Aggressive and Multidisciplinary Local Approach to Iterative Recurrences of Colorectal Liver Metastases.

BACKGROUND: Liver resection (LR) of colorectal metastases is associated with high recurrence risk. Aggressive local retreatment is advocated, but further recurrences may occur. Poor is known about presentation, treatment, and outcome of iterative recurrences. METHODS: A series of 323 consecutive patients undergoing first LR in the period 2004-2013 was reviewed. Patients with recurrence were included. Any local treatment (surgery, radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT)) was analyzed. If first recurrence (1st Rec) was treated, further recurrences and treatments were considered. RESULTS: Overall, 206 (63.8%) patients had 1st Rec; 105 (51.0%) were treated (72 surgery, 19 RFA, 14 SBRT). Among treated patients, 78.1% had 2nd Rec, 74.4% 3rd Rec, 72.2% 4th Rec. Liver involvement progressively decreased (from 81.6 to 30.8%), and pulmonary one increased (from 23.3 to 53.8%). The proportion of treated patients remained stable (1st Rec = 51%, 2nd Rec = 55%, 3rd Rec = 56.3%, 4th Rec = 69.2%): surgery and RFA decreased (from 35.4 to 23.1%; from 9.2 to 0%) and SBRT increased (from 6.8 to 46.2%). Overall, 105 patients received 205 treatments (133 operations in 80 patients). Surgery had the best local disease control: at 2 years 93.4% versus RFA 56.4% (p = 0.0008) and SBRT 74.0% (p = 0.051). In comparison with chemotherapy, recurrence treatment improved survival after 1st Rec (3-year survival 62.9 vs. 13.4%, p < 0.0001), 2nd Rec (61.3 vs. 22.5%, p < 0.0001), and 3rd Rec (2-year survival 88.9 vs. 30.8%, p = 0.005). CONCLUSIONS: Aggressive local treatment of recurrent metastases may improve survival, even in the case of iterative recurrences and extrahepatic lesions. Surgery is the standard, but a multidisciplinary approach should be adopted to enlarge the pool of treatable patients.

Emergency Transarterial Embolization in Postoperative Hip Bleeding: Indications, Techniques, and Results in a Retrospective Cohort.

BACKGROUND: The aim of this study is to report the results of transarterial embolization (TAE) in the setting of postoperative bleeding after hip surgery. METHODS: We retrospectively evaluated 40 patients (male:female = 15:25, median age = 68 years) who underwent TAE from 2006 to 2016: 77.5% underwent total hip arthroplasty, 20% open reduction internal fixation, and 2.5% external fixation. Preangiographic multidetector computed tomography angiography was performed in 20 (49%) cases, and 9 of them showed arterial extravasation. Twenty-seven TAEs were performed within a week from surgery; active bleeding was seen in 33 (80.5%) angiograms. Gelatin sponge, microparticles, coils, n-butyl cyanoacrylate, and combinations of them were used as embolic materials. RESULTS: Bleeding was controlled in all cases. The most frequently embolized arteries were branches of the deep femoral artery (n = 17). Permanent embolization agents (microparticles, coils, n-2-butyl-cyanoacrylate) were used in 88% of cases; temporary agents (gelfoam) in 12%. One procedure was complicated by arterial dissection. Hospital discharge averaged 20 days post-TAE (median = 17, range = 3-104). One-month survival rate was 97.5%. One patient died of ischemic bowel perforation. CONCLUSION: TAE is safe and effective in stopping the bleeding of the hip region and should be performed early, to avoid irreversible ischemic damage. Multidetector computed tomography angiography can be used to confirm doubtful evidence of ongoing bleeding. Several embolic materials can be used, each one offering different advantages. Low complication and mortality rates were observed. TAE seems to be the ideal first-line intervention when postoperative bleeding of the operated hip is detected.

Positron Emission Tomography-Computed Tomography for Patients with Recurrent Colorectal Liver Metastases: Impact on Restaging and Treatment Planning.

