Contrast-enhancing hepatic eosinophilic abscess during the hepatic arterial phase: a mimic of hepatocellular carcinoma

OBJECTIVE: Our objective was to review CT, MR, angiographic, and sonographic images obtained in patients with histopathologically proven contrast-enhancing hepatic eosinophilic abscesses during the hepatic arterial phase. CONCLUSION: On CT, MR, and angiographic images, eosinophilic abscess in the liver can show contrast enhancement during the hepatic arterial phase. If patients have peripheral hypereosinophilia or are at low risk for hepatocellular carcinoma or hepatic metastasis, those with small arterial-enhancing hepatic nodules need further preoperative evaluation, such as a sonographically guided biopsy.     

Double phase CT during hepatic arteriography for diagnosis of hepatocellular carcinoma

RATIONALE AND OBJECTIVES: The purpose of this study is to assess the diagnostic impact of double phase computed tomography during hepatic arteriography for hepatocellular carcinoma. MATERIALS AND METHODS: 118 hepatocellular carcinomas in 73 cirrhotic patients who underwent double phase computed tomography during hepatic arteriography were enrolled in this study. Double phase computed tomography during hepatic arteriography consisted of computed tomography images obtained at 5-10 s (first phase) and 40-50 s (second phase) after the initiation of an intraarterial administration of 40-60 ml of contrast medium through the hepatic artery. Diagnostic accuracy of the first phase computed tomography during hepatic arteriography alone and double phase computed tomography during hepatic arteriography images for hepatocellular carcinoma were separately analyzed by three blinded readers independently. Alternative-free response receiver operating characteristic curves were constructed to compare each set of computed tomography during hepatic arteriography images. RESULTS: The detection sensitivity of the double phase CTHA for HCC (mean, 83.1%) was significantly higher than that of the first phase CTHA alone (mean, 73.4%) (P < 0.01). Moreover, the positive predictive value of the double phase CTHA (mean, 93.7%) was higher than that of the first phase CTHA alone (87.4%). The area under the AFROC curve (Az value) of the double phase CTHA (mean, 0.88) was significantly higher than that of the first phase CTHA alone (mean, 0.77) (P < 0.05). CONCLUSIONS: Double phase computed tomography during hepatic arteriography can improve the diagnostic accuracy of hepatocellular carcinoma.     

Visualization of hepatic lymphatic vessels during transcatheter arterial chemoembolization for hepatocellular carcinoma

PURPOSE: To analyze visualization of hepatic lymphatic vessels during transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Retrospective review was conducted of 255 tumors in 161 patients treated by TACE with catheterization of the most distal portion of the tumor-feeding branches. All TACE procedures were performed with use of a mixture of iodized oil and anticancer drugs followed by gelatin sponge particles. Arteriograms and spot radiographs obtained during TACE were reviewed to determine whether hepatic lymphatic vessels appeared. Serial computed tomography (CT) images after TACE were evaluated along with clinical symptoms in cases that exhibited lymphatic vessel visualization. RESULTS: Hepatic lymphatic vessels were demonstrated in eight tumors (3.1%) in eight patients during TACE. The mean tumor diameter was 1.7 cm +/- 0.7 (range, 1.0-3.3 cm), and mean volume of injected iodized oil was 1.7 mL +/- 1.0 (range, 1-4 mL). Lymphatic vessels were demonstrated followed by marked portal vein visualization (n = 5) or extravasation of a small amount of contrast material (n = 2). In the remaining patient, these were depicted during the early stage of the TACE procedure. On CT after 1 week, iodized oil in the lymphatic systems in the hepatoduodenal ligament was seen in six patients, and it was shown to have been retained in four of these patients on follow-up CT performed 2, 7, 11, and 21 months later, respectively. None of these patients presented any clinical symptom other than postembolization syndrome. CONCLUSIONS: Hepatic lymphatic vessels were demonstrated in 3.1% of tumors treated by ultraselective TACE. Iodized oil in the lymphatic vessels may be retained for a relatively long time without specific symptoms.     

