Ablative Therapy in Non-HCC Liver Malignancy.

Surgical extirpation of liver tumors remains a proven approach in the management of metastatic tumors to the liver, particularly those of colorectal origin. Ablative, non-resective therapies are an increasingly attractive primary therapy for liver tumors as they are generally better tolerated and result in far less morbidity and mortality. Ablative therapies preserve greater normal liver parenchyma allowing better post-treatment liver function and are particularly appropriate for treating subsequent liver-specific tumor recurrence. This article reviews the current status of ablative therapies for non-hepatocellular liver tumors with a discussion of many of the clinically available approaches.

Post Yttrium-90 Imaging.

Transarterial radioembolization with yttrium-90 ( 90 Y) is a mainstay for the treatment of liver cancer. Imaging the distribution following delivery is a concept that dates back to the 1960s. As ß particles are created during 90 Y decay, bremsstrahlung radiation is created as the particles interact with tissues, allowing for imaging with a gamma camera. Inherent qualities of bremsstrahlung radiation make its imaging difficult. SPECT and SPECT/CT can be used but suffer from limitations related to low signal-to-noise bremsstrahlung radiation. However, with optimized imaging protocols, clinically adequate images can still be obtained. A finite but detectable number of positrons are also emitted during 90 Y decay, and many studies have demonstrated the ability of commercial PET/CT and PET/MR scanners to image these positrons to understand 90 Y distribution and help quantify dose. PET imaging has been proven to be superior to SPECT for quantitative imaging, and therefore will play an important role going forward as we try and better understand dose/response and dose/toxicity relationships to optimize personalized dosimetry. The availability of PET imaging will likely remain the biggest barrier to its use in routine post- 90 Y imaging; thus, SPECT/CT imaging with optimized protocols should be sufficient for most posttherapy subjective imaging.

Ruptured idiopathic hepatic artery pseudoaneurysm causing portal vein thrombosis with portal hypertension and variceal bleeding.

Portal vein thrombosis (PVT) is an important cause of noncirrhotic portal hypertension. Noncancerous extrinsic compression of portal vein to drive PVT formation is rare, but important to identify. A 64-year-old female with idiopathic hepatic artery pseudoaneurysm (HAPA) rupture 7 months prior presented with acute-onset hematemesis and melena and was found to have prehepatic portal hypertensive variceal bleeding. Her HAPA-related retroperitoneal hematoma had resulted in portal vein compression, thrombosis, and cavernous transformation despite prompt stent graft placement across the ruptured HAPA, and required definitive treatment by transjugular intrahepatic portosystemic shunt creation with portal vein reconstruction utilizing a trans-splenic access. This case highlights the importance of interval abdominal imaging and hypercoagulability screening for noncirrhotic patients at-risk for PVT, which identified the patient as a heterozygous carrier of Factor V Leiden.