CT灌注值分析及CT灌注成像鉴别肝细胞癌和肝局灶性结节增生的诊断价值

目的对肝细胞癌和肝局灶性结节增生的CT灌注值进行分析,以研究CT灌注成像对二者的鉴别作用,探讨其临床诊断价值。方法将张家港市第一人民医院在2015年3月至2015年11月期间收治的肝细胞癌患者24例作为实验组,肝局灶性结节增生患者17例作为对照组。应用CT扫描仪对所有研究对象进行平扫及全肝灌注扫描,对两组的实性部分的CT灌注值(肝动脉灌注量、门静脉灌注量、总肝灌注量、肝动脉灌注指数)进行分析比较;对肝细胞癌的实性成分、灶周组织及远处肝组织的CT灌注值进行分析比较;对肝局灶性结节增生的实性部分与远处肝组织的CT灌注值进行分析比较。结果与对照组相比,实验组的实性成分肝动脉灌注量为(43.32±19.56)mL/(min·100 mg)、肝动脉灌注指数为(67.86±11.62)%均较低,但门静脉灌注量较高(22.30±13.44)mL/(min·100 mg),差异均具有统计学意义。在实验组中,与灶周、远处肝组织相比,病灶的肝动脉灌注量(43.321±19.66)mL/(min·100 mg)、肝动脉灌注指数(67.86±11.62)%较高,但门静脉灌注量较低(22.30±13.44)mL/(min·100 mg),差异均具有统计学意义。在对照组中,与远处肝组织相比,病灶的肝动脉灌注量(67.69±23.54)mL/(min·100 mg)、肝动脉灌注指数(88.46±5.62)%较高,而门静脉灌注量较低(9.30±7.44)mL/(min·100 mg),差异均具有统计学意义。但上述情况的总肝灌注量的差异均无统计学意义。结论通过对肝细胞癌和肝局灶性结节增生CT灌注值的分析与比较,可知CT灌注成像对于二者的鉴别诊断具有重要的临床价值。     

Huge focal nodular hyperplasia difficult to distinguish from well-differentiated hepatocellular carcinoma

We present a 43‐year‐old man with huge focal nodular hyperplasia (FNH) that was difficult to distinguish from well‐differentiated hepatocellular carcinoma (HCC). He previously had abnormal portal vein circulation due to hypoplasia of the intrahepatic portal vein, which was treated with a superior mesenteric vein–inferior vena cava shunt. Laboratory findings included predominantly indirect hyperbilirubinemia with concomitant elevation in aspartate aminotransferase (AST), alanine aminotransferase (ALT), and ammonia. Serum α‐fetoprotein and des‐γ‐carboxy prothrombin were slightly elevated. Multidetector‐row computed tomography detected the primary tumor in the left liver lobe, which partially showed a central stellate scar. Gd ethoxybenzyl diethylenetriamine pentaacetic acid‐enhanced magnetic resonance imaging showed some low‐intensity areas in the tumor in the hepatocyte phase. 99mTc‐galactosyl human serum albumin scintigraphy showed normal intake of agent in the tumor. We could not rule out well‐differentiated HCC. Extended left hepatectomy was performed. Final histopathological findings showed that most of the tumor was FNH against a background of portal vein hypoplasia with moderate atypia and hemorrhage. And immunohistochemical analysis revealed high expression of organic anion transporter (OATP) 1B3 and low expression of multidrug resistance‐associated protein (MRP) 2 in a part of the tumor. The patient has remained alive with no hepatic lesion for 1 year after surgery. We describe a case of huge FNH that was difficult to distinguish from well‐differentiated HCC even by current fully preoperative imaging technology and demonstrate the effectiveness of curative surgical resection.     

