The impact of high-end ultrasound in the management of a patient with neuroendocrine tumor of the ileum.

Diagnostic imaging of jejuno-ileal neuroendocrine tumors (NETs) has been described as challenging. Follow-up requires the detection of metastatic spread as well as screening for local recurrence. Multimodal imaging concepts must often be applied.We report the case of a 45-year-old man with a history of ileal NET. At 2 points in follow-up of our patient, information provided by high-end ultrasound changed prognosis and treatment considerably: when positron emission tomography/computed tomography newly detected suspected hepatic metastases, contrast-enhanced ultrasound correctly identified the lesions as intrahepatic vascular shunts. Moreover, profound B-mode ultrasound solely detected ileal recurrence, leading to early removal of the tumor.

Gray scale and contrast-enhanced ultrasound imaging of malignant liver tumors of vascular origin.

OBJECTIVES: Malignant vascular tumors of the liver are rare. The aim of this study was to investigate the applicability of gray scale and contrast-enhanced ultrasonography in patients with epithelioid hemangioendothelioma (EHE) of the liver and hepatic angiosarcoma (HA) and to describe the clinical presentation. METHODS: We retrospectively analyzed all patients with epithelioid hemangioendothelioma or hemangiosarcoma of the liver from 1998 to 2011, who underwent ultrasound investigation. We describe the findings in gray scale and contrast-enhanced ultrasound and the clinical course of the disease of seven patients with EHE and five patients with HA. RESULTS: Ultrasound investigation in EHE showed mostly multiple hypoechoic irregular lesions close to the liver capsule and with a halo in some cases. Contrast enhancement revealed inhomogeneously and through all contrast phases vascularized tumors with a rim enhancement in 50%, with or without early wash out. All tumors had avascular parts. HA presented as multiple and irregular hypo-, iso- or hyperechoic lesions. After contrast enhancement, hypervascularization with individual patterns was evident in all patients. Of five, three had liquid parts. Patients with HA were significantly older (58 vs. 37 years, p = 0.014) and presented with lower thrombocyte counts (84 vs. 264, p = 0.0025) and with higher CEA levels (4.6 vs. 1.5, p = 0.03). CONCLUSION: EHE and HA are inhomogeneous tumors, explaining the high inter-individual variability and heterogeneity in ultrasound examination. The presence of multifocal lesions, heterogeneity and undefined margins may differentiate EHE or HA from hemangioma. A biopsy is essential in the diagnosis of vascular tumors.

Diagnostic value of ultrasound in detection of biliary tract complications after liver transplantation.

BACKGROUND: Biliary complications are significant source of morbidity after liver transplantation (LT). Cholangiography is the gold standard for diagnosis and specification of biliary complications. OBJECTIVES: Detailed analyses of ultrasound (US) as a safe imaging method in this regard are still lacking. Therefore we analyzed systematically the diagnostic value of US in these patients. PATIENTS AND METHODS: Retrospectively, 128 liver graft recipients and their clinical data were analyzed. All patients had a standardized US examination. The findings of US were compared to cholangiographic results in 42 patients. Following statistical analyses were performed: descriptive statistics, sensitivity, specificity, positive and negative predictive values (PPV, NPV). RESULTS: 42 patients had 54 different biliary complications (Anastomotic stenosis (AS) n = 33, ischemic type biliary lesions (ITBL) n = 18 and leakage n = 3). US detected n = 22/42 (52%) patients with biliary complications. The sensitivity, specificity, PPV and NPV of US were: 61%, 100%, 100%, 79% (95CI, 36-86%) for ITBL and 24%, 100, 100%, 31% (95CI, 9-46 %) for AS, respectively. CONCLUSIONS: US examination had no false positive rate. Therefore, it may be helpful as a first screening modality. But for the direct diagnosis of the biliary complication US is not sensitive enough.

Virus-induced tumor inflammation facilitates effective DC cancer immunotherapy in a Treg-dependent manner in mice.

