Nuclear medicine dynamic investigations in the diagnosis of Budd-Chiari syndrome

AIM:To investigate the hepatic hemodynamics in the Budd-Chiari syndrome(BCS) using per-rectal portal scintigraphy(PRPS) and liver angioscintigraphy(LAS).METHODS:Fourteen consecutive patients with BCS were evaluated by PRPS between 2003 and 2012.Ten of them underwent LAS and liver scan(LS) with Tc-99m colloid.Eleven patients had clinical manifestations and three were asymptomatic,incidentally diagnosed at PRPS.The control group included 15 healthy subjects.We used new parameters at PRPS,the liver transit time of portal inflow and the blood circulation time between the right heart and liver.PRPS offered information on the hepatic areas missing venous outflow or portal inflow,length and extent of the lesions,open portosystemic shunts(PSS),involvement of the caudate lobe(CL) as an intrahepatic shunt and flow reversal in the splenic vein.LAS was useful in the differential diagnosis between the BCS and portal obstructions,highlightingthe hepatic artery buffer response and reversed portal flow.LS offered complementary data,especially on the CL.RESULTS:We described three hemodynamic categories of the BCS with several subtypes and stages,based on the finding that perfusion changes depend on the initial number and succession in time of the hepatic veins(HVs) obstructions.Obstruction of one hepatic vein(HV) did not cause opening of PSS.The BCS debuted by common obstruction of two HVs had different hemodynamic aspects in acute and chronic stages after subsequent obstruction of the third HV.In chronic stages,obstruction of two HVs resulted in opening of PSS.The BCS,determined by thrombosis of the terminal part of the inferior vena cava,presented in the acute stage with open PSS with low speed flow.At least several weeks are required in the obstructions of two or three HVs for the spontaneous opening of dynamically efficient PSS.The CL seems to have only a transient important role of intrahepatic shunt in several types of the BCS.CONCLUSION:Dynamic nuclear medicine investigations assess the extent and length of hepatic venous obstructions,open collaterals,areas without portal inflow,hemodynamic function of the CL and reverse venous flow.     

Roles of Fibroblast Growth Factor-inducible 14 in Hepatocellular Carcinoma

The prognostic value of the fibroblast growth factor-inducible 14 (Fn14) expression in hepatocellular carcinoma(HCC) is unknown. Real-time PCR (RT-PCR), western blot assays and immunohistochemistry analysis were hereperformed in order to compare Fn14 expressios in paired liver samples of HCC and normal liver tissue. Mostof the tumor tissues expressed significantly higher levels of Fn14 compared to adjacent non-tumor tissues, withFn14High accounting for 54.6% (142/260) of all patients. The Pearson χ2 test indicated that Fn14 expression wasclosely associated with serum alpha fetal protein (AFP) (P=0.002) and tumor number (p=0.019). Univariate andmultivariate analyses revealed that along with tumor diameter and portal vein tumor thrombosis (PVTT ) type,Fn14 was an independent prognostic factor for both overall survival (OS) (HR=1.398, p=0.008) and recurrence(HR=1.541, p=0.001) rates. Fn14 overexpression HCC correlated with poor surgical outcome, and this moleculemay be a candidate biomarker for prognosis as well as a target for therapy.     

肝移植过程中合并小肠坏死2例

背景：肝移植过程中合并肠坏死发生率低,并且多放弃手术治疗导致患者死亡。 目的：回顾性分析肝移植过程中合并小肠坏死的常见原因,探讨可行的治疗方案。 方法：总结207例肝移植患者资料,其中2例患者肝移植过程中发现小肠坏死,病例1行肝移植联合坏死小肠切除,病例2放弃肝移植,保守治疗。 结果与结论：2例患者移植前均存在门脉系统血栓。病例1患者移植前上消化道出血,反复止血药物应用加重血栓,进而导致肠坏死发生。患者肝移植后第10天发现肠瘘,行造瘘术。造瘘术后患者合并腹腔、肺部感染。抗感染治疗并停用免疫抑制剂7 d后感染控制。造瘘术后40 d肠瘘愈合,康复出院。目前,随访两年余患者健康生存;病例2移植前大量腹水导致腹腔间室综合征发生,肠道静脉回流障碍导致广泛小肠坏死。放弃肝移植后第2天,患者因多脏器功能衰竭死亡。可见等待肝移植患者,如移植前存在门脉系统血栓,合并腹痛、腹胀等症状时,需警惕肠坏死发生;肝移植过程中如发现小肠坏死,可行肝移植联合坏死小肠切除,患者可获得良好预后。     

Isolated arterioportal fistula presenting with variceal hemorrhage

We report a case of life-threatening hematemesis due to portal hypertension caused by an isolated arterioportal fistula (APF). Intrahepatic APFs are extremely rare and are a cause of presinusoidal portal hypertension. Etiologies for APFs are comprised of precipitating trauma, malignancy, and hereditary hemorrhagic telangiectasia, but these were not the case in our patient. Idiopathic APFs are usually due to congenital vascular abnormalities and thus usually present in the pediatric setting. This is one of the first cases of adult-onset isolated APF who presented with portal hypertension and was successfully managed through endoscopic hemostasis and subsequent interventional radiological embolization.     