18F‐Fluorodeoxyglucose (FDG)‐PET features of focal nodular hyperplasia (FNH) of the liver

Abstract: Aim: The aim of this paper is to describe the imaging pattern of focal nodular hyperplasia (FNH) by ¹⁸F‐fluorodeoxyglucose (18F‐FDG) positron emission tomography (PET). Methods: Eight consecutive asymptomatic patients with histologic proof of FNH underwent 18F‐FDG PET imaging. The lesions were found incidentally. The 18F‐FDG PET imaging was performed with a dedicated PET tomograph after intravenous injection of 300–370 MBq 18F‐FDG. The 18F‐FDG accumulation in the lesions was (semi)quantified by calculating the standardized uptake value (SUV) and SUV has been corrected for the lean body mass (LBM). Eight patients with liver metastases spread from melanoma (n=2) and colorectal carcinoma (n=6) served as controls. The size of the FNH lesions and of the control group ranged from 2.0 to 8.5 cm (mean 4.83 cm±2.37) and from 1.5 to 6 cm (mean 3.28±1.52), respectively. Results: While in malignant liver lesions the accumulation of 18F‐FDG was significantly increased, all FNH lesions showed normal or even decreased accumulation of 18F‐FDG. In FNH lesions, SUV ranged between 1.5 and 2.6 (mean 2.12±0.38), whereas all liver metastases showed an increased SUV ranging between 6.20 and 16.00 (mean 10.07±3.79). The SUV corrected for LMB (SUV_LBM) was similar to the SUV and ranged between 0.9 and 2.2 (mean 1.81±0.41) for FNH and between 5.9 and 16.3 (mean 9.15±4.03), respectively. Conclusion: In contrast to liver metastases, there is no increased glucose metabolism in FNH in vivo. The imaging feature of FNH by 18F‐FDG‐PET imaging is not specific for FNH; however, it may be helpful to differentiate FNH from liver metastases in cancer patients if radiological methods are not diagnostic.     

Management of hepatocellular carcinoma: Enlightening the gray zones

Management of hepatocellular carcinoma (HCC) has been continuously evolving during recent years. HCC is a worldwide clinical and social issue and typically a complicates cirrhosis. The incidence of HCC is increasing, not only in the general population of patients with cirrhosis, but particularly in some subgroups of patients, like those with human immunodeficiency virus infection or thalassemia. Since a 3% annual HCC incidence has been estimated in cirrhosis, a bi-annual screening is generally suggested. The diagnostic criteria of HCC has recently had a dramatic evolution during recent years. HCC diagnosis is now made only on radiological criteria in the majority of the cases. In the context of cirrhosis, the universally accepted criteria for HCC diagnosis is contrast enhancement in arterial phase and washout in venous/late phase at imaging, the so called “typical pattern”. However, recently updated guidelines slightly differ in diagnostic criteria. Apart from liver transplantation, the only cure of both HCC and underlying liver cirrhosis, all the other treatments have to match with higher rate of HCC recurrence. The latter can be classified into curative (resection and percutaneous ablation) and palliative treatments. The aim of this paper was to review the current knowledge on management of HCC and to enlighten the areas of uncertainty.     

CT能谱成像鉴别肝癌和肝脏局灶性结节增生的临床价值

目的探讨CT能谱成像在鉴别肝癌和肝局灶性结节增生（FNH）中的应用价值。方法回顾性分析46例肝脏占位性病变患者（肝癌32例,FNH14例）行64层CT双期能谱扫描结果。测量病灶、正常肝组织和腹主动脉的能谱参数,对比分析两种占位性病变间不同能量水平下病灶-肝脏对比噪声比（CNR）、标准化碘浓度（NIC）、病灶与正常肝组织碘浓度比值（LNR）及病灶动脉期和门静脉期碘浓度的差异（ICD）等。结果除部分能量点外,肝癌和FNH在不同能量水平下的CNR随着单光子能量的增加而减小。肝癌和FNH的动脉期最佳CNR分别为3.6±1.1和8.3±2.7,门静脉期最佳CNR分别为1.8±0.3和1.1±0.2;肝癌和FNH动脉期NIC分别为0.3±0.1和0.4±0.1,门静脉期NIC分别为0.5±0.1和0.9±0.2;动脉期LNR分别为3.0±0.5和6.2±1.0,门静脉期LNR分别为1.0±0.1和1.2±0.3;动脉期和门静脉期ICD值分别为0.4±0.1g/L和1.2±0.3g/L。肝癌动脉期和门静脉期的NIC、LNR和ICD值均低于FNH,差异均有统计学意义（NIC比较,t值分别为-3.196、-6.518;LNR比较,t值分别为-12.911、-3.260;ICD比较,t值为-2.754,P均＜0.05）。动脉期LNR鉴别肝癌和FNH的敏感度和特异度最高,均为100%。结论 CT能谱成像分析对肝癌和FNH的检出和鉴别诊断有一定的价值,能提高检出效能和诊断准确性。     

