Solid Liver Masses Research Articles

528P Comparison of endoscopic ultrasound-guided tissue acquisition for solid liver masses: Menghini needle with a lateral reverse bevel vs. Franseen needle

528P Comparison of endoscopic ultrasound-guided tissue acquisition for solid liver masses: Menghini needle with a lateral reverse bevel vs. Franseen needle

Virtual non-enhanced dual-energy computed tomography reconstruction: a candidate to replace true non-enhanced computed tomography scans in the setting of suspected liver alveolar echinococcosis.

When a suspected hepatic alveolar echinococcosis (AE) lesion is detected on a contrast enhanced computed tomography (CT) scan, an additional triphasic or non-enhanced CT scan is required to determine the presence of calcification and enhancement. As a result, imaging costs and exposure to ionizing radiation will increase. We can create a non-enhanced series from routine contrast-enhanced images using dual-energy CT (DECT) and virtual non-enhanced (VNE) images. This study's objective is to assess virtual non-enhanced DECT reconstruction as a potential diagnostic tool for hepatic AE. Triphasic CT scans and a routine dual energy venous phase were acquired using a third-generation DECT system. A commercially available software package was used to generate VNE images. Individual evaluations were conducted by two radiologists. The study population consisted of 100 patients (30 AE, 70 other solid liver masses). All AE cases were diagnosed [no false positives/negatives, 95% confidence interval (CI) sensitivity: 91.3%-100%; 95% CI specificity: 95.3%-100%]. Interrater agreement was k: 0.79. In total, 33 (33.00%) of the patients had AE, which was detected using both true non-enhanced (TNE) and VNE images. The mean dose-length product of a standard triphasic CT was significantly higher than biphasic dual-energy VNE images. In terms of diagnostic confidence, VNE images are comparable with actual non-enhanced imaging when evaluating hepatic AE. Further, VNE images could replace TNE images with a substantial radiation dose reduction. Advances in knowledge: hepatic cystic echinococcosis and AE are serious and severe diseases with high fatality rates and a poor prognosis if managed incorrectly, especially AE. Moreover, VNE images produce equal diagnostic confidence to TNE images for assessing liver AE, with a significant reduction in radiation dose.

S1755 Intrahepatic Cholangiocarcinoma in a Patient With Alcoholic Liver Cirrhosis and Markedly Elevated Serum Alpha-Fetoprotein

Introduction: Intrahepatic cholangiocarcinoma (ICC) represents 5% of all primary liver malignancies, second only to hepatocellular carcinoma (HCC). Although risk factors such as primary sclerosing cholangitis, hepatolithiasis, and asbestos have been reported, the etiology of ICC is not well understood. An elevated serum AFP accompanied by a space-occupying solid lesion in a cirrhotic patient is typically indicative of HCC. In high-risk patients, such as those with chronic liver disease, AFP > 400 ng/mL has a high positive predictive value for HCC and a specificity of >95%. An elevated serum AFP greater than 20 ng/mL is seen in < 25% of ICC. Case Description/Methods: We present a patient with a past medical history of alcoholic liver cirrhosis Child-Pugh Class C presenting with acute change in mental status. On arrival, he was hemodynamically stable with classic stigmata of chronic liver disease on the exam. Non-contrast CT Head was non-revealing. Laboratory investigations revealed an obstructive pattern of transaminitis with a normal ammonia level, negative hepatitis panel, and serum AFP of 1955.8 ng/mL. EGD demonstrated portal hypertensive gastropathy. CT Abdomen/Pelvis demonstrated a large infiltrative heterogeneous mass involving the entire right hepatic lobe with a non-occlusive thrombus extending to the portal vein. Ultrasound-guided liver biopsy and immunohistochemical analysis demonstrated positive expression for cytokeratin 20, and CA 19-9. Neoplastic cells were negative for Hep-Par1, Glypican 3, and Arginase 1. The histological pattern (Figure) was consistent with poorly differentiated adenocarcinoma, most likely pancreaticobiliary in origin consistent with intrahepatic cholangiocarcinoma (ICC). Discussion: Elevated serum AFP accompanied by a space-occupying solid lesion in a cirrhotic patient is typically indicative of HCC. However, Xiong et al reported an increased risk by 3.92-fold of cholangiocarcinoma in patients with alcoholic liver disease. Even though, an increase in AFP has been reported in patients with ICC, an elevation higher than 20 ng/mL was seen in approximately 20% of the patients according to Wang et al. In our patient, surprisingly, the histopathological report showed findings consistent with ICC and negative hepatic markers, hence a high suspicious index should be held by clinicians for this entity upon approaching a patient with a solid liver mass associated with significantly elevated AFP levels.Figure 1.: On the left, histology of poorly differentiated adenocarcinoma composed of duct-like structures with high pleomorphism. H&E 400X. On the right, immunohistochemical study shows positive CA 19-9 stain of adenocarcinoma.

