Multiple hypervascular liver nodules in a heavy drinker of alcohol

A case of hypervascular nodules in the liver, but without hepatitis B or C virus infection in a 38-year-old woman with a history of alcohol abuse is presented. An ultrasound disclosed 1-2-cm hypoechoic tumors in the right and left lobes. Magnetic resonance imaging showed high-intensity tumors at both the T1-weighted and T2-weighted sequences. Incremental dynamic computed tomography and hepatic angiography revealed hypervascular tumors. Ultrasound-guided needle biopsy revealed no evidence of hepatocellular carcinoma, metastatic liver cancer, hemangioendothelioma, inflammatory pseudotumors or pseudolymphoma, but demonstrated stellate-scar fibrosis septa, which contained small unpaired arteries without hyperplasia dividing the nodule. Moreover, marked pericellular fibrosis, neutrophilic infiltration and Mallory bodies were observed in the cytoplasm. There was no evidence of bile duct proliferation. From these findings, the diagnosis of alcohol-induced fibrosis, distinctly different from focal nodular hyperplasia, was tenable. Further studies may provide insights into the pathogenesis of nodule formation and hypervascularity in heavy drinkers of alcohol.     

Signal intensity of the liver parenchyma in microbubble contrast agent in the late liver phase reflects advanced fibrosis of the liver.

BACKGROUND: Microbubble of Levovist accumulates in liver parenchyma, and the phenomenon has been reported as late liver-specific parenchymal. The aim of the present study was to compare the parenchymal enhancement effect of Levovist with the degree of liver dysfunction. PATIENTS AND METHODS: Sixty consecutive patients who consented to be treated were enrolled in this study. Pulse-inversion ultrasonography (US) in the liver parenchymal phase of enhancement with Levovist was performed in a preoperative examination. The mechanical index of pulse-inversion US was set at 1.3. The gray-scale intensity of the non-tumor area of the liver parenchyma at the level of the focal zone was measured. The hepatic fibrosis index was measured in each liver by morphometric analysis. The correlation between the gray-scale intensity of the non-tumor area of the liver parenchyma and the hepatic fibrosis index was assessed. RESULTS: There was a significant inverse correlation between the gray scale of the liver parenchyma and the hepatic fibrosis index (r = -0.809, P < 0.01). The average signal intensity of the liver parenchyma was 144.5 in a normal liver, 133.6 in chronic hepatitis, and 102.6 in liver cirrhosis, demonstrating a significant difference between a normal and cirrhotic liver (P < 0.01). CONCLUSIONS: The signal intensity of a microbubble disruption of the liver parenchyma in the late phase of enhancement with Levovist was considered to reflect the degree of hepatic fibrosis.     

Large benign rheumatoid nodules of the trunk in an elderly patient: radiologic appearance mimicking a soft-tissue sarcoma

An 80-year-old woman without any evidence of rheumatoid arthritis presented with two large (maximum diameter: 6 cm and 7 cm), rapidly growing, rubbery nodules on the trunk. Although the clinical and radiological appearance suggested malignancy, the nodules were pathologically identical to rheumatoid nodules in rheumatoid arthritis, and the nodules regressed spontaneously. The final diagnosis was benign rheumatoid nodules. Recognition of this rare clinical entity is important to avoid unnecessary examination and treatment.     

Large benign rheumatoid nodules of the trunk in an elderly patient: radiologic appearance mimicking a soft-tissue sarcoma

Abstract

An 80-year-old woman without any evidence of rheumatoid arthritis presented with two large (maximum diameter: 6?cm and 7?cm), rapidly growing, rubbery nodules on the trunk. Although the clinical and radiological appearance suggested malignancy, the nodules were pathologically identical to rheumatoid nodules in rheumatoid arthritis, and the nodules regressed spontaneously. The final diagnosis was benign rheumatoid nodules. Recognition of this rare clinical entity is important to avoid unnecessary examination and treatment.     

Diagnosis of small hepatic nodules detected by surveillance ultrasound in patients with cirrhosis: Comparison between contrast-enhanced ultrasound and contrast-enhanced helical computed tomography.

