[Imaging diagnosis of hepatocellular carcinoma. Addendum to hepatocellular carcinoma: diagnosis, staging and treatment strategies]. / Diagnóstico por técnicas de imagen del carcinoma hepatocelular. Addendum de carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica.

This addendum is aimed to review and discuss the updated non-invasive diagnostic algorithm recently published by the American Association for the Study of Liver Diseases (AASLD).

Diagnóstico por técnicas de imagen del carcinoma hepatocelular. Addendum de carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica / Imaging diagnosis of hepatocellular carcinoma. Addendum to hepatocellular carcinoma: diagnosis, staging and treatment strategies

El objetivo de este addedndum es Revisar y comentar el nuevo algoritmo para el diagnóstico no invasivo del carcinoma hepatocelular publicado recientemente por la American Association for the Study of Liver Diseases (AASLD) (AU)

This addendum is aimed to review and discuss the updated non-invasive diagnostic algorithm recently published by the American Association for the Study of Liver Diseases (AASLD) (AU)

Carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica / Hepatocellular carcinoma: diagnosis, staging, and treatment strategy

El carcinoma hepatocelular es un tumor de elevada incidencia y alta mortalidad. Estos datos justifican los programas de detección precoz para poder aplicar los tratamientos considerados curativos, lo que implicará una mayor supervivencia. La detección precoz debe realizarse mediante ecografía semestral en la población con riesgo de padecer este tipo de tumor, fundamentalmente en pacientes con cirrosis hepática. Debido a sus características vasculares, actualmente se puede realizar el diagnóstico de carcinoma hepatocelular por técnicas de imagen dinámicas (ecografía con contraste/TC/RM). En caso que el patrón de captación no sea característico en estas técnicas de imagen debe efectuarse una biopsia de la lesión. Una vez diagnosticado, se realiza la estadificación del tumor, lo que junto al estado clínico del paciente, determinará la estrategia terapéutica más adecuada en cada caso (AU)

Hepatocellular carcinoma is a tumor with a high incidence and high mortality. These data justify screening programs to enable curative treatments to improve survival rates. Screening the population at risk (mainly patients with cirrhosis of the liver) should include ultrasonographic examination twice yearly. Given the vascular characteristics of hepatocellular carcinoma, it can be detected using dynamic techniques (contrast-enhanced ultrasonography, CT, and MRI). In cases in which the enhancement pattern is not characteristic, these techniques should be complemented with lesion biopsy. Once hepatocellular carcinoma is diagnosed, the tumor is staged, and together with the clinical condition of the patient, the stage will determine the most appropriate treatment strategy in each case (AU)

Tratamiento percutáneo e intraarterial del carcinoma hepatocelular / Percutaneous and intra-arterial treatment of hepatocellular carcinoma

La mayoría de pacientes con un carcinoma hepatocelular (CHC) no son candidatos a resección quirúrgica o trasplante hepático debido al estadio en el momento diagnóstico. Para este grupo de pacientes existen una serie de tratamientos locorregionales que consiguen una alta tasa de respuestas objetivas. La ablación percutánea está considerada la mejor opción terapéutica para el CHC (estadio 0/A-BCLC) no tributario de tratamiento quirúrgico. En el carcinoma hepatocelular multifocal sin invasión vascular ni extensión extrahepática (estadio B- BCLC) la única opción terapéutica que ha demostrado mejorar la supervivencia en estudios controlados y aleatorizados es la quimioembolización. La valoración de la efectividad de estos tratamientos se basa en la reducción del tumor viable y se realiza mediante TC, RM o US con contraste. En este trabajo se revisan las indicaciones, la técnica y la eficacia terapéutica de los distintos tratamientos locorregionales en el CHC (AU)

Most patients with hepatocellular carcinoma (CHC) are not candidates for surgical resection or liver transplantation because of their stage at the time of diagnosis. There are a series of locoregional treatments that achieve a high objective response rate in this group of patients. Percutaneous ablation is considered the best treatment option for CHC (BCLC stage 0/A) not amenable to surgical treatment. In multifocal hepatocellular carcinoma without vascular invasion or extrahepatic extension (BCLC stage B), the only treatment option that has been shown to improve survival in randomized controlled trials is chemoembolization. The evaluation of the effectiveness of these treatments is based on the reduction of viable tumor observed at CT, MRI, or contrast-enhanced US. In this article, we review the indications, technique, and therapeutic efficacy of the different locoregional treatments for CHC (AU)

[Percutaneous and intra-arterial treatment of hepatocellular carcinoma]. / Tratamiento percutáneo e intraarterial del carcinoma hepatocelular.