A comparison of the antegrade core trap and reverse bevel needles for EUS-guided fine-needle biopsy sampling of liver mass: a prospective randomized cross over study.

Data on the use of EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) for pathology is limited. To prove superiority of the diagnostic rate of the newly designed modified Menghini-type needle with a beveled side-slot near the needle tip with slot cutting edge directed 20-gauge antegrade bevel (group A) over the original 22-gauge reverse bevel (group B) for EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) in a prospective crossover randomized controlled trial. The overall diagnostic accuracy rate of the 52 passes was 86.5% (45/52) and of group A versus B were 88.5% (23/26) versus 84.6% (22/26), respectively, p=0.858. Tissue adequacy levels of both groups were not significantly different (grade A: B: C=18:6:2 versus 16:7:3), p=0.839). Grading of blood contamination of both groups was not significantly different. However, it was found that the group-A needles could biopsy tissue of significantly longer length than that of the group B; 1.3cm (SD=0.76) versus 0.8cm (SD=0.54); p=0.007. The use of EUS-FNB of SLM is highly effective with similar levels of efficacy and number of adverse events between both types of needles. Thai Clinical Trial Registration No. TCTR2018081002.

Characterization of solid liver masses on ultrasound in adults

Liver carcinoma is the fifth leading cancer globally and the third top cause of mortality in 2012, there were 14 million new cases and 8.2 million fatalities. Objective: To accurately define solid liver masses in adults based on clinical presentation and ultrasound findings in order to obtain a definitive diagnosis in adults. Methods: It was a retrospective study consisting of total 128 individuals with untreated liver lesions examined on ultrasound (Toshiba Xario 100) at a private tertiary care hospital in Gujrat. From January 2021 to January 2022, 65 males and 63 females, ages ranging from 30 to 70 years. A convenient sampling technique was used to collect data by fully informed consent from patients to access. Data was entered and analyzed on SPSS version 22. Results: The current study included 128 patients aged ranging from 30–70 years, being examined using ultrasound for solid liver masses. The gender frequency was 65(50.8%) males and 63(49.2%) females. Ultrasound diagnosis interprets as 62(48.4%) Hepatocellular-carcinoma, 38(29.7%) hemangioma, 11(8.6%) FNH, 3(2.3%) metastasis, and 13(10.2%) cholangiocarcinoma. Moreover, ultrasound findings regarding liver masses diagnosed includes 99(38.7%) single masses, 29(11.3%) multiple masses, 47(18.4%) normal liver parenchyma and 81(31.6%) coarse liver. The common clinical complaints associated with solid hepatic lesions were right upper quadrant pain 80(35.4%), splenomegaly 69(30.5%) and 77(34.1%) hepatomegaly. Conclusions: It is concluded that the right upper quadrant pain, hepatomegaly has a correlation to solid liver masses and a weak relation to splenomegaly irrespective to age and gender. The most common solid liver mass was Hepatocellular carcinoma (HCC). Ultrasound is a noteworthy imaging modality to diagnose solid hepatic masses.

Perfusion-Diffusion Ratio: A New IVIM Approach in Differentiating Solid Benign and Malignant Primary Lesions of the Liver.

