Triphasic Liver Research Articles

Portal Venous and Hepatic Arterial Coefficients Predict Post-Hepatectomy Overall and Recurrence-Free Survival in Patients with Hepatocellular Carcinoma: A Retrospective Study.

The dominant artery blood supply is a characteristic of hepatocellular carcinoma (HCC). However, it is not known whether the blood supply can predict the post-hepatectomy prognosis of patients with HCC. This retrospective study investigated the prognostic value of the portal venous and arterial blood supply estimated on triphasic liver CT (as a portal venous coefficient, PVC, and hepatic arterial coefficient, HAC, respectively) in patients with HCC following hepatectomy. HCC patients who were tested by triphasic liver CT 2 weeks before hepatectomy and received R0 hepatectomy at the Second Affiliated Hospital, Kunming Medical University between January 1, 2016 and December 31, 2020, were retrospectively screened. Their PVC and HAC, and other variables were analyzed for the prediction of overall survival (OS) and recurrence-free survival (RFS) using the least absolute shrinkage and selection operator and Cox proportional hazard regression models. Four hundred and nineteen patients (53.2 ± 10.6 years of age and 370 men) were evaluated. A shorter OS was independently associated with higher blood albumin and total bilirubin grade [hazard ratio (HR) 2.020, 95% confidence interval (CI) 1.534-2.660], higher Barcelona Clinic Liver Cancer (BCLC) stage (HR 1.514, 95% CI 1.290-1.777), PVC ≤ 0.386 (HR 1.628, 95% CI 1.149-2.305), and HAC > 0.029 (HR 1.969, 95% CI 1.380-2.809). A shorter RFS was independently associated with male (HR 1.652, 95% CI 1.005-2.716), higher serum α-fetoprotein ≥ 400 ng/mL (HR 1.672, 95% CI 1.236-2.263), higher BCLC stage (HR 1.516, 95% CI 1.300-1.768), tumor PVC ≤ 0.386 (HR 1.641, 95% CI 1.198-2.249), and tumor HAC > 0.029 (HR 1.455, 95% CI 1.060-1.997). Tumor PVC or HAC before hepatectomy is valuable for independently predicting postoperative survival of HCC patients.

Imaging Appearance of Enlarged Cisterna Chyli Mimicking Retroperitoneal Nodal Disease; A Rare Case Report

It is very common to see enlarged retroperitoneal lymph nodes. However there are circumstances where we report an enlarged retroperitoneal lymph node that is actually not pathological rather an enlarged cisterna chyli mimicking retroperitoneal nodal disease. A case report of a patient with known hepatocellular carcinoma, CT scan triphasic liver was performed and a finding was made with enlarged retroperitoneal lymph node involved by the disease process, however MRI and FNAC correlation was advised, which turned out to be an enlarged cisterna chyli rather than enlarged retroperitoneal node.

Establishing Protocol-based Dose Metrics for Common Abdomen and Pelvis Computed Tomography Protocols

The majority of the existing diagnostic reference levels (DRLs) that have been established for computed tomography (CT) are based on various anatomical locations, such as the head, chest, abdomen, etc. However, DRLs are initiated to improve radiation protection by conducting a comparison of similar examinations with similar objectives. The aim of this study was to explore the feasibility of establishing dose baselines based on common CT protocols for patients who underwent enhanced CT abdomen and pelvis exams. Dose length product total (tDLPs), volumetric CT dose index (CTDIvol), size-specific dose estimate (SSDE), effective dose (E), and scan acquisition parameters for a total of 216 adult patients, who underwent an enhanced CT abdomen and pelvis exams over a one-year period, were obtained and retrospectively analyzed. Spearman coefficient and one-way ANOVA tests were used to check significant differences between dose metrics and the different CT protocols. The data exhibited 9 different CT protocols to acquire an enhanced CT abdomen and pelvis exam at our institute. Out of these, 4 were found more common, i.e., CT protocols were acquired for a minimum of 10 cases. Triphasic liver demonstrated the highest mean and median tDLPs across all 4 CT protocols. Triphasic liver protocol registered the highest E followed by gastric sleeve protocol with a mean of 28.7 and 24.7 mSv, respectively. Significant differences (p < 0.0001) were found between the tDLPs of anatomical location and the CT protocol. Evidently, wide variability exists across CT dose indices and patient dose metrics relying on anatomical-based dose baseline, i.e., DRLs. Patient dose optimizations require establishing dose baselines based on CT protocols rather than the anatomical location.