Value of hepatic arterial phase CT versus lipiodol ultrafluid CT in the detection of hepatocellular carcinoma

OBJECTIVE: To evaluate the role of hepatic arterial phase (HAP) spiral computed tomography (CT), as compared with iodized oil (Lipiodol ultrafluid [LUF]) CT for revealing nodular hepatocellular carcinomas (HCC). METHODS: Twenty-four cirrhotic patients underwent two-phase HCT examination: HAP 25 seconds and portal phase 70 seconds after injection of 1.5 mL/Kg contrast medium. All patients also underwent hepatic angiography and intraarterial infusion of iodized oil; LUF CT was performed 3-4 weeks after infusion. HCT images were compared with LUF CT images for detection of hepatic nodules. RESULTS: We found no significant difference between the sensitivity of HAP CT and LUF CT for nodules >10 mm, while HAP CT was more sensitive than LUF CT in revealing nodules <10 mm (47 vs. 27, p < 0.001). CONCLUSIONS: HCT should be considered as the first method for the detection of HCC, whereas LUF CT should be used only for therapy.     

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.     

肝动脉导管栓塞化疗治疗肝癌的护理

目的:探讨肝动脉栓塞化疗治疗肝癌的术前、术后的护理措施。方法:对36例行TACE的患者在术前充分准备、术后精心护理。结果:肝动脉栓塞化疗治疗有效率82 % ,术后出现不良反应的患者,经对症治疗、护理均痊愈。结论:肝动脉栓塞化疗治疗肝癌是手术不能切除或术后复发HCC的首选方法,细致、周到的护理是治疗成功的重要保证     

平阳霉素碘油乳剂栓塞治疗原发性肝癌的临床研究

评价平阳霉素碘油乳剂肝动脉栓塞对原发性肝癌肿瘤血管的祛血管作用及其强度和相应临床疗效。方法：对１１例原发性肝癌肝动脉注入ＰＬＥ,同期１８例原发性肝癌以丝裂霉素碘油乳剂作对照,观察并比较两组栓塞后肿瘤血管及肿瘤体积变化。结论ＰＬＥ对原发性肝癌肿瘤血管有祛血管作用,其强度大于ＭＬＥ。祛血管同时伴随肿瘤体积缩小。     

CTHA和CTAP在肝癌介入治疗中的应用

目的:研究肝动脉造影CT和经动脉门脉造影CT在肝癌介入治疗中的应用价值和意义。方法:10例原发性肝癌介入治疗前行肝动脉造影CT(CTHA)和经动脉门脉造影CT(CTAP)检查;术中行数字减影肝动脉造影(DSA)。结果:CTHA、CTAP联合检查与常规CT、DSA比较,分别多发现新癌灶11个(26/37)和12个(25/37)。准确判断非复发癌灶2个和1个坏死灶。结论:CTHA、CTAP是肝癌介入治疗前准确判断肿瘤数量和存活度最敏感和准确的方法,对于介入治疗方案的实施、疗效评价有很重要的作用。     

Influence of hepatic arterial embolization on diabetic patients with hepatocellular carcinoma

Uncontrollable change of diabetes mellitus (DM) has occurred in one of our patients who had received hepatic arterial embolization (HAE) for hepatocellular carcinoma (HCC). This prompted us to examine the influence of HAE to the diabetic patients with HCC. Thirty-four patients accompanying DM who had received HAE were examined fasted blood glucose (FBG) and the liver function before and after the procedure. HAE was performed using Gelatin Sponge and Lipiodol containing anticancer agents, either alone or combined. Of 34 patients 6 showed increase of FBG level of more than two times after HAE. The FBG level had a tendency to elevate as the grade of DM advanced. The tendency was also recognized on pre-HAE oral glucose tolerance test. However, FBG elevation had no relation to the changes of liver function (GPT, Choline Esterase), the difference of embolic materials and pre-HAE status of DM control. From the results, one must be aware that HAE or Lipiodol infusion to diabetic patients with HCC sometimes may cause uncontrollable change of DM, especially in case of advanced DM patients. Consequently, careful follow-up of HCC as DM is advisable for improvement of the patients' prognosis.     