Introduction In order to improve the efficacy of intravoxel incoherent motion (IVIM) parameters in characterising specific tissues, a new concept is introduced: the perfusion–diffusion ratio (PDR), which expresses the relationship between the signal S(b) decline rate as a result of IVIM and the rate of signal S(b) decline due to diffusion. The aim of this study was to investigate this novel approach in the differentiation of solid primary liver lesions. Material and Methods. Eighty-three patients referred for liver MRI between August 2017 and January 2020 with a suspected liver tumour were prospectively examined with the standard liver MRI protocol extended by DWI-IVIM sequence. Patients with no liver lesions, haemangiomas, or metastases were excluded. The final study population consisted of 34 patients with primary solid liver masses, 9 with FNH, 4 with regenerative nodules, 10 with HCC, and 11 with CCC. The PDR coefficient was introduced, defined as the ratio of the rate of signal S(b) decrease due to the IVIM effect to the rate of signal S(b) decrease due to the diffusion process, for b = 0. Results No significant differences were found between benign and malignant lesions in the case of IVIM parameters (f, D, or D∗) and ADC. Significant differences were observed only for PDR, with lower values for malignant lesions (p = 0.03). The ROC analysis yielded an AUC value for PDR equal to 0.74, with a cut-off value of 5.06, sensitivity of 81%, specificity of 77%, and accuracy of 79%. Conclusion PDR proved to be more effective than IVIM parameters and ADC in the differentiation of solid benign and malignant primary liver lesions.

Automated hemangioma detection using Otsu based binarized Kaze features

This study aims to detect liver hemangioma on CT images by using hybrid image processing methods as well as binarized histogram of gradients based Kaze feature extraction. Using hybrid strategies, automatic hemangioma detector design is the state of art of this study. Our study helps doctors to detect the solid liver masses. Proposed algorithm includes detection of hemangioma using Otsu auto-threshold based Histogram of Gradients (HOG) and Kaze feature extraction implementation. 48 liver CT images, 28 of which are hemangiomas and 20 of which are healthy liver images, are used as the dataset. CT images are obtained by the Department of the Radiology at Firat University. Presented work was implemented to 48-CT images and 91,66% accuracy was achieved for different shaped and sized hemangiomas. These results show that the developed algorithm could ease the process of detecting liver masses for radiologist and doctors could evaluate their findings easily.

Su1174 ENDOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION CYTOLOGY/BIOPSY WITH THE CELL BLOCK METHOD FOR SOLID LIVER MASS LESION

We have performed endoscopic ultrasound-guided fine needle aspiration cytology/biopsy (EUS-FNA) for solid liver mass lesion when it is considered to be technically easier to perform EUS-FNA than it is to perform percutaneous fine needle aspiration biopsy (P-FNA). In this study, the efficacy and safety of EUS-FNA for solid liver mass lesion were studied.

Differentiation of Solid Liver Masses by Diffusion Weighted MRI as Benign and Malignant

Differentiation of Solid Liver Masses by Diffusion Weighted MRI as Benign and Malignant

A Case of Recurrent Diverticulitis Complicated by Liver Abscesses

Liver abscesses are an unusual but life threatening complication of diverticulitis. The most common pathogens identified in diverticulitis are mixed enteric facultative and anaerobic species. However, the prevalence of group A streptococcus causing hepatic abscesses secondary to diverticulitis without bacteremia with organisms in the Streptococci Milleri group are rare. 54 year old male with history of multiple bouts of diverticulitis for the last 10 years presented with abdominal pain, fever of 102 degrees Fahrenheit, and chills. He was known to have three solid liver masses by CT of the abdomen at another hospital. There he was empirically treated with Vancomycin and Zosyn but left against medical advice without completing work-up. However, the patient's abdominal pain and fever persisted, leading the patient to return to the hospital. At the time of his second admission he presented with similar symptoms. Physical exam was significant for a low-grade fever of 99.7 degrees Fahrenheit and diffusely tender abdomen. Pertinent labs: WBC 14.9, AST: 107, ALT 96. Total Bilirubin 2.3 mg/dl, Direct Bilirubin 0.3 mg/dl, Lipase 415, and amylase 47. Hepatitis panel and ameobiasis antibody were negative. Diagnostic imaging with CT of the abdomen revealed 2 lesions (6.2 cm & 3.2 cm respectively) on the left lobe of the liver and one lesion in the right lobe of the liver (8.4 cm.) Aspiration grew heavy growth of strep intermedius on cultures. 2 CT guided drains were placed for drainage and patient was empirically initiated on zosyn monotherapy. Respiratory status started progressively worsening and he developed right exudative pleural effusions with mediastinal shift requiring 2 thoracentesis procedures. He also subsequently developed sigmoid diverticulitis and was discharged on clear liquid diet, antibiotic infusions to be completed outpatient, and recommended to get elective sigmoid resection after resolution of his symptoms. Although infection from portal vein source only accounts for 20% of cases, identification of a pyogenic liver abscess should warrant investigation for an intra-abdominal source including diverticulitis. Mortality from a pyogenic liver abscess has decreased to 15-20% from 80-100% with timely diagnosis and treatment with drainage and antibiotics. Prophylactic sigmoid resection in patients with recurrent bouts of diverticulitis can decrease future morbidity from complications as seen in the patient above.

