Ethylene vinyl alcohol copolymer for occlusion of specific portal branches during preoperative portal vein embolisation with n-butyl-cyanoacrylate.

OBJECTIVES: To evaluate the safety and efficacy of ethylene vinyl alcohol copolymer (EVOH) injection for selective occlusion of portal branches considered at risk for non-target embolisation during preoperative portal vein embolisation (PVE). METHODS: Twenty-nine patients (mean age, 57 ± 17 years) submitted to PVE with n-butyl-cyanoacrylate (NBCA) and additional EVOH for selected portal branches were retrospectively analysed. Indications for the use of EVOH and the selected portal branches were evaluated. Degree of hypertrophy of the future liver remnant (FLR) and kinetic growth were assessed by CT volumetry performed before and 3-6 weeks after PVE. Clinical outcome and histopathological analysis of portal veins occluded with EVOH were reviewed. RESULTS: EVOH was indicated intraoperatively for embolisation of selected portal branches that the operator reported at risk to provoke non-target embolisation with NBCA. Indications for the use of EVOH were embolisation of segment IV (n = 21), embolisation of segmental portal branches with early bifurcation (n = 7) and PVE in a 1-year-old girl with cystic hamartomas. All targeted portal branches were successfully embolised. There were no cases with non-target embolisation by EVOH. The degree of hypertrophy of the FLR was 14.3 ± 8.1% and the kinetic growth rate was 2.7 ± 1.8% per week. CONCLUSION: EVOH is safe and effective for embolisation of selected portal vein branches considered at risk for non-target embolisation. KEY POINTS: • EVOH is another effective liquid embolic agent for preoperative PVE. • EVOH is relatively simple to handle with a minimal risk of non-target embolisation. • During PVE, some portal branches considered complicated to occlude with NBCA may be efficiently embolised with EVOH.

Hepatic lymphatics: anatomy and related diseases.

The liver normally produces a large amount of lymph. It is estimated that between 25% and 50% of the lymph received by the thoracic duct comes from the liver. In normal conditions, hepatic lymphatics are not depicted on cross-sectional imaging. They are divided in lymphatics of deep system (lymphatics following the hepatic veins and the portal tract) and those of superficial system (convex surface and inferior surface). A variety of diseases may affect hepatic lymphatics and in general they manifest as lymphedema, lymphatic mass, or cystic lesions. Abnormal distended lymphatics are especially seen in periportal spaces as linear hypoattenuations on CT or strong linear hyperintensities on heavily T2-weighted MR imaging. Lymphatic tumor spread as in lymphoma and lymphangitic carcinomatosis manifests as periportal masses and regional lymph node enlargement. Lymphatic disruption after trauma or surgery is depicted as perihepatic fluid collections of lymph (lymphocele). Lymphatic malformation such as lymphangioma is seen on imaging as cystic spaces of variable size.

Fatty hepatocellular carcinoma: radiofrequency ablation--imaging findings.

PURPOSE: To describe the imaging features during follow-up after radiofrequency (RF) ablation of fat-containing hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Institutional review board approval was obtained; informed consent was waived. A retrospective search in an electronic radiologic archive was performed for a 40-month period between February 2004 and May 2007 to identify patients who had undergone RF ablation of fat-containing HCCs. The presence of intratumoral fat was determined at imaging (magnetic resonance or computed tomography) prior to the RF procedure; eight fat-containing HCCs, which had a mean size of 25 mm (range, 20-30 mm), were found. Images during follow-up were reviewed and compared with images prior to RF ablation to determine changes in fat content, complete or partial ablation, and local tumor progression. Tumor response was on the basis of assessment of lesion characteristics and enhancement for a follow-up of at least 6 months. RESULTS: Persistent fat content was found at imaging in all ablation zones. Six patients were considered to have completely ablated tumors (mean follow-up, 16 months; range, 6-29 months), and two patients had local progression (mean follow-up, 18 months; range, 14-22 months). In the ablation zone of completely ablated tumors, the fat content progressively decreased (n = 4) or was unchanged during follow-up (n = 2). In the two tumors with local progression, the fat portion enlarged (n = 1) or did not change after ablation (n = 1). CONCLUSION: Persistence of fat in the ablation zone during imaging follow-up after RF ablation of fat-containing HCCs does not necessarily indicate treatment failure. Changes in fat content of the ablation zone during follow-up (increase or decrease in size) could be used as additional criteria to determine success or failure of RF ablation in fat-containing HCC.

Algorithm for immediate cytologic diagnosis of hepatic tumors.

OBJECTIVE: Immediate cytologic assessment of hepatic lesions can help determine the adequacy of specimens and may yield a preliminary diagnosis. The purpose of this study was to analyze the diagnostic accuracy of on-site cytologic assessment compared with definitive cytologic examination in the detection and correct subtyping of malignant hepatic lesions. SUBJECTS AND METHODS: The study population included 472 consecutively registered patients with hepatic nodules who underwent sonographically guided fine-needle aspiration and core biopsies. During on-site cytologic analysis, the pathologist made a preliminary diagnosis of malignancy or negative for malignancy for each nodule. When a malignant lesion was diagnosed, immediate subtyping was attempted. RESULTS: With immediate cytologic analysis, 280 (80.9%) of 346 malignant nodules were correctly identified without false-positive cases. With immediate subtyping, 113 (68.1%) of 166 cases of hepatocellular carcinoma, 28 (77.8%) of 36 cases of cholangiocarcinoma, and 113 (85.0%) of 133 cases of metastasis were detected. CONCLUSION: High diagnostic accuracy for malignancy can be achieved with on-site cytologic evaluation of hepatic tumors. Specific diagnoses of hepatocellular carcinoma, cholangiocarcinoma, and metastasis also can be made on-site in most cases. The absence of false-positive diagnosis of malignancy at on-site cytologic examination may make additional biopsy unnecessary. We propose an algorithm for the cytohistopathologic management of hepatic tumors.

Embolization of a Jejunal Artery Pseudoaneurysm via Collateral Vessels.

Visceral artery pseudoaneurysms are rare and only few cases have been reported. They are considered to be life threatening in case of rupture. Rapid treatment is mandatory and endovascular procedure is recommended as the treatment of choice. Occasionally, endovascular approach is difficult to achieve, owing to unusual vascular anatomy. Whenever it is the case, an alternative method has to be considered. We report the case of a jejunal artery pseudoaneurysm that required an access via collateral vessels to accomplish complete occlusion in a 34-year-old woman who presented with a sudden epigastric pain 14 days after a cephalic duodenopancreatectomy.