Hepatic focal nodular hyperplasia in children: Imaging features on multi-slice computed tomography

AIM: To retrospectively analyze the imaging features of hepatic focal nodular hyperplasia (FNH) in children on dynamic contrast-enhanced multi-slice computed tomography (MSCT) and computed tomography angiography (CTA) images.METHODS: From September 1999 to April 2012, a total of 218 cases of hepatic FNH were confirmed by either surgical resection or biopsy in the Sun Yat-sen Memorial Hospital of Sun Yat-sen University and the Cancer center of Sun Yat-sen University, including 12 cases (5.5%) of FNH in children (age ≤ 18 years old). All the 12 pediatric patients underwent MSCT. We retrospectively analyzed the imaging features of FNH lesions, including the number, location, size, margin, density of FNH demonstrated on pre-contrast and contrast-enhanced computed tomography (CT) scanning, central scar, fibrous septa, pseudocapsule, the morphology of the feeding arteries and the presence of draining vessels (portal vein or hepatic vein).RESULTS: All the 12 pediatric cases of FNH had solitary lesion. The maximum diameter of the lesions was 4.0-12.9 cm, with an average diameter of 5.5 ± 2.5 cm. The majority of the FNH lesions (10/12, 83.3%) had well-defined margins. Central scar (10/12, 83.3%) and fibrous septa (11/12, 91.7%) were commonly found in children with FNH. Central scar was either isodense (n = 7) or hypodense (n = 3) on pre-contrast CT images and showed progressive enhancement in 8 cases in the equilibrium phase. Fibrous septa were linear hypodense areas in the arterial phase and isodense in the portal and equilibrium phases. Pseudocapsule was very rare (1/12, 8.3%) in pediatric FNH. With the exception of central scars and fibrous septa within the lesions, all 12 cases of pediatric FNH were homogenously enhanced on the contrast-enhanced CT images, significantly hyperdense in the arterial phase (12/12, 100.0%), and isodense in the portal venous phase (7/12, 58.3%) and equilibrium phase (11/12, 91.7%). Central feeding arteries inside the tumors were observed on CTA images for all 12 cases of FNH, whereas no neovascularization of malignant tumors was noted. In 9 cases (75.0%), there was a spoke-wheel shaped centrifugal blood supply inside the tumors. The draining hepatic vein was detected in 8 cases of pediatric FNH. However, the draining vessels in the other 4 cases could not be detected. No associated hepatic adenoma or hemangioma was observed in the livers of the 12 pediatric cases.CONCLUSION: The characteristic imaging appearances of MSCT and CTA may reflect the pathological and hemodynamic features of pediatric FNH. Dynamic multi-phase MSCT and CTA imaging is an effective method for diagnosing FNH in children.     

多层螺旋CT平扫及增强扫描在肝脏局灶性结节性增生中的诊断价值

目的探讨多层螺旋CT平扫及增强扫描在肝脏局灶性结节性增生(hepatic focal nodular hyperplasia,FNH)中的诊断价值。方法选择FNH患者及肝细胞癌患者各30例,均接受螺旋CT平扫及增强扫描。观察肝细胞癌与FNH大小及分布情况,比较肝细胞癌与FNH的螺旋CT平扫及增强扫描特征。结果 1 FNH位于肝包膜下16例(53.33%),显著高于肝细胞癌(20.00%),差异具有统计学意义(P0.05)。2肝细胞癌平扫表现为等或略低密度,内部可显示低密度囊变坏死区及高密度出血。FNH平扫表现为等或略低密度,其中心显示星芒状低密度区。肝细胞癌及FNH呈快进快出强化,FNH中心星芒状瘢痕区域于延迟期强化。与肝细胞癌比较,FNH存在中心瘢痕的比例更高,伴有门静脉癌栓及肝硬化的比例更低,其差异均具有统计学意义(P0.05)。结论螺旋CT可以清晰显示FNH的影像学特征,有助于诊断和鉴别诊断。     