Protocols-based notification versus diagnostic reference levels as an optimization tool in computed tomography

We compare a dose baseline optimization tool built around clinical protocols and notification of dose based on the diagnostic reference level (DRL). In regard to computed tomography (CT), retrospective analysis has been made of the volume CT dose-index (CTDIvol) and dose-length-product (DLP) for a total of 230 adult patients undergoing enhanced CT abdomen and pelvis examinations. From this, a dose baseline was established. The DRL based notification level (NL) was set at twice the Local DRL. The protocol baselines for dose were set at the median and 75th percentiles of dose spectrum. Spearman coefficient and one-way ANOVA tests were used for statistical correlation and differences between DLP and various CT protocols. Significant differences (p < 0.05) were found between DLPs for common CT protocols including routine Abd&Pelv + C, triphasic liver, gastric sleeve, pancreas phases, and tumour. The NL was set at 1194 mGy cm, while the median protocols dose baselines for routine Abd&Pelv + C, triphasic liver, gastric sleeve, pancreas phases, and tumor were 748, 1450, 1530, 1620, and 2040 mGy cm respectively. A significant reduction was observed in the number of dose notification counts when defining dose baselines at the 75th percentile for triphasic liver (26%), gastric sleeve (27%), pancreas phases (25%), and tumour (20%). The observed reductions associated with the established NLs based on CT clinical indications/protocols may limit the counts of notifications alerts and further allow an opportunity for CT protocol standardization and patient dose optimization.

Assessment of serum CXCL9 and pentraxin 3 as novel markers for hepatocellular carcinoma in cirrhotic hepatitis C patients.

Hepatocellular carcinoma (HCC) is the most frequent primary cancer of the liver. It is also one of the world's most common cancers and an important leading cause of cancer mortality in many parts of the world. As a result, it is essential to look for efficient markers for early and accurate HCC diagnosis. CXCL9 and pentraxin 3 are involved in the pathway of many cancers. The aim of the study was to assess the value of serum CXCL9 and pentraxin 3 as diagnostic markers of HCC among cirrhotic hepatitis C virus (HCV) patients. The current study was conducted on 90 candidates divided into 3 groups: group I - 30 patients with HCV induced liver cirrhosis without HCC; group II - 30 patients with HCV induced liver cirrhosis with HCC; group III - 30 healthy subjects (control group). All candidates were subjected to detailed history taking and thorough clinical examination, laboratory investigations, serum CXCL9, serum pentraxin 3, ultrasound abdomen and CT triphasic liver in group III. Serum CXCL9 and serum pentraxin 3 levels were significantly higher in group II than group I and significantly higher in group I than group III. Serum CXCL9 and serum pentraxin 3 could be utilized as diagnostic markers for HCC.

Assessment of Liver Diseases Using Triphasic Computed Tomography

The triphasic spiral liver computed tomography (CT) method is a standard way to find and describe a wide range of benign and cancerous liver lesions. This helps bring down the rates of death and illness among people with liver disease. Objective: To evaluate liver diseases in real time using Triphasic imaging procedure. Methods: A cross-sectional study was carried out at Al-Amin Diagnostic Center, Chattha Hospital, and Gondal Hospital. Before Triphasic CT Scan, each patient completed a form of written informed consent. A total of 65 people were examined. All diagnosed with various liver illnesses, as well as their findings were reviewed using Triphasic liver CT Scan. The typical patient was 53.5 years old. Patients' eligibility was determined using inclusion criteria. Results: The majority of data population was male 39 (60%) and female 26 (40%). The majority of the findings included Portal vein thrombosis 6 (9.2%) liver lesion 5 (7.7%), ascitis 3 (4.6%), cirrhosis of liver 6 (9.2% ), Hepatocellular carcinoma 12 (18.46% ), Dilated CBD 4 (6.2% ), cholilithiasis 8 (12.3%), portal hypertension 5 (7.7%), hepatic Mets 6 (9.2%), Hepatic contusion 6 (9.2%), Right lobe nodules 3 (4.6%), segment 8 tumor 1 (1.5%). Conclusions: Computer tomography is a useful modality for identifying liver pathology. sixty-five patients in this study were aged 30-84 years (60%) male and (40%) female and were found to have a greater incidence of hepatic cellular carcinoma in the liver (12) (18.46%) and it is more affected in males than females

