Effect of cirrhosis on accuracy of 99Tcm-tin colloid scintigraphy and ultrasound scanning in diagnosis of hepatocellular carcinoma

The effect of cirrhosis on the accuracy of ultrasonography and scintigraphy in the diagnosis of hepatocellular carcinoma (HCC) has not been established. We have therefore studied the findings on ultrasound and scintigraphy in four groups of patients. Fourteen had HCC and cirrhosis, 13 had HCC but no cirrhosis, 53 had cirrhosis but no HCC and 31 had evidence neither of cirrhotic nor malignant liver disease. The accuracies of a positive interpretation of HCC on ultrasound and scintigraphy in the absence of cirrhosis were 85% and 66% respectively (NS), but fell (significantly in the case of scintigraphy: p less than 0.05) to 80% and 31% respectively in the presence of cirrhosis (p less than 0.01). The poorer performance of scintigraphy in the presence of cirrhosis was a result both of its lower sensitivity (50% compared with 85%) and the greater frequency of false positives (28% vs 5%: p less than 0.001). The accuracy of a negative interpretation of HCC on scintigraphy in the absence of cirrhosis was 96% but fell to 84% in the presence of cirrhosis, whereas on ultrasound it remained the same (96%). In conclusion, we recommend ultrasound in preference to scintigraphy as a more accurate technique for the diagnosis of HCC in the presence of cirrhosis.     

Loss of echogenic lesion of focal fatty infiltration in fibrotic liver

Five alcoholics with chronic liver disease showed focal low density areas of the liver that varied in distribution on computed tomography (CT) but no corresponding lesions on ultrasonography. The densities of these areas on CT were much lower than that of spleen. All the areas disappeared 2 days to 4 weeks after patients entered the hospital, suggesting that they were focal areas of fatty liver. Four patients had liver cirrhosis and one liver fibrosis. These observations may add further evidence to our previous finding that increased echogenecity of the liver produced by fatty infiltration is attenuated by complicating fibrosis.     

Value of ultrasonography in the diagnosis of cirrhoses. Prospective study of 128 patients

This prospective study was carried out in order to assess the accuracy of ultrasound in the diagnosis of cirrhosis. One hundred and twenty eight alcoholic patients were included. A careful ultrasonographic examination of the liver was performed before liver biopsy (100 patients). In 15 cases, liver histology was normal, steatosis and/or fibrosis, cirrhosis were diagnosed in 13 and 72 cases respectively. Ultrasonic patterns were classified by the same examiner, according to several criteria: volume, irregular outline, coarse and fine bright echo pattern, attenuation of the ultrasound beam, splenomegaly, ascite, portal hypertension. Cirrhosis was diagnosed in 58 out of 72 patients (80.5%). Specificity was 78.5%, positive and negative predictive values were 90.6% and 61% respectively, and global efficacy was 80%. Irregular outline (0.66), hepatomegaly (0.66) and attenuation of the ultrasound beam (0.64) were the best signs. In case of fine bright echo pattern, the diagnosis of cirrhosis would be missed. The results suggest that ultrasonography is a good test for screening alcoholics for cirrhosis. Therefore, it is useful when liver biopsy is contra indicated or refused or when liver is not detected at the clinical examination.     

门脉循环γ照相,B超和肝功能测定对肝硬化诊断的对比研究

本文应用门脉循环γ照相测定门脉分流指数，评估其在肝硬化诊断中的作用，并与Ｂ超和５组肝功能测定进行对比。研究表明，核素门脉分流指数随着慢性肝病的肝纤维化进程不断升高，正常人＜慢性肝炎＜代偿期肝硬化＜失代偿期肝硬化。本法敏感性为９２．３％，Ｂ超为７７．４％，肝功能总体为７０．９％；本法特异性为１００％，准确率９５．１％，阳性预测值１００％，阴性预测值８８．４％。说明门脉循环γ照相是安全、简便，早期诊断肝硬化的可靠方法。     

