Trans-caval trans-jugular liver biopsy—a technical modification of trans-jugular liver biopsy

Objective:

To (a) describe the technical modification of trans-caval TJLB and (b) review our series of nine cases.

Methods:

We performed a retrospective review of all trans-caval TJLBs performed; we assessed indications for the procedure, technical success, complications, adequacy of specimen and histological positivity.

Results:

The technical success rate of the procedure was 9/9 (100%); the minor complication rate was 1/9 (11%), adequate specimen was obtained in all cases and a histological diagnosis was achieved in 8/9 (89%) cases.

Conclusion:

This preliminary report suggests that trans-caval modification of TJLB is a relatively safe procedure that may be useful in cases where conventional TJLB is infeasible.

Advances in knowledge:

(a) We describe the technique of trans-caval TJLBs and report our findings in the largest series of published cases. (b) Trans-caval TJLB is relatively safe and can be used to increase the success rates of conventional TJLB.Trans-jugular liver biopsy (TJLB) is an established technique in patients unsuitable for a percutaneous trans-abdominal liver biopsy. TJLB procedure involves biopsy of the liver parenchyma through trans-jugular venous access, with the biopsy needle placed in the right hepatic vein (commonly described) or the middle or left hepatic veins. However, a TJLB may be not technically feasible in a small subset of cases where hepatic venous cannulation is not possible, owing to unsuitable hepatic venous anatomy, occluded hepatic veins [Budd–Chiari syndrome (BCS)] or markedly shrunken liver. In such cases, a technical modification of TJLB, called a direct trans-caval TJLB, can be performed. In this study, we (a) describe the technical modification of the trans-caval TJLB and (b) review the results of a series of nine cases where the trans-caval TJLB was carried out.     

Preoperative detection of colorectal liver metastases in fatty liver: MDCT or MRI?

Objective

To compare the diagnostic value of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the preoperative detection of colorectal liver metastases in diffuse fatty infiltration of the liver, associated with neoadjuvant chemotherapy.

Materials and methods

Twenty preoperative tri-phasic MDCT (4-64-row, Siemens) and dynamic contrast-enhanced MRI (1.5 T or 3.0 T, Siemens) examinations of patients with colorectal cancer and liver metastases in diffuse steatosis were retrospectively evaluated. All patients underwent surgical resection for liver metastases (time interval 1-60 days). The amount of fatty infiltration of the liver was determined histopathologically by semi-quantitative percent-wise estimation and ranged from 25 to 75%.

Results

Overall, 51 metastases were found by histopathology of the resected liver segments/lobes. The size of the metastases ranged from 0.4 to 13 cm, with 18 (35%) being up to 1 cm in diameter. In the overall rating, MDCT detected 33/51 lesions (65%), and MRI 45/51 (88%). For lesions up to 1 cm, MDCT detected only 2/18 (11%) and MRI 12/18 (66%). One false positive lesion was detected by MDCT. Statistical analysis showed that MRI is markedly superior to MDCT, with a statistically significant difference (p < .001), particularly for the detection of small lesions (≤1 cm; p < .004). There was no significant difference between the two modalities in the detection of lesions > 1 cm.

Conclusion

For the detection of colorectal liver metastases after neoadjuvant chemotherapy and consecutive diffuse fatty infiltration of the liver, MRI is superior to MDCT, especially for the detection of small lesions.     

Acoustic radiation force impulse elastography of the liver: can fat deposition in the liver affect the measurement of liver stiffness?

Purpose  

The aim of this study was to compare acoustic radiation force impulse (ARFI) results between livers with and without fat deposition.     

Chronological evaluation of liver enhancement in patients with chronic liver disease at Gd-EOB-DTPA-enhanced 3-T MR imaging: does liver function correlate with enhancement?

Purpose  

To investigate the chronological relationship between scan delay and liver enhancement for the hepatobiliary phase on Gd-EOB-DTPA-enhanced MRI and evaluate the effects of liver function on liver enhancement.     

Pediatric liver tumors – a pictorial review

Hepatic masses constitute about 5–6% of all intra-abdominal masses in children. The majority of liver tumors in children are malignant; these malignant liver tumors constitute the third most common intra-abdominal malignancy in the pediatric age group after Wilms’ tumor and neuroblastoma. Only about one third of the liver tumors are benign. A differential diagnosis of liver tumors in children can be obtained based on the age of the child, clinical information (in particular AFP) and imaging characteristics. The purpose of this review is to report typical clinical and imaging characteristics of benign and malignant primary liver tumors in children.     

