Repeated percutaneous hepatic perfusion with melphalan can maintain long-term response in patients with liver cancers.

Chemosaturation (CS; CHEMOSAT®, Delcath Systems Inc.) temporarily administers melphalan into the liver by percutaneous hepatic perfusion (PHP). CS-PHP can effectively control growth in liver tumors, but efficacy and tolerability of sequential treatments are unclear. We analyzed outcomes of sequential CS-PHP treatment. Patients with either unresectable intrahepatic metastases of ocular melanoma (OM, n = 9), cholangiocarcinoma (CCA, n = 3), or hepatocellular carcinoma (HCC, n = 1) were recruited retrospectively. Response was assessed by tomography imaging. Ten patients (mean age 60 years) with more than one CS-PHP treatment were included. CS-PHP was administered 2-6 times in the OM patients, 3 times in the CCA, and the HCC patient received 6 treatments. Overall response rate (ORR) to CS-PHP was 80%, and stable disease was achieved in one patient. Median hepatic progression-free survival (hPFS) was 336 days (range 0-354) for OM, 251 days for the CCA patient, and 256 days for the HCC patient. At the end of observation (153-701 days after first CS-PHP), 6/10 patients were still alive (5/9 with OM, 0 with CCA, and 1 with HCC). Death cases were not related to CS-PHP. Adverse events were mostly hematologic, grade I-IV, and self-resolving. The liver function was not deteriorated by CS-PHP. We conclude that repeated CS-PHP treatments were effective and well tolerated in the long term.

Segmental intrahepatic cholestasis as a technical complication of the transjugular intrahepatic porto-systemic shunt.

BACKGROUND: Segmental intrahepatic cholestasis caused by transjugular intrahepatic portosystemic shunt (TIPS) (SIC-T), is a rare complication of this technique and only referred by case reports. Thus, we conducted a systematic, retrospective analysis to provide evidence regarding prevalence and consequences of this TIPS-induced bile duct compression. AIM: To assess prevalence and outcome of SIC-T in a large TIPS-cohort. METHODS: In this retrospective cohort study, we screened the institutional databases for all consecutive patients that were treated by TIPS-placement or TIPS-revision between January 2005 and August 2013. We analyzed radiologic images for signs of biliary congestion. Cases that were indicative of SIC-T were reviewed by two independent radiologists and additional patient data was collected. Descriptive statistics of patient demographics, indications for TIPS and procedural details were registered. Logistic regression analysis was performed to identify predictors for the development of SIC-T. RESULTS: We analyzed 135 cirrhotic patients who underwent TIPS (mean age 55 years, 79% male gender). Etiology of cirrhosis was alcohol in most cases and indications for TIPS were mainly refractory ascites and recurrent variceal bleeding. TIPS revision was necessary in 31 patients. We identified 4 cases (2.9%) of SIC-T in direct proximity of the TIPS-stent. Diagnosis was confirmed by CT-scan, MRI or endoscopic retrograde cholangio pancreaticography (ERCP). In two patients TIPS was implanted via the right and in one through the medial hepatic vein. One patient received TIPS-prolongation by multiple revisions. Most patients were asymptomatic but one cholangitic abscess necessitated a transhepatic drain. Logistic regression analysis identified TIPS-placement other than from medial hepatic vein to right portal vein as risk factor (OR 21.0) for SIC-T. CONCLUSION: SIC-T ads to (mostly late) complications in the interventional treatment of cirrhotic portal hypertensions and can lead to cholangitic abscesses. Patients, particularly with multiple interventions, should be screened for SIC-T.

Interactive Volumetry Of Liver Ablation Zones.

Percutaneous radiofrequency ablation (RFA) is a minimally invasive technique that destroys cancer cells by heat. The heat results from focusing energy in the radiofrequency spectrum through a needle. Amongst others, this can enable the treatment of patients who are not eligible for an open surgery. However, the possibility of recurrent liver cancer due to incomplete ablation of the tumor makes post-interventional monitoring via regular follow-up scans mandatory. These scans have to be carefully inspected for any conspicuousness. Within this study, the RF ablation zones from twelve post-interventional CT acquisitions have been segmented semi-automatically to support the visual inspection. An interactive, graph-based contouring approach, which prefers spherically shaped regions, has been applied. For the quantitative and qualitative analysis of the algorithm's results, manual slice-by-slice segmentations produced by clinical experts have been used as the gold standard (which have also been compared among each other). As evaluation metric for the statistical validation, the Dice Similarity Coefficient (DSC) has been calculated. The results show that the proposed tool provides lesion segmentation with sufficient accuracy much faster than manual segmentation. The visual feedback and interactivity make the proposed tool well suitable for the clinical workflow.

