Hepatocellular carcinoma: multimodality management.

BACKGROUND: Hepatocellular carcinoma is one of the most common tumors worldwide. Surgical resection has been the standard treatment but can only be applied to a small percentage of patients. In recent years, several other treatment options, including ablative procedures and transplantation, have been used in patients with hepatocellular carcinoma. METHODS: For 6 years, 110 patients with hepatocellular carcinoma were managed at the Medical College of Wisconsin. Fifty-five patients received only chemotherapy (n = 5) or palliative treatment (n = 50) because of advanced cirrhosis (P <.03) or tumor. Thirty-one patients had tumor ablation with percutaneous ethanol injection, cryoablation, radiofrequency ablation, or arterial chemoembolization. Twenty-eight patients underwent surgical resection (n = 18) or hepatic transplantation (n = 10). Relatively more patients (38%; P <.001) were treated with ablation in the second period of the study (1998-2000). RESULTS: Thirty-day mortality was 3% with ablation and 0% with resection. Median survival was 6 months with no treatment, 27 months with ablation (P <.001), and 35 months with resection (P <.001). Patients who underwent liver transplantation had the longest median survival (53 months). A multivariate analysis suggested that treatment modality (ablation or resection; P <.001) and Child-Pugh classification (P <.01) were the most important factors predicting outcome. CONCLUSIONS: This study suggests that treatment of hepatocellular carcinoma requires multidisciplinary expertise and that ablation and operation can be performed safely. Outcome is influenced most by treatment modality and Child-Pugh classification. Patients in Child-Pugh classes A and B should be treated with ablation, surgical resection, or liver transplantation.

Ablation of liver metastasis: is preoperative imaging sufficiently accurate?

The recent introduction of cryotherapy and radiofrequency ablation of liver metastasis has expanded the indications for treatment. As technology has advanced, a percutaneous approach has been developed. Percutaneous treatment, however, requires accurate preoperative imaging. From 1993 to 1999, 179 patients underwent operative exploration for treatment of suspected hepatic metastases from colorectal carcinoma. One hundred seventy-seven patients were staged by preoperative CT, two patients were staged by MRI, and complete data were available in 176. Hepatic tumor count by preoperative imaging was compared to intraoperative tumor count obtained by inspection, palpation, ultrasonographic examination using a 3.5/7.5 MHz T probe, and careful gross sectioning of the resected specimen. Post hoc analysis was performed on 35 CT scans by two radiologists who specialize in abdominal CT. These radiologists were blinded to the intraoperative findings. Their interpretations were compared to the intraoperative counts and to each other. Thirty-four (19%) of 179 patients were deemed untreatable at operation because of unsuspected overwhelming liver involvement in 11 (6%) or extrahepatic metastases in 23 (13%). For the group, CT was accurate in 80 patients (45%), showed more lesions than were found in 16 (9%), and showed fewer metastases than were found in 80 (45%). When the preoperative scan predicted a solitary metastasis, it was correct in 45 (65%) of 69 patients and underestimated disease in 24 (35%). In the post hoc analysis, the mean numbers of lesions reported by the two radiologists did not differ from the mean number of tumors found; however, the radiologists' counts agreed on 16 (59%) and disagreed on 11 (41%) of the scans. The accuracy of CT decreased with increasing numbers of lesions. Regardless of the type of preoperative imaging, intraoperative findings altered the course of the operation in 96 (55%) of 176 patients. Preoperative imaging is not sufficiently accurate to permit adequate percutaneous treatment of hepatic metastases from colorectal carcinoma.

Multiphase hepatic CT with a multirow detector CT scanner.