Management of small hepatocellular carcinoma in cirrhosis:Focus on portal hypertension

The incidence of hepatocellular carcinoma(HCC) is rising worldwide being currently the fifth most common cancer and third cause of cancer-related mortality.Early detection of HCC through surveillance programs have enabled the identification of small nodules with higher frequency,and nowadays account for 10%-15% of patients diagnosed in the West and almost 30% in Japan.Patients with small HCC can be candidates for potential curative treatments:liver transplantation,surgical resection and percutaneous ablation,depending on the presence of portal hypertension and co-morbidities.This review will analyze recent advancements in the clinical management of these individuals,focusing on issues related to the role of portal hypertension,the debate between resection and ablative therapies and the future impact of molecular technologies.     

门静脉减压对大鼠广泛肝切除术后肝功能的保护作用和肝再生的影响

 目的 评估门静脉减压对肝切除后肝功能的保护作用和对肝再生的影响.方法 雄性SD大鼠180只,随机分为单纯肝切除组、脾动脉结扎组、奥曲肽组和哌唑嗪组.观察肝切除各组术后肝衰竭、生存率、门 静脉压力和组织学改变.结果 处理组的处理措施可以适度降低门静脉压力,在生存率及门静脉压力改变上具有明显差异.在术后24h即可观察到有丝分裂,与单纯肝切除组相比有明显差异.结论 笔者首次证明适度降压不仅可以减轻肝损伤,还可以使肝再生提前,可以尽早地恢复有效肝细胞数,从而避免肝衰竭的发生.     

基于电子射野影像装置的容积调强弧形治疗二维剂量验证研究

目的 基于电子射野影像装置(EPID)建立二维剂量精确重建模型并验证容积调强弧形治疗(VIMAT)剂量,与其他测量工具进行比较与分析。方法 采用EPID进行VIMAT的二维剂量验证,基于卷积、反卷积以及修正函数建立二维剂量重建模型。通过电离室测量的离轴比剂量曲线并用最小二乘法确定计算模型参数。对 12例不同部位肿瘤患者的VIMAT计划用电离室测量中心点剂量,采用其他平面剂量测量工具测量相应平面剂量分布。所有工具测量深度均设置为10 cm,并采用γ分析法比较测量结果。结果 对中心点绝对剂量,EPID与电离室测量结果偏差<1.5%。对平面剂量,2%2 mm标准下EPID与Seven29、Matrixx的平均γ通过率分别为98.9%、99.8%,3%3 mm标准下EPID与治疗计划系统计算结果的平均γ通过率为99.9%。结论 基于EPID建立的二维剂量重建模型能很好地用于调强放疗二维剂量验证工作,今后将考虑将该模型拓展到均匀模体的三维剂量验证中。     

三次曝光技术在后颈电子线补量中的应用

目的:IP板与自制十字板合用,采用三次曝光照相技术拍摄射野证实片,用于后颈电子线补量照射范围的确定。方法:将自制十字补板和IP板放置在相应位置,分三次曝光拍摄射野证实片,确定电子线后颈量的照射范围,然后在模拟机下同体位拍摄复合定位片,评价照射范围是否符合治疗要求。结果:8例需要后颈电子线补量的病人使用三次曝光方法拍摄射野证实片,经模拟定位机同治疗体位拍摄复合定位片证实,经主管医生确认电子线后颈补量照射野范围均符合治疗要求,PTW 2D-ARRAY729矩阵验证剂量误差符合要求。结论:采用三次曝光技术确定电子线照射野的方法,可用于鼻咽癌及其他口咽部肿瘤治疗时对后颈电子线补量,该方法操作简单方便、实用。     

Unusual spontaneous porto‐systemic shunt: The importance of diagnosing non‐anatomical porto‐systemic shunts to improve portal flow in pediatric living–related liver transplantation. Case report

Collateral circulation secondary to liver cirrhosis may cause the development of large PSSs that may steal flow from the main portal circulation. It is important to identify these shunts prior to, or during the transplant surgery because they might cause an insufficient portal flow to the implanted graft. There are few reports of “steal flow syndrome” cases in pediatrics, even in biliary atresia patients that may have portal hypoplasia as an associated malformation. We present a 12‐month‐old female who received an uneventful LDLT from her mother, and the GRWR was 4.8. During the early post‐operative period, she became hemodynamically unstable, developed ascites, and altered LFT. The post‐operative ultrasound identified reversed portal flow, finding a non‐anatomical PSS. A 3D CT scan confirmed the presence of a mesocaval shunt through the territory of the right gonadal vein, draining into the right iliac vein, with no portal inflow into the liver. The patient was re‐operated, and the shunt was ligated. An intraoperative Doppler ultrasound showed adequate portal inflow after the procedure; the patient evolved satisfactorily and was discharged home on day number 49. The aim was to report a case of post‐operative steal syndrome in a pediatric recipient due to a mesocaval shunt not diagnosed during the pretransplant evaluation.