Vaccination using DCs pulsed with tumor lysates or specific tumor-associated peptides has so far yielded limited clinical success for cancer treatment, due mainly to the low immunogenicity of tumor-associated antigens. In this study, we have identified intratumoral virus-induced inflammation as a precondition for effective antitumor DC vaccination in mice. Administration of a tumor-targeted DC vaccine during ongoing virus-induced tumor inflammation, a regimen referred to as oncolysis-assisted DC vaccination (ODC), elicited potent antitumoral CD8+ T cell responses. This potent effect was not replicated by TLR activation outside the context of viral infection. ODC-elicited immune responses mediated marked tumor regression and successful eradication of preestablished lung colonies, an essential prerequisite for potentially treating metastatic cancers. Unexpectedly, depletion of Tregs during ODC did not enhance therapeutic efficacy; rather, it abrogated antitumor cytotoxicity. This phenomenon could be attributed to a compensatory induction of myeloid-derived suppressor cells in Treg-depleted and thus vigorously inflamed tumors, which prevented ODC-mediated immune responses. Consequently, Tregs are not only general suppressors of immune responses, but are essential for the therapeutic success of multimodal and temporally fine-adjusted vaccination strategies. Our results highlight tumor-targeting, replication-competent viruses as attractive tools for eliciting effective antitumor responses upon DC vaccination.

Grading of hypervascular hepatocellular carcinoma using late phase of contrast enhanced sonography - a prospective study.

BACKGROUND: Outcome of patients with hepatocellular carcinoma is influenced by their histological grade. Invasive biopsy of the lesions is the gold standard in this regard. AIMS: We therefore analysed the diagnostic accuracy of contrast enhanced ultrasound for non-invasive grading of hypervascular hepatocellular carcinoma in liver cirrhosis. METHODS: According to the tumour perfusion kinetics on contrast enhanced ultrasound two grading groups were prospectively defined: well-differentiated hepatocellular carcinoma (US-G1) and higher grade hepatocellular carcinoma (US-G2/G3). Immediately after contrast enhanced ultrasound-grading, biopsies of hepatocellular carcinoma-lesions (n=95, 1.2-12.5 cm) were obtained and analysed for tumour grading (G). Descriptive statistics, sensitivity, specificity positive and negative predictive values, diagnostic likelihood ratios and interoperator reproducibility were calculated (κ). RESULTS: Histologically 77 (81.1%) patients had G2-G3 and 18 (18.9%) had G1 tumours. Higher grade hepatocellular carcinoma showed more often a washout in the portal or late phase (p<0.0001). The sensitivity, specificity, positive predictive values and negative predictive values of contrast enhanced ultrasound for grading of hepatocellular carcinoma for all patients were 94% (CI: 72-99%), 95% (CI: 88-99%), 81% and 99% and for patients with tumours<5 cm 100%(95% CI: 79-100), 96% (95% CI: 80-99), 92% and 100%. Positive and negative diagnostic likelihood ratios' were 18 and 26 and 0.06 and 0, respectively. κ=0.941 (p<0.001). CONCLUSIONS: Contrast enhanced ultrasound has a high diagnostic value and reproducibility for non-invasive grading of hypervascular hepatocellular carcinoma >1cm in patients with liver cirrhosis.

Clinical feasibility of liver elastography by acoustic radiation force impulse imaging (ARFI).

BACKGROUND: Transient elastography is increasingly used for assessment of liver fibrosis. Acoustic radiation force impulse imaging (ARFI) is a new technology to perform liver elastography. AIMS: We evaluated the clinical feasibility, validity and accuracy of the ARFI method and compared it to Fibroscan(®) and liver histology. METHODS: Ultrasonographic elastography of the liver using ARFI was performed in 29 patients with liver cirrhosis, 70 patients with liver disease and 23 healthy controls. RESULTS: ARFI was feasible in all patients providing a mean propagation velocity of 1.65±0.93 m/s. ARFI results of the right and left liver lobes were comparable (p<0.001). In cirrhotic patients, ARFI gave significantly higher values than in the other patients (p<0.001). Rate of invalid measurements was lower in ARFI than in Fibroscan(®) (p<0.04). Both elastography methods were highly correlated to each other (p<0.001). Furthermore, ARFI correlated to histological grading of liver fibrosis (p<0.001) and to inflammatory activity (p<0.05). Liver steatosis had no statistical influence on ARFI results (p=0.2) in contrast to Fibroscan(®) (p<0.05). CONCLUSIONS: The new ultrasonographic method of ARFI elastography allows valid, accurate and flexible evaluation of liver stiffness. It seems more feasible in patients with liver cirrhosis than Fibroscan(®). ARFI elastography of the left liver lobe is also possible. Liver steatosis does not seem to influence ARFI elastography.