肝脏局灶性结节性增生与甲胎蛋白阴性肝癌的鉴别诊断

目的探讨肝脏局灶性结节性增生（focalnodularhyperplasia,FNH）与AFP阴性肝癌的鉴别诊断。方法回顾性分析本所1996年3月～1999年３月三年间经手术病理证实的18例FNH及254例AFP阴性肝癌的临床、影像学资料。结果FNH多见于青壮年（40岁以下占66.7%）、多无症状（66.7%）、肝炎背景多阴性（83.3%）、肝功能多正常（72.0%）;71.4%在彩色多普勒超声见到特征性的粗大中央血管（1～3mm）,血液流速高、阻力系数低;CT动态扫描85.7%早期显著增强,53.3%强化均匀,部分有中央星状疤痕,73.3%静脉相等密度;MRI检查中央疤痕在T2WI呈高信号,83.3%增强后早期明显强化,66.7%信号均一。而AFP阴性肝癌多见于中老年（40岁以上85.8%）,多有症状（74.0%）,多有肝炎背景（87.4%）,肝功能多异常（66.1%）;彩色多普勒超声示动脉血流高流速、高阻力,常见晕圈、门静脉栓子;CT动态扫描早期强化明显但不均匀（96.6%）,89.7%静脉相低密度;MRI早期明显强化,信号不均一（91.7%）。结论FNH在临床及影像学上有一定特征,多种检查方法联合应用并与临床相结合,部分病人可与AFP阴性肝癌鉴别。     

18F-fluorodeoxyglucose (FDG)-PET features of focal nodular hyperplasia (FNH) of the liver

AIM: The aim of this paper is to describe the imaging pattern of focal nodular hyperplasia (FNH) by l8F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET). METHODS: Eight consecutive asymptomatic patients with histologic proof of FNH underwent 18F-FDG PET imaging. The lesions were found incidentally. The 18F-FDG PET imaging was performed with a dedicated PET tomograph after intravenous injection of 300-370 MBq 18F-FDG. The 18F-FDG accumulation in the lesions was (semi)quantified by calculating the standardized uptake value (SUV) and SUV has been corrected for the lean body mass (LBM). Eight patients with liver metastases spread from melanoma (n=2) and colorectal carcinoma (n=6) served as controls. The size of the FNH lesions and of the control group ranged from 2.0 to 8.5 cm (mean 4.83 cm +/- 2.37) and from 1.5 to 6 cm (mean 3.28 +/- 1.52), respectively. RESULTS: While in malignant liver lesions the accumulation of 18F-FDG was significantly increased, all FNH lesions showed normal or even decreased accumulation of 18F-FDG. In FNH lesions, SUV ranged between 1.5 and 2.6 (mean 2.12 +/- 0.38), whereas all liver metastases showed an increased SUV ranging between 6.20 and 16.00 (mean 10.07 +/- 3.79). The SUV corrected for LMB (SUVLBM) was similar to the SUV and ranged between 0.9 and 2.2 (mean 1.81 +/- 0.41) for FNH and between 5.9 and 16.3 (mean 9.15 +/- 4.03), respectively. CONCLUSION: In contrast to liver metastases, there is no increased glucose metabolism in FNH in vivo. The imaging feature of FNH by 18F-FDG-PET imaging is not specific for FNH; however, it may be helpful to differentiate FNH from liver metastases in cancer patients if radiological methods are not diagnostic.     

Contribution of CT to characterization of focal nodular hyperplasia of the liver.

Our personal series of 20 cases of focal nodular hyperplasia (FNH) of the liver is presented. All lesions were studied with computed tomography (CT), 16 of which with surgical control. Retrospective evaluation of the CT features of the identified FNH, along with those of five hepatocellular adenomas (HCA) and 30 hepatocellular carcinomas (HCC), allowed the definition of specific patterns leading to a correct characterization of FNH in 78% of cases. This greatly reduced the diagnostic errors, with the sole exception of patients with fatty liver in whom nuclear medicine may eventually provide a correct characterization. Fine-needle biopsy is thus only necessary in the dubious cases. A precise diagnostic workup of FNH is necessary, since it may avoid the surgical intervention.     