Aim: To investigate the diagnostic value for the diagnosis of small (1-2 cm) hepatic nodules detected by surveillance ultrasound in patients with cirrhosis using contrast-enhanced ultrasound (CEUS) compared with that of contrast-enhanced helical computed tomography (CECT). Methods: Seventy-two liver cirrhosis patients with 103 small hepatic nodules (1-2 cm) detected by surveillance ultrasound were enrolled in the present study. All patients underwent CEUS with SonoVue as well as CECT. Nodules which appeared by contrast enhancement during the arterial phase and contrast wash-out during the late phase on CEUS or CECT were diagnosed as malignant (hepatocellular carcinoma [HCC]). Histopathology obtained from biopsy or surgery served as the gold standard. Results: According to the above diagnostic criteria, the sensitivity (i.e. rate of correct diagnosis of HCC) was 91.1% (51/56 HCC) for CEUS and the specificity (i.e. the rate of correct exclusion of HCC) was 87.2% (41/47 regenerative nodules [RN]).Therefore, the diagnostic accuracy of CEUS was 89.3% (92/103 all nodules). Using the same diagnostic criteria, the sensitivity, specificity and accuracy of CECT were 80.4% (45/56 HCC), 97.9% (46/47 RN), and 88.4% (91/103 all nodules). Overall, there was no significant difference between CEUS and CECT in the diagnostic confidence of small hepatic nodules. Eighty-six nodules (45 HCC and 41 RN) were correctly diagnosed by both modalities and six (five HCC and one RN) were misdiagnosed by both. Conclusion: The ability of CEUS in the characterization of small nodules (1-2 cm) detected by surveillance US in patients with liver cirrhosis is similar to that of CECT.     

How to characterize non-hypervascular hepatic nodules on contrast-enhanced computed tomography in chronic liver disease: feasibility of contrast-enhanced ultrasound with a microbubble contrast agent

Background and Aim: Although hypervascular appearance is characteristic in hepatocellular carcinoma (HCC), hepatic nodules without hypervascular appearance are sometimes found in patients with chronic liver disease (CLD). The aim of the present study was to clarify the efficacy of contrast‐enhanced ultrasound (CEUS) with Levovist to characterize small, non‐hypervascular hepatic nodules on contrast‐enhanced computed tomography (CECT) in patients with CLD. Methods: The subject was 41 hepatic nodules (<30 mm, 18.5 ± 5.6 mm) which showed non‐hypervascular appearance on CECT in 35 patients with CLD; their histological results were 31 HCC (15 well, 14 moderate, and two poor) and 10 regenerative nodules (RN). CEUS with Levovist was performed under intermittent scanning (1‐s interval) using APLIO at the early phase and the liver‐specific phase, and the contrast enhancement of the nodule was assessed in comparison to that of the surrounding liver parenchyma. The contrast‐enhanced findings with the time‐intensity analysis were compared with the histological results. Results: Twelve nodules with weak enhancement in the liver‐specific phase were HCC, regardless of their early‐phase appearances. The other 29 nodules with equivalent or weak enhancement in the early phase and equivalent enhancement in the liver‐specific phase were 19 HCC and 10 RN. Among them, the maximum‐intensity ratio of tumor to non‐tumor in the early phase was significantly higher in HCC than in RN (P < 0.01, n = 16), and the receiver‐operating characteristic analysis showed a sensitivity of 1.0 and a specificity of 0.83 for their characterization. Conclusion: CEUS with Levovist may be an alternative to biopsy to characterize small, non‐hypervascular hepatic nodules on CECT in patients with CLD.     

Contrast-enhanced gray-scale harmonic ultrasound in the efficacy assessment of ablation treatments for hepatocellular carcinoma.

BACKGROUND: The aim of this study was to compare contrast-enhanced gray-scale harmonic ultrasound with multiphasic spiral computed tomography in the assessment of treatment efficacy of non-surgically treated HCC. METHODS: We studied 56 HCCs treated by percutaneous ethanol injection (31 cases), radiofrequency ablation (three cases), trans-arterial chemoembolization (12 cases), and combined treatment (10 cases). The efficacy of therapies was blindly assessed by multiphasic computed tomography and gray-scale harmonic ultrasound with a second-generation contrast agent (sulfur hexafluoride). RESULTS: On computed tomography 30 tumors (53.6%) showed complete necrosis, while 26 lesions (45.4%) were still viable. On contrast-enhanced ultrasound examination 33/56 nodules (58.9%) had no contrast enhancement in the arterial phase, while 23/56 lesions (41.1%) were still vascularized. All the nodules assessed as completely necrotic on computed tomography did not show arterial enhancement on contrast-enhanced ultrasound and diagnostic agreement was found in 53/56 cases (94.6%) (P<0.001). Contrast-enhanced ultrasound demonstrated relative sensitivity and specificity of 87.0% and 98.4%. CONCLUSIONS: Contrast-enhanced harmonic ultrasound is promising in the efficacy evaluation of ablation treatments for HCC. Nodules vascularized in the arterial phase on contrast harmonic ultrasound should be considered still viable and addressed to additional treatment without further evaluation.     

