Subcapsular Lesions Research Articles

Intraoperative Frozen Section Evaluation of Pancreatic Specimens and Related Liver Lesions.

Frozen sections are essential in the surgical management of patients, especially those with pancreatic masses, because frozen sections can provide answers intraoperatively and aid in treatment decisions. Pancreas frozen sections are challenging because of the small tissue size, processing artifacts, neoadjuvant treatment effects, and concurrent pancreatitis-like obstructive changes. The authors present a review of intraoperative evaluation of pancreatic specimens. To provide an approach to the diagnosis of pancreatic adenocarcinoma on frozen sections and to discuss commonly encountered pitfalls. Indications for pancreas frozen sections and specific margin evaluation will be discussed. We will also review frozen section diagnosis of subcapsular liver lesions and tumors other than metastases of pancreatic ductal adenocarcinoma. Data sources included a literature review and the personal experiences of the authors. The features for diagnosis of pancreatic adenocarcinoma include disordered architecture, glands at abnormal locations, and atypical cytology. It is important to be aware of the pitfalls and clues on frozen section. The evaluation of resection margins can be challenging, and in the setting of the resection of cystic tumors, the key is the diagnosis of high-grade dysplasia or cancer. Finally, it is vital to remember the differential diagnosis for subcapsular liver lesions because not all lesions will be metastases of adenocarcinomas or bile duct adenomas. Frozen sections remain a useful tool for the intraoperative management of patients with pancreatic tumors.

Assessment of efficacy and safety of irreversible electroporation versus TACE for treatment of difficult location hepatocellular carcinoma

IntroductionRadiofrequency ablation (RFA) and microwave ablation (MWA) are widely accepted as the established treatment options for patients diagnosed with early-stage hepatocellular carcinoma (HCC) who are deemed unfit for surgical procedures. However, the effective implementation of these techniques is hindered by various challenges, primarily associated with the precise targeting of tumors within the liver. The utilization of thermal ablative methods is not recommended for hepatocellular carcinoma (HCC) that is located near intestinal loops, bile ducts, or in eccentric positions. The unmet need for non-thermal methods in the treatment of hepatocellular carcinoma (HCC) was addressed following the introduction of irreversible electroporation (IRE) as an innovative approach.Aim of the workTo assess the efficacy, safety, and outcomes of IRE in the treatment of difficult-located HCC compared to transarterial chemoembolization (TACE).MethodsThis is a prospective study that included 24 patients with HCC who presented to the National Hepatology and Tropical Medicine Research Institute (NHTMRI) during the period from January 2017 to January 2020. Ten patients underwent IRE, while 14 patients underwent TACE.ResultsSixteen patients (66.7%) were males; eight patients were females (33.3%). Their median age was 60.5 years (48–70 years). Seventeen patients (70.8%) were Child–Pugh class A, while seven patients (29.2%) were Child–Pugh class B. All the study population had a single focal lesion; the mean size of the focal lesions was 2.94 ± 0.59 cm. The most frequent difficult locations of HCC were segment V focal lesions adjacent to both the common bile duct and portal vein in eight patients (33.3%) followed by lesions adjacent to the inferior vena cava in five patients (20%) followed by the subcapsular lesions in three patients (12.5%) and lesions adjacent to the right kidney in two patients (8.3%). Complete response (CR) was higher in the IRE group (80%) compared to the TACE group (50%). Clinical decompensation occurred in six patients in the IRE group (60%) and eight patients in the TACE group (57.1%) (P value 1). Recurrence occurred in five patients (50%) treated with IRE and in seven patients (50%) treated with TACE (P value 1). Within the IRE group, two patients (20%) remained alive; on the other hand, within the TACE group six patients (42.9%) remained alive by the end of the study (P value 0.388).ConclusionOur data suggest that IRE is an effective procedure in the treatment of difficult-located HCC in terms of complete response, fewer sessions, and fewer side effects as compared to TACE.

A retrospective study of irreversible electroporation for tumors adjacent to perihepatic important structure.