Clinicopathological features of focal nodular hyperplasia-like nodules in 130 cirrhotic explant livers

OBJECTIVES: Focal nodular hyperplasia-like nodules (FNH-like nodules) are focal lesions occurring in liver cirrhosis and are morphologically very similar to classical FNH in an otherwise normal liver. They are sometimes misdiagnosed as hepatocellular carcinoma (HCC) on imaging because both types of lesions show arterial-phase enhancement. Although the morphological, immunohistochemical, and imaging features of FNH-like nodules are well-known, their pathogenesis and role in hepatocarcinogenesis have not been studied in detail. Therefore, we performed a detailed pathological evaluation of 130 cirrhotic explant livers and correlated these data with the clinical features of the patients. METHODS: All cirrhotic explant livers were uniformly sliced at 5-mm intervals and all detected focal lesions were microscopically classified according to internationally accepted criteria. The obtained data regarding FNH-like nodules were then correlated with other pathological findings and with clinical data obtained during pretransplant evaluation and recorded in a database. RESULTS: FNH-like nodules were present in 15% of patients and their small size (75% of cases < 1 cm) appears to preclude detection by imaging in almost all cases. The presence of esophageal varices and pretransplant treatment with chemoembolization were independently and significantly associated with the presence of FNH-like nodules. There were no associations between FNH-like nodules on the one hand and low-grade dysplastic nodules, high-grade dysplastic nodules, and HCCs on the other hand. CONCLUSIONS: The clinicopathological features of FNH-like nodules support the hypothesis that vascular alterations in liver cirrhosis play an important role in their pathogenesis and that FNH-like nodules do not have an increased risk of malignant transformation.     

Focal nodular hyperplasia-like nodule with reduced expression of organic anion transporter 1B3 in alcoholic liver cirrhosis

We report a patient with alcoholic liver cirrhosis who had a 15 mm focal nodular hyperplasia (FNH)-like nodule in the liver. This FNH-like nodule was diagnosed as hepatocellular carcinoma (HCC) mainly based on hypervascularity during the hepatic arterial phase, washout pattern during the equilibrium phase and low signal intensity during the hepatobiliary phase in gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI; it was surgically resected. Its histology exhibited hepatocyte hyperplasia, fibrous septa containing unpaired small arteries accompanied by reactive bile ductules, remarkable iron deposits and sinusoidal capillarization, and was compatible with the diagnosis of an FNH-like nodule. When we analyzed the images of the present nodule retrospectively, low signal intensity on in-phase and isosignal intensity on opposed-phase T1-weighted MRI may have reflected iron deposits in the FNH-like nodule. In addition, a low signal intensity on T2-weighted MRI and no detection in diffusion-weighted MRI may help in distinguishing FNH-like nodules from HCC, since these image findings are inconsistent with typical HCC. Immunohistochemical analysis revealed a markedly reduced expression of organic anion transporter (OATP) 1B3 in this nodule, which implied decreased Gd-EOB-DTPA uptake by hepatocytes and accounted for the low signal intensity during the hepatobiliary phase on Gd-EOB-DTPA-enhanced MRI. To the best of our knowledge this is the first report in which an FNH-like nodule was assessed for OATP1B3 expression.     

Patients with nodular regenerative hyperplasia should be considered for hepatocellular carcinoma screening

The incidence of hepatocellular carcinoma (HCC) appears to be increasing across the globe. Well‐established protocols for screening are available, and the most common underlying liver problem associated with the development of HCC is cirrhosis. However, with few exceptions, patients without cirrhosis are generally not screened for HCC. Nodular regenerative hyperplasia (NRH) is not associated with the development of significant fibrosis or impaired liver synthetic function. The major clinical impact of NRH appears to be in the development of portal hypertension. Patients with NRH are also not recommended to undergo routine screening for the development of HCC. This report describes a case of a 44‐year‐old woman with NRH found to have de novo HCC. Emerging evidence suggest a possible pathogenetic relationship between NRH and HCC. The case described here and our review of the published work suggests that additional studies regarding the epidemiological association between NRH and HCC may change the current notion that NRH is not a premalignant lesion, and further studies assessing the utility of routine screening of NRH patients for HCC should be considered.     

Imaging of focal nodular hyperplastic-like nodules in alcoholic liver cirrhosis patients using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid magnetic resonance imaging

We report on two patients with a history of alcohol abuse who presented with multiple hepatic nodules. Dynamic computed tomography revealed multiple nodular lesions, which were enhanced at the early contrast phase and washed out at the portal phase. In the hepatobiliary phase using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid magnetic resonance imaging (Gd-EOB-DTPA MRI), these tumors did not show any uptake, thus suggesting the presence of hepatocellular carcinoma. An ultrasound-guided biopsy revealed a slight increase in cell density, sinusoidal dilatation, and contained unpaired small arteries. According to immunohistochemical analyses, these arteries were positive for CD34 and alpha-smooth muscle actin. From these findings, the nodules were diagnosed to be focal nodular hyperplastic (FNH)-like nodules arising in alcoholic-cirrhosed livers. The differential diagnosis of FNH-like nodules arising in alcoholic liver cirrhosis and hepatocellular carcinoma is difficult with Gd-EOB-DTPA MRI, and therefore histological confirmation is necessary.     