Detection of hypervascular hepatocellular carcinoma by dynamic magnetic resonance imaging with double-echo chemical shift in-phase and opposed-phase gradient echo technique: comparison with dynamic helical computed tomography imaging with double arterial phase

PURPOSE: The technique of double-echo chemical shift gradient echo magnetic resonance imaging (MRI) with the fast low-angle shot (double-echo FLASH) sequence provides in-phase and opposed-phase images in a single breath hold. The purpose of this study was to evaluate the efficacy of dynamic MRI with double-echo FLASH imaging for the detection of hypervascular hepatocellular carcinoma by comparing it with dynamic helical computed tomography (CT) imaging with double arterial phase. MATERIALS AND METHODS: Twenty-nine patients with 67 hypervascular hepatocellular carcinoma nodules who underwent both dynamic MRI with double-echo FLASH imaging (repetition time/echo time/flip angle: 160/3.6, 7.0/80 degrees ) and dynamic helical CT imaging with double arterial phase were enrolled in the study. For dynamic MRI, precontrast, arterial, portal venous, and equilibrium phase images were obtained before and approximately 19, 60, and 120 seconds, respectively, after intravenous injection of 0.1 mmol/kg of gadopentetate dimeglumine at a rate of 2 ml/s. For dynamic CT imaging, quadraphase images, including early arterial, late arterial, portal venous, and equilibrium phases, were obtained serially approximately 20, 30, 70, and 180 seconds, respectively, after intravenous administration of 2 ml/kg of 300 mgI/ml of nonionic contrast medium at a rate of 5 ml/s. Three masked observers independently interpreted images obtained with each technique in random order, separately and without patient identifiers. Sensitivity and positive predictive values as well as the area below the alternative-free response receiver operating characteristic curve (Az) for each imaging technique were calculated and compared statistically. RESULTS: Mean sensitivity and positive predictive values of MRI for hypervascular hepatocellular carcinoma were 48% and 94%, respectively, and those of CT imaging were 47% and 91%, respectively. In 11 (38%) of the 29 patients, at least one observer judged dynamic MRI to be superior, whereas in 5 patients (17%), dynamic CT was judged to be superior. There was no significant difference in the sensitivity and positive predictive values between these techniques (p > 0.05). There was no significant difference either in mean Az values between CT (0.55) and MRI (0.57) (p = 0.61). CONCLUSION: Dynamic MRI with double-echo FLASH imaging can detect hypervascular hepatocellular carcinoma as well as dynamic helical CT imaging with double arterial phase.     

Detection of hepatocellular carcinoma: comparison of dynamic MR imaging with dynamic double arterial phase helical CT

OBJECTIVE: Three-dimensional (3D) Fourier transformation-enhanced fast gradient-echo sequences with a special spectral inversion recovery pulse and fat suppression developed for abdominal imaging, including MR angiography, can show enhanced areas clearly. The purpose of this study was to evaluate the efficacy of dynamic MR imaging with the pulse sequences for the detection of hypervascular hepatocellular carcinoma by comparing it with that of dynamic helical CT with double arterial phase imaging. SUBJECTS AND METHODS: Fifty-three patients with 103 hypervascular hepatocellular carcinoma nodules who underwent both dynamic MR imaging with 3D Fourier transformation-enhanced fast gradient-echo sequences with a special spectral inversion recovery pulse and dynamic helical CT with double arterial phase imaging were enrolled in the study. For dynamic MR imaging, unenhanced, arterial, portal venous, and equilibrium phase images were obtained before and approximately 19, 60, and 120 sec, respectively, after injection of gadopentetate dimeglumine. Three observers independently interpreted the images obtained with each technique in a blinded manner and in random order. RESULTS: Mean sensitivity and positive predictive values of CT for hypervascular hepatocellular carcinoma (66% and 97%, respectively) were higher than those of MR imaging (63% and 96%, respectively), but there was no significant difference in detecting sensitivity among the observers (p < 0.05). CT and MR imaging were complementary, with some tumors undetected by CT but revealed on MR imaging. There was also no significant difference in A(z) values between CT (0.74) and MR imaging (0.71) (p < 0.05). CONCLUSION: Dynamic MR imaging with 3D Fourier transformation-enhanced fast gradient-echo sequences with a special spectral inversion recovery pulse is recommended to improve the detection of hypervascular hepatocellular carcinoma nodules in addition to the use of dynamic helical CT with double arterial phase imaging.     

