Small nodular hepatocellular carcinoma treated by laser thermal ablation in high risk locations: preliminary results

Objectives

To demonstrate the effectiveness and the safety of laser thermal ablation (LTA) in patients with unresectable hepatocellular carcinoma (HCC) deemed not accessible for other percutaneous procedures (radiofrequency ablation, sclerotherapy).

Methods

From September 2003 to August 2008, 140 patients with HCC nodules were treated. In 49 patients, the lesions were localized in “critical sites”. A total of 29 men and 20 women (age range 51–79 years; Child–Pugh score A = 75.51%, B = 24.49%) with 52 nodules (mean diameter 2.0?±?1.2 cm) were treated in 95 percutaneous LTA sessions. We compared major and minor complications observed in the two groups of patients. Effectiveness was defined as the percentage of HCCs completely ablated after percutaneous LTA. Follow-up was carried out with computed tomography (CT) at 1, 3, 6, 9, and 12 months.

Results

No major complications or deaths were registered. In a few patients (8.16%), minor complications were observed. No substantial differences were observed on comparing the percentage of minor and major complications in these patients with the remaining patients. A difference in terms of effectiveness was found.

Conclusion

LTA can be considered a safe treatment in “critical nodules”.     

肝癌合并肝动脉-肝门静脉瘘介入治疗方式的探讨

目的 探讨改进介入方式的化疗栓塞术(TACE)治疗肝癌合并肝动脉.门静脉瘘(HAPF)的应用价值.方法 对38例不同类型的肝癌合并HAPF患者(A组)在瘘El处用明胶海绵或(和)无水乙醇封堵瘘口,再行TACE;对43例不同类型肝癌合并HAPF(B组)利用改进的介入方法治疗,即越过瘘口后对肝段或肝亚段动脉行碘油化疗乳剂栓寒,再行与A组相同治疗.术后1～3个月内复查CT评价碘油沉积情况.结果 A组中央型HAPF(11例)碘油沉积良好5例(45.5%),周围型(27例)沉积良好19例(70.4%);B组中央型(14例)沉积良好10例(71.4%),周围型(29例)沉积良好21例(72.4%).B组中央型HAPF较A组碘油沉积率明显提高(P=0.041,P<0.05);B组周围型与A组碘油沉积率相比无统计学意义(P=0.642,P>0.05).结论 采用改进法介入方式治疗中央型HAPF可有效增加碘油沉积率,对于周围型在增加碘油沉积率方面效果不明显,且越过瘘口的操作有一定的困难.     

Contrast-enhanced US of hepatocellular carcinoma

PURPOSE: To evaluate the capabilities of contrast-enhanced ultrasound (CEUS) in the characterization of hepatocarcinoma (HCC) in terms of accuracy as compared to spiral CT and diagnostic gain as compared to conventional and Doppler US. MATERIALS AND METHODS: Forty-three patients with viral hepatopathy or cirrhosis diagnosed with HCC (6 histologically and 37 cytologically proven) were retrospectively studied. Between January 2002 and May 2003, all patients were evaluated with CEUS after detection of at least one suspicious nodule on US. CEUS features of HCCs were retrospectively compared with those on conventional and Doppler US, and spiral CT. RESULTS: HCCs varied between 1.2 cm and 18 cm in diameter; 14/43 were small' (< or = 2 cm). In 18/43 patients, HCC was multifocal. Doppler US revealed 24/43 hypervascular nodules. On CEUS, 37/43 (86%) showed contrast enhancement in the arterial phase, 13/37 (35%) with negative colour and power Doppler US examination; in 6/37 (16%) contrast enhancement in the arterial phase was not visible on spiral CT. On CEUS, 6/43 hypovascular HCCs were characterized as malignant in the sinusoidal phase. On CEUS, the sinusoidal phase revealed additional nodules not visible on baseline US in 3/18 multifocal HCCs. CONCLUSIONS: CEUS diagnosis of HCC in cirrhotic liver is possible with a combination of the arterial phase, which shows tumoral hypervascularity in the microcirculation, and the sinusoidal phase, which allows to confirm the malignancy of the nodule.     