MEN 1 and 2: the role of diagnostic imaging

PURPOSE: To report the results of a retrospective study on the use of the different imaging methods in the diagnosis of type 1 and type 2 multiple endocrine neoplasias, and to provide an overall evaluation of the diagnostic yield of the various examinations performed correlating the results with the surgical findings. MATERIALS AND METHODS: The study was conducted by reviewing the data of 12 patients, of whom four with MEN1 and eight with MEN2, assessed with different imaging modalities. In the patients with MEN1 the examinations revealed 4 parathyroid hyperplasias, 4 gastro-pancreatic endocrine-secreting lesions, one hypophyseal adenoma, one bronchial carcinoid and two bilateral adrenal hyperplasias. In the patients with MEN2 the examinations revealed 6 medullary thyroid carcinomas (MTC), 4 pheochromocytomas and 3 parathyroid hyperplasias. RESULTS: In MEN1 the parathyroid hyperplasias were diagnosed by scintigraphy in all four cases, whereas neck ultrasound was positive in only two cases. The gastro-pancreatic endocrine-secreting lesions were demonstrated in all four patients with CT and endoscopic ultrasound (two patients also underwent scintigraphy with octreotide, which was positive). In only one patient with MEN1 did the chest X-ray detect a bronchial carcinoma, confirmed by CT. CT also enabled identification of a single hypophyseal adenoma. The patients with MEN2 were divided into two groups: one consisting of asymptomatic patients undergoing screening following positive genetic testing and one of symptomatic patients. In the first group the imaging examinations diagnosed one MTC and three pheochromocytomas; all patients in the second group had MTC (detected by positive ultrasound and scintigraphy examinations). DISCUSSION AND CONCLUSIONS: Given the rarity of this condition we believe that the only statistically important finding in our series concerns the sensitivity of the imaging examinations performed in that, with adequate clinical and laboratory data, the possible problem of false positive results is exceptional. The role of diagnostic imaging in the management of patients with MEN1 and 2 is twofold: identification of the target organs of lesions suspected on the basis of clinical and laboratory findings to enable adequate medical and/or surgical treatment; staging of malignant lesions to enable correct surgical planning. In particular, our study once again highlights the diagnostic efficacy of CT for the diagnosis of pheochromocytomas and of the combination of biopsy plus ultrasound and ultrasound plus scintigraphy for the diagnosis of MTC in MEN 2. As for MEN1 spiral CT was found to have good sensitivity (66%) in localising endocrine neoplasias of the gastrointestinal tract; endoscopic ultrasound on the other hand revealed good diagnostic efficacy, showing constantly positive findings. Finally, in both pathologies we believe that the assessment of parathyroid conditions to be mainly a matter for nuclear medicine.     

Emission tomography for assessment of diffuse alcoholic liver disease.

A method of quantitative liver tomoscintigraphy (SPECT) was compared for accuracy with planar scintigraphy (PS) in a group of patients with diffuse alcoholic liver disease. SPECT sensitivity was also compared with that of transmission computed tomography (CT), US, aminopyrine breath test (ABT) and liver chemistries (LC). One hundred and fourteen alcoholic patients with proven liver disease and 17 patients free of liver disease were included. Seven quantitative scintigraphic features and a score, including all criteria were considered. With a specificity of 95%, the sensitivity was 79% in steatosis and 97% in cirrhosis. SPECT showed a better sensitivity than PS (SPECT 89%, PS 66%), especially in patients with steatosis. In the same subsets of patients, SPECT sensitivity also compared favorably with that of transmission CT (SPECT 92%, CT 65%), ultrasonography (SPECT 88%, US 53%) and ABT (SPECT 90%, ABT 63%).     

Usefulness of 111In labeled leukocytes scintigraphy combined with 99mTc phytate liver scintigraphy for diagnosis of hepatic abscess comparing with CT and US]

111In labelled leukocyte scintigraphy (ILLS) was performed in five patients with hepatic abscess. For the accurate diagnosis of hepatic abscess, ILLS was superimposed on 99mTc phytate liver scintigraphy. The results of ILLS were compared with CT and US findings. Four of five patients (80%) showed abnormal accumulations in the liver. The smallest abscess detected was 46 mm x 43 mm. CT scan showed rim enhancement, which was a specific finding for hepatic abscess, in three patients. It was rather difficult to diagnose hepatic abscess by US. In two cases without definite rim enhancement on CT, the abscesses were diagnosed as hot spots by ILLS. We conclude that ILLS combined with 99mTc liver scintigraphy is useful for the diagnosis of hepatic abscess.     

Evaluation of ultrasonic and scintigraphic studies of the liver.