Irreversible electroporation has been proved as a feasible and safe method against tumor in liver. However, few studies focused on tumors adjacent to perihepatic important structure like vessels, biliary system and gall bladder. These structures limit the effectiveness of conventional treatments. The aim of this article is to analyze the clinical outcomes of patients with hepatic tumors at the special sites who received IRE treatment and provide reliable evidence for broadening the scope of IRE's clinical application. The clinical information of patients who underwent IRE ablation for tumors adjacent to perihepatic important structure between February 2017 and December 2021 was collected and retrospectively analyzed. All patients underwent contrast-enhanced CT or MRI for further evaluation at the 1-month follow-up and every 3 months thereafter. Post-ablation complications, recurrence, progression-free survival and overall survival were evaluated to analyze the prognosis of IRE ablation adjacent to perihepatic important structure. Categorical variables are presented as numbers followed by percentages. Continuous data are presented as the mean ± deviation. The tumor size and IRE ablation size were evaluated by the maximum diameters. Thirty-two patients who underwent IRE ablation for tumor adjacent to perihepatic important structure were studied in this research. There were 39 lesions in 32 patients treated with IRE ablation. Fourteen of them (35.9%) were located adjacent to the porta hepatis, and 8 of them (20.5%) were located adjacent to the hepatocaval confluence. Subcapsular lesions accounted for 15.4% (6 of 39 lesions). The other 11 lesions were in the para gallbladder (5 of 39 lesions, 12.8%), the caudate lobe (5 of 39 lesions, 12.8%) and the colonic hepatic flexure (1 of 39 lesions, 2.6%). According to the Clavien-Dindo classification system for complications, all relative patients with cancer experienced complications below class III except one patient who developed postoperative hemorrhagic shock and improved after timely treatment. Recurrence in situ was observed in 5 of 32 (15.6%) patients. The median PFS of the patients who received IRE ablation was 384 days, and the median OS was 571 days. IRE ablation is a feasible and safe treatment strategy for tumors adjacent to perihepatic important structure. With improved equipment, optimized therapeutic parameters and long-term clinical trials, IRE will play an increasingly important role in the treatment of tumors in liver.

Splenic Lymphatic Malformation With Papillary Endothelial Proliferation: A Rare Histologic Variant or a Unique Entity?

Lymphatic malformations (LMs) are congenital anomalies of the lymphatic system due to abnormalities that occur during the development of the lymphovascular system. Also known as lymphangiomas, they are usually multifocal, affect multiple organ systems, and are seen in a variety of developmental or overgrowth syndromes. Splenic lymphangiomas are uncommon and usually occur in the context of multiorgan lymphangiomatosis. Within the spleen, 7 prior cases have been reported of LMs with unusual papillary endothelial proliferations (PEPs), which can mimic more aggressive splenic lymphovascular tumors. It is not currently known if splenic LM-PEP represents a unique entity, or is simply an unusual, site-specific, morphologic variant of LM. To address this question, we conducted a retrospective, single-institutional review of this rare entity and systematically evaluated its clinical, histologic, radiologic, electron microscopical, and molecular features. In all 3 splenic LM-PEPs, the clinical course was benign, imaging demonstrated subcapsular lesions with characteristic "spoke-and-wheel" appearance, histology showed distinctive PEPs within lymphatic microcysts, immunohistochemistry confirmed a lymphatic endothelial phenotype and electron microscopy demonstrated lesional endothelial cells, rich in mitochondria and intermediate filaments with prominent cytoplasmic lumina and vacuoles and lacking Weibel-Palade granules. Occasional lymphothelial cells were situated within the cytoplasm of another lesional cell, appearing to be engulfed. Next-generation sequencing identified a PIK3CA mutation in 1 patient, while in 2 others no molecular alterations were identified. We conclude with a summary of all prior published cases and discuss key diagnostic elements that distinguish this benign entity from its more aggressive mimickers.

Updated information regarding management of hepatic epithelioid hemangioendothelioma.

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare hepatic vascular tumor with a borderline biological behavior between hemangioma and hemangiosarcoma. It tends to be multiple or diffuse subcapsular lesions across the liver but has no characteristic clinical manifestations or imaging findings. On computed tomography and magnetic resonance imaging, these lesions usually have a hypodense appearance with heterogeneous enhancement and a "halo sign" or "lollipop sign" may be evident in some cases. HEHE is diagnosed mainly based on a pathological examination along with differential immunohistochemical markers such as CAMTA1, CD31, CD34, CD10, vimentin, and factor VIII antigen. Currently, there are no standardized treatment guidelines for HEHE, and surgery (curative resection and liver transplantation) remains the mainstay of treatment. Studies have indicated that extra-hepatic metastasis might not be a contraindication for resection or transplantation. Systemic chemotherapeutic agents including doxorubicin, vincristine, interferon-a, 5-fluorouracil, and thalidomide, as well as VEGF-related agents are being investigated, but no agents have been approved for the treatment of HEHE.