How to detect hepatocellular carcinoma in cirrhosis

Cirrhosis predisposes to hepatocellular carcinoma (HCC) which develops by sequential steps of de-differentiation of hepatocytes from regenerative nodules via borderline (dysplastic) nodules to frankly malignant HCC. Effective treatment depends on early recognition of HCC, so the key tasks for imaging are firstly recognising the presence of a suspicious lesion, and secondly differentiating between benign, borderline and malignant nodules. Screening of high-risk cirrhotic patients with sonography and measurement of alpha fetoprotein (AFP) is helpful but will not reliably differentiate small HCC from benign or dysplastic nodules. Large HCCs can usually be recognised by their characteristic morphology on imaging, but the appearances of smaller benign and malignant nodules show considerable overlap on unenhanced sonography, CT and MRI. Increasing degrees of histological malignancy are associated with increasing arterialisation and loss of portal blood supply, so the recognition of HCC requires the use of dynamic imaging with contrast-enhanced CT or T1-weighted MRI with gadolinium enhancement. Sonography with microbubble contrast media now offers another method for detecting arterialised nodules; however, some non-malignant nodules show arterial hypervascularity and a minority of HCCs are hypovascular, so the assessment of perfusion does not conclusively distinguish benign from malignant lesions. Kupffer cell function is another attribute of liver tissue which can be explored using MRI with superparamagnetic iron oxide particles (SPIO). Experience thus far suggests that uptake of SPIO is an effective discriminator between benign and malignant nodules. The combination of SPIO with gadolinium-enhanced MRI offers the opportunity for imaging characterisation of cirrhotic nodules by cellular function as well as by blood supply, and this approach is now proposed as the examination of choice for detecting HCC in cirrhosis.     

Hepatocellular carcinoma in association with hepatic focal nodular hyperplasia

Purpose: To report the association between hepatocellular carcinoma (HCC) and hepatic focal nodular hyperplasia (FNH) and the possible impact on clinical decision-making with regard to resective approaches in patients with FNH.

Material and Methods: We retrospectively analyzed the findings in 77 adult patients who underwent liver resections for FNH between October 1989 and September 2001 at our center. HCC within the confines of FNH was found in two patients. We demonstrate the magnetic resonance imaging (MRI) and macroscopic and microscopic findings.

Results: Presurgical MRI demonstrated heterogeneous signal characteristics of moderately hyperintense FNH on T2-weighted images and, after IV administration of super-paramagnetic iron oxide particles, HCC in FNH was barely delineable. Both patients underwent successful right hemihepatectomy to remove the suspicious FNH with diameters of 12 and 14 cm; intralesional HCC diameters were 3 and 5 cm, respectively. Patients could be rapidly dismissed. However, one patient died after recurrence of HCC 1.5 years after surgery, whereas the other patient continues tumor-free 4 years after surgery. Alpha-feto-protein was normal in both patients.

Conclusion: In FNH with rapid growth tendency and heterogenic MR appearance, surgical removal should be considered to overcome the risk of inadequate therapy in the very rare group of patients with HCC in association with FNH.     

完全腹腔镜肝切除术治疗肝细胞癌合并肝硬化的研究

目的：探讨完全腹腔镜肝切除术（PLH）治疗肝细胞癌合并肝硬化的可行性、安全性及疗效。方法：2003—07～2012—07的17例肝细胞癌合并肝硬化患者在全麻下行PLH,共治疗20个肿瘤,平均肿瘤直径（4．4±1．4）cm。肝功能Child—Pu小A级6例,B级11例。结果：17例均顺利完成PLH。平均手术时间（143．4±50．3）min,平均术中出血量（334．1±221．9）ml。无一例中转开腹,未出现大出血、严重胆漏、肝功能衰竭等并发症。术后平均住院时间（6．4±2．4）d。术后随访12～73个月（平均39．3个月）,1例肿瘤切除边缘复发,5例发现肝内新病灶,1例肺转移。经皮射频消融治疗4例,肝动脉化学栓塞（TACE）2例,6例死于肿瘤复发或肝功能衰竭。结论：PLH治疗肝细胞癌合并肝硬化安全可行,治疗效果肯定,具有局部创伤小、全身炎症反应轻、术后恢复快等优势,最适于肝脏表浅部位的肿瘤。     