Most patients with hepatocellular carcinoma (CHC) are not candidates for surgical resection or liver transplantation because of their stage at the time of diagnosis. There are a series of locoregional treatments that achieve a high objective response rate in this group of patients. Percutaneous ablation is considered the best treatment option for CHC (BCLC stage 0/A) not amenable to surgical treatment. In multifocal hepatocellular carcinoma without vascular invasion or extrahepatic extension (BCLC stage B), the only treatment option that has been shown to improve survival in randomized controlled trials is chemoembolization. The evaluation of the effectiveness of these treatments is based on the reduction of viable tumor observed at CT, MRI, or contrast-enhanced US. In this article, we review the indications, technique, and therapeutic efficacy of the different locoregional treatments for CHC.

[Hepatocellular carcinoma: diagnosis, staging, and treatment strategy]. / Carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica.

Hepatocellular carcinoma is a tumor with a high incidence and high mortality. These data justify screening programs to enable curative treatments to improve survival rates. Screening the population at risk (mainly patients with cirrhosis of the liver) should include ultrasonographic examination twice yearly. Given the vascular characteristics of hepatocellular carcinoma, it can be detected using dynamic techniques (contrast-enhanced ultrasonography, CT, and MRI). In cases in which the enhancement pattern is not characteristic, these techniques should be complemented with lesion biopsy. Once hepatocellular carcinoma is diagnosed, the tumor is staged, and together with the clinical condition of the patient, the stage will determine the most appropriate treatment strategy in each case.

Characterization of focal liver lesions: comparative study of contrast-enhanced ultrasound versus spiral computed tomography.

The purpose of this study was to compare the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) with spiral computed tomography (SCT) for the characterization of focal liver lesions (FLL) and to determine the degree of correlation between the two techniques. Seventy-seven FLL (45 hepatocellular carcinomas; 12 metastases; ten hemangiomas; two regenerating/dysplastic nodules; eight focal nodular hyperplasias) detected with ultrasound (US) were prospectively evaluated by CEUS using a second-generation contrast agent and SCT (with an interval of no more than one month between the two techniques). Independent observers made the most probable diagnosis and the results were compared with the final diagnoses (histology n = 59; MRI n = 18). Statistical analysis was performed by the Chi-square and Kappa tests. CEUS provided a correct, specific diagnosis in 69/77 (90%) of the FLL, while SCT did so in 67/77 (87%). The sensitivity, specificity, and diagnostic accuracy for malignancy were 91%, 90%, and 91%, respectively, for CEUS and 88%, 89%, and 88%, respectively, for SCT. No statistically significant difference was found between CEUS and SCT in the characterization of FLL (p > 0.05). In addition, agreement between the two imaging techniques was good (k = 0.75). We conclude that CEUS and SCT provide a similar diagnostic accuracy in the characterization of FLL, with a good degree of correlation between the two techniques.

[Melanoma metastasis to the gallbladder]. / Metástasis de melanoma en la vesícula biliar.

Metastasis to the gallbladder is rare. Malignant melanoma is the tumor that most often metastasizes to this site. For this reason, the finding of solid lesions in the gallbladder wall in patients with advanced stage melanoma should lead to the suspicion of metastatic disease. The aim of this report is to describe and illustrate a case of surgically confirmed malignant melanoma metastasis to the gallbladder and to review the most significant ultrasound findings described in the literature for gallbladder lesions caused by melanoma.

Metástasis de melanoma en la vesícula biliar / Melanoma metastasis to the gallbladder

Las metástasis (M1) en la vesícula biliar son infrecuentes, siendo el melanoma maligno (MM) el tumor que con mayor frecuencia metastatiza a este nivel. Por este motivo, en los pacientes con melanoma en estadios avanzados el hallazgo de lesiones sólidas en la pared vesicular debe hacer sospechar la posibilidad de enfermedad metastásica. El objetivo de esta comunicación es mostrar un caso de esta patología, comprobado mediante cirugía, y revisar los hallazgos ecográficos más relevantes de las lesiones de la vesícula biliar producidas por el melanoma descritos en la literatura

Metastasis to the gallbladder is rare. Malignant melanoma is the tumor that most often metastasizes to this site. For this reason, the finding of solid lesions in the gallbladder wall in patients with advanced stage melanoma should lead to the suspicion of metastatic disease. The aim of this report is to describe and illustrate a case of surgically confirmed malignant melanoma metastasis to the gallbladder and to review the most significant ultrasound findings described in the literature for gallbladder lesions caused by melanoma

New aspects of diagnosis and therapy of hepatocellular carcinoma.

