors: pre-existing hepatic disease, second myeloablative transplant, allogeneic transplant for leukaemia beyond second relapse, conditioning with busulfan-containing regimens, prior treatment with gemtuzumab ozogamicin, diagnosis of primary haemophagocytic lymphohistiocytosis, adrenoleucodystrophy or osteopetrosis (2B). Prostaglandin E1 is not recommended in the prophylaxis of VOD (SOS) due to lack of efficacy and toxicity (1B). Pentoxifylline is not recommended in the prophylaxis of VOD (SOS) due to lack of efficacy (1A). Ursodeoxycholic acid is suggested for use in the prophylaxis of VOD (SOS) (2C). Heparin (unfractionated and low molecular weight) is not suggested for use in the prophylaxis of VOD (SOS) due to the risk of increased toxicity (2B). Antithrombin is not suggested for the prophylaxis of VOD (SOS) due to lack of efficacy (2B).

TREATMENT

Defibrotide is recommended in the treatment of VOD (SOS) in adults and children (1B). Tissue plasminogen activator is not recommended for use in the treatment of VOD (SOS) due to the associated risk of haemorrhage (1B). N-acetylcysteine is not routinely recommended for use in the treatment of veno-occlusive disease due to lack of efficacy (1A). Methylprednisolone may be considered for use in the treatment of veno-occlusive disease with the appropriate caveats of caution regarding infection (2C). Judicious clinical care, particularly in the management of fluid balance, is recommended in the management of VOD (SOS) (1C). Early discussion with critical care specialists and a specialist hepatology unit is recommended in the management of VOD (SOS) and other treatment options including transjugular intrahepatic portosystemic shunt or hepatic transplantation may be considered (1C).

SUMMARY

A joint working group established by the Haemato-oncology subgroup of the British Committee for Standards in Haematology (BCSH) and the British Society for Blood and Marrow Transplantation (BSBMT) has reviewed the available literature and made recommendations for the diagnosis and management of veno-occlusive disease of the liver following haematopoietic stem cell transplantation (HSCT). This guideline includes recommendations for both prophylaxis and treatment of the condition and includes recommendations for children and adults undergoing HSCT.

Abdominal complications following neutropenia and haematopoietic stem cell transplantation: CT findings

In haematology units, acute abdominal symptoms are common and often challenging for the clinician in charge. Two haematological conditions that may induce specific diagnoses are of particular concern: neutropenia and haematopoietic stem cell transplantation. Clinical and biological manifestations, including abdominal pain, fever, diarrhoea, hepatic cytolysis, or cholestasis are often non-specific. Computed tomography is often the primary imaging screening technique performed in such patients, as it is widely available, performs well for this indication, and may demonstrate evocative findings. The aim of this review is to provide the spectrum of specific diagnoses encountered and the corresponding key CT features in patients presenting with acute abdominal disorders following neutropenia and/or haematopoietic stem cell transplantation.

Hepatic veno-occlusive disease after taking Gynura Rhizome: The value of multidetector computed tomography in diagnosing the disease and evaluating the clinical therapeutic effect

AIM

  We conducted this study to evaluate the role of multidetector computed tomography (MDCT) in diagnosing and differential diagnosis hepatic veno-occlusive disease (HVOD), and as well as assessing the clinical therapeutic effects.

METHODS

  From 2007 to 2010, 10 inpatients with weight increasing, liver pains, ascites, jaundice and history of taking gynura rhizome before hospitalization were scanned with a 64-MDCT. The data were reconstructed every 0.625 mm and reviewed using multiplanar reconstruction (MPR) and liver CT angiography (CTA) on a GE AW4.2 workstation. Patients were re-scanned with MDCT after medication so that the clinical therapeutic effect could be evaluated before the patients discharging from hospital.

RESULTS

  In 10 HVOD patients, the diagnoses of MDCT were coincident with clinical results. All patients had ascites and pleural fluid, hepatomegaly except the caudate lobe in MDCT. Failure to view hepatic veins in hepatic 3 phase scans, but portal veins and inferior vena cava were unobstructed. In portal-phase, hepatic enhancements were non-uniform. Three patients were incorrectly diagnosed before hospital admission. All patients improved significantly after hepato-protection and supporting therapy. No ascites, hydrothorax, hepatomegaly and obstruction of hepatic veins were observed by MDCT before patients were discharged from hospital.

CONCLUSION

  Multidetector computed tomography combined with MPR and liver CTA images are helpful in the diagnosis and differential diagnosis of HVOD and in the evaluation of clinical therapeutic effects.

Definitive diagnosis of hepatic sinusoidal obstruction syndrome induced by pyrrolizidine alkaloids

OBJECTIVE

Hepatic sinusoidal obstruction syndrome (HSOS) induced by a Chinese medicinal herb Tusanqi is increasingly being reported in recent years. The aim of the study was to investigate the possibility of using blood pyrrole-protein adducts test as a confirmatory diagnostic method.

METHODS

Patients with HSOS according to international diagnostic criteria associated with Tusanqi from January 2006 to August 2010 in Zhongshan Hospital Fudan University were included and clinical features were collected. Pyrrole-protein adducts in blood sample were determined with ultra performance liquid chromatography-mass spectrometry (UPLC-MS) while pyrrolizidine alkaloids (PAs) in available herbal preparations were analyzed by high performance liquid chromatography-ultraviolet (HPLC-UV).

RESULTS

Five patients (age 41-72 years, median age 54 years, all women) were included. Ascites (5/5), jaundice (5/5) and hepatomegaly (4/5) were common manifestations. The imaging features were diffused, patchy hepatic enhancement, periportal edema and ascites. Pathology ascertained that blood flow was obstructive at the site of sinusoid. PAs (Seneionine and seneciphylline) were identified in all the three available herbal preparations ingested by the HSOS patients. Pyrrole-protein adducts were unequivocally found in all the five blood samples. Two patients recovered, two developed chronic illness and one died due to liver failure and hepatic encephalopathy.

CONCLUSIONS

The detection of blood pyrrole-protein adducts using a UPLC-MS approach is a specific, reliable, unambiguous and confirmatory test for HSOS induced by PA, and should be used together with the conventional HSOS clinical diagnostic criteria for the definitive diagnosis of PA-induced HSOS.

Acoustic radiation force impulse elastography and contrast-enhanced sonography of sinusoidal obstructive syndrome (Veno-occlusive Disease): preliminary results

We report quantitative liver acoustic radiation force impulse (ARFI) elastographic findings in 2 cases of sinusoidal obstructive syndrome and liver contrast-enhanced sonographic features in one of these cases. To our knowledge, findings in this condition from these techniques have not been reported previously. Acoustic radiation force impulse elastography showed median high shear wave velocities (case 1, 2.75 m/s; case 2, 2.58 m/s) that normalized after specific treatment for sinusoidal obstructive syndrome; therefore, ARFI elastography provided quantitative information that helped diagnose this condition as well as monitor the response to treatment. Contrast-enhanced sonographic findings in one of the cases showed patchy liver enhancement that correlated with the high-velocity patchy distribution on ARFI elastography in that case and enhanced multidetector row computed tomographic findings in the other case. This contrast-enhanced sonographic pattern progressively normalized during follow-up after specific treatment. The elastographic features in both cases and contrast-enhanced sonographic features in one of them contributed to early diagnosis and follow-up of sinusoidal obstructive syndrome in both patients. Further prospective studies are necessary to define the role of ARFI elastography and contrast-enhanced sonography in the early diagnosis and clinical follow-up of this condition.