肝硬化相关小肝癌的血供特点和MRI表现

目的:通过分析肝硬化相关小肝癌的MRI平扫及增强扫描的信号特点,结合其血供情况,总结小肝癌的MRI特点,提高小肝癌的诊断水平。方法:对经临床和病理证实的48个肝硬化相关小肝癌行MRI平扫及增强扫描,对其影像学资料进行回顾性分析。结果:48个肝硬化相关小肝癌中,T1WI以稍低、低信号(68.8%)为主,T2WI以稍高、高信号(70.8%)为主,其中10例在T1WI同相位呈等或高信号,在T1WI反相位呈等或低信号影;19例可见假包膜。动态增强扫描后,强化方式有5种:无强化、边缘轻度强化、速升速降、缓升速降及速升缓降;以速升速降(35个,72.9%)为主。结论:肝硬化相关小肝癌的血供方式有5种:动脉、门脉血供均减少;动脉、门脉血供正常或略增加;动脉血供增加,门脉血供减少;门脉血供增加;动脉、门脉血供均增加。其中以动脉血供增多、门脉血供减少为主要血供方式,结合MRI信号特点,可提高早期诊断与鉴别诊断水平。     

肝硬化结节与小肝癌的CT、MRI诊断

在肝硬化结节及小肝癌的早期诊断方面,CT、MRI仍是目前临床工作中最重要的方法,本文阐述肝硬化结节演变为肝癌过程中的几个重要环节的CT、MRI表现及国内、外对此的研究现状,这几个环节包括肝硬化再生结节、发育不良性结节(低、中、高级)、小肝癌及肝癌,它们在CT、MRI表现上各有特征,但相互间也有影像学表现上的重叠,故多数较典型者可以通过CT密度值、MRI信号值及增强表现判断其性质,少部分诊断有困难的病灶可以通过双动脉期扫描、MR菲立磁增强及灌注成像等方法提供更多的诊断信息。     

左肾癌并发肝局灶性结节增生及肝脓肿1例

男,65岁,无明显诱因出现恶心、呕血,量约200 mL,色紫,含食物残渣,无腹痛、腹泻及其他不适,未处理.2 d后再次呕血,大便发黑,于当地就诊,给予奥美拉唑抑酸、止血等治疗无再呕血.为进一步诊治来本院,起病来患者精神不佳,食欲睡眠可,小便正常,体重无明显减轻,无头痛头晕、咳嗽咳痰,无腰部酸胀不适、尿频尿急尿痛及肉眼血尿.     

Imaging of benign hypervascular hepatocellular nodules in alcoholic liver cirrhosis: differentiation from hypervascular hepatocellular carcinoma

OBJECTIVES: To retrospectively describe imaging analyses of benign hypervascular hyperplastic liver nodules (HHN) that resulted from alcoholic liver cirrhosis and to examine the possibility of imaging differentiation between these nodules and hypervascular hepatocellular carcinoma (HCC). METHODS: Ten histopathologically confirmed HHN arise in alcoholic liver cirrhosis, and 9 HCC were examined. Magnetic resonance imaging (MRI) (10 HHN and 9 HCC), superparamagnetic iron oxide-enhanced T2-weighted MRI (6 HHN and 4 HCC), and dual-phase computed tomography hepatic arteriography (5 HHN and 6 HCC) were performed, respectively. RESULTS: On T1-weighted magnetic resonance images, 7 HHNs showed hyperintensity and 3 showed iso- to hypointensity, and all HCCs showed hypointensity compared with surrounding liver. On T2-weighted magnetic resonance images, 2 HHNs showed hyperintensity and 8 showed iso- to hypointensity. In contrast, 1 HCC showed hypointensity and 8 showed hyperintensity. On superparamagnetic iron oxide-enhanced T2 MRI, all HHNs showed iso- to hypointensity, and all HCCs showed hyperintensity. All HHN and HCCs subjected to dual-phase computed tomography hepatic arteriography showed enhancement on early-phase images and coronalike enhancement on late-phase images. CONCLUSIONS: Imaging findings of highly-well differentiated HCCs possibly overlap with HHN. So, for correct diagnosis of HHN, at first, we should suspect HHN based on clinical findings and MRI findings, and then perform core needle biopsy to verify the radiological diagnosis.     