Embolization of the hepatic falciform artery to prevent supraumbilical skin rash during transcatheter arterial chemoembolization for hepatocellular carcinoma

A dilated hepatic falciform artery (HFA) arising from the left hepatic artery was demonstrated on arteriography prior to chemoembolization of an unresectable hepatocellular carcinoma (HCC) located predominantly in the left lobe of the liver. The HFA was occluded by microcoils to prevent a possible toxic supraumbilical skin rash following chemoembolization of the HCC via the left hepatic artery. There were no postprocedure complications. We consider this procedure useful for improving the safety of chemoembolization.     

Radiological assessment of hepatic vein invasion by hepatocellular carcinoma using combined computed tomography hepatic arteriography and computed tomography arterial portography

Purpose

The aim of this study was to elucidate computed tomography hepatic arteriography (CTHA) and CT arterial portography (CTAP) findings characteristic of hepatocellular carcinoma (HCC) with large hepatic venous invasion (HVI) and then to examine whether the presence of minute HVI can be diagnosed based on each finding.

Materials and methods

Combined CTHA and CTAP of 106 HCCs were examined. Two radiologists analyzed the radiological findings of five nodules with large HVI (group vv2). The remaining 101 nodules were classified into two groups: group vv1, positive minute HVI; group vv0, negative HVI. They examined whether each finding observed in group vv2 could be detected in groups vv1 and vv0.

Results

Analysis of group vv2 identified (a) tumor thrombus, (b) early inflow of the contrast into the hepatic vein proximal to the invaded site, and (c) partially decreased portal venous flow in the peripheral parenchyma subject to the involved hepatic vein. Findings (b) and (c) were observed in 16% of group vv1. A significant difference in frequency of finding (c) was obtained between groups vv1 and vv0. The positive and negative predictive values of finding (c) were 66.7% and 77.9%, respectively.

Conclusion

Findings (b) and (c), especially the latter, may partly contribute to the radiological diagnosis of minute HVI.     

Detection of hepatocellular carcinoma: combined T2-weighted and dynamic gadolinium-enhanced MRI versus combined CT during arterial portography and CT hepatic arteriography

PURPOSE: The purpose of this study was to compare the preoperative detectability of hepatocellular carcinomas (HCCs) using combined T2-weighted and dynamic gadolinium-enhanced MRI and combined CT during arterial portography (CTAP) and CT hepatic arteriography (CTHA). METHOD: Thirty-three patients with 43 HCCs underwent T2-weighted and dynamic gadolinium-enhanced MRI and combined CTAP and CTHA. The diagnosis was established by pathologic examination following surgical resection in 26 patients and by biopsy in 7 patients. The MR protocol included fast SE with two TEs (including T2-weighted imaging) and precontrast and gadolinium-enhanced T1-weighted fast multiplanar spoiled gradient-recalled echo images with dynamic study. The MR images of all sequences and the paired CTAP and CTHA images were independently reviewed by three radiologists. Image review was conducted on a segment-by-segment basis. Diagnostic accuracy was evaluated with receiver operating characteristic analysis. RESULTS: The accuracies (Az values) of MRI of all sequences and combined CTAP and CTHA for all observers were 0.960 and 0.959, respectively. The mean sensitivities of MRI and CT were 90 and 94%, respectively. The differences were not statistically significant. The mean specificity of MRI (99%) was significantly higher than that of combined CTAP and CTHA (92%). CONCLUSION: Combined T2-weighted and dynamic gadolinium-enhanced MRI is as accurate as combined CTAP and CTHA for preoperative detection of HCCs.     