Value of contrast-enhanced intraoperative ultrasound for cirrhotic patients with hepatocellular carcinoma： A report of 20 cases

AIM： To assess the clinical value of contrast-enhanced intraoperative ultrasound （CE-IOUS） as a novel tool in partial hepatectomy for cirrhotic patients with hepatocellular carcinoma （HCC）.
METHODS： From January 2007 to September 2007, a total of 20 consecutive cirrhotic patients with HCC scheduled to undergo partial hepatectomy were studied. Preoperative contrast enhanced computer tomography （CT） and/or magnetic resonance （MR） scans were performed within 1-2 wk before operation. Intraoperative ultrasound （IOUS） and CE-IOUS were carried out after mobilization of the liver. Lesions on precontrast and postcontrast scans were counted and mapped. CE-IOUS was performed with intravenous injection of ultrasound contrast agents SonoVue （Bracco Imaging, Milan, Italy）. Arterial, portal and late phases of contrast enhancement were recorded and analyzed. Nodules showing arterial phase hyper-enhancing and/or hypo-enhancing in late parenchymal phase were considered malignant and removed surgically. Ultrasound-guided biopsy and ethanol ablation would be an option if the nodule could not be removed surgically. Newly detected nodules on IOUS showing iso-enhancement in both arterial and late phases were considered benign. These nodules were either removed surgically if they were close to the main lesion or followed by examinations of alpha-fetoprotein （AFP） level and ultrasound and/or CT/MR every 3 too.
RESULTS： IOUS found 41 nodules in total, among which 17 （41.46%） were newly detected compared to preoperative imaging. Thirty-three nodules were diagnosed malignant by CE-IOUS, including one missed by IOUS. The sensitivity and specificity of CE-IOUS on detecting HCC nodules are 100% （33/33 and 100% （9/9）, respectively. Nine nodules were considered benign by CE-IOUS, four was confirmed at histology and five by follow-up. CE-IOUS changed the surgical strategy in 35% （7/20） of patients and avoid unnecessary intervention in 30% （6/20） of patients.
CONCLUSION： CE-IOUS is a usef     

Hepatic ultrasound in a population with high incidence of invasive amoebiasis: evidence for subclinical,self-limited amoebic liver abscesses

About 10% of successfully treated amoebic liver abscesses (ALA) do not completely resolve and can be detected by ultrasound as typical residual liver lesions. The frequency of these residues should be an indicator for the prevalence of ALA in a given population, and may help to solve the question whether non-clinical, self-healing ALAs occur. We have performed hepatic ultrasound in 1036 adult individuals living in a high-risk area for ALA in Central Vietnam and identified typical ALA residual lesions in about 1.2% of the subjects. As expected, these lesions were associated with positive amoeba serology and were found in 11.9% of individuals with a previous ALA history. However, more than 50% of the residues were identified in individuals who had never developed symptoms suspected for ALA and who never received any ALA specific treatment, suggesting that subclinical, self-limited hepatic amoeba abscesses truly exist.     

Assessment of regional myocardial hypoperfusion with myocardial contrast echocardiography using intravenous bolus application in patients with acute chest pain: a double case report.

Myocardial contrast echocardiography using power Doppler harmonic imaging is able to document myocardial hypoperfusion. Two case reports demonstrate the potential of intravenous bolus application of microbubbles in patients with acute chest pain due to myocardial ischaemia to detect regional low flow conditions. The case reports will focus on the necessity to present Doppler intensity kinetics by Doppler intensity vs time plots or coloured M-modes to present the data more objectively. In addition, the hypoperfusion detected with myocardial contrast echocardiography via bolus injection of microbubbles can only be proven by changes of regional perfusion between repetitive myocardial contrast echocardiography measurements or by additional perfusion analysis, e.g. by scintiscanning.     