BACKGROUND: The impact of fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) for patients with colorectal liver metastases (CLM) still is debated. Its relevance could be enhanced in the case of recurrent disease. The current study aimed to elucidate the role of PET-CT in restaging and treatment planning for recurrent CLM. METHODS: A series of 352 consecutive patients undergoing their first liver resection for CLM between 2005 and 2014 was reviewed. Of these patients, 224 (63.6 %) had a recurrence. The 107 patients who had received PET-CT at diagnosis of recurrence before chemotherapy were analyzed. CT was available in all cases, and magnetic resonance imaging (MRI) was available in 64 cases. RESULTS: Extrahepatic lesions were found in 59 patients. Liver and lung recurrences were detected with excellent sensitivity by CT/MRI and PET-CT (liver: 100 vs. 96.7 %; lung: 95.8 vs. 95.8 %). In detecting other recurrence sites, PET-CT had higher sensitivity than CT/MRI (91.5 vs. 54.2 %, p < 0.01; lymph nodes: 93.5 vs. 64.5 %, p = 0.011; peritoneum: 80 vs. 20 %, p = 0.023; bones: 87.5 vs. 37.5 %, nonsignificant difference). For 28.8 % (17/59) of the patients, the diagnosis of extrahepatic disease was obtained thanks to PET-CT (39.5 % considering nonpulmonary lesions). PET-CT modified treatment strategy in 16 (14.9 %) patients, excluding from surgery 15 (20.3 %) of 74 patients resectable at CT/MRI. This latter subgroup had a lower survival rate than the patients resectable after PET-CT (2-year survival, 22.7 vs. 77.8 %; p = 0.004), similar to the patients unresectable at CT/MRI (57.6 %). CONCLUSIONS: In the authors' experience, PET-CT has offered a relevant contribution to restaging of recurrent CLM. It disclosed one fourth of extrahepatic lesions and prevented worthless surgery for about 20 % of patients.

Non-healing post-surgical fistulae: treatment with image-guided percutaneous injection of cyanoacrylic glue.

OBJECTIVES: To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments. METHODS: Eighteen patients (14 males; age range 33-84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection. RESULTS: In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1-5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0-58 days). No complications occurred. Reoperation was needed in one patient. CONCLUSIONS: Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.

Benign biliary strictures refractory to standard bilioplasty treated using polydoxanone biodegradable biliary stents: retrospective multicentric data analysis on 107 patients.

OBJECTIVES: To assess mid-term outcome of biodegradable biliary stents (BBSs) to treat benign biliary strictures refractory to standard bilioplasty. METHODS: Institutional review board approval was obtained and patient consent was waived. 107 patients (61 males, 46 females, mean age 59 ± 16 years), were treated. Technical success and complications were recorded. Ninety-seven patients (55 males, 42 females, aged 57 ± 17 years) were considered for follow-up analysis (mean follow-up 23 ± 12 months). Fisher's exact test and Mann-Whitney U tests were used and a Kaplan-Meier curve was calculated. RESULTS: The procedure was always feasible. In 2/107 cases (2 %), stent migration occurred (technical success 98 %). 4/107 patients (4 %) experienced mild haemobilia. No major complications occurred. In 19/97 patients (18 %), stricture recurrence occurred. In this group, higher rate of subsequent cholangitis (84.2 % vs. 12.8 %, p = 0.001) and biliary stones (26.3 % vs. 2.5 %, p = 0.003) was noted. Estimated mean time to stricture recurrence was 38 months (95 % C.I 34-42 months). Estimated stricture recurrence rate at 1, 2, and 3 years was respectively 7.2 %, 26.4 %, and 29.4 %. CONCLUSION: Percutaneous placement of a BBS is a feasible and safe strategy to treat benign biliary strictures refractory to standard bilioplasty, with promising results in the mid-term period. KEY POINTS: • Percutaneous placement of a BBS is 100 % feasible. • The procedure appears free from major complications, with few minor complications. • BBSs offer promising results in the mid-term period. • With a BBS, external catheter/drainage can be removed early. • BBSs represent a new option in treating benign biliary stenosis.

Diagnostic accuracy of ¹¹C-choline PET/CT in comparison with CT and/or MRI in patients with hepatocellular carcinoma.