Preparation of crystalline bovine liver β-glucuronidase

Summary A method is described for the preparation of pure -glucuronidase from bovine liver. The procedure includes ammonium sulfate, acetone and ethanol fractionation and a simple two-step ion exchange chromatography. The yield is acceptable and the method requires only standard laboratory equipment. The pure enzyme is easily crystallized from ammonium sulfate. Some practical applications of the pure -glucuronidase are discussed.     

Measurement of liver T₁ and T₂ relaxation times in an experimental mouse model of liver fibrosis

Purpose:

To characterize changes in relaxation times of liver using quantitative magnetic resonance imaging (MRI) in an experimental mouse model of liver fibrosis. Quantitative MRI is a potentially robust method to characterize liver fibrosis. However, correlation between relaxation times and fibrosis stage has been controversial.

Materials and Methods:

Liver fibrosis was induced in male adult C57BL/6N mice (22–25 g; n = 12) by repetitive dosing of carbon tetrachloride (CCl₄). The animals were examined with a series of spin‐echo (SE) images with varying TRs and multiecho SE imaging sequence at 7 T before and 2, 4, 6, and 8 weeks after CCl₄ insult. Hepatic T₁ and T₂ values were measured. Histology was performed with hematoxylin‐eosin staining and Masson's trichrome staining.

Results:

Significant increase (P < 0.001) in hepatic T₁ was found at 2, 4, 6, and 8 weeks following CCl₄ insult as compared with that before insult. Meanwhile, hepatic T₂ at 2, 4, 6, and 8 weeks after CCl₄ insult was significantly higher (P < 0.001) than that before the insult. Liver histology showed collagen deposition, edema, and infiltration of inflammatory cells in livers with CCl₄ insult.

Conclusion:

Both longitudinal and transverse relaxation times may serve as robust markers for liver fibrosis. With the advent of single breath‐hold sequences for MR relaxometry, quantitative mapping of relaxation times can be routinely and reliably performed in abdominal organs and hence may be valuable and robust in detecting liver fibrosis at early phase and monitoring its progression. J. Magn. Reson. Imaging 2012;36:152–158. © 2012 Wiley Periodicals, Inc.     

Detection of liver metastasis: is diffusion-weighted imaging needed in Gd-EOB-DTPA-enhanced MR imaging for evaluation of colorectal liver metastases?

Purpose

We compared diagnostic ability for detecting hepatic metastases between gadolinium ethoxy benzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) on a 1.5-T system, and determined whether DWI is necessary in Gd-EOB-DTPA-enhanced MRI for diagnosing colorectal liver metastases.

Materials and methods

We assessed 29 consecutive prospectively enrolled patients with suspected metachronous colorectal liver metastases; all patients underwent surgery and had preoperative Gd-EOB-DTPA-enhanced MRI. Overall detection rate, sensitivity for detecting metastases and benign lesions, positive predictive value, and diagnostic accuracy (Az value) were compared among three image sets [unenhanced MRI (DWI set), Gd-EOB-DTPA-enhanced MRI excluding DWI (EOB set), and combined set].

Results

Gd-EOB-DTPA-enhanced MRI yielded better overall detection rate (77.8?C79.0?%) and sensitivity (87.1?C89.4?%) for detecting metastases than the DWI set (55.9?% and 64.7?%, respectively) for one observer (P?<?0.001). No statistically significant difference was seen between the EOB and combined sets, although several metastases were newly detected on additional DWI.

Conclusions

Gd-EOB-DTPA-enhanced MRI yielded a better overall detection rate and higher sensitivity for detecting metastases compared with unenhanced MRI. Additional DWI may be able to reduce oversight of lesions in Gd-EOB-DTPA-enhanced 1.5-T MRI for detecting colorectal liver metastases.     

Combination of ablation and embolization for intermediate-sized liver metastases from colorectal cancer: what can we learn from treating primary liver cancer?