S1741 Gelatinous Ascites and a Double Duct Sign: A Case of Pancreatic Adenocarcinoma

Introduction: Pseudomyxoma peritonei (PMP) is a rare disorder characterized by the accumulation of gelatinous material within the abdomen and pelvis. While usually appendiceal in origin, it can be seen with mucinous tumors arising from the ovary, GI tract, urachus, and pancreas. We describe a case of pancreatic adenocarcinoma diagnosed due to the clinical syndrome precipitated by pseudomyxoma peritonei. Case Description/Methods: A 59-year-old Hispanic male presented to the hospital for evaluation due to a 2 month history of poor oral intake and worsening abdominal fullness, distension, discomfort, and intermittent pain. The patient reported one prior hospitalization for pancreatitis of unclear etiology, 3 years ago. A CT abdomen & pelvis was obtained; findings reported include multiple hepatic subcapsular cystic liver lesions, abdominal omental caking, ascites, and extrahepatic biliary and pancreatic ductal dilatation without definitive evidence of a mass. CEA and CA 19-9 were found to be elevated at 49.4 and 416 respectively. CT chest revealed a left-sided pleural effusion. Upper endoscopy and colonoscopy were negative. Paracentesis yielded gelatinous ascites. Clinical suspicion for appendiceal malignancy was raised which required surgical exploration and biopsy to confirm. An MRI of the abdomen was obtained to assess for pancreatic mass given presence of double duct sign. MRI revealed 2.2 x 2.7 x 5 cm lesion in the body of the pancreas, pseudomyxoma peritonei with scalloping of the liver and extension into the right posterior mediastinum via the esophageal hiatus, metastatic deposits in the porta hepatis and peritoneal carcinomatosis. No apparent abnormality in the appendix was observed. EUS FNA was performed; splenic vessel invasion by the mass was noted. Cytopathology supported a diagnosis of pancreatic adenocarcinoma. The patient was initiated on palliative chemotherapy with gemcitabine and nab-paclitaxel which led to a significant reduction in ascites and pleural effusion and improvement in symptoms. Discussion: This case highlights the potential of malignancies such as pancreatic adenocarcinoma to cause pseudomyxoma peritonei despite it more commonly being associated with appendiceal origin. Knowledge of this can help guide diagnostic and therapeutic plans.

Assessment of the relationship between hepatocellular carcinoma location and its response to transarterial chemoembolization

BackgroundTransarterial chemoembolization (TACE) is the recommended treatment in intermediate stage of hepatocellular carcinoma (HCC). Many indices are used to predict the outcome of the TACE. The location of the HCC has not been enough studied as a prognostic variable.ResultsWe evaluated 149 HCC nodules (111 patients) and analyzed the association between the response to TACE and the nodule location. There was a significant difference between the complete response (CR) and the non-CR group in the location of the HCC regarding its segment and the response to TACE with the anterior segment lesions achieving higher rates of complete response (CR) (P .03), and the distance between the tumor and the liver capsule with the subcapsular lesions showing higher rate of non-CR (P .02). However, there was no significant difference between the CR and the non-CR groups regarding the location between the right and the left lobes (P .48) and the central versus peripheral lesions (P .41).ConclusionsThe location of the HCC can improve the prediction of the tumor response to TACE. Anterior segment tumors showed a higher rate of complete response and subcapsular lesions showed a higher rate of recurrence after TACE.

No-Touch Radio Frequency Ablation for a Subcapsular Hepatocellular Carcinoma: A Case Report and Review of Literature

AbstractRadiofrequency Ablation of subcapsular lesions poses a challenge due to the risks of tumour seeding along the track, hemorrhage and lower efficacy. “No touch ablation” is a relatively novel technique used in the ablation of subcapsular HCC with good results. This technique avoids direct puncture of the tumour by inserting more than one electrodes adjacent to and outside the tumor and activating them sequentially to perform ablation. The risk of track site seeding and haemorrhage is significantly reduced. We describe a case of a subcapsular HCC in a 65-year-old female patient which was successfully treated with this novel technique.