PURPOSE: In recent decades, the use of radiopharmaceuticals in the assessment of hepatocellular carcinoma (HCC) has become established, and new findings indicate that radiolabelled choline has considerable potential in this setting. Therefore, in this study we aimed to assess the diagnostic role of (11)C-choline positron emission tomography (PET)/CT, compared with conventional imaging with CT/MRI, in patients with HCC. METHODS: The study population comprised 45 patients (male to female ratio = 37:8, median age 70.5 years) referred to our institution owing to HCC: 27 at initial diagnosis and 18 for restaging after recurrence. In all cases we performed whole-body (11)C-choline PET/CT and compared its findings with contrast-enhanced CT (n = 35) or MRI (n = 29) or both (n = 15) for a total of 50 paired scans. The reference standard was either histological proof (21 patients) or a multidisciplinary consensus. Diagnostic accuracy was then determined in a scan-based (SBA) and a lesion-based analysis (LBA). RESULTS: On SBA the sensitivity and specificity for PET were 88 and 90 %, respectively, whereas for CT/MRI they were 90 and 73 %, respectively (p > 0.05). On LBA the overall sensitivity and specificity were 78 and 86 %, respectively, for PET vs 65 and 55 % for CT/MRI. Overall we investigated 168 disease sites, of which 100 were in the liver and 68 were extrahepatic. When considering only liver lesions, (11)C-choline PET and CT/MRI showed an accuracy of 66 and 85 %, respectively, while for extrahepatic lesions PET showed an accuracy of 99 %, while the accuracy of CT/MRI was 32 %. In both cases, there was a statistically significant difference in accuracy between the two modalities (p < 0.01). Combination of the PET results with those of CT/MRI resulted in the highest diagnostic accuracy in both analyses, at 92 % for SBA and 96 % for LBA. In 11 patients (24 %) the PET findings modified the therapeutic strategy, the modification proving appropriate in 10 of them. CONCLUSION: (11)C-Choline PET showed good accuracy in investigating patients with HCC and prompted a change in treatment planning in almost one fourth of patients. The main strength of (11)C-choline PET/CT resides in its ability to detect extrahepatic HCC localizations, but the combination with conventional imaging modalities allowed for the highest diagnostic accuracy.

Percutaneous Image-Guided Cryoablation of Breast Cancer: A Systematic Review.

A systematic review of the clinical safety and efficacy of percutaneous breast cancer cryoablation was performed. Of 202 papers screened, seven matched the inclusion criteria. Cryoablation was mainly performed under ultrasound guidance, and on average two cryoprobes were used. Complete local tumor control was noted in 73% of patients (mean follow-up, 8 mo). No major complications were noted. The cosmetic outcome was satisfactory. Breast cancer cryoablation is safe, although local tumor control is suboptimal. The best results are achieved with small (<15 mm) ductal tumors treated by application of multiple cryoprobes.

Simultaneous bilateral magnetic resonance angiography to evaluate thoracic outlet syndrome.

PURPOSE: This paper presents a new magnetic resonance angiography (MRA) protocol for the evaluation of thoracic outlet syndrome (TOS) that allows for a separate assessment of veins and arteries while using a single, simultaneous and bilateral (SB-MRA) single contrast injection, valid for both abduction and adduction acquisitions. MATERIALS AND METHODS: From 2009 to 2013 we performed 38 MRA studies for clinically suspected TOS (13 M, 25 F; mean age, 35.9 years; σ = 11.13). Twin peripheral 20G intravenous catheters were placed in a cubital vein in both arms and connected to a single power injector by two lines joined with a connector. A 3T MR system with a wide gantry was used. Two groups of four radiologists assessed all the images. Group A judged the full examinations, Group B had only the late acquisitions. Differences were evaluated using the Chi square test. TOS was confirmed only after integration with the clinical history. RESULTS: Seventeen (45 %) patients were diagnosed with predominant venous TOS (VTOS), nine (24 %) with predominant arterial TOS (ATOS) and 12 (32 %) had an indeterminate or nonvascular condition. Group A radiologists identified significantly more VTOS than group B (p = 0.049). Interobserver agreement was very high. CONCLUSIONS: SB-MRA is a safe and reliable protocol for the study of TOS. It provides a supplementary early acquisition that allows for separate assessment of veins and arteries, permits the investigation of the collateral venous flow with a single injection of contrast material and provides a higher diagnostic power for VTOS. SB-MRA is helpful for the diagnosis of TOS of vascular origin.