Ultrasonic and scintigraphic examination of the liver took place in 148 patients. 29 had normal livers, 36 had cirrhosis, 11 had obstructive jaundice, 12 had fatty livers, 60 had focal liver defects. In case of diffuse liver disease the accuracy of both methods is about the same except for fatty liver which is poorly diagnosed by scintigraphy. Focal liver disease is determined with a relative high percentage false-negative for scintigraphy and a relative high percentage false-positive for echography. It is recognized that previous knowledge of the scintigraphic result may raise the accuracy of ultrasound examination of the liver. As echography could distinguish cystic from solid lesions both methods of liver imaging are considered complementary.     

The accuracy of ultrasound in the detection of cirrhosis of the liver

The association of high amplitude echoes returned from the liver and cirrhosis is well recognized. There have been no reports in the literature as to the overall incidence of this finding in the clinical situation. We report our experience in a series of 67 patients with proven cirrhosis who had liver biopsy and an ultrasound examination within three months of one another. In 43 patients cirrhosis was suggested by recognition of a bright liver echo pattern. In 23 patients the liver echo pattern was normal, although additional relevant information was shown in half of this group. The detailed pathology has been analysed in an attempt to account for the false negative examinations, revealing a strong trend for cases of micronodular cirrhosis to give positive ultrasound examinations and macronodular cirrhosis negative examinations.     

肝断层及平面显像在肝占位性病变鉴别诊断中的意义──与B超、CT比较

本文对９２例临床可疑肝占位性病变患者进行了肝胶体及血池断层与平面显像，计算了肝血流灌注指数，并对照同期的病理及肝动脉造影资料，探讨了核素显像、ＣＴ及Ｂ超的诊断价值。研究表明，三种方法对肝癌及肝囊肿的诊断准确性无显著性差异（Ｐ＞０．０５），但断层显像对肝血管瘤的诊断（９３％）明显优于ＣＴ（８４％）和Ｂ超（８０％）；平面肝显像难以发现直径３ｃｍ以下的病变，对肝占位灶的检出率明显低于断层显像（Ｐ＜０．０５）。联合肝、胆道系统显像有助于降低假阳性率，其价值有待进一步探讨。     

The role of arterial stimulation and simultaneous venous sampling in addition to cross-sectional imaging for localisation of biochemically proven insulinoma

Insulinomas, although rare, cause considerable morbidity but are frequently amenable to surgical cure. Laparoscopic surgery can now be considered if the tumour is localised pre-operatively, but the optimal imaging approach has not been determined. The objective of this study was to evaluate the ability of different imaging investigations, including CT, MRI, endoscopic ultrasound, octreotide scintigraphy and arterial stimulation with simultaneous venous sampling (ASVS), to localise insulinomas. All patients with biochemically proven insulinoma at our institution underwent ASVS along with other imaging investigations as part of their routine investigation. The results of these investigations were compared with histological findings. Twenty-eight patients with biochemically proven insulinoma confirmed by histology were identified. Ultimately ASVS localised a lesion in all patients. Seventeen patients (61%) had laparoscopic surgery. Tumor-detection rates for other imaging investigations included 43.5% of cases using CT, 71% using MRI, 86% using endoscopic ultrasound and 33% using octreotide scintigraphy. In four patients, the ASVS was the only test to correctly localise the lesion. ASVS should be considered routinely before surgery to ensure accurate localisation of insulinomas.     

Long-term follow-up of hepatitis using computed tomography

Computed tomography of the liver was performed on two patients with subacute hepatitis. The CT findings included the presence of multiple regenerative nodules in the atrophied liver, shown by decreased CT attenuation. Complications due to hepatitis, such as massive ascites and splenomegaly, were also observed. The CT observations during the course of the disease suggested that the hepatic necrosis had been repaired by hypertrophy of regenerating nodules, not by an increase in the number of nodules, which ultimately gave rise to postnecrotic cirrhosis. Scintigraphy confirmed atrophy and repair of the liver. Thus, CT and scintigraphy were considered to be useful for the diagnosis of extensive hepatic necrosis and for evaluating the process of liver repair.     

Intrabiliary rupture of hydatid cyst: diagnosis with MRI and hepatobiliary isotope study

Intrabiliary rupture is the most common complication of hepatic hydatid cyst yet it is unusual, occurring in only 3-17% of cases. The diagnosis is rarely difficult on ultrasound and CT when typical radiological features are present. In rare cases of complete evacuation, when characteristic findings of hydatid cyst are absent or when there is no evidence of the previous existence of liver hydatid cyst, the diagnosis may be difficult. In difficult cases, MRI, MRCP, ERCP and (99)Tc(m)-mebrofenin hepatobiliary scintigraphy are employed. We present a rare case of surgical obstructive jaundice due to rupture of a liver hydatid cyst into the biliary tract and gall bladder, with complete evacuation of its contents leading to misdiagnosis on CT and ultrasound. MRCP and (99)Tc(m)-mebrofenin hepatobiliary scintigraphy were able to establish a firm pre-operative diagnosis.     