Endoscopic Ultrasound Liver Biopsies Accurately Predict the Presence of Fibrosis in Patients With Fatty liver

Endoscopic Ultrasound Liver Biopsies Accurately Predict the Presence of Fibrosis in Patients With Fatty liver

KRAS mutation analysis by next-generation sequencing in endoscopic ultrasound-guided sampling for solid liver masses.

KRAS mutation analysis may provide ancillary diagnostic yield in an endoscopic ultrasound (EUS)-guided histopathological evaluation. We evaluated the clinical impact of KRAS mutation analysis with cytological and histological evaluations in EUS-guided tissue sampling, using a core biopsy needle for solid liver masses. EUS-guided fine needle biopsy (EUS-FNB) using a core biopsy needle was performed in patients with primary or metastatic liver masses that were suspected malignancies. KRAS mutations were analyzed in all specimens obtained. The peptide nucleic acid (PNA)-mediated polymerase chain reaction (PCR) clamping method was compared with a next-generation sequencing (NGS) method for detecting KRAS mutations. EUS-FNB with a core biopsy needle was performed in 28 patients with solid liver masses located in the liver's left lobe. The diagnostic accuracies for malignancy of on-site cytology, cytology using Papanicolaou staining, and histology including immunohistochemical stains were 82.1%, 85.7%, and 89.3%, respectively. KRAS gene mutations were observed in 14.3% of patients by the PNA-PCR clamping method. The NGS method detected more KRAS mutations than the PNA-PCR clamping method: in 25% of patients. Adding the results of KRAS mutation analysis to the cytohistopathological evaluation, the overall diagnostic accuracy of EUS-guided tissue sampling was 96.4%. EUS-guided tissue sampling for solid liver masses in the left lobe provided high diagnostic accuracy from cytological and histological evaluations. KRAS mutation analysis provided additional diagnostic yield in patients with inconclusive cytohistopathological results from EUS-guided tissue sampling. The NGS method detected additional KRAS mutations in patients with negative PNA-mediated PCR clamping test results.

Role of ultrasonography in diagnosis of solid space occupying lesion in the liver correlation with FNAC.

This cross sectional study was carried enrolling 47 subjects with suspected solid liver mass, in the Department of Radiology and Imaging, Dhaka Medical College Hospital, Dhaka, over a period of twelve months. The aim of this study was to evaluate the diagnostic usefulness of transabdominal ultrasonography in the diagnosis of solid SOL in the liver. Majority of the respondents (42.55%) were found between 41-60 years of age. Five (10.63%) subjects were found below 20 years of age. There were 31 men (65.95%) and 16 women (34.05%). Majority of the metastasis were multiple (85%), hypoechoic (35%) and only 15% had internal calcifications. HCC was single lesion (61.53%) with hyperechoic (38.35%) echogenicity, with a central halo (76.92%) and 15.38% had internal calcifications. Majority of the cholangiocarcinoma were solitary (80%), hypoechoic (60%) and 60% had internal calcifications. Hepatoblastoma were solitary and had calcifications (60%) with mixed echogenicity (60%). Majority of the adenomas were solitary (80%), hypoechoic (60%) and only 20 % had internal calcifications. The validity of transabdominal sonography for the diagnosis of metastasis was confirmed by calculating sensitivity (100%), specificity (96.42%), accuracy (97.87%), positive (95%) and negative predictive (100%) values by using the standard formula given. The sensitivity, specificity, accuracy, positive and negative predictive values for HCC were 92.3%, 97.05%, 95.74%, 92.3% and 97.05% respectively. The sensitivity, specificity, accuracy, positive and negative predictive values for cholangiocarcinoma and hepatoblastoma were 80%, 97.61%, 95.74%, 80% and 97.61% respectively. Sensitivity, specificity, accuracy, positive and negative predictive values were 80%, 100%, 97.87%, 100% and 97.67% respectively for adenoma. From the study result it was concluded that transabdominal ultrasonography could be reliable, non- ionizing and relatively cheap procedure for diagnosis solid hepatic mass lesion.