Hepatocellular carcinoma is one of the major cancer killers. It affects patients with chronic liver disease who have established cirrhosis, and currently is the most frequent cause of death in these patients. The main risk factors for its development are hepatitis B and C virus infection, alcoholism and aflatoxin intake. If acquistion of risk factors is not prevented and cirrhosis is established, the sole option to improve survival is to detect the tumor at an early stage when effective therapy may be indicated. Early detection plans should be based on hepatic ultrasonography every 6 months, whereas determination of tumor markers is not efficient. Upon detection of a hepatic nodule, there is a need to establish unequivocal diagnosis, either through biopsy or through the application of non-invasive criteria based on the specific radiology appearance of the tumor: fast arterial uptake of contrast followed by venous washout. Effective treatment for liver cancer includes surgical resection, liver transplantation and percutaneous ablation. These options provide a high rate of complete responses and are assumed to improve survival that should exceed 50% at 5 years. If the tumor is diagnosed at an advanced stage, the sole option that improves survival is transarterial chemoembolization. Ongoing research should further advance the time at diagnosis and identify new and effective options targeting molecular pathways governing tumor progression.

Is microbubble-enhanced ultrasonography sufficient for assessment of response to percutaneous treatment in patients with early hepatocellular carcinoma?

The objective of this study was to assess the efficacy of contrast-enhanced ultrasonography (CEUS) with SonoVue to evaluate the response to percutaneous treatment (ethanol injection/radiofrequency) of hepatocellular carcinoma in comparison with spiral computed tomography (CT) immediately and 1 month after treatment. Forty-one consecutive cirrhotic patients with early stage tumor (not suitable for resection) were included. Spiral CT and CEUS were performed in all patients before treatment, in the following 24 h, and 1 month later. The results of each examination were compared with the 1-month spiral CT, considered the gold standard technique. The 24-h CEUS and the 24-h spiral CT sensitivity to detect residual disease were 27% and 20%, respectively. The 24-h CEUS and the 24-h spiral CT positive predictive value of persistent vascularization detection were 75% and 66%, respectively. The 1-month CEUS detected partial responses in ten out of 11 cases (91% sensitivity, 97% specificity, 95% accuracy). Spiral CT and CEUS performed in the 24 h following treatment are slightly useful to evaluate therapeutic efficacy. The 1-month CEUS has a high diagnostic accuracy compared with spiral-CT in the usual assessment of percutaneous treatment response.

Pilot study of treatment of biochemotherapy-refractory stage IV melanoma patients with autologous dendritic cells pulsed with a heterologous melanoma cell line lysate.

Eleven AJCC stage IV melanoma patients with progressive disease after treatment with biochemotherapy were treated with autologous dendritic cells pulsed with heterologous tumor cell lysates. The vaccine used mature DCs (CD1a+++, CD40++, CD80++, CD83+, and CD86+++) generated from peripheral blood monocytes in the presence of GM-CSF and IL-4. After 7 days, DCs were matured with a defined cocktail of cytokines (IL-1+IL-6+TNF-alpha+PGE2) and simultaneously pulsed with lysates of heterologous melanoma cell lines, for 2 days. A total of 4 x 10(6) DCs was injected monthly under ultrasound control in an inguinal lymph node of normal appearance. The study was closed when all patients died as a consequence of tumor progression. No sign of toxicity was observed during the study. One patient experienced a partial response lasting 5 months, and two patients showed a mixed response which lasted 3 months. The median survival of the whole group was 7.3 months (range 3-14 months). This vaccination program had specific antitumoral activity in highly pretreated and large tumor burden stage IV melanoma patients and was well tolerated. The clinical responses and the median survival of the group of patients, together with the low toxicity of our DC vaccine, suggest that this approach could be applied to earlier AJCC stage IV melanoma patients.

The use of contrast-enhanced ultrasound in the management of the cirrhotic patient and for detection of HCC.