Criteria for the selective use of contrast-enhanced intra-operative ultrasound during surgery for colorectal liver metastases.

BACKGROUND: Contrast-enhanced intra-operative ultrasound (CE-IOUS) for colorectal liver metastases (CLMs) has become a part of clinical practice. Whether it should be selectively or routinely applied remains unclear. The aim of this study was to define criteria for the use of CE-IOUS. METHODS: One-hundred and twenty-seven patients underwent a hepatectomy for CLMs using IOUS and CE-IOUS. All patients underwent computed tomography (CT) and/or magnetic resonance imaging (MRI) within 2 weeks prior to surgery. The reference was histology, and imaging at 6 months after surgery. Univariate and multivariate analyses were performed. Statistical significance was set at P = 0.05. RESULTS: Using IOUS an additional 172 lesions in 51 patients were found. CE-IOUS found 14 additional lesions in 6 patients. Seventy-eight CLMs in 38 patients appeared within 6 months after surgery. The sensitivity, specificity, positive- and negative-predictive value were 63%, 98%, 100% and 27% for pre-operative imaging, 87%, 100%, 100% and 52% for IOUS, and 89%, 100%, 100% and 56% for IOUS+CE-IOUS, respectively. CE-IOUS allowed better tumour margin definition in 23 patients (18%), thus assisting resection. Analyses indicated that the presence of multiple (P = 0.014), and isoechoic CLMs (P = 0.049) were independently correlated with new findings at CE-IOUS. CONCLUSIONS: Compared with IOUS, CE-IOUS improved detection and resection guidance. These additions are significant and demand its use in cases with multiple and isoechoic CLMs.

Biodegradable biliary stent implantation in the treatment of benign bilioplastic-refractory biliary strictures: preliminary experience.

OBJECTIVES: To evaluate feasibility, safety, and outcome of patients treated with biodegradable biliary stents for benign biliary stenosis refractory to other treatments. METHODS: Between March 2011 and September 2012, ten patients (seven men, three women; age 59 ± 7 years) with recurrent cholangitis due to postsurgical biliary stricture, previous multiple unsuccessful (two to five) bilioplasties, and unsuitability for surgical/endoscopic repair underwent percutaneous implantation of a biodegradable biliary stent. Patients were followed-up clinically and with ultrasound at 1, 3 and 6 months, and then at 6-month intervals. RESULTS: Stent implantation was always feasible. No immediate major or minor complications occurred. In all patients, 48-h cholangiographic control demonstrated optimal stent positioning and stenosis resolution. In a median follow-up time of 16.5 months (25th-75th percentiles = 11-20.25 months) no further invasive treatment was needed. Three patients experienced transient episodes of cholangitis. Neither re-stenosis nor dilatation of the biliary tree was documented during follow-up. No stent was visible at the 6-month follow-up. CONCLUSIONS: Percutaneous placement of biodegradable biliary stents represents a new option in treating benign biliary stenoses refractory to treatment with bilioplasty. This technique seems to be feasible, effective and free from major complications. Further investigations are warranted to confirm our preliminary results.

Contrast Enhanced EUS for Predicting Solid Pancreatic Neuroendocrine Tumor Grade and Aggressiveness.

Pancreatic neuroendocrine tumor (PNET) behavior assessment is a daily challenge for physicians. Modern PNET management varies from a watch-and-wait strategy to surgery depending on tumor aggressiveness. Therefore, the aggressiveness definition plays a pivotal role in the PNET work-up. The aggressiveness of PNETs is mainly based on the dimensions and histological grading, with sometimes a lack of specificity and sensibility. In the last twenty years, EUS has become a cornerstone in the diagnostic phase of PNET management for its high diagnostic yield and the possibility of obtaining a histological specimen. The number of EUS applications in the PNET work-up has been rapidly increasing with new and powerful possibilities. The application of contrast has led to an important step in PNET detection; in recent years, it has been gaining interesting applications in aggressiveness assessment. In this review, we underline the latest experiences and opportunities in the behavior assessment of PNETs using contact-enhanced EUS and contested enhanced harmonic EUS with a particular focus on the future application and possibility that these techniques could provide.

Proposal of early CT morphological criteria for response of liver metastases to systemic treatments in gastroenteropancreatic neuroendocrine tumors: Alternatives to RECIST.