Colorectal cancer liver metastases (CRLMs) are common. Treating CRLMs with thermal ablation can prolong survival, but compared to lesions smaller than 3 cm, local control rates and overall survival are relatively worse with larger, intermediate (3–5 cm) lesions. Local recurrence rates range between 1.7%–20.2% and 6.7%–68.9% for CRLMs less than 3 cm and greater than 3 cm, respectively. Worse outcomes are also present when ablating intermediate size hepatocellular carcinoma (HCC) and there are some pathological similarities with CRLMs, namely the presence of micrometastatic disease. Combining ablation with transarterial chemoembolization is more effective in treating intermediate-size HCC than ablation alone. A meta-analysis of robust randomized controlled trials demonstrated long-term improved survival with combination therapy compared to ablation alone (odds ratio at 1, 3 and 5 years of 2.74, 2.77 and 5.23, respectively). There is, however, minimal evidence for combination therapy in CRLMs, limited to a handful of studies that are predominantly retrospective and have heterogeneous inclusion criteria. Given the difficulty in successfully treating intermediate CRLMs, the strong evidence for combination therapy in intermediate HCC and potential pathological similarities, formal evaluation of combination treatment in CRLM is merited. This review highlights existing evidence for treatment of intermediate-size liver lesions and highlights where trials in CRLMs should focus.

Colorectal cancer was the third most common cancer in the world in 2018 with nearly 2 million cases and it had the second highest number of cancer-related deaths (1). Colorectal liver metastases (CRLMs) are present in around a third of patients with colorectal cancer (2). Surgery, aiming for a complete “R0 resection”, is the gold standard treatment of CRLMs in anatomically and clinically appropriate cases (3), yet despite this, only around a quarter of patients with CRLMs achieve hepatic resection (2). In patients with CRLMs that are not amenable to resection primarily or after systemic therapy and in those unfit for surgery, local ablative therapies can be considered. Ablative therapies can also be considered in conjunction with resection (4) and can prolong survival when used in addition to chemotherapy (5).These local ablative therapies include both local and locoregional treatments. Microwave ablation (MWA) and radiofrequency ablation (RFA) are local thermal treatments and are now commonly used in the treatment of CRLMs. Locoregional interventions include transarterial chemoembolization (TACE) and radioembolization.Thermal ablative methods can provide effective local control of CRLM, with the lowest rates of local recurrence achieved in lesions smaller than 3 cm (6, 7). There is evidence that combining thermal ablation with TACE in treating larger hepatocellular carcinoma (HCC) improves long-term survival with no increase in complications (8), but data supporting this combination approach (ablation and TACE or bland embolization) for treatment of larger CRLMs are lacking.This review aims to examine the current published data evaluating treatment of intermediate-size liver tumors (3–5 cm) with thermal ablation alone and combination therapy with TACE and ablation. Outcome data in HCC is summarized and areas for further research in the field of CRLM are highlighted.     

MRI of the liver: Can true FISP replace HASTE?

PURPOSE: To determine the diagnostic accuracy of two fast breath-hold magnetic resonance (MR) imaging sequences, half-Fourier acquired single turbo spin-echo (HASTE) and true fast imaging with steady state precession (TrueFISP), for the detection and characterization of focal liver lesions MATERIALS AND METHODS: A total of 186 patients with suspected focal liver lesions were enrolled in this study. All patients underwent the same standardized study protocol including HASTE and TrueFISP. A consensus reading based on all available image data served as a standard of reference for classifying lesions into cysts, hemangiomas, focal nodular hyperplasia, or malignant/other lesions. All malignant lesions, as well as hepatic adenomas and abscesses, were histologically verified. Each separated by an eight-week interval, HASTE and TrueFISP images were retrospectively reviewed in random order for the detection and characterization of focal hepatic lesions. Finally, a receiver operating characteristic (ROC) analysis was calculated. RESULTS: HASTE images had an overall sensitivity of 0.86 and a specificity of 0.91, whereas TrueFISP showed an overall sensitivity and specificity of 0.79 and 0.83, respectively (p>0.1). CONCLUSION: Neither HASTE nor TrueFISP alone are sufficient for the detection and characterization of hepatic lesions.     