Imaging findings of human hepatic fascioliasis: a case report and review of the literature

BackgroundFascioliasis is a food-borne hepatobiliary zoonosis caused by Fasciola hepatica and Fasciola gigantica. Human infestations are predominantly seen in developing countries where the disease is endemic, but, due to the increase in international travel rates, hepatic fascioliasis is also appearing in nonendemic areas including Europe and the USA. The clinical and laboratory findings are usually nonspecific. Cross-sectional imaging can be very helpful in the diagnosis of fascioliasis as well as to differentiate it from other liver diseases with a very similar clinical picture. The objectives of this case report are to discuss imaging findings of hepatic fascioliasis and to review the literature.Case presentationWe report the case of a 35-year-old Iranian patient who presented with right upper quadrant pain, low-grade fever, fatigue, and anorexia. The patient had a history of recent travel to the Gilan Province of Iran, almost a month before the onset of symptoms, which is an endemic area of fascioliasis in the country. Laboratory examinations revealed eosinophilia, elevated hepatic enzymes, and slightly raised C-reactive protein. Contrast-enhanced computed tomography of the patient shows clusters of focal ill-defined hypodense lesions with mild peripheral enhancement in the right liver lobe and subcapsular regions. Magnetic resonance imaging of the liver revealed multiple ill-defined lesions of low signal intensity on the T1-weighted image and high signal intensity on the T2-weighted image, extending from the liver capsule into deeper parenchyma toward periportal regions, which shows mild peripheral enhancement on post-contrast images. Imaging-based diagnosis of fascioliasis was made depending on the characteristic distribution of subcapsular tracts/lesions on the above-mentioned imaging, which was then confirmed by serologic tests using enzyme-linked immunosorbent assay. The patient was treated with triclabendazole, showing great clinical improvement, and was eventually discharged in good health condition.ConclusionThe imaging findings in this case report highlight the importance of cross-sectional imaging for further evaluation of suspected cases of fluke-induced liver disease. The hypothesis of hepatic fascioliasis should be always considered when consistent radiological findings are observed. Clusters of tortuous subcapsular lesions with peripheral contrast enhancement extending into deeper liver parenchyma are characteristic imaging findings that strongly suggest hepatic fascioliasis.

Intraoperative Use of Indocyanine Green Fluorescence in Hepatobiliary and Pancreatic Cancer Resections: Current State and Considerations

Introduction: Surgery for hepatobiliary and pancreatic malignancies often has unfavourable outcomes due to incomplete resection, with positive histopathological margins and locoregional metastases. Intraoperative use of indocyanine green fluorescence (ICG) with near-red infrared light can improve tumor detectability and achieve R0 status. Methods: Review of current literature. Results: ICG fluorescence and bile excretion allows for real-time visualisation of malignant tissues and assessment of resection margins. In liver surgery it can identify subcapsular lesions, a property especially useful in minimally invasive surgery where there is loss of tactile feedback and direct visual inspection. It can also delineate hepatic segmental anatomy for anatomical resections. Hepatocellular carcinomas tend to uniformly uptake ICG, whereas primary or metastatic adenocarcinomas like cholangiocarcinomas and colorectal liver metastases as well as poorly differentiated hepatocellular carcinomas show rim enhancement. In pancreatic cancer, fluorescence of the resection margin has been shown to correspond to presence of malignancy on histopathological assessement. ICG can also help to detect micrometastases and extrahepatic spread and distinguish between scar tissue and disease following neoadjuvant chemoradiotherapy. However the technique has limitations: wide variability of method and dose of administration, no visualisation of deep seated lesions, high background fluorescence, false positives up to 40% requiring additional verification by other modalities like intraoperative ultrasound or frozen section for newly detected lesions. Conclusion: ICG fluorescence can offer increased detectability of malignancy and improve post-operative outcomes in hepatobiliary and pancreatic resections. However there are limitations such as superficial depth of detection and low specificity which need improvement to achieve maximum benefit.