Angiographic evaluation of hepatic arterial damage after transarterial chemoembolization for hepatocellular carcinoma

PURPOSE: The aim of this study was to assess the incidence, degree, and predictors of hepatic arterial damage (HAD) after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A total of 33 patients with unresectable HCC underwent TACE alone using a mixture of iodized oil, epirubicin, and gelatin sponge. A follow-up angiogram was available for 76 of 109 sessions, and HAD was evaluated at each subsegment of the hepatic artery using a three-grade scale (1, no or slight wall irregularity; 2, overt stenosis; 3, occlusion). Grades 2 and 3 were considered to indicate significant HAD. The predictors of HAD were analyzed by multivariate analysis. RESULTS: A total of 161 hepatic arteries were embolized from the lobar (n = 43), segmental (n = 40), subsegmental (n = 72), or more distal (n = 6) level. The follow-up period between the initial and last sessions ranged from 70 to 1505 days (median 497 days). Significant HAD occurred in 37 of 231 subsegmental hepatic arteries (16%) and in 16 of 33 patients (48%). The accumulated dose of epirubicin per artery (P = 0.001) and Child-Pugh score (P < 0.001) were significant predictors. CONCLUSION: TACE is more likely to induce HAD in cirrhotic patients with impaired liver function and when a high dose of the chemotherapeutic agent was used.     

Evaluation of optimal timing of arterial phase imaging for the detection of hypervascular hepatocellular carcinoma by using triple arterial phase imaging with multidetector-row helical computed tomography

PURPOSE: We evaluated the optimal timing of arterial phase imaging for detection of hypervascular hepatocellular carcinoma by using triple arterial phase imaging with multidetector-row helical computed tomography. MATERIALS AND METHODS: Forty-nine patients with 90 hypervascular hepatocellular carcinomas (3 to 50 mm in diameter; mean, 18.7 mm) underwent triple arterial phase imaging of the whole liver using a multidetector-row helical computed tomography. At 20 seconds, 30 seconds, and 40 seconds after intravenous administration of 100 mL of 300 mgI/mL of nonionic contrast medium at a rate of 4 mL/s, early, middle, and late arterial phase images were obtained serially during a single breath-hold with an interscan delay of 5 seconds. Detector-row configurations of 4 mm x 4, scan pitch of 5.5, and scan time of 5 seconds for each phase were used. Forty prospective reconstruction images of 5-mm thickness for each phase were obtained. The images from each phase were interpreted separately for detection of hypervascular hepatocellular carcinoma by 3 observers independently who were unaware of tumor burden in the liver. Sensitivity, positive predictive value, and area under the receiver operating characteristic curve values for each arterial phase were calculated and compared statistically. RESULTS: The mean sensitivity and positive predictive values for hypervascular hepatocellular carcinoma diagnosis of blind readers were 37% and 87% for the early arterial phase, 73% and 85% for the middle arterial phase, and 49% and 81% for the late arterial phase, respectively. The middle arterial phase imaging showed significantly superior sensitivity compared with the early and late arterial phase for detecting hepatocellular carcinoma (P < 0.05). Mean area under the receiver operating characteristic curve value of the middle arterial phase imaging (0.84) was significantly higher that that of the early (0.56) or late arterial phase (0.62; P < 0.05). CONCLUSION: If a single arterial phase is used for diagnosis of hypervascular hepatocellular carcinoma, the middle phase (delay time of 30 seconds) is optimal.     

多层螺旋CT双动脉期与门静脉期增强扫描对原发性肝癌检出价值的比较

目的 评价多层螺旋CT(MSCT)双动脉期与门静脉期增强扫描对原发性肝癌(HCC)癌灶检出的价值.方法 回顾性分析94例经病理证实的HCC患者的MSCT平扫、动脉早期(20～22 s)、动脉晚期(34～37 s)和门静脉期(60 s)资料,并采用X2检验分别对≤3 cm和>3 cm的病灶在各期相的检出率进行比较.结果 94例术中共发现318个病灶,其中≤3 cm者86个,>3 cm者232个.动脉早期、动脉晚期和门静脉期检出≤3 cm病灶的敏感度分别为39.5%(34个)、67.4%(58个)、44.2%(38个),差异有统计学意义(X2=15.38,P<0.01).上述3期检出>3 cm病灶的敏感度分别为89.6%(208个)、99.6%(231个)和99.1%(230个),差异有统计学意义(X2=39.09,P<0.01);阳性预测值均为100%.上述3期检出病灶的总敏感度分别为76.1%(242个)、90.9%(289个)和84.3%(268个),阳性预测值分别为88.3%(242/274)、86.3%(289/335)和93.7%(268/286),差异均有统计学意义(X2值分别为25.62和9.29,P值均<0.05).结论 双动脉期扫描有利于提高病灶的检出率,特别是对于小HCC,动脉晚期的扫描显得尤其重要.     