Quantitative analysis of contrast-enhanced ultrasonography: differentiating focal nodular hyperplasia from hepatocellular carcinoma

Objective:

To explore the potential of quantitative analysis of contrast-enhanced ultrasonography (CEUS) in differentiating focal nodular hyperplasia (FNH) from hepatocellular carcinoma (HCC).

Methods:

34 cases of FNH and 66 cases of HCC (all lesions <5 cm) were studied using CEUS to evaluate enhancement patterns and using analytic software Sonoliver® (Image-Arena™ v.4.0, TomTec Imaging Systems, Munich, Germany) to obtain quantitative features of CEUS in the region of interest. The quantitative features of maximum of intensity (IMAX), rise slope (RS), rise time (RT) and time to peak (TTP) were compared between the two groups and applied to further characterise both FNH and HCC with hypoenhancing patterns in the late phase on CEUS.

Results:

The sensitivity and specificity of CEUS for diagnosis of FNH were 67.6% and 93.9%, respectively. For quantitative analysis, IMAX and RS in FNHs were significantly higher than those in HCCs (p<0.05), while RT and TTP in FNHs were significantly shorter (p<0.05). Both the 11 FNHs and 62 HCCs with hypo-enhancing patterns in the late phase were further characterised with their quantitative features, and the sensitivity and specificity of IMAX for diagnosis of FNH were 90.9% and 43.5%, RS 81.8% and 80.6%, RT 90.9% and 71.0%, and TTP 90.9% and 71.0%, respectively.

Conclusion:

The quantitative features of CEUS in FNH and HCC were significantly different, and they could further differentiate FNH from HCC following conventional CEUS.

Advances in knowledge:

Our findings suggest that quantitative analysis of CEUS can improve the accuracy of differentiating FNH from HCC.Dynamic contrast-enhanced ultrasonography (CEUS) has noticeably improved the detection and characterisation of focal liver lesions during the past decade [1]. The enhancement patterns of the lesion are evaluated in three vascular phases (the hepatic arterial, portal venous and late phases), where the hepatic arterial phase provides information on the degree and pattern of vascularity and the portal venous and late phases provide important information on the differention between benign and malignant liver lesions [1]. A previous study has shown that CEUS using SonoVue® (Bracco, Milan, Italy) and spiral-CT provides similar diagnostic accuracy in the characterisation of focal liver lesions [2].The typical enhancement of focal nodular hyperplasia (FNH) on CEUS showed hyperenhancement in the three vascular phases with a stellate vascular and centrifugal enhancement in the arterial phase or a hypoenhancing central scar in the late phase [1, 3–5]. However, these features have not been observed in all cases of FNH, particularly in small lesions. A study on FNH showed that 3 out of 13 lesions (23.1%) were hypoenhancing in the late phase [6] and 3 out of 10 lesions <3 cm had spoke-wheel patterns and 2 had central scars [4]. There is also a broad variation of stellate vascular enhancement in FNHs with a range from 27.3% to 73.3% and of central scar with a range from 36.4% to 63.3% [3–5]. Thus, it can be difficult to differentiate atypical FNHs from other hypervascular malignant tumours, such as hepatocellular carcinoma (HCC), and hypervascular metastases [3]. Furthermore, a hypoenhancing central scar has been described in fibrolamellar HCC and sclerosing or scirrhous HCC [7, 8], and a central feeding artery with spoke-wheel sign has also been described in two scirrhous HCCs [8]. Hence, a comprehensive approache rather than simply estimating the haemodynamics could be beneficial for differential diagnosis.The current low-mechanical-index techniques for CEUS are capable of real-time demonstration of continuous haemodynamic changes in both the liver and hepatocellular nodules, from which time–intensity curves can be obtained by means of analytic software and then a series of semi-quantitative perfusion measurements extracted and analysed [9–11]. This method has shown a possible benefit in diagnosing FNH by enabling analysis of the quantitative parametric curves of the five types of hypervascular liver lesions [9]. In the present study, CEUS was applied to evaluate enhancing patterns of FNH and HCC; quantitative features of CEUS in the two groups were generated with the analytic software Sonoliver® (TomTec Imaging Systems, Germany) and compared to explore their potential in the differential diagnosis. Furthermore, the quantitative analysis of CEUS was used to characterise both FNH and HCC with hypoenhancing patterns in the late phase on CEUS.     