Evaluation of sound speed for detection of liver fibrosis: prospective comparison with transient dynamic elastography and histology.

OBJECTIVE: The degree of liver fibrosis determines the prognosis and treatment of patients with chronic viral hepatitis. Transient elastography (TE) has been accepted as a noninvasive method for assessment of liver fibrosis. Sound velocity (SV) changes are also dependent on elastic properties of tissue. The aim of this pilot study was to evaluate whether SV estimation of liver tissue allows the determination of fibrosis stages in patients with chronic viral hepatitis. METHODS: Prospectively, 50 healthy volunteers and 149 patients received stiffness (TE, 50-Hz vibrator, 5-MHz array) and SV (conventional ultrasound, C5-2-MHz transducer) measurements. Eighty-four patients received representative liver biopsies. The estimated SV and stiffness were compared using liver biopsy as a reference (METAVIR fibrosis stage [F] scoring system [Hepatology 1996; 24:289-293]). Descriptive statistics, analysis of variance, receiver operating characteristic curve analysis, and box plot analysis as well as intra-operator and interoperator reproducibility analyses were performed. RESULTS: The SV ranged from 1540 to 1650 m/s. The mean SV ± SD was significantly different between healthy volunteers (1559 ± 11 m/s) and patients with F0-F3 (1575 ± 21 mm/s) and F4 (1594 ± 18 m/s) disease (P < .001). For detection of liver cirrhosis, the area under the receiver operating characteristic curve for SV was 0.80 (95% confidence interval, 0.69-0.89). With a cutoff value of 1589 m/s, the sensitivity, specificity, and positive and negative predictive values of SV for detection of liver cirrhosis were 82%, 76%, 70%, and 86%, respectively. Sound velocity measurements were reproducible (15%) and had acceptable operator independence (19%). CONCLUSIONS: The SV of liver tissue depends on the fibrosis stage. An SV of 1589 m/s or higher detects cirrhosis with high sensitivity. Therefore, SV measurement appears to be a promising new method for noninvasive quantification of liver fibrosis.

Antitumoural immunity by virus-mediated immunogenic apoptosis inhibits metastatic growth of hepatocellular carcinoma.

BACKGROUND AND AIMS: Viral infection of a dying cell dictates the immune response against intracellular antigens, suggesting that virotherapy may be an effective tool to induce immunogenic cell death during systemic cancer treatment. Since viruses and proteasome inhibitors both induce accumulation of misfolded proteins, endoplasmic reticulum (ER) stress and immune responses during treatment of hepatocellular carcinoma (HCC) with bortezomib and the tumour-specifically replicating virus hTert-Ad (human telomerase reverse transcriptase promoter-regulated adenovirus) were investigated. METHODS: Unfolded protein response (UPR) pathways and ER stress-mediated apoptosis were investigated by western blots, caspase-3 assays, 4',6-diamidino-2-phenylindole (DAPI) and Annexin V staining in HCC cells following hTert-Ad/bortezomib treatment. Oncolysis was assessed in subcutaneous HCC mouse models. Antiviral/antitumoural immune responses were characterised in immunocompetent HCC mouse models by ELISA, ELISpot assays and pentamer staining. Systemic efficacy of antitumoural immunity was investigated by determination of lung metastases burden. RESULTS: Bortezomib and hTert-Ad trigger complementary UPR pathways but negatively interfere with important recovery checkpoints, resulting in enhanced apoptosis of HCC cells in vitro and improved oncolysis in vivo. In immunocompetent mice, bortezomib inhibited antiviral immune responses, whereas ER stress-induced apoptosis of infected HCC resulted in caspase-dependent triggering of antitumoural immunity. In therapeutic settings in immunocompetent, but not in immunodeficient or CD8-depleted mice, virotherapy-induced antitumoural immunity efficiently inhibited outgrowth of non-infected lung metastases. Immunotherapeutic efficacy could be significantly improved by bortezomib in experiments with low viral doses. CONCLUSION: Proteasome inhibition during virotherapy disrupts the UPR, leading to enhanced ER stress-induced apoptosis, improved local oncolysis and antitumoural immunity. The results suggest that combining intratumoural virotherapy with adjuvant systemic therapies, which specifically support the function of the virotherapy as an antitumoural vaccine, is a promising immunotherapeutic strategy against HCC.