低频与高频超声诊断肝脏疾病的比较研究

目的:探讨高频超声诊断肝脏疾病的临床价值。方法:选择我院行肝脏超声检查的患者,先行低频超声检查,再行高频超声检查。高频超声或常规低频超声发现肝脏占位性病变且病灶距皮下≤70mm者120例(实性病灶83例,囊性病灶37例);早期肝硬化53例,轻度脂肪肝95例,共268例纳入研究。病灶长径20mm的患者,中、重度脂肪肝,以及晚期肝硬化除外。对比分析高频超声和低频超声显示肝脏病灶的能力。结果:距皮下≤70mm的肝内实性病灶,高频超声发现83例,低频超声发现47例(χ2=45.97,P0.001);最大径5mm的实性占位性病灶,高频超声发现43例,低频超声发现或疑似9例(χ2=56.23,P0.001)。距皮下≤70 mm的肝内囊性病灶,高频超声发现37例,低频超声发现25例(χ2=14.32,P0.001),另外12例低频超声诊断为实性病变。早期肝硬化患者,高频超声发现硬化结节53例,低频超声发现或疑似硬化结节22例(χ2=43.81,P0.001)。轻度脂肪肝患者,高频超声诊断95例,低频超声72例(χ2=26.17,P0.001)。结论:高频超声可明显提高肝脏表浅部位微小病灶的检出率,可以早期诊断肝硬化、脂肪肝等弥漫性病变,是常规超声的有效补充。     

Risk assessment of posthepatectomy liver failure using hepatobiliary scintigraphy and CT volumetry.

A major part of morbidity and mortality after liver resections is caused by inadequate remnant liver function leading to liver failure. It is therefore important to develop accurate diagnostic tools that can predict the risk of liver resection-related morbidity and mortality. In this study, preoperative hepatobiliary scintigraphy of the future remnant liver and CT volumetric measurement of the future remnant liver were performed on patients who were to undergo liver resection. The accuracy of risk assessment for postoperative morbidity, liver failure, and mortality was evaluated. METHODS: Forty-six patients who were scheduled for liver resection because of hepatobiliary tumors, including 17 patients with parenchymal disease (37%) and 13 patients with hilar cholangiocarcinoma (28%), were assessed preoperatively. Hepatobiliary scintigraphy was performed by drawing regions of interest around the future remnant to calculate (99m)Tc-mebrofenin uptake in it. CT volumetry was used to measure the volume of the total liver, the tumors, and the future remnant. Receiver-operating-characteristic analysis was performed to assess cutoff values for risk assessment of morbidity, liver failure, and mortality. Furthermore, univariate and multivariate analyses were performed to determine factors related to morbidity and mortality. RESULTS: Morbidity and mortality rates were 61% and 11%, respectively. Liver failure occurred in 6 patients (13%). Significantly decreased uptake in the future remnant was found in patients in whom liver failure and liver failure-related mortality developed (P=0.003 and 0.02, respectively). The volume of the future remnant was not significantly associated with any of the outcome parameters. In receiver-operating-characteristic analysis, uptake cutoff values for liver failure and liver failure-related mortality were 2.5%/min/body surface area and 2.2%/min/body surface area, respectively. In multivariate analysis, uptake was the only significant factor associated with liver failure. CONCLUSION: Preoperative measurement of (99m)Tc-mebrofenin uptake in the future remnant liver on hepatobiliary scintigraphy proved more valuable than measurement of the volume of the future remnant on CT in assessing the risk of liver failure and liver failure-related mortality after partial liver resection.     