Emergency hepatic arterial embolization for secondary hypercalcemia in hepatocellular carcinoma.

Two successive hepatic arterial embolizations were performed in a patient with hypercalcemia secondary to hepatocellular carcinoma. The first procedure was performed on an emergency basis due to a cardiovascular episode and was immediately beneficial. The second procedure, performed five months later for a recurrence, was effective in 3 days; 13 months later, there had been no recurrence.     

Intrahepatic recurrence after percutaneous radiofrequency ablation of hepatocellular carcinoma: analysis of the pattern and risk factors

PURPOSE: To evaluate the pattern and risks for intrahepatic recurrence after percutaneous radiofrequency (RF) ablation for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: We studied 62 patients with 72 HCCs (< or =4 cm) who were treated with percutaneous RF ablation. The mean follow-up period was 19.1 months (6.0-49.1). We assessed the incidence and cumulative disease-free survival of local tumor progression (LTP) and intrahepatic distant recurrence (IDR). To analyze the risk factors, we examined the following, for the LTP: (1) tumor diameter, (2) contact with vessels, (3) degree of approximation to hepatic hilum, (4) contact with hepatic capsule, (5) presence of ablative safety margin, (6) degree of benign periablational enhancement and (7) serum alpha-fetoprotein; for the IDR: (1) severity of hepatic disease, (2) presence of HBsAg, (3) serum alpha-fetoprotein, (4) whether RF ablation was the initial treatment and (5) multiplicity of tumor for IDR. RESULTS: The incidence of overall recurrence, LTP and IDR was 62.9%, 26.4% and 53.2%, respectively. The cumulative disease-free survival rates were 52%, 82% and 56% at 1 year, 26%, 63% and 30% at 2 years, respectively. Univariate analysis showed that the significant risk factors for LTP were: a tumor with a diameter >3 cm, contact of HCC with a vessel and an insufficient safety margin (p<0.05). A multivariate stepwise Cox hazard model showed that the measurement of a tumor diameter >3 cm and insufficient safety margin were independent factors. Only the increased serum alpha-fetoprotein was a significant risk factor for IDR (p<0.05). CONCLUSION: Intrahepatic recurrence after percutaneous RF ablation is common. Large HCC (>3 cm) with high serum alpha-fetoprotein should be treated more aggressively because of higher risk for recurrence.     

Intrahepatic portal-to-portal venous shunts in cirrhosis: a potential mimic of hepatocellular carcinoma

Two intrahepatic portal-to-portal venous shunts demonstrated at computed tomography (CT) and ultrasound in a 40-year-old woman with cirrhosis are described. The shunts appeared as hypervascular hepatic foci on CT, simulating multifocal hepatocellular carcinoma. Follow-up multiphase CT with multiplanar reformation and Doppler ultrasound confirmed the correct diagnosis. Recognition of intrahepatic portal-to-portal venous shunts as a rare mimic of hepatocellular carcinoma in cirrhosis should prevent misinterpretation or inappropriate management.