Usefulness of endoscopic ultrasound-guided sampling using core biopsy needle as a percutaneous biopsy rescue for diagnosis of solid liver mass: Combined histological-cytological analysis.

Endoscopic ultrasound (EUS)-guided fine needle aspiration (EUS-FNA) is one of the alternative methods for tissue sampling of liver solid mass. However, the diagnostic efficacy using cytology alone was limited. In this study, we evaluate the diagnostic accuracy of EUS-guided fine needle biopsy (EUS-FNB) as a percutaneous biopsy rescue for liver solid mass. The EUS-FNB using core biopsy needle for liver solid mass was performed prospectively for patients who were failure to acquire a tissue or achieve a diagnosis using percutaneous liver biopsy. The primary outcome was the diagnostic accuracy of EUS-FNB for malignancy and specific tumor type. The secondary outcomes were the median numbers of passes required to establish a diagnosis, the proportions of patients in whom immunohistochemical (IHC) stain was possible and obtained adequate specimen, and safety of EUS-FNB. Twenty-one patients (12 women; mean age, 63 years [range, 37-81]) underwent EUS-FNB for solid liver masses. The median number of needle passes was 2.0 (range, 1-5). On-site cytology and cytology with Papanicolaou stain showed malignancy in 16 patients (76.2%) and 17 patients (81.0%), respectively. In histology with HE stain, 19 patients (90.5%) were diagnosed malignancy and optimal to IHC stain. The overall diagnostic accuracy for malignancy and specific tumor type were 90.5% and 85.7%, respectively. No complications were seen. EUS-FNB with core biopsy needle for solid liver mass may be helpful in the management of patients who are unable to diagnose using percutaneous liver biopsy.

Solid Liver Masses: Approach to Management from the Standpoint of a Radiologist

Solid liver masses are being discovered at increasing rates due to the widespread use of medical imaging. Ultrasound, computed tomography, and magnetic resonance imaging play important and often complementary roles in detecting and diagnosing solid liver masses. Morphologic and enhancement characteristics as well as clinical history frequently allow a confident imaging diagnosis. Still, diagnosing liver masses with imaging alone remains a challenge, and masses that do not meet specific diagnostic criteria may require biopsy. Newly developed standardized terminology and imaging criteria have facilitated the imaging diagnosis of hepatocellular carcinoma (HCC) in patients with cirrhosis. Hepatobiliary-secreted MRI contrast agents have improved the ability to diagnose focal nodular hyperplasia and may also improve the detection and imaging diagnosis of HCC. These exciting new contrast agents are the subject of active investigation.

Abstracts and Case Studies From the College of American Pathologists 2012 Annual Meeting (CAP '12)

Abstracts and Case Studies From the College of American Pathologists 2012 Annual Meeting (CAP '12)

Semiquantitative Strain Elastography of Liver Masses

This study was designed to determine the utility of semiquantitative strain elastography in differential diagnosis of solid liver masses. A total of 103 patients with focal liver masses underwent abdominal sonographic examinations and freehand elastography of focal hepatic lesions. Eighty-two patients (79.7%) with 93 focal hepatic lesions were included in the study. Twenty-one patients (20.3%) were excluded from the study because of technical limitations of semi-quantitative strain elastography and difficulty in detection of normal liver parenchyma on gray-scale sonography. We evaluated different focal hepatic lesions such as hemangiomas, focal nodular hyperplasia, nodular regenerative hyperplasia, adenomas, hepatocellular carcinomas, metastases, and cholangiocarcinomas. The stiffness of the lesions was determined by measurement of strain values on semiquantitative strain elastography. The strain index value (strain ratio of liver parenchyma and focal lesions) of each lesion was calculated. Mean strain index values of benign and malignant liver lesions were compared. The mean strain index value of malignant liver lesions ± SD (2.82 ± 1.82) was significantly higher than that of benign liver lesions (1.45 ± 1.28; P< .0001). Hemangiomas had a significantly lower mean strain index value than other benign lesions (P < .0034). There was no statistically significant difference between strain index values of different types of malignant lesions (P > .05). Semiquantitative strain elastography may be helpful for differentiating benign and malignant liver masses. The substantial overlap between strain index values of benign and malignant liver masses limits clinical usefulness of this technique.

