Radiofrequency ablation of hepatocellular carcinoma: treatment success as defined by histologic examination of the explanted liver

PURPOSE: To retrospectively evaluate the effectiveness of radiofrequency (RF) ablation of hepatocellular carcinoma (HCC) by using histologic examination of the explanted liver. MATERIALS AND METHODS: The study was approved by the medical center Institutional Review Board, with waiver of informed consent. Forty-seven HCC nodules in 24 patients (18 men, six women; age range, 33-71 years; mean age, 56 years) were treated with single or double RF ablation sessions prior to liver transplantation. Histologic data from hematoxylin-eosin staining of explanted liver specimens were retrospectively reviewed to determine treatment success, which was defined as the absence of residual or recurrent viable carcinoma cells at treatment site. Tumor size and the presence of large (> or =3 mm) abutting vessels that were observed during imaging were tested as potential predictors of treatment success or failure (Fisher exact test). In patients who underwent postablation computed tomographic (CT) or magnetic resonance (MR) imaging within 3 months prior to transplantation (21 patients with 44 tumors), imaging results were analyzed for sensitivity and specificity of residual or recurrent tumor by using histologic data as the reference standard. RESULTS: Thirty-five (74%) of 47 ablated tumors, including 29 (83%) of 35 tumors less than 3 cm, were found to be successfully treated on the basis of histologic findings after a mean interval of 7.5 months between RF ablation and transplantation. Nodules that were successfully treated had mean maximal diameter of 2.0 cm, and nodules that were unsuccessfully treated had mean maximal diameter of 3.1 cm (P=.014). Seven (47%) of 15 perivascular lesions were successfully treated whereas 28 (88%) of 32 nonperivascular lesions were successfully treated (P <.01). Imaging correlation showed 100% (33 of 33) specificity and 36% (four of 11) sensitivity of postablation CT and MR imaging for the depiction of residual or recurrent tumor. CONCLUSION: Histologic evidence directly validates RF ablation as an effective treatment of small (<3 cm) HCC.     

The utility of MRCP in preoperative mapping of biliary anatomy in adult-to-adult living related liver transplant donors

PURPOSE: To assess the utility of magnetic resonance cholangiopancreatography (MRCP) in preoperative mapping of biliary anatomy in adult-to-adult living related liver transplant (LRLT) donors. MATERIALS AND METHODS: From 57 potential donors with preoperative MRCP, 27 cases (16 men, 11 women, age range 22-51 years, mean 37.2 years) underwent right lobe resection and had intraoperative cholangiography (IOC) for comparison. The MRCP and IOC reports were retrospectively reviewed in all 27 cases. The MRCP was performed on 1.5 Tesla MR magnets using breath-hold heavily T2-weighted sequences in axial/coronal thin sections, and variable-thickness rotating slabs. The accuracy of preoperative MRCP for biliary mapping in potential LRLT donors was analyzed compared to the IOC findings. RESULTS: Of 27 donors, 26 (96.3%) had MRCP which showed adequate information of central intrahepatic biliary anatomy. Of these, 19 had normal bifurcation confirmed by IOC, and single biliary anastomosis was created in the recipient at transplantation. MRCP correctly predicted 17 of 19 normal cases (sensitivity for normals: 89.5%). In seven donors with variant biliary anatomy, two separate biliary anastomoses were performed in the recipient. MRCP correctly predicted five of seven variants (sensitivity for variants: 71.4%). Overall, MRCP had an accuracy 84.6% (22/26). CONCLUSIONS: MRCP has potential in the preoperative assessment of nondilated bile ducts in LRLT donors, however further improvements are desired to increase its quality and accuracy.     

Atypical avian influenza (H5N1)

We report the first case of avian influenza in a patient with fever and diarrhea but no respiratory symptoms. Avian influenza should be included in the differential diagnosis for patients with predominantly gastrointestinal symptoms, particularly if they have a history of exposure to poultry.     

Macrovesicular hepatic steatosis in living related liver donors: correlation between CT and histologic findings