Hepatocellular carcinoma (HCC) is the leading cause of death in liver cirrhosis. Ultrasound (US) is widely accepted as the screening imaging modality of choice for HCC in patients with a history of chronic liver disease. However, the US characteristics of HCCs are non-specific and thus, other imaging techniques or biopsy are usually necessary to characterize focal liver lesions (FLL) and confirm malignancy. Blood flow to HCC is mainly arterial, making dynamic CT and MRI the most commonly used techniques to detect the characteristic arterial hypervascularization. Recently, the development of second-generation US contrast agents and microbubble-specific software has changed the role of US in real-time evaluation of the macro and microvascularization of FLLs. With this technology, the accuracy of US in the diagnosis of HCC and its differentiation from other FLLs such as regenerating nodules has improved dramatically. In addition, contrast-enhanced ultrasound may also be a useful tool in the staging of HCC and in the evaluation of percutaneous treatment.

[Evaluation of the efficacy and efficiency of a multidisciplinary unit for the treatment of patients with colorectal cancer]. / Evaluación de la eficacia y eficiencia de una unidad multidisciplinaria para la atención de pacientes con cáncer colorrectal.

INTRODUCTION: Because of the increased complexity of the diagnostic-therapeutic approach to colorectal cancer (CRC), these patients should be managed in specialized multidisciplinary units. The aim of this study was to evaluate the efficacy and efficiency of a CRC unit (CRCU) in the diagnostic-therapeutic management of these patients. PATIENTS AND METHODS: Two groups of 50 patients with colon cancer treated in our center before and after the implementation of the CRCU were selected. Fulfillment with the protocol in terms of tumoral staging, surgical and adjuvant treatment, follow-up, interval until treatment, hospital stay, morbidity and early mortality, and the overall duration of the diagnostic-therapeutic process was analyzed. In addition, clinical workload was evaluated and a cost-minimization analysis was performed. RESULTS: The CRCU reduced the interval until surgery (20.3 12.0 vs 28.0 20.4 days; p = 0.05), hospital stay (9.8 7.7 vs 14.5 9.3 days: p = 0.01), the time to the start of adjuvant treatment (29.4 10.2 vs 39.7 19.8 days; p = 0.03) and the overall duration of the process (60.4 23,8 vs 82.1 46.1 days; p = 0.05), representing a saving of 978.85 E per patient. This improvement took place despite an increase in clinical workload (24% in 5 years in relation to the number of admissions) and had no effect on morbidity (26 vs 24%; NS) or immediate mortality (6 vs 4%; NS). CONCLUSION: Specialized multidisciplinary units increase the efficacy and efficiency of the management of patients with CRC.

Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma.

Radiofrequency (RF) ablation is an alternative to percutaneous ethanol injection (PEI) for single nonsurgical hepatocellular carcinoma (HCC) and is currently used as adjuvant therapy before liver transplantation. This phase II study assesses the treatment-related complications and response rate of RF for the treatment of single HCC < or = 5 cm. Percutaneous RF was performed under conscious sedation and ultrasound (US) guidance with an electrical generator connected to a single cooled-tip electrode. Neoplastic cells in peripheral blood (reverse transcription-polymerase chain reaction for alpha fetoprotein [AFP] messenger RNA) were analyzed before and after RF. Treatment response was assessed by spiral computed tomography (CT) at 1 month and every 3 months by US or spiral CT thereafter. Thirty-two patients (20 men; age 67 +/- 4 years; 78% hepatitis C virus; 24 Child-Pugh A) with a mean tumor size of 2.8 cm (25 patients < or = 3 cm) were treated by RF (1.25 sessions; mean time, 22.1 +/- 2 minutes). Adjuvant PEI was performed in 9 cases. Complete response was achieved in 21 patients (65%), being significantly higher for HCC < or = 3 cm (76% vs. 29%, P = .03). After a median follow-up of 10 months, 8 patients showed treatment-related morbidity. Four of them (12.5%) showed biopsy-proven needle-track seeding detected between 4 to 18 months. Neoplastic seeding was related to subcapsular location (P = .009), poor differentiation degree (P = .02), and baseline AFP levels (P = .02). Thus, RF ablation with cooled-tip needle for HCC is associated with a high risk of neoplastic seeding. Iatrogenic dissemination was related to subcapsular location or an invasive tumoral pattern, and has to be considered when selecting curative treatments for HCC or adjuvant therapies before liver transplantation.

Early detection of hepatic artery thrombosis after liver transplantation by Doppler ultrasonography: prognostic implications.