RECIST 1.1 criteria are commonly used with computed tomography (CT) to evaluate the efficacy of systemic treatments in patients with neuroendocrine tumors (NETs) and liver metastases (LMs), but their relevance is questioned in this setting. We aimed to explore alternative criteria using different numbers of measured LMs and thresholds of size and density variation. We retrospectively studied patients with advanced pancreatic or small intestine NETs with LMs, treated with systemic treatment in the first-and/or second-line, without early progression, in 14 European expert centers. We compared time to treatment failure (TTF) between responders and non-responders according to various criteria defined by 0%, 10%, 20% or 30% decrease in the sum of LM size, and/or by 10%, 15% or 20% decrease in LM density, measured on two, three or five LMs, on baseline (≤1 month before treatment initiation) and first revaluation (≤6 months) contrast-enhanced CT scans. Multivariable Cox proportional hazard models were performed to adjust the association between response criteria and TTF on prognostic factors. We included 129 systemic treatments (long-acting somatostatin analogs 41.9%, chemotherapy 26.4%, targeted therapies 31.8%), administered as first-line (53.5%) or second-line therapies (46.5%) in 91 patients. A decrease ≥10% in the size of three LMs was the response criterion that best predicted prolonged TTF, with significance at multivariable analysis (HR 1.90; 95% CI: 1.06-3.40; p = .03). Conversely, response defined by RECIST 1.1 did not predict prolonged TTF (p = .91), and neither did criteria based on changes in LM density. A ≥10% decrease in size of three LMs could be a more clinically relevant criterion than the current 30% threshold utilized by RECIST 1.1 for the evaluation of treatment efficacy in patients with advanced NETs. Its implementation in clinical trials is mandatory for prospective validation. Criteria based on changes in LM density were not predictive of treatment efficacy. CLINICAL TRIAL REGISTRATION: Registered at CNIL-CERB, Assistance publique hopitaux de Paris as "E-NETNET-L-E-CT" July 2018. No number was assigned. Approved by the Medical Ethics Review Board of University Medical Center Groningen.

Usefulness of alpha-fetoprotein response in patients treated with sorafenib for advanced hepatocellular carcinoma.

BACKGROUND & AIMS: Tumor shrinkage has been considered a fundamental surrogate efficacy measure for new cancer treatments. However, in patients treated with sorafenib for advanced hepatocellular carcinoma (HCC), tumor shrinkage rarely accompanies increased survival, thereby questioning the prognostic value of imaging-based Response Evaluation Criteria in Solid Tumors (RECIST). We investigated the prognostic usefulness of a decrease in serum alpha-fetoprotein (AFP) and compared it to RECIST. METHODS: In HCC patients treated with sorafenib with baseline AFP >20 ng/ml, AFP response was defined as a >20% decrease in AFP during 8weeks of treatment. Patients were also assessed by RECIST and were categorized as having radiologically proven progressive disease or disease control (consisting of complete or partial responses and stable disease). Comparisons of survival by RECIST and AFP response were corrected for guarantee-time bias by the landmark method. RESULTS: We evaluated 85 patients for AFP response, among them, 82 were also evaluated by RECIST. In the analysis of AFP response, 32 out of 85 patients (37.6%) were responders, whereas 58 out of 82 patients (70.7%) achieved disease control. In landmark analysis, the hazard ratios (HR) for survival according to AFP response and disease control were 0.59 (p=0.040) and 1.03 (p=0.913), respectively. In multivariate analysis, only AFP response (HR=0.52; p=0.009) and Cancer of the Liver Italian Program dichotomized stage (HR=0.42; p=0.002) were prognostic factors of survival. CONCLUSIONS: Assessment of AFP response may be considered as an alternative to RECIST to capture sorafenib activity in HCC.

Case Report: New CDKN1B Mutation in Multiple Endocrine Neoplasia Type 4 and Brief Literature Review on Clinical Management.