OBJECTIVE: The aim of this study was to evaluate a new injection-acquisition technique performed using a multirow detector CT scanner for separation of three distinct hepatic circulatory phases (hepatic artery, portal venous inflow, hepatic venous) and to determine which of these phases is optimal for detecting hypervascular neoplasm. MATERIALS AND METHODS: Two sequential acquisitions were performed during a single breath-hold followed by a third acquisition beginning 60 sec after injection. Injection-to-scan delay for the first acquisition was the individual patient's circulation time, which was determined by a preliminary mini bolus. The mean attenuation of the upper abdominal aorta, portal vein, and hepatic parenchyma were determined for each imaging pass in 20 patients with cirrhosis and 20 patients without cirrhosis. Tumor-to-liver contrast for hypervascular primary and metastatic neoplasm was evaluated in a different set of 16 cirrhotic patients and nine noncirrhotic patients. Three-dimensional CT arteriograms were obtained from first-pass data. RESULTS: Three distinct circulatory phases (hepatic artery, portal vein inflow or late arterial, and hepatic venous) were seen in cirrhotic and noncirrhotic patients. Maximum tumor-to-liver contrast for hypervascular primary and metastatic neoplasm occurred during the second pass for both cirrhotic (p < 0.006) and noncirrhotic (p < 0. 001) patients. A three-dimensional hepatic-mesenteric CT arteriogram of normal or anomalous hepatic vessels without venous overlay was obtained from first-pass data in all patients. CONCLUSION: Rapid-sequence hepatic helical CT allows selection of the optimal time interval for hypervascular tumor detection. A new paradigm for rapid hepatic CT acquisition-namely, hepatic arterial, portal vein inflow, and hepatic venous phases-is recommended to replace hepatic artery dominant and portal venous phases.

Applicability of American College of Radiology appropriateness criteria in a general internal medicine clinic.

OBJECTIVE: The American College of Radiology (ACR) Appropriateness Criteria for Imaging and Treatment Decisions are intended to help radiologists and referring physicians use imaging procedures appropriately and cost-effectively, but these criteria have not undergone empirical testing. To assess how readily the ACR appropriateness criteria can be applied to clinical practice, we retrospectively examined their applicability in a general ambulatory care setting. MATERIALS AND METHODS: From all requests during an 8-month period for noninterventional CT, sonography, MR imaging, and nuclear medicine imaging procedures received from a general internal medicine clinic, we excluded cases for which relevant clinic notes were unavailable or incomplete. Three experienced radiologists classified cases by consensus, using data from radiology requests and clinic notes. Cases were classified as a "complete match" if the features matched a clinical condition and variant included in the ACR appropriateness criteria; as a "partial match" if the features matched a clinical condition but did not match all features of a variant; or as "unmatched." RESULTS: Of 316 cases, there were 202 complete matches (64%) and 37 partial matches (12%). Of the 77 unmatched cases (24%), 14 pertained to asymptomatic patients. CONCLUSION: The ACR appropriateness criteria could be applied to 76% of the imaging procedure requests that we received from a general internal medicine clinic. These results suggest that the ACR appropriateness criteria can be applied to diagnostic imaging in a general ambulatory-care setting.

Appropriateness of imaging procedure requests: do radiologists agree?

OBJECTIVE: We explored the agreement among radiologists in their evaluation of the appropriateness of individual requests for imaging procedures. MATERIALS AND METHODS: We reviewed 318 noninterventional CT, sonographic, MR imaging, and nuclear medicine procedures ordered at a general internal medicine clinic during 8 months in 1995. Five subspecialty radiologists used data from the radiology request from and clinic notes to independently rate the appropriateness of each requested imaging procedure on a four-point scale. The radiologists were unaware of the results achieved by each procedure. Each case was reviewed by at least three radiologists, of whom at least one had relevant subspecialty expertise. Agreement among radiologists was analyzed using Cohen's kappa statistic and weighted kappa statistics and Cronbach's alpha statistic. RESULTS: Nonchance agreement (kappa) was .19 +/- .05; weighted kappa was .24 +/- .05. Interrater agreement was significantly greater than that expected from chance alone (p < .01). The composite score, defined as the average of the radiologists' scores for each case, showed moderate reliability, as evidenced by a value for Cronbach's alpha of 70. CONCLUSION: In the absence of explicit criteria, we found modest but statistically significant agreement among radiologists about the appropriateness of individual requests for imaging procedures. The disagreement among radiologists highlights the importance of developing well-reasoned, explicit criteria by which to judge the appropriateness of diagnostic radiology procedures. Further study is needed to elucidate the relationship between appropriateness and actual patient outcomes.

Positive predictive value of clinical suspicion for abdominal aortic aneurysm. Implications for use of ultrasonography.

To measure the positive predictive value (PPV) of clinical suspicion of abdominal aortic aneurysm (AAA), as confirmed by ultrasonography, we reviewed the records of 343 patients at a university medical center referred to ultrasonography for newly suspected AAA. Positive predictive value was 11.1% for large aneurysms of at least 5.0 cm and 18.7% for aneurysms of at least 3.5 cm, and was higher for men and older patients. For patients under 50 years of age, PPV was only 2.6%. Ultrasonography for clinically suspected AAA has a low positive predictive yield, particularly for men under age 50 and for women.