We assessed the usefulness of routine Doppler ultrasonography for early detection of hepatic artery thrombosis after orthotopic liver transplantation and repercussions in patient prognosis. Seventeen confirmed cases of early hepatic artery thrombosis initially diagnosed by Doppler ultrasonography (10 of them before clinical indication) were reviewed. All patients underwent Doppler ultrasonographic studies in the first 3 days after orthotopic liver transplantation. Twelve cases of hepatic artery thrombosis (70.6%) were detected by this early Doppler ultrasonography. All 10 unsuspected cases of hepatic artery thrombosis and 5 of the 7 cases diagnosed after clinical indication were treated by revascularization. Grafts were salvaged in 80% of asymptomatic patients and in 42.8% of symptomatic patients. Furthermore, biliary complications were less serious in the first group. In conclusion, Doppler ultrasonography performed routinely in the first 3 days after orthotopic liver transplantation may permit early detection of hepatic artery thrombosis, even before clinical indications. This allows hepatic artery repermeabilization before liver function damage, improving graft rescue and patient prognosis.

Abdominal sonographic study of autosomal dominant polycystic kidney disease.

PURPOSE: The purpose of this study was to determine whether kidney size in patients who have autosomal dominant polycystic kidney disease (ADPKD) is related to renal function, hypertension, or extrarenal manifestations of the disease and to sonographically evaluate the abdominal manifestations of ADPKD. METHODS: Between 1994 and 1998, 400 individuals from 85 families with a history of ADPKD were examined. There were 213 persons with ADPKD and 187 unaffected family members; there were 182 males and 218 females, 1-82 years old (mean, 39.3 years). We obtained a complete medical history, performed a physical examination, measured the arterial blood pressure and serum creatinine levels, and performed abdominal sonography on each subject. The sonographic features that were studied were renal length and the presence and number of cysts on the kidneys, liver, and pancreas. RESULTS: There was a relationship between kidney size and age (p < 0.05), kidney size and renal function (p < 0.001), and kidney size and hypertension (p < 0.001). The overall prevalence of hepatic cysts in patients with ADPKD was 67%, and the prevalence increased with age. The presence of hepatic cysts was related to the severity of renal disease. Females had more severe polycystic liver disease, and massive polycystic liver disease (ie, hepatomegaly with innumerable cysts) was seen only in females. The prevalence of pancreatic cysts in the 187 persons in whom the pancreas was well evaluated sonographically was 5%. CONCLUSIONS: Kidney size in patients with ADPKD is related to renal function, hypertension, and extrarenal involvement and can be used to predict the outcome of the disease. Hepatic cysts are very common in patients with ADPKD and are related to age and renal function; pancreatic cysts are infrequent in these patients.

Sonographic appearance of a retained surgical sponge in the neck.

We report the sonographic appearance and clinical course of a retained surgical sponge in the neck beginning 6 months after a partial thyroidectomy. Sonograms showed a subcutaneous curvilinear hyperechoic interface with marked acoustic shadowing obscuring the left side of the neck. Three months later, a fistulous tract could be seen. Surgical exploration revealed a florid foreign tissue reaction due to a retained surgical sponge. Early diagnosis of retained sponges is important to enable expeditious removal before complications develop.

Randomized controlled trial of interferon treatment for advanced hepatocellular carcinoma.

The aim of this randomized controlled trial was to assess the efficacy of interferon alfa-2b (IFN) for the treatment of advanced hepatocellular carcinoma (HCC). Fifty-eight patients with HCC who were not suitable for resection, transplantation, ethanol injection, or arterial embolization were stratified according to their Okuda stage and randomized to receive IFN (3 x 10(6), 3 times a week, for 1 year) (n = 30) or symptomatic treatment (n = 28). Both groups were identical in terms of age, sex, performance status, presence of constitutional syndrome, Child-Pugh class, Okuda stage, multinodularity, portal thrombosis, and extrahepatic spread. Adhesion to IFN treatment was adequate in 27 patients, with a mean duration of treatment of 8 +/- 3 months. However, IFN treatment was associated with side effects in 23 patients, leading to treatment discontinuation in 13 patients. Two of the 30 patients (6.6%) presented a partial response with greater than 50% size reduction and normalization of alpha-fetoprotein levels. The survival at 1 and 2 years according to intention to treat was not different between the 2 groups (58% and 38% vs. 36% and 12%, respectively, Breslow P =. 19, log rank P =.14) and the absence of difference was maintained when dividing patients according to their Okuda stage. The probability of presenting tumor progression (P =.17), or deterioration of Child-Pugh class (P =.37), performance status (P =. 07), or Okuda stage (P =.44) was not modified by IFN treatment. These results indicate that IFN is not properly tolerated in patients with cirrhosis and advanced HCC and that its administration prompts no benefit in terms of tumor progression rate and survival.