Research on focal nodular hyperplasia with MSCT and postprocessing

AIM： To investigate and evaluate the pathological features and diagnostic value of focal nodular hyperplasia （FNH） with multiection spiral computed tomography （MSCT） and postprocessing. METHODS： A total of 25 patients with FNH who had undergone MSCT and postprocessing were included in the investigation. All patients had been pathologically or clinically confirmed with FNH. A number of 75 cases of hepatic carcinomas, hemangiomas and adenomas were randomly selected at a same period for a comparative study. RESULTS： There was a single focus in 22 cases and multiple foci in 3 cases. On the plain scan, 17 lesions showed hypodensity, 7 isodensity and 4 hyperdensity （the case with fatty liver）. With contrast, 28 lesions were enhanced evenly or in the nodules in the arterial phase; 13 lesions still showed hyperdensity, 11 lesions isodensity and 4 lesions hypodensity in the parenchymatous phase; in the delayed phase only 5 lesions showed hyperdensity but 9 lesions showed isodensity or slight hypodensity and 14 lesions showed hypodensity. Twelve lesions of 28 had central asteroid scars. Thickened feeding arteries in postprocessing were seen in 24 lesions, and were integrated into the parenchymatous lesions with a gradual and smooth course. On the contrary, there were no artery penetrated into the lesion found in any of comparative hepatic tumors. CONCLUSION： Doctors could make a correct diagnosis and differentiation of FNH on evaluation of the characteristic appearance on MSCT with postprocessing,     

Improved diagnosis of well‐differentiated hepatocellular carcinoma with gadolinium ethoxybenzyl diethylene triamine pentaacetic acid‐enhanced magnetic resonance imaging and Sonazoid contrast‐enhanced ultrasonography

Aim: Two new imaging modalities have been developed recently that are directed at the focal liver lesions: gadolinium ethoxybenzyl diethylene triamine pentaacetic acid (Gd‐EOB‐DTPA)‐enhanced magnetic resonance imaging (MRI) and Sonazoid contrast‐enhanced ultrasonography (CEUS). We investigated the usefulness of these modalities for the diagnosis of small (<2 cm), well‐differentiated hepatocellular carcinoma (HCC). Methods: A total of 15 nodules from 13 patients, which were histologically diagnosed as well‐differentiated HCC, were subjected to this study. Lesions that showed hypervascularity in the arterial phase and washout in the portal or late non‐hemodynamic phase were regarded as HCC in the dynamic studies of all imaging modalities. Results: By multidetector computed tomography (MDCT), six of 15 (40%) nodules were diagnosed as HCC. Gd‐EOB‐DTPA‐enhanced MRI diagnosed HCC in nine of the 15 (60%) nodules. Of the nine nodules that were not diagnosed by MDCT, four could be diagnosed by Gd‐EOB‐DTPA‐enhanced MRI. In Sonazoid CEUS, 10 of 15 nodules (67%) were diagnosed as HCC. Four of nine nodules that could not be diagnosed as HCC by MDCT, were diagnosed by Sonazoid CEUS. A total of 11 of the 15 (73%) nodules were diagnosed as HCC by Gd‐EOB‐DTPA‐enhanced MRI and Sonazoid CEUS in addition to MDCT. Conclusion: Gd‐EOB‐DTPA‐enhanced MRI and Sonazoid CEUS had greater diagnostic value for small, well‐differentiated HCC than did conventional MDCT.     