小肝癌的SCTAR及SCTA表现与血管造影的相关性研究

目的通过螺旋CT动脉门静脉造影(SCTAP)、螺旋CT动脉造影(SCTA)与肝动脉造影比较,显示小肝癌的血流动力学特性及影像特征。方法22例原发性肝细胞癌(HCC)或HCC术后肝内转移病人(男18人、女4人,年龄34～65岁,平均44.6岁),共79个病灶(0.1～3cm,平均直径1.8cm)。5例SCTAP与17例SCTA,结果分别与肝动脉造影术比较。结果5例SCTAP显示28个小病灶中,26个低密度,2个等密度;17例SCTA发现51个病灶,42个表现为高密度,9个表现为等密度;两组血管造影分别显示17、32个病灶,其中高密度41个,等密度8个。与血管造影相比,SCTAP显示小于2cm的病灶及所有小于3cm的病灶数差异具有显著性(P<0.05)或高度显著性(P<0.01);SCTA对小于3cm的病灶数较血管造影有显著性差异(P<0.05。)结论SCTAP及SCTA可准确反映小肝癌的血流动力学特性,在显示小肝癌方面优于肝动脉造影,可以为临床提供更丰富的影像学资料。     

Improved diagnosis of hepatic perfusion disorders: value of hepatic arterial phase imaging during helical CT.

The liver has a unique dual blood supply, which makes helical computed tomography (CT) a highly suitable technique for hepatic imaging. Helical CT allows single breath-hold scanning without motion artifacts. Because of rapid image acquisition, two-phase (hepatic arterial phase and portal venous phase) evaluation of the hepatic parenchyma is possible, improving tumor detection and tumor characterization in a single CT study. The arterial and portal venous supplies to the liver are not independent systems. There are several communications between the vessels, including transsinusoidal, transvasal, and transplexal routes. When vascular compromise occurs, there are often changes in the volume of blood flow in individual vessels and even in the direction of blood flow. These perfusion disorders can be detected with helical CT and are generally seen as an area of high attenuation on hepatic arterial phase images that returns to normal on portal venous phase images; this finding reflects increased arterial blood flow and arterioportal shunting in most cases. Familiarity with the helical CT appearances of these perfusion disorders will result in more accurate diagnosis. By recognizing these perfusion disorders, false-positive diagnosis (hypervascular tumors) or overestimation of the size of liver tumors (eg, hepatocellular carcinoma) can be avoided.     

Contrast enhancement patterns of hepatic tumours during the vascular phase using coded harmonic imaging and Levovist to differentiate hepatocellular carcinoma from other focal lesions

The purpose of the study was to assess contrast enhancement patterns of hepatic tumours during the vascular phase using contrast-enhanced ultrasound and Levovist to differentiate hepatocellular carcinoma from other hepatic tumours. 89 hepatic tumours in 82 consecutive patients were evaluated using coded harmonic ultrasound imaging. The procedure used a phase inversion harmonic technique and coded technology. We observed images for 2 min from the beginning of the administration as the vascular phase using continuous transmission and intermittent transmissions of 1 s or 2 s. The contrast agent Levovist was administered intravenously as a bolus infusion of 2.5 g. Tumour vessels with flow spreading into the tumour and/or homogeneously stained hyperechoic images were observed in 34 of the 41 hepatocellular carcinomas (sensitivity, 82.9%; specificity, 93.8%). Peripheral enhancements were characteristic of intrahepatic cholangiocarcinoma and metastatic hepatic tumours (sensitivity, 60.0% and 83.3%; specificity, 65.5% and 76.4%, respectively). Pooling at the periphery or throughout the tumour was apparent only in haemangioma (sensitivity, 76.5%; specificity, 100%). A tortuous feeding artery and spoke-like vascularization were evident only in the two focal nodular hyperplasias. Contrast-enhanced ultrasound using coded harmonic ultrasound imaging and Levovist provided detailed information about tumour vascularity and contrast enhancement patterns in hepatic tumours.