P-0091 Prediction of Hcc in Cirrhotic Patients with an Arterially Enhancing Liver Mass

IntroductionAbout 80% of hepatocellular carcinomas (HCCs) appear in cirrhotic population. A liver mass in a cirrhotic patient should be considered a HCC until proven otherwise. Arterial enhancement is considered an essential characteristic of HCC and is used as a radiologic feature for noninvasive diagnosis of HCC. We aimed to determine whether clinical, laboratory, and/or radiologic data can improve the prediction of HCC in cirrhotic patients with an arterially-enhancing liver mass. MethodsWe analyzed 23 patients with cirrhosis and a solid liver mass diagnosed on screening ultrasound and further characterized as an arterially-enhancing mass on contrast-enhanced MRI. The diagnosis of liver cirrhosis was based on clinical data. Results23 patients (15 male and 8 female; mean age 60.66 years) with liver cirrhosis presented an arterially-enhancing liver mass on MRI. The cause of liver cirrhosis was HCV-associated in 14 patients, alcoholic in 2, alcoholic and HCV-associated in 3, and HBV-associated in 4 patients; 17 patients were in Child-Pugh class A and 6 in class B. A positive noninvasive HCC diagnosis included all arterially enhancing lesions>2cm (n=15). Independent predictors of HCC for arterially-enhancing lesions>2cm were also age>57 yrs (n=11), AFP>20ng/mL (n=8), and delayed hypointensity (n=13). Arterially-enhancing lesions<2cm (n=8) were further evaluated by contrast-enhanced ultrasonography (CEUS). A positive noninvasive HCC diagnosis included all arterially-enhancing lesions<2cm on both MRI and CEUS, with portal venous washout (n=4). The presence of delayed hypointensity was the only independent predictor of HCC among patients with arterially-enhancing lesions<2cm (n=6). ConclusionIndependent predictors of HCC in cirrhotic patients with an arterially-enhancing liver mass were age>57 yrs, AFP>20ng/mL, and delayed hypointensity. Delayed hypointensity of an arterially-enhancing liver mass was the strongest independent predictor of HCC, regardless of the size of the lesion.

Neonatal mesenchymal hamartoma of liver: An unusual presentation

Mesenchymal hamartoma of the liver is the second most common benign liver tumor in children. Typically, it presents as a large benign cystic, solid or mixed liver mass in a child younger than 3 years and amenable to complete resection. We report a neonate with Mesenchymal hamartoma of the liver presenting as giant intra abdominal cyst and its rare association with malrotation of bowel.

Shear Wave Elastography of Abdominal and Retroperitoneal Masses and Inflammatory Processes: A Feasibility Study

The purpose of the study was to evaluate the feasibility of assessment of elasticity of abdominal and retroperitoneal masses and inflammatory processes with shear wave elastography performed during sonographic examination. We evaluated with ultrasound 18 consecutive patients with adrenal and/or liver masses and abdominal inflammatory processes. Quantitative shear wave elastography was performed with Aixplorer (Supersonic) with convex abdominal transducer and/or linear one. We evaluated with supersonic shear wave elastography 16 adrenal and 5 liver masses, Crohn's disease, ulcerative colitis and inflammatory changes related to arterial graft. All the solid adrenal, liver masses and bowel inflammatory lesions showed the elasticity map. The adrenal cysts (some not obvious on B-mode imaging) did not show elasticity signal, as shear waves do not propagate through liquids. Shear wave elastography of abdominal and retroperitoneal masses and inflammatory processes is a feasible technique that can be performed during ultrasound examination and has shown some potential for differential characterization of adrenal or liver masses and inflammatory bowel diseases. Shear wave elastography may deliver the information on the extent of inflammatory abdominal processes. Further large-scale studies evaluating the possibility of differentiation and evaluation of extent of abdominal and retroperitoneal lesions using shear wave elastography are warranted.