S2186 A Case of Abdominal Cocooning From Appendiceal Carcinomatosis

Introduction: Abdominal cocooning is a rare radiologic finding where thickened peritoneal membrane surrounds the intestines causing bowel to become trapped and adhered to each other. This is usually a result of chronic inflammation and can be associated with infections like tuberculosis (TB) or chronic processes like sarcoidosis, peritoneal dialysis, VP shunts, or carcinomatosis. Patients typically present with intractable nausea, vomiting, abdominal pain and distension. Here, we present a case of abdominal cocooning with recurrent ascites secondary to appendiceal carcinomatosis. Case Description/Methods: 41-year-old male with history of remote polysubstance use (IV and alcohol) and incarceration who presented to the ED with progressively worsening abdominal distension and intractable nonbloody, nonbilious emesis. This patient had been hospitalized for a similar presentation weeks prior. At that time, he was found to have large volume ascites (SAAG 1.1, 774 nucleated cells, 3% segs) and was diagnosed with alcoholic cirrhosis though RUQ ultrasound with liver doppler and lab work were normal. CT abdomen and pelvis showed “peritoneal thickening concerning for peritonitis” (Figure) and the patient was treated for presumed spontaneous bacterial peritonitis. He presented to our facility weeks later with recurrent ascites (SAAG 1.2, 795 nucleated cells, 1% segs). Triphasic liver CT showed findings that were “highly suspicious for encapsulating peritoneal sclerosis/abdominal cocoon”. Ultimately, a peritoneal biopsy was performed given concerns for carcinomatosis vs. TB infection. Final pathology showed goblet cell adenocarcinoma with presumed appendiceal origin. Colonoscopy was unsuccessful due to cementing of the peritoneum. Patient was not a candidate for chemotherapy due to having severe malnutrition requiring the initiation of total parenteral nutrition. He was discharged with outpatient GI oncology follow up. Discussion: Although cirrhotic ascites is commonly diagnosed and treated by physicians, it is vital that clinicians are also aware of the diagnostic findings of noncirrhotic ascites. In this case, the degree of WBC count elevation with low segmented cells likely indicated TB or carcinomatosis at the initial presentation. Familiarity with imaging findings of abdominal cocooning may have also contributed to an expedited diagnosis. This case reiterates the importance of questioning and further exploring symptom etiologies when routine workup is not consistent with common causes of an everyday complaint.Figure 1.: Peritoneal thickening consistent with abdominal cocooning with large-volume ascites.

Simultaneous IVC/SVC Endovascular Sharp Recanalization in A Patient with Budd-Chiari Syndrome, Systemic Lupus Erythematosus and Antiphospholipid Syndrome, A Case Report

Abstract:&#x0D; Background: Budd‐Chiari syndrome (BCS) is a rare life-threatening condition and is caused by an obstruction to the hepatic venous outflow. We herein report a case of BCS complicated with inferior vena cava (IVC) and superior vena cava (SVC) stenosis that was managed by a simultaneous IVC/SVC sharp recanalization.&#x0D; Case presentation: A forty-year-old lady came to the clinic complaining of distended abdomen. She is a known case of antiphospholipid syndrome and systemic lupus erythematosus. Triphasic liver computed tomography showed a heterogeneous liver with nutmeg appearance and attenuation of hepatic veins with caudate hypertrophy. There was a severe dilatation of the azygos and hemiazygos veins with multiple posterior mediastinal and retrocrural tortuous collaterals recanalizing the IVC distally. Contrast enhanced CT of the chest showed a chronic complete occlusion of the left brachiocephalic vein with enlargement of the left superior intercostal vein, hemiazygos, and azygos veins. SVC was patent with multiple calcific foci of the wall likely related to chronic thrombosis. Through the right femoral access, inferior venacavogram was obtained, which showed suprahepatic IVC complete occlusion. Then, an upper venous access was obtained through the right internal jugular vein. Followed by a venogram which showed a complete occlusion at the right brachiocephalic vein with extensive collaterals were noted. Sharp recanalization from the jugular access of the brachiocephalic vein/SVC was performed targeting the balloon within the SVC that was advanced from the azygos vein, which followed by placing a covered stent graft. Then Multiple balloon angioplasties were made at the level of suprahepatic IVC followed by placing a non-covered stent.&#x0D; Conclusion: It was a Successful recanalization for the completely occluded suprahepatic IVC and placement of IVC stent, and a Successful recanalization for the completely occluded right brachiocephalic vein and placement of a stent.