Radiofrequency ablation of subcapsular lesions with internally cooled perfusion electrode: ex vivo study

Purpose To compare the ex vivo efficiency of an internally cooled perfusion (ICP) electrode and an internally cooled (IC) electrode for radiofrequency ablation (RFA) of subscapular lesions. Material and methods Using 200 W generator and ICP electrode (group A, n = 10) or 15 gauge or 17 gauge IC electrode (group B, n = 10 and group C, n = 10), RFA was applied to the bovine liver for 12 min. Each electrode was inserted at a 3 cm depth into the liver block, and the proximal end of the active exposure portion of each electrode was located at a capsule of the liver block. During RFA, normal saline was pumped through the side hole of the ICP electrode into the tissue at an injection rate of 0.5 mL/min. Results The ICP electrode achieved larger capsular ablative area and ablative volume than the IC electrode: 7.29 ± 1.59 cm2 and 44.56 ± 10.08 cm3 in group A; 4.36 ± 1.29cm2 and 30.15 ± 5.97 cm3 in group B; and 3.57 ± 0.99cm2 and 24.52 ± 4.21 cm3 in group C (p < .05), respectively. Mean impedance of ICP RFA was lower than IC RFA: 41.5 ± 3.75Ω in group A; 52.4 ± 5.64Ω in group B; and 58.1 ± 10.98Ω in group C (p < .05). Conclusion RFA using the ICP electrode more efficiently created a larger capsular ablative area and ablative volume of ablation than IC RFA for subcapsular lesions. The results were obtained in an ex vivo liver model without tumor simulation inside.

Laparoscopic ablation therapies for hepatocellular carcinoma: could specific indications for the laparoscopic approach influence the effectiveness?

Percutaneous thermo-ablation (TA) may be unfeasible for the tumor location: laparoscopic ablation therapies (LATs) are an alternative option. The aim of this study is to assess the efficacy of LATs in the treatment of HCC not eligible for percutaneous TA or surgical resection. LAT was offered to 503 patients fulfilling at least one of the following criteria: (a) patients with a single nodule or up to three nodules smaller than 3cm not suitable for surgery; (b) patients not suitable for percutaneous TA; (c) short-term recurrence of HCC (< 3months). Technical success was achieved with one session in 467 patients (93%). One-month mortality and severe morbidity rates were 0.4% and 2.19%, respectively. During a median follow-up of 38.4months in the remaining 501 patients, 361 (67%) developed intrahepatic recurrence: it appeared as a local tumor progression (LTP) in 74 cases (15%). Subcapsular lesions showed lower LTP rates (p = 0.008), as well as HCC nodules contiguous to viscera (p = 0.012). In the treatment of HCC, LAT has proved to be a safe and effective technique that enables to treat lesions not eligible for percutaneous approach, with a low morbidity rate.

P1305 Rare complication of a frequent disease

Abstract Introduction Splenic abcess represents a rare complication of left-sided infective endocarditis. Unlike splenic infarction, which is a more benign condition, splenic abcess requires rapid diagnosis and treatment as its course can be fatal. We present the case of a 52- year old male, with diabetes and hypertension, admitted for shortness of breath and fever in the past two months. Clinical examination revealed respiratory distress, tachypnea, diastolic murmur on the left sternal border. Baseline laboratory investigations showed elevated inflammation markers, leukocytosis and thrombocytosis. Enterococcus faecalis was isolated from the hemocultures. Transthoracic echocardiography revealed a dilated left ventricle (LV), with preserved LV ejection fraction, with severe aortic regurgitation due to valve destruction. A large (11mm diameter) vegetation-like structure attached to the ventricular side of the right coronary cusp, protruding into the left ventricular outflow tract was identified. Further evaluation by transoesopahgeal echocardiography did not identify other lesions, except for secondary moderate mitral regurgitation, with intact mitral leaflets. Dual antibiotic therapy with Ampicilin and Gentamycin was initiated. Surgery was planned after infection control. The first three days were uneventful, with rapid resolution of fever and inflammatory markers, but on the fourth day, the patient developed severe abdominal pain, with its focal point in the left hypochondrium. Contrast abdominal CT was performed and large multiple subcapsular lesions were identified. These findings, correlated with the symptomatology, suggested embolic splenic abcess and infarction. The patient successfully underwent laparoscopic splenectomy, but soon after he developed sepsis with respiratory failure and neurological deterioration (with normal CT scan) and was admitted to the intensive care unit, where he was intubated and mechanically ventilated. Consensus after discussions between cardiology, cardiac surgery and neurology services was to immediately replace the aortic valve, given the inability to otherwise control the infection. Intraoperative images were consistent with perforation of the right coronary cusp. During hospitalization in the ICU following cardiac surgery, the patient was extubated and his neurological function markedly improved. Repeated TTE and TEE showed normal prosthetic valve function and resolution of mitral regurgitation. The patient continued to improve clinically until his discharge. Conclusions We presented a case of a rare pathogenic entity- splenic abscess and infarction- due to systemic embolization from infective aortic valve endocarditis. Multidisciplinary teamwork was required between cardiologist, intensive care specialist, neurologist, infectionist, general surgeon and cardiac surgeon. Splenectomy was performed before valve replacement, a treatment-course characteristic in the occurrence of these rare cases.