Focal masses in cirrhotic liver: CT and MR imaging features.

The development of hepatic cirrhosis triggers attempted repair through regenerative nodules of parenchyma among bands of scar tissue. Some authors believe that this regeneration initiates an evolutionary process that may lead to nodular enlargement and cellular dedifferentiation to malignancy. Both the destructive and reparative processes in cirrhosis produce changes that the radiologist must recognize when imaging the cirrhotic liver. This essay describes the CT and MR features of masses and masslike lesions in the cirrhotic liver, including the identifying characteristics and overlapping appearances of CT and MR.

Hepatic helical CT: contrast material injection protocol.

PURPOSE: To develop and compare contrast material injection protocols suitable for hepatic helical computed tomography (CT). MATERIALS AND METHODS: Monophasic and biphasic helical CT were performed with contrast material with an iodine load of 50 g at 3 mL/sec for 60 seconds or at 5 mL/sec for 10 seconds and 2 mL/sec for 65 seconds, respectively. In 58 men and 51 women, aged 22-77 years, aortic and hepatic enhancement curves were constructed from a cluster acquisition with a slip-ring scanner operating in a nonhelical mode. RESULTS: The monophasic protocol produced a higher peak aortic enhancement (180 HU +/- 47 [+/- 1 standard deviation]) than the biphasic protocol (150 HU +/- 24). Peak hepatic enhancement (63-64 HU +/- 15) was equivalent. Calculated equilibrium time for the monophasic protocol was 95.1 seconds and for the biphasic protocol was 101.4 seconds. The contrast enhancement index differed only marginally between the two protocols (P < .4). CONCLUSION: Monophasic and biphasic protocols produced equivalent results when tailored for the shorter temporal window of a rapid-sequence helical acquisition.

Periportal halo: a CT sign of liver disease.

Periportal halos are defined as circumferential zones of decreased attenuation identified around the peripheral or subsegmental portal venous branches on contrast-enhanced computed tomography (CT). These halos probably represent fluid or dilated lymphatics in the loose areolar zone around the portal triad structures. While this CT finding is nonspecific, it is abnormal and should prompt close scrutiny of the liver in search of an underlying etiology. Periportal halos which may be due to blood are commonly seen in patients with liver trauma. Periportal edema may cause this sign in patients with congestive heart failure and secondary liver congesion, hepatitis, or enlarged lymph nodes and tumors in the porta hepatis which obstruct lymphatic drainage. This CT sign has also been observed in liver transplants (probably secondary to disruption and engorgement of lymphatic channels) and in recipients of bone marrow transplants who might develop liver edema from microvenous occlusive disease. While the precise pathophysiologic basis of periportal tracking has not been proven, it represents a potentially important CT sign of occult liver disease.

Periportal tracking in hepatic trauma: CT features.

In retrospective review, 51 cases of hepatic trauma were analyzed for type and location of injury. More than half of these cases (62%) demonstrated periportal zones of decreased attenuation, which is presumed to represent blood in the periportal region. This finding has been termed "periportal tracking" and may be an important sign of subtle liver injury.

Stenosis of the internal carotid artery: assessment using color Doppler imaging compared with angiography.

The percentage of diameter stenosis of the internal carotid artery was estimated directly from color Doppler images obtained in both longitudinal and transverse planes and compared with the results of digital subtraction angiography in 49 patients (95 carotid arteries). Peak systolic velocity measurements were obtained by placing the sample volume in the highest-velocity flow stream with the angle-correction cursor parallel to the color-encoded lumen. Arterial stenoses were categorized on a grade 1-5 scale: 1 = 0-15%, 2 = 16-49%, 3 = 50-75%, 4 = 76-99%, and 5 = occlusion. Percent diameter stenosis could not be determined in 12 color Doppler flow imaging studies (13%) due to calcified plaque. Of the remaining 83 arteries evaluated by both techniques, the respective categories by color Doppler flow imaging/angiography were grade 1 (16/26), grade 2 (25/24), grade 3 (30/19), grade 4 (5/8), and grade 5 (7/6). Percent diameter stenosis determined by color Doppler flow imaging was greater than by angiography in 25% and less than by angiography in 4%. Peak systolic velocity measurements did not separate the hemodynamically insignificant (less than 50% diameter stenosis) grade 1 and grade 2 lesions, but were in agreement in 86% of grades 3-5 stenotic categories, as determined by measurements from the color Doppler flow image. A direct measurement of percent diameter stenosis from the color Doppler flow image was possible in 87% of cases. Peak systolic velocity provided correlative diagnostic information when assessing hemodynamically significant lesions.