Membranous Budd-Chiari syndrome in Caucasians.

OBJECTIVE: Budd-Chiari syndrome (BCS) is characterized by an obstruction of hepatic venous outflow. Membranous obstruction of the inferior vena cava (IVC) is a curable cause of primary BCS but is very rare in Western Europe. To date, there is only very limited information on membranous BCS in the Western world. We here report the diagnosis and management of five Caucasian patients with membranous BCS. MATERIAL AND METHODS: Out of 23 patients with BCS diagnosed between 2004 and 2007 we identified five with a membranous web of the IVC. Diagnostic evaluation of BCS included laboratory tests, ultrasound Doppler imaging, CT and MRI. RESULTS: The clinical presentation of membranous BCS was heterogeneous. The time frame from first clinical symptoms to diagnosis ranged from 3 weeks to 60 years. Liver cirrhosis was misdiagnosed in 4/5 patients. CT did not establish the correct diagnosis of membranous BCS in any of our patients. In contrast, abdominal Doppler ultrasonography showed collaterals and a web in the IVC which was confirmed by Doppler-MRI and hepatovenography. Four patients underwent interventional treatment with balloon dilatation of short-segment venous stenoses or complete occlusions. Therapy was successful: in all cases it resulted in a normalized extrahepatic blood flow and reduction of spleen size. CONCLUSIONS: Membranous BCS may be underdiagnosed in Caucasians. Doppler ultrasound should be used as the initial diagnostic procedure for membranous BCS. Although CT is considered the "gold standard" in addition to angiography, it could not detect membranous obliteration in our cases. Patients can be effectively treated by interventional endovascular therapy.

[Color Doppler ultrasound of the liver circulation]. / Dopler jetrene cirkulacije.

Color Doppler Ultrasound (CDUS) is a valuable method for evaluation of morphological and hemodynamic changes of liver circulation occurring in various pathological conditions. In some of these conditions CDUS has a decisive diagnostic role, thus making further, potentially harmful invasive diagnostic procedures unnecessary. Except for the analysis of vascular liver diseases, as well as repercussions of circulatory impairment to the liver, utilization of CDUS provides valuable information for characterization of diffuse parenchymal and focal liver lesions. CDUS has advantages as compared to the other imaging modalities as it is widely available and noninvasive. The possible disadvantage is not related to the method itself, but is due to lack of expertise, i.e. training of the operator. In this article we review the present position of CDUS in evaluation of impairment of liver circulation: disorders of the venous outflow from the liver (Budd-Chiari syndrome, right-sided heart diseases, veno-occlusive disease), disorders of/in liver parenchyma (vascular anomalies-fistulae, solid tumors, circulatory changes that occur in diffuse liver diseases) and obstruction of the blood inflow to the liver (stenosis and thrombosis of hepatic artery and portal vein).

Ultrasonography in patients with Budd-Chiari syndrome: diagnostic signs and prognostic implications.

BACKGROUND/AIMS: We analyzed sonomorphological signs of Budd-Chiari syndrome (BCS) and their potential for prognosis prediction. METHODS: Forty-five consecutive patients were included. Analysis included the frequencies of sonomorphological signs and their predictive value for diagnosis of BCS, mean values of laboratory and color Doppler data in different therapeutic groups and survival. RESULTS: Specific ultrasound signs were identified at the level of the hepatic veins in 71% of the patients and in 33% at the level of the caval vein, i.e. thrombosis, stenosis, fibrotic cord or insufficient recanalization of the vessels. The frequent non-specific signs were splenomegaly (78%), inhomogeneous liver parenchyma (76%), intrahepatic collaterals (73%), caudate lobe hypertrophy (67%), ascites (56%) and extrahepatic collaterals (44%). The combination of specific signs and "caudate lobe hypertrophy" offered the highest predictive value to identify patients with BCS (p=0.014) with a specificity of 100%. Mean survival was significantly different between the patients with or without portal hypertension (n=25, 41.1+/-7.6, 95% CI (26.2-55.9) versus n=20, 89.4+/-4.5, 95% CI (80.5-98.2), p=0.004) and with or without portal vein thrombosis (n=12, 29.8+/-10.7, 95% CI (8.9-50.7) versus n=33, 79.3+/-6.1, 95% CI (67.4-91.1), p=0.003). CONCLUSIONS: We present a comprehensive description of sonomorphological signs in BCS. The combination of ultrasound signs "altered hepatic and/or caval veins" and "caudate lobe hypertrophy" was the best strategy to diagnose BCS. Patients with portal vein thrombosis or portal hypertension have a poor prognosis.