Diagnostic performance of gadoxetic acid\u2013enhanced liver MRI versus multidetector CT in the assessment of colorectal liver metastases compared to hepatic resection

BackgroundImaging is an essential tool in the management of patients with Colorectal cancer (CRC) by helping evaluate number and sites of metastases, determine resectability, assess response to treatment, detect drug toxicities and recurrences. Although multidetector computed tomography (MDCT) is the first tool used for staging and patient’s surveillance, magnetic resonance imaging (MRI) is the most reliable imaging modality that allows to assess liver metastases. Our purpose is to compare the diagnostic performance of gadoxetic acid-(Gd-EOB) enhanced liver MRI and contrast-enhanced MDCT in the detection of liver metastasis from colorectal cancer (mCRC).MethodsOne hundred and twenty-eight patients with pathologically proven mCRC (512 liver metastases) underwent Gd-EOB MRI and MDCT imaging. An additional 46 patients without mCRC were included as control subjects. Three radiologists independently graded the presence of liver nodules on a five-point confidence scale. Sensitivity and specificity for the detection of metastases were calculated. Weighted к values were used to evaluate inter-reader agreement of the confidence scale regarding the presence of the lesion.ResultsMRI detected 489 liver metastases and MDCT 384. In terms of per-lesion sensitivity in the detection of liver metastasis, all three readers had higher diagnostic sensitivity with Gd-EOB MRI than with MDCT (95.5% vs. 72% reader 1; 90% vs. 72% reader 2; 96% vs. 75% reader 3). Each reader showed a statistical significant difference (p < <.001 at Chi square test). MR imaging showed a higher performance than MDCT in per-patient detection sensitivity (100% vs. 74.2% [p < <.001] reader 1, 98% vs. 73% [p < <.001] reader 2, and 100% vs. 78% [p < <.001] reader 3). In the control group, MRI and MDCT showed similar per-patient specificity (100% vs. 98% [p = 0.31] reader 1, 100% vs. 100% [p = 0.92] reader 2, and 100% vs. 96% [p = 0.047] reader 3). Inter-reader agreement of lesion detection between the three radiologists was moderate to excellent (k range, 0.56–0.86) for Gd-EOB MRI and substantial to excellent for MDCT (k range, 0.75–0.8).ConclusionGadoxetic acid-enhanced MRI performs significantly better in the detection of mCRC, than MDCT, particularly in patients treated with chemotherapy, in subcapsular lesions, and in peribiliary metastases.

Role of Artificial Ascites Pre-Radiofrequency Ablation of Sub Capsular Liver Tumors

AbstractBackground: Radiofrequency ablation for liver tumours is a common practice because of its many advantages including feasibility, relatively low cost, being a day case procedure, and minimal invasiveness. Sub-capsular hepatomas manage-ment represents a challenge due to liability of thermal injury to major organs and occurrence of serious complications.Aim of Study: To assess the safety and technical efficacy of percutaneous radiofrequency ablation after artificial ascites in sub-capsular hepatoma.Methods: In our study, 18 patients had hydro dissection procedure done to facilitate ultrasound guided Radiofrequency Ablation (RFA) for sub-capsular hepatic lesions. Hydro dissection was performed with 5% dextrose in water to displace adjacent structures away from the liver capsule. RFA system with cluster or single internally cooled electrodes were used for treatment of hepatic malignancies. The feasibility, safety, and efficacy of this technique were assessed on follow-up.Results: Our patients' mean age was 59.6 years old. No major complications related to hydro dissection were recorded. One of our patients had a thermal injury (5.5%). No patients suffered from biliary injury, haemorrhage or tumour seeding. Mean hydro dissection displacement of nearby organs was 1.6cm.Conclusion: Hydro-dissection (artificial ascites) proved to improve technical efficacy and safety for ultrasound guided radiofrequency of sub-capsular hepatomas.

Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT.

The purpose of this study was to evaluate the imaging characteristics of liver metastases overlooked at contrast-enhanced CT. The records of 746 patients with a diagnosis of liver metastases from colorectal, breast, gastric, or lung cancer between November 2010 and September 2017 were reviewed. Images were reviewed when liver metastases were first diagnosed, and images from prior contrast-enhanced CT examinations were checked if available. These lesions were classified into two groups: missed lesions (those missed on the prior images) and detected lesions (those correctly identified and invisible on the prior images or there were no prior images). Tumor size, contrast-to-noise ratio, location, presence of coexisting liver cysts and hepatic steatosis, and indications for examination were compared between the groups. The t test and Fisher exact test were used to analyze the imaging characteristics of previously overlooked lesions. The final analysis included 137 lesions, of which 68 were classified as missed. In univariate analysis, contrast-to-noise ratio was significantly lower in missed lesions (95% CI, 2.65 ± 0.24 vs 3.90 ± 0.23; p < 0.001). The proportion of subcapsular lesions (odds ratio, 3.44; p < 0.001), hepatic steatosis (odds ratio, 6.35; p = 0.007), and examination indication other than survey of malignant tumors (odds ratio, 9.07; p = 0.02) were significantly higher for missed lesions. Liver metastases without sufficient contrast enhancement, those in patients with hepatic steatosis, those in subcapsular locations, and those found at examinations for indications other than to assess for tumors were significantly more likely to be overlooked.

Efficacy and Safety of Microwave Ablation (MWA) for Hepatocellular Carcinoma (HCC) in Difficult Anatomical Sites in Egyptian Patients with Liver Cirrhosis

Background and aim:Imaging guided microwave ablation (MWA) for hepatocellular carcinoma (HCC) has become a widely used method over recent years. Tumors close to the diaphragm, gastrointestinal tract, gallbladder, pancreas, hepatic hilum and major bile duct or vessels are generally considered relative contraindications for microwave ablation. This study was conducted to assess the effectiveness and safety of ultrasonography-guided MWA in treating patients with HCC in difficult anatomical sites in comparison to those in conventional sites.Patients and methods:Eighty-eight patients were included and divided into two groups: the study group of 44 with 46 lesions lying <5mm from the diaphragm, hepatic capsule, gall bladder (GB) or large vessel; and the control group of 44 patients with 50 lesions in non-risky sites. Each lesion was ablated using an ultrasound guided microwave probe using a detailed protocol.Results:Most of the patients were males, with a mean age of 57.8 years. In the study group, two patients had lesions adjacent to the GB, twelve were perivascular and 32 were subcapsular. The overall successful ablation rates were 84.8% and 92% in the study and control groups, respectively. Within the study group, ablation rates were 100%, 75% and 87.5% for lesions close to the GB, perivascular lesions and subcapsular lesions, respectively. One patient developed a subcutaneous abscess, with good outcome after proper treatment. Fever, pain and asymptomatic pleural effusion were reported after ablation without statistically significant difference between the groups or among subgroups.In conclusion:MWA for HCC in difficult anatomical sites is as effective and safe as for ordinary sites.