Arterial enhancement fraction in evaluating the therapeutic effect and survival for hepatocellular carcinoma patients treated with DEB-TACE

BackgroundArterial enhancement fraction (AEF), derived from triphasic CT scans, is considered to indirectly reflect the ratio of hepatic arterial perfusion to total perfusion. The purpose of this study was to retrospectively investigate the relationship between AEF and treatment response and survival in hepatocellular carcinoma (HCC) patients treated with drug-eluting bead (DEB) TACE.MethodsAEF of primary lesion (AEFpre) and residual tumor (AEFpost) in 158 HCC patients were obtained from triphasic liver CT examinations pre- and post-treatment. Wilcoxon-signed rank test was used to compare the AEFpre and AEFpost for different response groups. Survival curves for overall survival (OS) in patients with different AEF were created by using Kaplan-Meier method. Cox regression analyses were used to determine the association between AEF and OS.ResultsThere was no correlation between AEFpre and treatment response. After DEB-TACE, AEFpost was significantly lower than AEFpre either in the partial response group (38.9% vs. 52.7%, p < 0.001) or in the stable disease group (49.3% vs. 52.1%, p = 0.029). In the progression disease group, AEFpost was numerically higher than AEFpre (55.5% vs. 53.0%, p = 0.604). Cox regression analyses showed that risk of death increased in patients with AEFpre > 57.95% (HR = 1.66, p = 0.019) or AEFpost > 54.85% (HR = 2.47, p < 0.001), and the risk reduced in patients with any reduction in tumor AEF (decrease ratio ≥ 0) and with increased AEF but not exceeding the ratio of 0.102 (increase ratio < 0.102) (HR = 0.32, p < 0.001).ConclusionsThe change in AEF of viable tumor is correlated with response of HCC to DEB-TACE. In addition, the AEF could be a helpful predictor in future studies on the embolization treatment for HCC.

P1705ARE DIRECT-ACTING ANTI-VIRAL DRUGS ACCUSED OF INCREASED INCIDENCE OF HEPATOCELLULAR CARCINOMA IN ENDEMIC AREA: A PILOT STUDY

Abstract Background and Aims Great progression in treating hepatitis C infection has been made with the new Interferon-free regimens. Reports about developing hepatocellular carcinoma after DAAs have been spotlighted. Kidney transplantation and hemodialysis are considered risk factors for developing malignancies. Here we are evaluating the prevalence of HCC after DAAs treatment in high risk population. Method This cross-sectional study was held in Urology and Nephrology Center, Mansoura University, Egypt including. Total number of 165 patients received DAAs included in this study in 2 phases. The first phase included 50 patients (12 hemodialysis and 38 kidney transplant recipients). All patients completed DAAs course as treatment for hepatitis C infection (HCV) 24 months ago. Alfa feto protein and liver ultrasound (Use of both modalities combined yielded sensitivity (99.2%) and specificity (68.3%)) was used to screening of HCC for all patients. Triphasic CT liver with 86% to 94% sensitivity was done for all hemodialysis patients and KTRs with suspicious lesions or high alfa-feto protein. Results Our patients mean age was 52.32±3.2 years with male predominance. Mean Hemodialysis duration was 48.21±12.3 months and mean kidney transplantation duration was 36.21±6.7 months. Baseline laboratory investigations: ALT: 39.17±16.3 iu/l, Albumin: 3.6±1.32 g/dl, Bilirubin: 0.54±0.21, Hemoglobin: 10.57±1.9 g/dl, AFP: 5.3±2.4 ng/ml. Baseline liver US: normal (49%), enlarged (42%) and cirrhotic (9%) (No focal lesions). Fibro scan: F0 (26%), F1 (31%), F2 (32%) and F3 (11%). None of them experienced hepatic encephalopathy attacks or bleeding varices. All hemodialysis patients received Ombitasvir/Paritaprevir/Ritonavir (OMV/PTV/RTV) regimen (3 months). Only 2 KTRs received OMV/PTV/RTV regimen (3 months), the remaining 36 KTRs received Sofosbuvir/Daclatasvir regimen (6 months). Only 1 case reported relapse within 3 month after completing treatment. The rest achieved 12-week and 24-week SVR successfully. After 2 years from completing treatment, there was significant improvement in ALT levels. Four KTRs passed to graft failure due to accelerated immunologic response (rejection episodes) and 7 KTRs showed rise of serum creatinine (biopsy-proven rejection). Mean AFP rose up to 7.6±2.4 ng/ml with no statistical difference. Three hemodialysis patients and 4 KTRs showed rise in alfa-feto protein above normal values (10ng/dl). Four out of them exceeded 500ng/ml (1 HD and 3 KTRs). Abdominal US revealed: no change (39 patients), enlargement (6 patients) and cirrhosis (5 patients). Suspicious mass was found in 11 patients. Triphasic CT then was done for all hemodialysis patients and 9 KTRs. Regarding hemodialysis, 1 patient was diagnosed as HCC based on increased enhancement by Triphasic CT and alfa-fetoprotein was &amp;gt;500 ng/ml. Regarding KTRs, HCC was diagnosed in 2 patients and liver metastasis secondary to lymphoma was diagnosed in 1 case. The other patients with suspicious lesions (5 patients) showed uniform enhancement by Triphasic CT suggesting benign lesions. So, we have 3 (6%) out of 50 patients has been diagnosed as HCC after DAAs. By retrieval of their data, HCV duration was over 10 years and the liver was cirrhotic or enlarged with cirrhotic changes by ultrasound. Baseline ALT was slightly high without significant improvement after treatment. Also, baseline alfa-feto protein was high. The 3 patients were F2 or F3. Conclusion Hepatocellular carcinoma incidence after Direct-acting anti-virals is related mostly to the poor condition of the patients at baseline not to the drug itself and HCC in such cases could be considered as a part of disease progression not a drug complication.