Background: The fourth type of multiple endocrine neoplasia (MEN) is known as a rare variant of MEN presenting a MEN1-like phenotype and originating from a germline mutation in CDKN1B. However, due to the small number of cases documented in the literature, the peculiar clinical features of MEN4 are still largely unknown, and clear indications about the clinical management of these patients are currently lacking. In order to widen our knowledge on MEN4 and to better typify the clinical features of this syndrome, we present two more cases of subjects with MEN4, and through a review of the current literature, we provide some possible indications on these patients' management. Case Presentation: The first report is about a man who was diagnosed with a metastatic ileal G2-NET at the age of 34. Genetic analysis revealed the mutation p.I119T (c.356T>C) of exon 1 of CDKN1B, a mutation already reported in the literature in association with early-onset pituitary adenomas. The second report is about a 76-year-old woman with a multifocal pancreatic G1-NET. Genetic analysis identified the CDKN1B mutation c.482C>G (p.S161C), described here for the first time in association with MEN4 and currently classified as a variant of uncertain significance. Both patients underwent biochemical and imaging screening for MEN1-related diseases without any pathological findings. Conclusions: According to the cases reported in the literature, hyperparathyroidism is the most common clinical feature of MEN4, followed by pituitary adenoma and neuroendocrine tumors. However, MEN4 appears to be a variant of MEN with milder clinical features and later onset. Therefore, these patients might need a different and personalized approach in clinical management and a peculiar screening and follow-up strategy.

Thermal Ablation of Liver Tumors Guided by Augmented Reality: An Initial Clinical Experience.

Background: Over the last two decades, augmented reality (AR) has been used as a visualization tool in many medical fields in order to increase precision, limit the radiation dose, and decrease the variability among operators. Here, we report the first in vivo study of a novel AR system for the guidance of percutaneous interventional oncology procedures. Methods: Eight patients with 15 liver tumors (0.7−3.0 cm, mean 1.56 + 0.55) underwent percutaneous thermal ablations using AR guidance (i.e., the Endosight system). Prior to the intervention, the patients were evaluated with US and CT. The targeted nodules were segmented and three-dimensionally (3D) reconstructed from CT images, and the probe trajectory to the target was defined. The procedures were guided solely by AR, with the position of the probe tip was subsequently confirmed by conventional imaging. The primary endpoints were the targeting accuracy, the system setup time, and targeting time (i.e., from the target visualization to the correct needle insertion). The technical success was also evaluated and validated by co-registration software. Upon completion, the operators were assessed for cybersickness or other symptoms related to the use of AR. Results: Rapid system setup and procedural targeting times were noted (mean 14.3 min; 12.0−17.2 min; 4.3 min, 3.2−5.7 min, mean, respectively). The high targeting accuracy (3.4 mm; 2.6−4.2 mm, mean) was accompanied by technical success in all 15 lesions (i.e., the complete ablation of the tumor and 13/15 lesions with a >90% 5-mm periablational margin). No intra/periprocedural complications or operator cybersickness were observed. Conclusions: AR guidance is highly accurate, and allows for the confident performance of percutaneous thermal ablations.

Myosteatosis Is Not Associated with Complications or Survival in HCC Patients Undergoing Trans Arterial Embolization.

Alterations in nutritional status, in particular sarcopenia, have been extensively associated with a poor prognosis in cirrhotic patients regardless of the etiology of liver disease. Less is known about the predictive value of myosteatosis, defined as pathological fat infiltration into the skeletal muscle. We retrospectively analyzed a cohort of 151 cirrhotic patients with unresectable hepatocellular carcinoma (HCC) who underwent their first trans-arterial embolization (TAE) between 1 March 2011 and 1 July 2019 at our Institution. Clinical and biochemical data were collected. Sarcopenia was assessed using the L3-SMI method while myosteatosis with a dedicated segmentation suite (3D Slicer), using a single slice at an axial plane located at L3 and calculating the IMAC (Intramuscular Adipose Tissue Content Index). The sex-specific cut-off values for defining myosteatosis were IMAC > −0.44 in males and >−0.31 in females. In our cohort, 115 (76%) patients were included in the myosteatosis group; 128 (85%) patients had a coexistent diagnosis of sarcopenia. Patients with myosteatosis were significantly older and showed higher BMI than patients without myosteatosis. In addition, male gender and alcoholic- or metabolic-related cirrhosis were most represented in the myosteatosis group. Myosteatosis was not associated with a different HCC burden, length of hospitalization, complication rate, and readmission in the first 30 days after discharge. Overall survival was not influenced by the presence of myosteatosis.