Contrast imaging techniques to diagnose hepatocellular carcinoma in cirrhotics outside regular surveillance

Introduction and aimThe American Association for the Study of the Liver (AASLD) recommends contrast computerized tomography (CT-scan) and magnetic resonance (MRI) to diagnose hepatocellular carcinoma (HCC) arising in cirrhotic patients under semiannual surveillance with abdominal ultrasound (US). A US guided fine needle biopsy (FNB) serves the same purpose in radiologically undiagnosed tumors and incidentally detected nodules in cirrhotics outside surveillance. In this population, we evaluated the performance of radiological diagnosis of HCC according to 2010 AASLD recommendations.Materials and methodsAll cirrhotic patients with a liver nodule incidentally detected by US were prospectively investigated with a sequential application of CT-scan/MRI examination and a FNB.ResultsBetween 2011 and 2015, 94 patients (mean age 67 years) had a liver nodule (total 120) detected by US in the context of histologically confirmed cirrhosis. Mean nodules diameter was 40 (10–160) mm, 87 (73%) <5 cm. At histology, 84 (70%) nodules were HCC, 8 (7%) intrahepatic cholangiocarcinoma, 6 (5%) metastases, 2 (2%) neuroendocrine tumors and 20 (16%) benign lesions. Hyperenhancement in arterial phase followed by wash-out in venous phases on at least one radiological technique was demonstrated in 62 nodules (61 HCC, 1 high grade dysplastic nodule), with a specificity of 97% (IC95%: 85–100%), sensitivity 73% (IC95%: 62–81%) and diagnostic accuracy 80%, being 64% for ≥5 cm HCC. Sensitivity of AFP >200 ng/mL was 12% (IC95%: 6–23%).ConclusionA single contrast imaging technique showing a typical contrast pattern confidently identifies HCC also in cirrhotic patients with an incidental liver nodule, thereby reducing the need for FNB examinations.     

Focal nodular hyperplasia coexistent with hepatoblastoma in a 36-d-old infant

Focal nodular hyperplasia(FNH) is a benign hepatic tumor characterized by hepatocyte hyperplasia and a central stellate scar.The association of FNH with other hepatic lesions,such as adenomas,hemangiomas and hepatocellular carcinoma,has been previously reported,but FNH associated with another hepatic tumor is rare in infants.Here we report a case of FNH coexistentwith hepatoblastoma in a 36-d-old girl.Computed tomography(CT) imaging showed an ill-delineated,inhomogeneous enhanced mass with a central star-like scar in the right lobe of the liver.The tumor showed early mild enhancement at the arterial phase(from 40 HU without contrast to 52 HU at the arterial phase),intense enhancement at the portal phase(87.7HU) and 98.1HU in the 3-min delay scan.A central scar in the tumor presented as low density on non-contrast CT and slightly enhanced at delayed contrast-enhanced scanning.This infant underwent surgical resection of the tumor.Histopathology demonstrated typical FNH coexistent with a focal hepatoblastoma,which showed epithelioid tumor cells separated by proliferated fibrous tissue.     

Enhanced glypican-3 expression differentiates the majority of hepatocellular carcinomas from benign hepatic disorders

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) is a common malignant tumour worldwide, and its differential diagnosis from benign lesions of the liver is often difficult yet of great clinical importance. In the present study, we analysed whether glypican-3 is useful in differentiating between benign and malignant liver diseases and whether it influences the growth behaviour of HCC. METHODS: Northern blot analysis and in situ hybridisation. RESULTS: Northern blot analysis indicated that expression of glypican-3 mRNA was either low or absent in normal liver, in focal nodular hyperplasia (FNH), and in liver cirrhosis. In contrast, expression of glypican-3 mRNA was markedly increased in 20 of 30 and moderately increased in five of 30 HCC samples. The average increase in glypican-3 mRNA expression in HCC was significant compared with expression in normal liver (21.7-fold increase, p<0.01). In comparison with FNH or liver cirrhosis, glypican-3 mRNA expression in HCC was increased 7.2- (p<0.05) and 10.8-fold (p<0.01), respectively. In addition, pushing HCCs exhibited significantly higher glypican-3 mRNA expression than invading tumours (p<0.05). In situ hybridisation analysis demonstrated weak expression of glypican-3 mRNA in normal hepatocytes and bile ductular cells, and weak to occasionally moderate signals in hepatocytes forming nodules of liver cirrhosis and in regenerated hepatic nodules of FNH. In contrast, glypican-3 in situ hybridisation signals were intense in hepatic cancer cells with even higher levels in pushing HCCs than in invading HCCs. CONCLUSIONS: These findings suggest that glypican-3, in many cases, has the potential to differentiate between benign and malignant liver diseases.