Targeted nalmefene with simple medical management in the treatment of heavy drinkers: a randomized double-blind placebo-controlled multicenter study

BACKGROUND: Clinical studies with opioid antagonists for treatment of problem drinking have mainly been conducted in specialized alcohol treatment centers, included structured psychosocial treatment, and have focused on maintaining abstinence after a period of abstinence from alcohol. METHODS: This multisite, randomized double-blind study investigated targeted nalmefene in reducing heavy drinking. Specialized alcohol treatment centers and private general practices enrolled 403 subjects (328 men, 75 women). Subjects were instructed to take nalmefene 10 to 40 mg (n=242) or placebo (n=161) when they believed drinking to be imminent. After 28 weeks, 57 subjects from the nalmefene group continued into a 24-week randomized withdrawal extension. Concomitant psychosocial intervention was minimal and no treatment goals were imposed. Alcohol consumption was recorded using the time-line follow-back method. Biochemical indicators of alcohol use were also measured. RESULTS: The mean monthly number of heavy drinking days (HDDs) during the 12-week period before inclusion was 15.5 (SD 6.9) in the nalmefene group and 16.2 (SD 6.9) in the placebo group. During treatment, the mean numbers of HDDs were 8.6 to 9.3 in the nalmefene group and 10.6 to 12.0 in the placebo group (p=0.0065). The levels of serum alanine aminotransferase and gamma-glutamyl transferase decreased in the nalmefene group compared with the placebo group (p=0.0088 and 0.0023). During the randomized withdrawal period, subjects randomized to placebo apparently returned to heavier drinking. Subjects receiving nalmefene reported more nausea, insomnia, fatigue, dizziness, and malaise than subjects on placebo. CONCLUSIONS: Nalmefene appears to be effective and safe in reducing heavy drinking, even when accompanied by minimal psychosocial support.     

Innovations in imaging for chronic total occlusions: a glimpse into the future of angiography's blind-spot.

Chronic total occlusions (CTOs) are a subset of lesions that present a considerable burden to cardiovascular patients. There exists a strong clinical desire to improve non-surgical options for CTO revascularization. While several techniques, devices, and guide wires have been developed and refined for use in CTOs, the inability of angiography to adequately visualize occluded arterial segments makes interventions in this setting technically challenging. This review describes the current status of several invasive and non-invasive imaging techniques that may facilitate improved image guidance during CTO revascularization, with the goals of improving procedure safety and efficacy while reducing the time required to complete these interventions. Cardiac imaging also has important potential roles in selecting patients most likely to benefit from revascularization as well as pre-procedural planning, post-procedural assessment of revascularized segments and long-term outcomes studies. Modalities discussed include non-invasive techniques, such as CT(computed tomography) angiography and cardiac magnetic resonance imaging (MRI), as well as invasive techniques, such as intravascular ultrasound, optical coherence tomography, intravascular MRI, and conventional angiography. While some of these techniques have some evidence to support their use at present, others are at earlier stages of development. Strategies that combine imaging techniques with the use of interventional therapies may provide significant opportunities to improve results in CTO interventions and represent an active area of investigation.     

Usefulness of computed tomography during cholangiography for the diagnosis of multiple hepatic peribiliary cysts: a report of three cases with chronic liver disease

Hepatic peribiliary cysts are composed of multiple tiny cysts along the larger portal tracts and have been reported to be harmless. On clinical images, peribiliary cysts resemble other diseases such as biliary dilatations, cholangitis, or periportal edema. Therefore, it is important to distinguish peribiliary cysts from these diseases using a combination of several imaging modalities. Herein, we report three cases of peribiliary cysts. The first case underwent laparotomy for the presumptive diagnosis of intrahepatic cholangiocarcinoma. In the remaining two cases, hepatic peribiliary cysts were diagnosed and laparotomy was avoided. Magnetic resonance cholangiography contributed to the diagnosis, owing to their characteristic distribution. In addition, computed tomography during cholangiography (cholangio-CT) demonstrated that the cysts had no communication with the intrahepatic biliary system. Therefore, cholangio-CT is considered to be the most useful modality for the diagnosis of peribiliary cysts.     