COMPARISON OF IMAGE FINDINGS WITH HISTOPATHOLOGICAL DIAGNOSIS ON ULTRASOUND GUIDED PERCUTANEOUS LIVER BIOPSY IN RELATION TO HEPATOCELLULAR CARCINOMA

ABSTRACTOBJECTIVES: To compare the image findings with histopathological diagnosis on ultrasound guided (USG) percutaneous biopsies of liver lesions in relation to hepatocellular carcinoma (HCC) and to assess the role of hepatitis B virus (HBV) and hepatitis C virus (HCV) in evolution of HCC.METHODS: This descriptive cross-sectional study included biopsies performed on patients reporting to Kuwait Teaching Hospital, Peshawar, Pakistan from 01-07-2017 to 30-09-2017. The patient selection was based on findings on various image modalities like triphasic liver computed tomography (CT) or dynamic magnetic resonance imaging (MRI), in which percutaneous liver biopsy was indicated. The biopsies were routinely processed for histological examination on hematoxyllin and eosin stain and application of immunohistochemical stains for detecting HCC.RESULTS: A total number of 82 USG percutaneous biopsies were performed on various sites out of which 41 (50%) were performed on liver lesions. On imaging 12 (30%) were diagnosed as hepatocellular carcinoma whereas 16 (39%) cases were confirmed on histopathology, which either showed Hep-Par-1 or arginase positivity. On imaging 11/16 (68.75%) were either diagnosed as HCC or were suspicious of it. A sensitivity of 75% and specificity of 95% was calculated for diagnosis of HCC on imaging. The correlation between image and biopsy diagnosis of HCC was statistically significant (p value 0.05).CONCLUSION: The present study concludes that Image findings are helpful in the initial diagnosis of HCC which shows an increasing trend to be associated HCV as compared to HBV with a remarkably declining trend.KEY WORDS: Image-Guided Biopsy (MeSH); Ultrasonography (MeSH); Liver (MeSH); Carcinoma, Hepatocellular (MeSH); Hepacivirus (MeSH); Hepatitis B virus (MeSH); Immunohistochemistry (MeSH); Histology (MeSH).

Liver lesions detected in a hepatitis B core total antibody-positive patient masquerading as hepatocellular carcinoma: a rare case of peliosis hepatis and a review of the literature

Peliosis Hepatis (PH) is a rare vascular disorder of the liver, characterized by the presence of cystic blood-filled cavities distributed throughout the hepatic parenchyma. The pathogenesis of PH remains controversial. The preoperative diagnosis of PH is difficult, due to the non-specific imaging characteristics of PH and almost all cases are diagnosed on histology post resection. This study presents a case of PH masquerading as hepatocellular carcinoma (HCC). The patient is a 45-year old Chinese lady, who presented with transaminitis. She was found to be hepatitis B virus core total antibody-positive with an alpha-fetoprotein (AFP) of 29.4 ng/ml. Triphasic liver computed tomography showed several arterial hypervascular lesions and hypoenhancing lesions on the venous phase, particularly in the segments 6/7. Subsequently, a magnetic resonance imaging scan showed multiple lesions in the right hemiliver with an indeterminate enhancement patterns. Subsequently, she decided to undergo a resection procedure. Histopathology revealed findings consistent with PH with some unusual features. This case demonstrates a clinical conundrum, in which PH presented with a raised AFP, in a patient with risk factors for the development of HCC. The clinical suspicion of PH should be high in patients, who present with multiple hepatic lesions with variable enhancement patterns.

Role of yttrium-90 in the management of unresectable hepatocellular carcinoma and hepatic metastases.

Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death in the world. The management of unresectable HCC and hepatic metastases from various solid tumors is a clinical dilemma. There is paucity of data on the treatment of unresectable HCC and hepatic metastases with yttrium-90 (90Y) radioembolization. Thirty patients (mean age; 55.2years; range 43-82years) comprising 21 patients with HCC (12 patients have cirrhosis of which 3 patients belong to Child-Pugh class A and 9 patients belong to Child-Pugh class B), 7 patients with metastasis from colorectal cancer, 1 patient with metastasis from melanoma, and 1 patient with metastasis from ovarian carcinoma underwent resin-based 90Y radioembolization between 2013 and 2015 in our study. In all the patients, after embolization of non-target vasculature, SPECT and planar scintigraphy were done with the injection of 5-6mCi (185-222MBq) of 99mTc-labeled macroaggregated albumin (MAA) into the hepatic artery. Then, lung shunt fraction was assessed and dose was calculated based on body surface area (BSA) method for SIR-Spheres. Post therapeutic 90Y bremsstrahlung SPECT and 90Y PET was performed within 30 hours following therapy to see the hepatic and extrahepatic distribution of spheres. Side effects following therapy were noted in all the patients. All patients were followed up with triphasic CT liver 3months following therapy. Therapeutic response was evaluated with necrosis criteria used for therapy response assessment in solid tumors. On follow up, 14 patients (46%) developed minor side effects following treatment and resolved without active intervention. The most common side effects include mild abdominal pain in 11 patients (36%), nausea in 8 patients (26%), and fatigue in 6 patients (20%). On follow up imaging at 3months following treatment, a complete response was observed in two patients (7%), partial response in seven patients (23%), stable disease in 15 patients (50%), and progressive disease in six patients (20%). This study provides supportive evidence of the safety and efficacy on 90Y radioembolization for the treatment of unresectable HCC and hepatic metastases from various solid tumors. 90Y PET is a better radionuclide technique for assessing the hepatic and extrahepatic distribution of spheres following therapy compared to 90Y Bremsstrahlung SPECT. Thus, 90Y radioembolization is proving to be promising treatment with average disease control rates around 80% and should be widely utilized.

Comparison of organ-specific-radiation dose levels between 70 kVp perfusion CT and standard tri-phasic liver CT in patients with hepatocellular carcinoma using a Monte-Carlo-Simulation-based analysis platform

PurposeThe aim of this study was to systematically compare organ-specific-radiation dose levels between a radiation dose optimized perfusion CT (dVPCT) protocol of the liver and a tri-phasic standard CT protocol of the liver using a Monte-Carlo-Simulation-based analysis platform. Methods and materialsThe complete CT data of 52 patients (41 males; mean age 65±12) with suspected HCC that underwent dVPCT examinations on a 3rd generation dual-source CT (Somatom Force, Siemens) with a dose optimized tube voltage of 70kVp or 80kVp were exported to an analysis platform (Radimetrics, Bayer). The dVPCT studies were matched with a reference group of 50 patients (35 males; mean age 65±14) that underwent standard tri-phasic CT (sCT) examinations of the liver with 130kVp using the calculated water-equivalent-diameter of the patients. The analysis platform was used for the calculation of the organ-specific effective dose (ED) as well as global radiation-dose parameters (ICRP103). ResultsThe organ-specific ED of the dVPCT protocol was statistically significantly lower when compared to the sCT in 14 of 21, and noninferior in a total of 18 of 21 examined items (all p<0.05). The EDs of the dVPCT examinations were especially in the dose sensitive organs such as the red marrow (17.3mSv vs 24.6mSv, p=<0.0001) and the liver (33.3mSv vs 46.9mSv, p=0.0003) lower when compared to the sCT. ConclusionOur results suggest that dVPCT performed at 70 or 80kVp compares favorably to sCT performed with 130kVp with regard to effective organ dose levels, especially in dose sensitive organs, while providing additional functional information which is of paramount importance in patients undergoing novel targeted therapies.

4-D Predicted Accumulated Dose Versus Time Weighted Average 4D-CBCT Recalculated Dose Variations in Liver SABR