Fetal hydrocephalus, intrauterine diagnosis and therapy considerations: an experimental rat model.

MATERIALS AND METHODS: Fetal hydrocephalus is induced by a single intraperitoneal injection of 8 mg/kg 6-aminonikotinamide (6-AN), a niacinamide antagonist, in Sprague-Dawley rats on day 13 of gestation. Laparotomy was carried out in some rats 3, 6, 7 and 8 days after the intraperitoneal injection. The fetuses were collected by uterotomy and fixed in a formalin solution after measuring head circumference and body length for further histological investigations. The ventricular areas and volumes of the lateral ventricles were measured using a computer morphometric technique after all fetuses were serially sectioned sagittally or coronally. Furthermore, 8 maternal rats (4 treated with 6-AN and 4 controls) were used for ultrasound investigation. The fetal ventricular system and the central canal were demonstrated and compared by transabdominal ultrasound in the 6-AN and control groups. On day 19 of gestation the cerebrospinal fluid (CSF) was drained in some fetuses for 18 h through a thin micro-catheter, which was inserted into the lateral ventricle. In some other fetuses the intracranial pressure (ICP) and the intra-amniotic pressure (IAP) were measured after Doppler sonography of the cerebral blood flow (CBF). These measurements were carried out using a transuterine approach following the laparotomy. RESULTS: Hydrocephalus was produced due to the closure of all outlets of the fourth ventricle. Macrocephalus was clear on day 17 (4 days after 6-AN injection). The entire ventricular system was dilated, including the aqueduct and foramen of Monro, and cerebellar hypoplasia was revealed. CONCLUSION: Increased ICP in 6-AN fetuses was associated with decreasing CBF. The cerebral mantel was better developed after CSF drainage. The intra-amniotic pressure was increased in all pregnant rats and was either similar to or higher than ICP.

Changes of duplex parameters and splenic size in liver transplant recipients during a long period of observation.

AIM: To assess the changes of portal and arterial velocities, resistance index, spleen and liver size during a long observation period (13.7 years) after orthotopic liver transplantation (OLT). METHODS: Two hundred and sixty patients were recruited retrospectively for this study and divided into groups with defined time intervals after OLT. The cross-sectional changes of portal and arterial velocities, resistance index, spleen and liver size between the defined time intervals were studied. The complications detected by ultrasound were compared to gold standard methods. RESULTS: The mean values for liver size were all within the normal range. The splenic size decreased between the time intervals 100 and 1,000 d after OLT (t; P<0.01). While portal and arterial flow velocities decreased up to 5.5 years (t; portal velocity P<0.01, maximal systolic velocity P=0.05, maximal end diastolic velocity P<0.01), RI increased during this interval (t: P<0.01). Higher RI values were found in older patients (r=0.24, P<0.001). CONCLUSION: The arterial and portal velocities show adaptation processes continuing over the course of many years after OLT and are reported for the first time. The vascular complications detected by ultrasound occur mostly up to 100 d after OLT.

Recurrence of Budd-Chiari syndrome after liver transplantation in paroxysmal nocturnal hemoglobinuria.

Venous thrombembolism is a major complication of paroxysmal nocturnal hemoglobinuria (PNH). Often, veins of atypical localization are afflicted, resulting in cerebral, mesenteric, or hepatic venous thrombosis. We present a patient who received an orthotopic liver graft for chronic Budd-Chiari syndrome in 1988. PNH was the only thrombophilic predisposition identified in this patient. After transplantation, he repeatedly suffered from hemorrhage. Subsequently, the patient discontinued prophylactic anticoagulation nearly 10 years after transplantation. Within 6 months Budd-Chiari syndrome recurred, but stabilized after anticoagulation therapy with low-molecular-weight heparin was reinstituted. The patient is clinically stable 14 years after receiving the liver graft. Eleven cases of relapsing Budd-Chiari syndrome have been reported in the literature. Of these, four patients suffered from PNH. All patients transplanted for PNH-associated Budd-Chiari syndrome in these reports suffered from either major bleeding or thrombosis. In conclusion, patients afflicted with PNH appear to be at high risk of incurring complications after liver transplantation.