PURPOSE: To assess degree of macrovesicular steatosis with unenhanced computed tomography (CT) and correlate it with histologic findings in potential donors for living related liver transplantation. MATERIALS AND METHODS: Forty-two candidates underwent unenhanced CT within 4 weeks of core liver biopsy. An experienced liver pathologist, blinded to both CT and surgical findings, retrospectively reviewed biopsy specimens and determined degree of macrovesicular steatosis. A radiologist blinded to histologic grading calculated mean hepatic attenuation in each donor liver by averaging 25 region-of-interest (ROI) measurements on five sections (five ROIs per section). Mean splenic attenuation was calculated with three separate ROI measurements. Liver attenuation index (LAI) was derived and defined as the difference between mean hepatic and mean splenic attenuation. Body mass index (BMI) was determined for each patient. Linear regression analysis was used to correlate degree of macrovesicular steatosis with both LAI and BMI. RESULTS: LAI correctly predicted degree of macrovesicular steatosis in 38 (90%) of 42 cases. In four of four livers, LAI below -10 HU correlated with greater than 30% macrovesicular steatosis (unacceptable for liver transplantation). In nine of 11 livers, LAI was between -10 and 5 HU and correctly predicted 6%-30% steatosis (relative contraindication). In two of 11 cases, LAI overestimated degree of hepatic steatosis. LAI above 5 HU correctly predicted 0%-5% steatosis in 25 of 27 livers. In two of 27 cases, parenchymal hemosiderin deposition led to an increase in LAI into the normal range, despite mild histologically confirmed steatosis. Degree of histologic macrovesicular steatosis correlated well with LAI (r = 0.92) and marginally with BMI (r = 0.45). Of 27 potential donors with normal livers at CT and acceptable LAI levels, four (15%) were deemed poor donor candidates because core biopsy revealed subtle hepatic necrosis and nonspecific hepatitis. CONCLUSION: Although unenhanced CT quantifies the degree of macrovesicular steatosis relatively well, it may preclude a liver biopsy only in a small percentage of potential donors with low LAI (unacceptable degree of steatosis). Core liver biopsy is still necessary in the majority of donors with normal LAI to identify those with both fatty liver and coexistent hemosiderin deposition or radiologically occult diffuse liver diseases.     

Influence of large peritumoral vessels on outcome of radiofrequency ablation of liver tumors

PURPOSE: The effect of large vessels (>/=3 mm) contiguous to hepatic tumors was evaluated with respect to clinical tumor recurrence rates after radiofrequency (RF) ablation. MATERIALS AND METHODS: The first 105 malignant liver tumors treated by RF ablation therapy at our institution with pathologic analysis or a minimum of 6 months of clinical follow-up were reviewed. The original pretreatment imaging studies were reviewed by a radiologist who was blinded to the cases, and, based on lesion contiguity to vessels of at least 3 mm, the lesions were categorized as perivascular or nonperivascular. Treatment outcomes with respect to local tumor recurrence between these two groups were then compared. Logistic regression analysis was performed to take into account other variables and to determine whether this categorization was an independent predictor of treatment outcome. RESULTS: There were 74 nonperivascular tumors and 31 perivascular tumors. Mean tumor size was 2.4 cm and mean follow-up was 11.3 months. Residual or locally recurrent tumors were documented in 20 of 105 cases (19%). In the nonperivascular group, five of 74 (7%) had either incompletely treated tumor (manifested within 6 months) or local recurrence beyond 6 months. In the perivascular group, 15 of 31 (48%) had incompletely treated or locally recurrent tumor (P <.001). Subanalysis of lesion size (61 tumors 4 cm), tumor type (40 hepatocellular carcinomas, 48 colorectal metastases, and 17 other metastases), access (53 intraoperative, 52 percutaneous), and RF device (45 Radiotherapeutics electrodes, 18 Rita electrodes, and 42 Radionics electrodes) showed similar results. Multivariate logistic regression analysis showed that presence or absence of a large peritumoral vessel is an independent, and the dominant, predictor of treatment outcome. CONCLUSION: The presence of vessels at least 3 mm in size contiguous to hepatic tumors is a strong independent predictor of incomplete tumor destruction by RF ablation. Modified ablation strategies should be considered to improve destruction of these tumors.     

The relationship between health behavior and pain scale in patients with low back pain in Thailand

The purpose of the study was to evaluate the relationship between health behavior and pain scale in patients with low back pain. One hundred eighty patients with low back pain attending the Orthopedic Unit at Sapasithiprasong Hospital in Thailand participated in the study. The participants completed a questionnaire related to demographic data and preventive health behavior, illness health behavior and sick role health behavior. Statistical analysis was used to calculate means, standard deviations and percentages, multiple regression evaluated the relationship between demographic data and pain scale, and Pearson's correlation assessed the relationship between the three health behaviors and pain scale. Generally, the results showed most participants had a lower quality of health behavior. The most common causes of low back pain were lifting heavy loads, incorrect positioning and everyday activity (43.9, 17.8 and 10.6%, respectively). The level of participant's income was found to be statistically relevant to pain scale (p < 0.05). There was also a statistically significant association between the three health behaviors and pain scale (p = 0.0001, 0.005, 0.0001, respectively). The findings of this study illustrate the crucial role that Thai health care professionals play in changing the health behavior of patients with low back pain in order to improve the patient's quality of life.