“Unusual” course of lymphadenopathy in patients with Kawasaki disease: clinical case and literature data

Kawasaki disease is an acute febrile illness of childhood, one of its characteristic features is lymphadenopathy. Most often it manifests unilateral painful more than 1.5 sm in diameter enlargement of single or several cervical lymph nodes. In some cases increase in size can be observed in other lymph nodes groups: axillary, inguinal, paratracheal, para-aortic, retroperitoneal, mesenteric. In that case the dimension is smaller than 1.5 sm in diameter. Usually it occurs at the same time as fever and fades away after inflammation is terminated. Most typical morphological features are non-purulent necrotic changes with subcapsular necrotic lesions and non-specific changes: presence of enlargement of paracortical zone and expansion of sinus. The article presents a clinical case of Kawasaki disease diagnosis accompanied by severe lymphadenopathy, persistence of fever and progression of lymphadenopathy, appearance of supraclavicular lymph node after the introduction of intravenous immunoglobulin. This reflects the non-smooth course of the disease and required differential diagnosis, primarily with lymphoproliferative disease. A review of “unusual” cases of lymphadenopathy in patients with Kawasaki disease described in the literature is presented. The importance of carrying out a histological examination of the lymph node in a nonsmooth course of the disease is underlined. Histological variants of lymph node involvement in patients with Kawasaki disease are described.

Diagnostic imaging of hepatic tuberculosis: case series.

Hepatic tuberculosis (TB) shows non-specific symptoms, and liver imaging may provide diagnostic clues. Here we describe a series of patients with hepatic TB showing characteristic radiological findings. Single-centre retrospective evaluation of patients with hepatic TB diagnosed over a period of 16 years who underwent ultrasound, computed tomography (CT) and/or magnetic resonance imaging (MRI). Hepatic lesions were classified as miliary, nodular, serohepatic or cholangitis. Of 14 patients with hepatic TB, five were co-infected with the human immunodeficiency virus. All patients had additional extrahepatic TB localisations. An interferon-gamma release assay was performed in 11/14 patients, ultrasound and CT were available for all patients and MRI for four. Observed patterns were miliary (n = 6) with multiple nodules < 2 cm; nodular (n = 5), characterised by a variable number of nodules (2-7 cm); and serohepatic (n = 3), with multiple nodular subcapsular lesions with a thin, smooth wall. Shared findings were hypoechoic lesions on ultrasound, hypodense lesions with ring enhancement on CT, while MRI lesions were hypointense on T1- and hyperintense on T2-weighted images. Ultrasound, CT and MRI can independently contribute to detection of hepatic TB. While a miliary pattern or calcifications are characteristic, no pattern is completely pathognomonic and the diagnosis depends on microbiological evidence. Particularly in risk groups, characteristic radiological findings may prompt targeted diagnostic work-up.

Bleeding Complications After Percutaneous Liver Biopsy: Do Subcapsular Lesions Pose a Higher Risk?

The purpose of this study is to determine the incidence of moderate and severe bleeding complications after subcapsular liver mass biopsy and compare it with the incidences of such complications after nonsubcapsular liver mass biopsy and after random biopsy. This retrospective review of ultrasound-guided liver biopsies was performed between January 2006 and February 2015. Biopsy type, needle size, the number of needle passes, and mass size and depth were recorded. A mass was categorized as subcapsular if it abutted the capsule and if the needle entered the mass directly without first traversing normal liver. Patients were observed postprocedurally, and the electronic medical record and findings from imaging performed within 1 month of the procedure were reviewed to assess for bleeding. Bleeding complications were categorized by size (with mild bleeding denoted by perihepatic blood ≤ 2 cm thick; moderate bleeding denoted by perihepatic blood > 2 cm thick, observation of blood elsewhere in the upper abdomen, or a combination of both findings; and severe bleeding denoted by blood extending into the lower abdomen, pelvis, or both). Bleeding rates were compared between groups using the Fisher exact test. Of a total of 1876 biopsies, 347 (18.5%) involved subcapsular masses, 760 (40.5%) involved nonsubcapsular masses, and 769 (41.0%) were random biopsies. There were no significant differences in biopsy type (p = 1.00), needle size (p = 0.12), or the number of needle passes (p = 0.10) when subcapsular and nonsubcapsular masses were compared. Thirteen moderate or severe bleeding complications (0.69%) occurred overall. The bleeding rate after subcapsular mass biopsy (3/347; 0.86%) was not statistically different from that noted after nonsubcapsular mass biopsy (5/760; 0.66%) (p = 0.71) or after random biopsy (5/769; 0.65%) (p = 0.71). Moderate and severe bleeding complications are rare after subcapsular liver mass biopsy, and their incidence is not significantly higher than that noted after nonsubcapsular mass biopsy or random biopsy. Biopsy of subcapsular lesions should no longer be considered contraindicated.