Diffuse liver disease: MRI with Gd-DTPA versus CT and ultrasound

Twenty-nine patients with diffuse liver disease were examined by ultrasound, CT and MRI. MRI was performed using T1- and T2-weighted spin-echo sequences as well as fast gradient-echo-sequences. The paramagnetic contrast agent Gd-DTPA was applied intravenously (0.1 mmol/kg). in patients with hepatitis, MRI could be used in guiding liver biopsies as inflammatory changes were clearly delineated. CT and ultrasound were superior to MRI in the detection of focal or diffuse fatty degeneration. On the other hand MRI was more helpful in differentiating fatty changes and neoplasm. In liver cirrhosis, fibrotic changes were most clearly demonstrated by MRI. In patients suffering from hemochromatosis MRI offers advantages over CT and ultrasound in the diagnosis and follow up due to the paramagnetic properties of iron, resulting in a reduction in signal intensity. In patients with Wilson's disease a characteristic pattern of parenchymal changes was seen. Administration of Gd- DTPA contributes additional information about perfusion conditions in the liver parenchyma, however this information was not of diagnostic relevance in the cases we studied. Correspondence to: T.J. Vogl     

CT demonstration of retrohepatic gallbladder in severe cirrhosis

In two patients with hepatic cirrhosis and marked morphological distortion of the liver, the gallbladder was identified in a retrohepatic position on ultrasound and CT. The etiology of this anomalous position and the importance of the preoperative diagnosis of both congenital and acquired anomalous position of the gallbladder in patients with acute cholecystitis is discussed.     

Assessment of portosystemic shunting from superior mesenteric vein by duodenal administration of iodoamphetamine I123.

Portosystemic shunting (PSS) from the superior mesenteric vein (SMV) was evaluated with the duodenal administration of iodoamphetamine I123 (IMP) in patients with chronic hepatitis and liver cirrhosis. After duodenal intubation, IMP was administered through a tube, and then scintigraphy including the pulmonary and hepatic regions was performed. In all patients, images of the liver and/or lungs were observed within 10 min and became clear with time, due to a good absorption of IMP from the intestine. On the other hand, IMP appears not to be absorbed from the stomach. The portosystemic shunt index was calculated by dividing counts of lungs by counts of liver and lungs. The shunt index (mean +/- SE) was 1.5% +/- 0.8%, 12.6% +/- 3.7% and 28.3% +/- 4.5% in chronic hepatitis, compensated cirrhosis and decompensated cirrhosis, respectively. This index was significantly higher in cirrhosis, especially in decompensated cirrhosis. Therefore, transintestinal portal scintigraphy with IMP could be a useful method for the non-invasive and quantitative evaluation of PSS from the SMV in portal hypertension.     

Opportunistic Screening of Patients for Hepatic Steatosis: Clinical Follow-Up and Diagnostic Yield

PurposeHepatic steatosis is a common incidental finding on abdominal imaging that is not always reported or recognized as having clinical significance. Because of its association with liver disease, cirrhosis, and diabetes, the aim of this study was to bring attention to this finding and provide clinical guidance to referring clinicians by inserting standardized text into radiology reports of patients with incidentally detected hepatic steatosis.MethodsPatients with incidentally discovered hepatic steatosis on abdominal ultrasound or CT had standard text inserted into the impression sections of their diagnostic imaging reports. A total of 1,256 patients whose reports were tagged between April 2016 and September 2017 were retrospectively identified and their electronic medical records reviewed to determine subsequent acknowledgment in the medical record or clinical action in response to the tagged report. Information regarding patient demographics, the type of provider who ordered the examination, and the acuity of the examination results was also recorded.ResultsAcknowledgment and subsequent clinical action were more likely in patients whose examinations was ordered by primary care providers, whose examination results were not urgent, and who were in the ultrasound group. The overall diagnostic yield in patients who underwent clinical evaluation was nonalcoholic fatty liver disease in 70%, nonalcoholic steatohepatitis in 6%, and alcoholic hepatitis in 17%.ConclusionsOpportunistic screening for incidental hepatic steatosis on abdominal CT and ultrasound is feasible, with substantial yield for patients with clinically important entities including nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.     

Nuclear magnetic resonance imaging of liver hemangiomas

Nine patients with cavernous hemangioma of the liver were examined by nuclear magnetic resonance imaging (MRI) with a 0.5 T superconductive magnet. Spin-echo technique was used with varying time to echo (TE) and repetition times (TR). Results were compared with 99mTc red blood cell (RBC) scintigraphy, computed tomography (CT), echography, and arteriography. Four illustrated cases are reported. It was possible to establish a pattern for MRI characteristics of cavernous hemangiomas; rounded or smooth lobulated shape, marked increase in T1 and T2 values as compared with normal liver values. It is concluded that, although more experience is necessary to compare the specificity with that of ultrasound and CT, MRI proved to be very sensitive for the diagnosis of liver hemangioma, especially in the case of small ones which may be missed by 99mTc-labeled RBC scintigraphy.