Quantify the variations to tumor and normal tissues between 4D predicted accumulated dose and doses recalculated on time weighted average 4D CBCT static derived series in liver SABR 25 pts with 38 liver metastatic lesions underwent gold seed fiducial placement, triphasic liver scan, respiratory correlated 4D CT. Lesions were localized on the static Hepatic arterial/portal venous phase CT (as they were well visualized) and fused to corresponding 4D-dataset and ITV thus defined. A dose of 39gy in 6 fractions was planned using step using step and shoot IMRT. The finalized plan Structure were deform registered and dose warped across all the 4D datasets by intensity-based-free-form deformable registration and final 4D predicted accumulated dose thus calculated. Treatment was executed using 4D-CBCT image guidance on a 6 DOF couch. The final planned CT dataset is further dose deformed on to first set-up corrected time weighted Avg. derived static series from 4D-CBCT dataset. Using deformable image registration, subsequent fraction doses on reference geometry (first time weighted average series) were added up to get final delivered doses. The contribution of different geometric errors to changes between the accumulated and delivered dose were quantified and changes greater than 1 gray, reported as percent change (normalized to prescription dose) were considered significant All patients had accumulated dose deviations relative to the planned static prescription dose >5%, ranging 3-18% in tumors and 5-25% in normal tissues. Residual setup errors were most often the largest cause of the deviations, followed by deformations and breathing variations. Gold seed markers, while producing delineation artifacts and deformation errors, were good surrogate for treatment verification when 4D CBCT was used (with acquisition time of 3mts). These deformation errors were minimized with proper deformation QA using registration refining tools and alignment locks Accumulated dose deviations ranging from 5-20% relative to the static plan are observed in all pts undergoing liver SABR. Modalities which impede breathing motion like diaphragmatic compression will produce more deformation errors leading to erroneous prediction of 4D dose and accumulated dose.

Impaired visibility of the hepatic veins on the multi-detector computed tomography in patients with cirrhosis.

To determine the prevalence and associations of the impaired visibility of the hepatic veins (HV) on the multi-detector row computed tomography (MDCT) in cirrhotic patients. Eighty-seven consecutive cirrhotic patients undergoing triphasic liver MDCT were enrolled. The patency of the HV and the direction of the blood flow in the main portal vein, inhomogeneity of the liver, portal vein thrombosis (PVT), a spontaneous splenorenal shunt, splenic indexes (cm(3)), contour abnormalities, and enlargement of the fissure were evaluated. The prevalence of the impaired visibility of the HV was 38% in the patients with cirrhosis. No significant associations exist between the impaired visibility of the HV and age (p=0.96), sex (p=0.14), portal vein thrombosis (p=0.29), or splenic indexes (p=0.32). Inhomogeneity of the liver (p=0.0001), marked contour abnormalities, (p=0.0001), splenorenal shunt (p=0.02), enlargement of fissure (p=0.0001), and hepatofugal flow (p=0.01) were significantly associated with the impaired visibility of the HV. Inhomogeneity of the liver, marked contour abnormalities, and hepatofugal flow are independently associated with the impaired visibility of the HV in cirrhotic patients on hepatic venous phase CT.

Determination of Radiation Absorbed Dose to Primary Liver Tumors and Normal Liver Tissue Using Post-Radioembolization (90)Y PET.

Background: Radioembolization with Yttrium-90 (90 Y) microspheres is becoming a more widely used transcatheter treatment for unresectable hepatocellular carcinoma (HCC). Using post-treatment 90 Y positron emission tomography/computerized tomography (PET/CT) scans, the distribution of microspheres within the liver can be determined and quantitatively assessed. We studied the radiation dose of 90 Y delivered to liver and treated tumors.Methods: This retrospective study of 56 patients with HCC, including analysis of 98 liver tumors, measured and correlated the dose of radiation delivered to liver tumors and normal liver tissue using glass microspheres (TheraSpheres®) to the frequency of complications with modified response evaluation criteria in solid tumors (mRECIST). 90 Y PET/CT and triphasic liver CT scans were used to contour treated tumor and normal liver regions and determine their respective activity concentrations. An absorbed dose factor was used to convert the measured activity concentration (Bq/mL) to an absorbed dose (Gy).Results: The 98 studied tumors received a mean dose of 169 Gy (mode 90–120 Gy; range 0–570 Gy). Tumor response by mRECIST criteria was performed for 48 tumors that had follow-up scans. There were 21 responders (mean dose 215 Gy) and 27 non-responders (mean dose 167 Gy). The association between mean tumor absorbed dose and response suggests a trend but did not reach statistical significance (p = 0.099). Normal liver tissue received a mean dose of 67 Gy (mode 60–70 Gy; range 10–120 Gy). There was a statistically significant association between absorbed dose to normal liver and the presence of two or more severe complications (p = 0.036).Conclusion: Our cohort of patients showed a possible dose–response trend for the tumors. Collateral dose to normal liver is non-trivial and can have clinical implications. These methods help us understand whether patient adverse events, treatment success, or treatment failure can be attributed to the dose that the tumor or normal liver received.