Stereological investigation of the posterior hippocampus in affective disorders.

Hippocampus volumes have been shown to be decreased in patients with major depression, but volume measurements are inconsistent in patients with bipolar disorder. Both disorders are associated with deficits in hippocampus-mediated cognitive functions. However, the underlying pathophysiology is widely unknown. In this post-mortem study, we used design-based stereology on Nissl-stained serial sections to investigate the number of neurons, oligodendrocytes and astrocytes in substructures of the posterior hippocampus in eight patients with major depression, eight patients with bipolar disorder and ten control patients without a neuropsychiatric disorder. Compared to controls, patients with bipolar disorder had significantly more neurons in the cornu ammonis subfield 1 (CA1) and the subiculum, while the number of oligodendrocytes was higher only in CA1. In patients with major depression, the density of oligodendrocytes was higher in CA2/3, CA4 and the subiculum. The dose of antidepressants correlated with the density and number of oligodendrocytes in CA2/3, indicating that antidepressants may affect our results. Treatment with neuroleptics expressed in chlorpromazine equivalents and benzodiazepines expressed in diazepam equivalents correlated negatively with the number of oligodendrocytes in CA2/3 and CA4, respectively, suggesting that treatment with these drugs do not influence cell number. We did not detect alterations in either volumes of substructures or numbers of astrocytes. Increased cell numbers argue for a denser packing of neurons and oligodendrocytes as a result of a decreased neuropils. This neuropathological process may be based on neurodevelopmental disturbances and may contribute to altered microconnectivity and cognitive deficits in affective disorders.

Orthotopic liver transplantation for giant liver haemangioma: A case report.

In liver haemangiomas, the risk of complication rises with increasing size, and treatment can be obligatory. Here we present a case of a 46-year-old female who suffered from a giant haemangioma causing severe portal hypertension and vena cava compression, leading to therapy refractory ascites, hyponatremia and venostasis-associated thrombosis with pulmonary embolism. The patients did not experience tumour rupture or consumptive coagulopathy. Surgical resection was impossible because of steatosis of the non-affected liver. Orthotopic liver transplantation was identified as the only treatment option. The patient's renal function remained stable even though progressive morbidity and organ allocation were improbable according to the patient's lab model for end-stage liver disease (labMELD) score. Therefore, non-standard exception status was approved by the European organ allocation network "Eurotransplant". The patient underwent successful orthotopic liver transplantation 16 mo after admission to our centre. Our case report indicates the underrepresentation of morbidity associated with refractory ascites in the labMELD-based transplant allocation system, and it indicates the necessity of promptly applying for non-standard exception status to enable transplantation in patients with a severe clinical condition but low labMELD score. Our case highlights the fact that liver transplantation should be considered early in patients with non-resectable, symptomatic benign liver tumours.

RFA-cut: Semi-automatic segmentation of radiofrequency ablation zones with and without needles via optimal s-t-cuts.

In this contribution, we present a semi-automatic segmentation algorithm for radiofrequency ablation (RFA) zones via optimal s-t-cuts. Our interactive graph-based approach builds upon a polyhedron to construct the graph and was specifically designed for computed tomography (CT) acquisitions from patients that had RFA treatments of Hepatocellular Carcinomas (HCC). For evaluation, we used twelve post-interventional CT datasets from the clinical routine and as evaluation metric we utilized the Dice Similarity Coefficient (DSC), which is commonly accepted for judging computer aided medical segmentation tasks. Compared with pure manual slice-by-slice expert segmentations from interventional radiologists, we were able to achieve a DSC of about eighty percent, which is sufficient for our clinical needs. Moreover, our approach was able to handle images containing (DSC=75.9%) and not containing (78.1%) the RFA needles still in place. Additionally, we found no statistically significant difference (p<;0.423) between the segmentation results of the subgroups for a Mann-Whitney test. Finally, to the best of our knowledge, this is the first time a segmentation approach for CT scans including the RFA needles is reported and we show why another state-of-the-art segmentation method fails for these cases. Intraoperative scans including an RFA probe are very critical in the clinical practice and need a very careful segmentation and inspection to avoid under-treatment, which may result in tumor recurrence (up to 40%). If the decision can be made during the intervention, an additional ablation can be performed without removing the entire needle. This decreases the patient stress and associated risks and costs of a separate intervention at a later date. Ultimately, the segmented ablation zone containing the RFA needle can be used for a precise ablation simulation as the real needle position is known.