Damping index of Doppler hepatic vein waveform to assess the severity of portal hypertension and response to propranolol in liver cirrhosis: a prospective nonrandomized study.

BACKGROUND AND AIMS: Alterations in the Doppler hepatic vein (HV) waveform are associated with cirrhosis and portal hypertension. We prospectively evaluated the correlation between the extent of abnormal Doppler HV waveforms expressed as damping index (DI) and the hepatic venous pressure gradient (HVPG) and response to propranolol in patients with cirrhosis. MATERIAL AND METHODS: In 76 patients with cirrhosis (69 men and seven women), both DI of Doppler HV waveform and HVPG were measured, and the relationship between them was analysed. DI was calculated by the minimum velocity/maximum velocity of the HV waveform. An HVPG>12 mmHg was defined as severe portal hypertension. In a subgroup of 19 patients receiving propranolol, changes in both DI and HVPG were evaluated after propranolol administration for 3 months. One author (S. K. B.) performed all DI of Doppler HV waveform studies. RESULTS: Abnormal HV waveforms were seen in 66 of 76 patients (86.8%). DI significantly correlated with the grade of HVPG, i.e. with higher HVPG increased DI was observed (P<0.01). By logistic regression analysis, DI>0.6 was significantly more likely to be severe portal hypertension (odds ratio: 14.19, 95% confidence interval: 4.07-49.55). Receiver-operating characteristic curve according to the value of 0.6 of DI showed a sensitivity of 75.9% and a specificity of 81.8% for the presence of severe portal hypertension. In 19 patients of the propranolol subgroup, change of DI following propranolol treatment also significantly correlated with that of HVPG (P<0.01). CONCLUSIONS: Damping index of the HV waveform by Doppler ultrasonography might be a non-invasive supplementary tool in evaluating the severity of portal hypertension and in responding to propranolol in patients with liver cirrhosis.     

Elevated Resistive Index in the Hepatic Artery as a Predictor of Fulminant Hepatic Failure in Patients with Acute Viral Hepatitis: A Prospective Study Using Doppler Ultrasound

To assess the sensitivity and specificity of the resistive index of the hepatic artery, which is related to the vascular resistance of the artery, for the prediction of fulminant hepatic failure, we performed Doppler ultrasonography examinations on the hepatic arteries of 72 patients with acute viral hepatitis (25 of whom developed fulminant hepatic failure and 47 of whom recovered without developing fulminant hepatic failure) as well as the hepatic arteries of age- and sex-matched controls. The mean resistive index of the hepatic arteries in patients who developed fulminant hepatic failure was significantly larger than that of patients who recovered without developing fulminant hepatic failure (P < 0.01). When a resistive index cutoff level of 0.74 was used, an 84% sensitivity and a 94% specificity were obtained for the prediction of fulminant hepatic failure. An elevated resistive index of the hepatic artery may be useful for predicting the patient's clinical outcome and determining the need for a liver transplantation in patients with acute viral hepatitis.     

CASE REPORT: Primary cystic keratinizing squamous cell carcinoma of the liver in a patient with treated nasopharyngeal carcinoma

Primary squamous cell carcinoma of the liver is very rare; only 18 cases have been recorded. In the present report we document an additional case who had a unique history of stage III non-keratinizing nasopharyngeal carcinoma treated with a full course of radiotherapy in July 1993. Two small hypoechoic cyst-like lesions in the left hepatic lobe were identified at the same time. In July 1995 the 50-year-old patient reported to be suffering from abdominal fullness and tenderness. A large hypodense tumour was demonstrated in the left hepatic lobe by abdominal echography. The patient was diagnosed as having metastatic carcinoma and received two courses of pre-operative chemotherapy followed by left lobectomy of the liver and resection of adherent tissues on 9 August 1995. Pathological study demonstrated a large hepatic cystic keratinizing squamous cell carcinoma, which most likely arose from a solitary hepatic cyst. Tumour seedings, probably secondary to tumour rupture, were also revealed on the omentum, peritoneum and diaphragm. However, regional lymph nodes were free of tumour. Systemic work-up failed to demonstrate evidence of local recurrence of nasopharyngeal carcinoma, metastatic lesion or any second primary tumour site.