Identifying Aberrant Hepatic Arteries Prior to Intra-arterial Radioembolization

Failing to identify aberrant hepatic arteries before radioembolization (RE) may compromise its treatment efficacy due to inadequate biodistribution of radioactive microspheres. The purpose of this study was to evaluate how often aberrant hepatic arteries were identified correctly in clinical practice, with computed tomography (CT), and during angiography in patients with liver tumors who received a workup for RE. The presence and vascularization pattern of aberrant (i.e., accessory and replaced) hepatic arteries was assessed on triphasic liver CT in 110 patients. Subsequently, radiological reports on CT and angiographic procedures were reviewed to determine whether aberrant hepatic arteries were identified correctly in clinical practice. The intrahepatic biodistribution of (99m)Tc-MAA and radioactive microspheres was assessed on SPECT/CT and PET/CT in all patients with unidentified aberrant hepatic arteries. Thirty-seven of 110 patients (34%) had aberrant hepatic arteries. In 18 of 37 (49%) patients, the aberrant hepatic arteries were correctly identified on CT and in 32 of 37 (86%) during angiography. Aberrant right hepatic arteries were identified more frequently than aberrant left hepatic arteries on CT (54 vs. 44%) and during angiography (100 vs. 69%, p = 0.007). In five patients (14%), an aberrant left hepatic artery remained unidentified, resulting in a lack of (99m)Tc-MAA and (90)Y activity in the segmental territory of the unidentified aberrant hepatic arteries. Aberrant left hepatic arteries were the most common unidentified aberrant hepatic arteries, resulting in incomplete radiation coverage. We formulated a practical approach to identify aberrant hepatic arteries correctly before RE.

Peritoneal carcinomatosis secondary to spread of hepatocellular carcinoma originated upon a healthy liver

This is a female, 34 years, who presented with pain at the right iliac fosse and pre-syncopal symptoms. As background, she has undergone a right ovarian cystectomy due to a serous cystadenoma several years ago and appendectomy. At physical examination she had signs of peritoneal irritation and heterogeneous free fl uid was detected on ultrasound, suggesting hemoperitoneum, so urgent laparotomy was decided. A peripheral liver tumor was seen in segment VII, it was partially removed and pathological diagnosis was hepatocellular carcinoma (HCC). At that time, liver function tests and alpha-fetoprotein were within normal limits and hepatitis B and C virus serology were negative. The patient was moved to a referral centre, where a triphasic liver CT and MR-angiography (Fig. 1) were performed. small remaining tumor was observed within segment VII of the liver, without distance disease, so a formal resection of segment VII was made. The specimen showed a grade II HCC, 20 mm of diameter, with a satellite 1 mm away, without vascular invasion (Fig. 3A). No systemic or local therapy as secondary prophylaxis was administered. The fourth-month follow-up control showed multiple peritoneal implants

MRI Arterial Enhancement Fraction in Hepatic Fibrosis and Cirrhosis

Fibrosis leads to altered liver hemodynamics. The arterial enhancement fraction, which is defined as the ratio of hepatic arterial perfusion to the total hepatic perfusion, can provide noninvasive assessment of hepatic perfusion. The aim of this study was to show that the arterial enhancement fraction values correlate with histopathologic stage of liver fibrosis, thus providing a reliable noninvasive radiologic alternative to liver biopsy for the detection and staging of hepatic fibrosis. We evaluated hepatic fibrosis stage (denoted by Metavir score [F]) and arterial enhancement fraction of patients who underwent standard triphasic liver MRI and liver biopsy within 1 year from January 2005 to December 2010. Prototype software was used to calculate the arterial enhancement fraction. Statistical analysis included nonparametric tests and area under the receiver operating characteristic curve (AUC). One hundred fourteen patients (69 men and 45 women; median age, 52.5 years) were divided into groups according to the Metavir score. The mean arterial enhancement fraction was 24.2% ± 11.6% for F0, 35.2% ± 18.7% for F1, 30.2% ± 12.5% for F2, 37.5% ± 16.4% for F3, and 59.8% ± 16.6% for F4. The mean arterial enhancement fraction values differed significantly between Metavir scores (p < 0.001) and showed a positive correlation with Metavir score (r = 0.693; p < 0.001). The optimal mean arterial enhancement fraction cutoffs were 32.96% or more (AUC = 0.8343) for detection of mild fibrosis, 33.33% or more (AUC = 0.8524) for detection of moderate fibrosis, 38.43% or more (AUC = 0.8819) for detection of severe fibrosis, and 45.76% or more (AUC = 0.9161) for detection of cirrhosis. Arterial enhancement fraction using triple-phase MRI can provide a reliable noninvasive method to assess hepatic fibrosis.