Color Doppler evaluation of arterial stenoses and occlusions involving the neck and thoracic inlet.

Color Doppler flow imaging is a new technique providing simultaneous display of a gray-scale tissue and a color-flow vascular image. We demonstrate its ability to predict accurately occlusions of numerous vessels, including the internal carotid, external carotid, common carotid, subclavian and innominate arteries. Alterations in flow direction and changes in spectral wave form provide useful clues to the presence of these occlusions. The cases are correlated with angiographic findings and functional flow diagrams of the hemodynamic changes involved.

Color Doppler ultrasound imaging of lower-extremity venous disease.

A color Doppler ultrasound imaging device was used to evaluate 475 patients with suspected lower-extremity venous thrombosis. Occlusive and nonocclusive femoral and popliteal thrombi were detected in 200 studies (42%). In phase 1 of the study (240 examinations), peripheral augmentation with the use of periodic calf compression was required to show color flow throughout the femoropopliteal venous segment. In phase 2 (235 examinations), with a software upgrade to enhance detectability of slow flow, spontaneous flow could be appreciated in the normal, partly thrombosed, and recanalized femoral popliteal veins without augmentation. Augmentation was often necessary to view tibioperoneal veins. Of the total study group, conventional venography was performed for correlation in 47 patients. In the other patients, clinicians relied on the color Doppler test for the definitive diagnosis of the presence or absence of femoral popliteal venous thrombosis and treated these patients on the basis of the color Doppler test result. In the femoral veins, color Doppler studies and venography agreed in all 12 positive and 35 negative cases. In the popliteal veins, there was agreement in five isolated popliteal thromboses and in 10 femoral popliteal thromboses; there were two false-negative color Doppler studies of isolated popliteal thromboses. In four patients, Doppler studies detected nonocclusive thrombus not evident on venography. Color Doppler imaging is easy to perform and does not require augmentation to view color flow in the femoropopliteal venous segment. Eccentric thrombus and partially canalized thrombus can be shown. Initial experience suggests color Doppler imaging may be useful in the detection of tibioperoneal venous thrombosis.

Evaluation and treatment of intraabdominal bilomas.

In a 3-year period, 21 intraabdominal bilomas developed in 18 patients. Fifteen of the patients had a solitary biloma, and the other three patients each had two separate concurrent bilomas. The major cause of biloma formation was postoperative bile leakage from a bile duct after laparotomy done primarily for surgery on the gallbladder or liver. Maximal diameter of the bilomas in the transaxial plane ranged from 2 to 19 cm. Sixteen of the bilomas were in the right upper quadrant, and five were in the left upper quadrant. Two large right-sided collections extended caudally into the lower abdomen. The contours of the bilomas were configured by the diaphragm, mesenteries, liver, and other abdominal organs. On CT and sonography, the bilomas were invariably well demarcated, but most did not have an identifiable capsule. CT did demonstrate a thin rim on four bilomas and a thick rim on one. In 19 bile collections, the CT numbers were less than 20 H. The combination of the clinical history, the location, and the CT appearance of the lesion led to the correct diagnosis in each case. Percutaneous drainage was an effective form of therapy that often eliminated the need for surgical drainage.

Demonstration of the normal extrahepatic biliary tract with computed tomography.

When optimum computed tomography (CT) technique and computed angiotomography are utilized, the normal extrahepatic biliary ducts (equal to or less than 6 mm in diameter in patients without cholecystectomy) can be demonstrated in approximately 30% of clinical scans. Measurement of the anteroposterior diameter of the bile duct is more accurate than recording the transverse diameter, since the apparent transverse dimension will vary depending on the orientation of the duct in the plane of section. Phantom studies indicate that the absolute error of measurement is approximately one pixel diameter irrespective of duct diameter. The normal and abnormally dilated extrahepatic biliary ducts should be distinguished with CT.