Hollow fiber–liquid phase microextraction of barbiturates in liver samples

Barbiturates, especially phenobarbital, are involved in intoxication cases in Brazil and other countries. Liver tissue can be a useful alternate specimen when blood is not available (decomposition, severe fire, and exsanguination cases). Because the liver is a very complex matrix, it is essential is to eliminate potential interfering substances in this specimen before instrumental analysis of target compounds. In recent years, novel strategies for sample preparation have gained acceptance in the field of analytical toxicology. The objective of this work was to develop a gas chromatography–mass spectrometry (GC–MS) method using hollow fiber–liquid phase microextraction (HF–LPME) for determination of barbiturates (phenobarbital, secobarbital, pentobarbital, and butalbital) in liver samples. An aliquot of homogenized and acidified liver in aqueous solution (equivalent to 50 mg tissue) was submitted to extraction by the use of a 9-cm hollow fiber. The fiber was filled with eucalyptus oil in its pores and its lumen was filled with a NaOH solution (pH 13; acceptor phase). After extraction in an ultrasonic bath for 5 min, the acceptor phase was withdrawn and derivatized in the injector port of the GC–MS with trimethylanilinium hydroxide for flash methylation. A totally “green chemistry” approach of the sample extraction was obtained, because relatively large amounts of organic solvent generally used for extraction could be substituted by an essential oil used as a supported liquid membrane for HF–LPME. This method was validated and successfully applied to liver samples collected from five deceased persons with previous history of exposure to barbiturates. Phenobarbital concentrations in the liver found in these actual cases ranged from 1.3 to 16.7 μg/g.     

Screening of biomarkers for liver adenoma in low-dose-rate γ-ray-irradiated mice

Purpose: Chronic low-dose-rate (20 mGy/day) γ-irradiation increases the incidence of hepatocellular adenomas (HCA) in female B6C3F1 mice. The purpose of this study is to identify potential serum biomarkers for these HCAs by a new approach.

Material and methods: Microarray analysis were performed to compare the gene expression profiles of HCAs from mice exposed to low-dose-rate γ-rays with those of normal livers from non-irradiated mice. From the differentially expressed genes, those for possibly secretory proteins were selected. Then, the levels of the proteins in sera were analysed by ELISA.

Results: Microarray analysis identified 4181 genes differentially expressed in HCAs (>2.0-fold). From these genes, those for α-fetoprotein (Afp), α-1B-glycoprotein (A1bg) and serine peptidase inhibitor Kazal type-3 (Spink3) were selected as the genes for candidate proteins. ELISA revealed that the levels of Afp and A1bg proteins in sera significantly increased and decreased, respectively, in low-dose-rate irradiated mice with HCAs and also same tendency was observed in human patients with hepatocellular carcinomas.

Conclusion: These results indicate that A1bg could be a new serum biomarker for liver tumor. This new approach of using microarray to select genes for secretory proteins is useful for prediction of novel tumor markers in sera.     

The use of <Superscript>18</Superscript>F-FDG PET/CT in colorectal liver metastases—comparison with CT and liver MRI

PURPOSE: We compared 18-fluoro-2-deoxyglucose ((18)F-FDG) positron emission tomography-CT (PETCT) with contrast-enhanced whole-body CT (ceCT) in identifying extrahepatic disease and with manganese dipyridoxyl diphosphate (Mn-DPDP) liver MRI for liver metastases in patients with colorectal liver metastases being considered for surgery. METHODS: Sixty-five patients (median age 65 years; 42 men) with colorectal cancer and known or suspicious liver metastases and who underwent a PETCT, ceCT and Mn-DPDP MRI were identified. Results were retrospectively reviewed for extrahepatic disease on PETCT and ceCT, and for the presence and number of liver metastases on PETCT and Mn-DPDP MRI. Proof of metastases was based on histopathology or clinical/imaging follow-up, demonstrating disease progression or response. RESULTS: PETCT identified unexpected extrahepatic disease not detected on ceCT, leading to change in surgical management in 17%. There were three other false-positive cases on PETCT. For liver metastases on a per-patient basis, the sensitivity and specificity of both PETCT and Mn-DPDP MRI were 98% and 100%, respectively. On a per-lesion basis, PETCT and MRI were discordant in 15% (10/66 scans). MRI correctly identified more sub-centimeter metastases in eight scans. PETCT correctly identified more metastases in one case and confirmed disease in one equivocal MRI. CONCLUSION: PETCT has incremental benefit over conventional ceCT in identifying extrahepatic disease in metastatic colorectal cancer. PETCT has high sensitivity and specificity for the presence of liver metastases and should be included early in initial pre-surgical evaluation and could potentially guide the use of Mn-DPDP MRI. However, Mn-DPDP MRI is superior for small liver metastases and remains a prerequisite for surgical planning in patients with confined liver metastases.