Diagnosis and staging of hepatocellular carcinoma (HCC): current guidelines.

One of the key strategies to improve the prognosis of HCC, beside prevention, is to diagnose the tumor in early stages, when the patient is asymptomatic and the liver function is preserved, because in this clinical situation effective therapies with survival benefit can be applied. Imaging techniques are a key tool in the surveillance and diagnosis of HCC. Screening should be based in US every 6 months and non-invasive diagnostic criteria of HCC based on imaging findings on dynamic-MR and/or dynamic-CT have been validated and thus, accepted in clinical guidelines. The typical vascular pattern depicted by HCC on CT and or MRI consists on arterial enhancement, stronger than the surrounding liver (wash-in), and hypodensity or hyposignal intensity compared to the surrounding liver (wash-out) in the venous phase. This has a sensitivity of around 60% with a 96-100% specificity. Major improvements on liver imaging have been introduced in the latest years, adding functional information that can be quantified: the use of hepatobiliary contrast media for liver MRI, the inclusion of diffusion-weighted sequences in the standard protocols for liver MRI studies and new radiotracers for positron-emission tomography (PET). However, all them are still a matter of research prior to be incorporated in evidence based clinical decision making. This review summarizes the current knowledge about imaging techniques for the early diagnosis and staging of HCC, and it discusses the most relevant open questions.

Guía de Práctica Clínica sobre Diagnóstico y Tratamiento del Carcinoma Hepatocelular (actualización del documento de consenso de la AEEH, SEOM, SERAM, SERVEI, SETH) / Diagnosis and treatment of hepatocellular carcinoma. Update consensus document from the AEEH, SEOM, SERAM, SERVEI and SETH

El carcinoma hepatocelular es la neoplasia primaria de hígado más común y una de las causas de muerte más frecuentes en los pacientes afectos de cirrosis hepática. Simultáneamente al reconocimiento de la relevancia clínica de esta neoplasia, en los últimos anos ˜ han aparecido novedades importantes en el diagnóstico, estadificación y tratamiento del carcinoma hepatocelular. Por tal motivo, desde la Asociación Espanola ˜ para el Estudio del Hígado se ha impulsado la necesidad de actualizar las guías de práctica clínica, invitando de nuevo a todas las sociedades involucradas en el diagnóstico y tratamiento de esta enfermedad a participar en la redacción y aprobación del documento (la Sociedad Espanola ˜ de Trasplante Hepático, la Sociedad Espanola ˜ de Radiología Médica, la Sociedad Espanola ˜ de Radiología Vascular e Intervencionista y la Sociedad Espanola ˜ de Oncología Médica). Se ha tomado como documento de referencia las guías de práctica clínica publicadas en 2009 aceptadas como Guía de Práctica Clínica del Sistema Nacional de Salud, incorporando los avances más importantes que se han obtenido en los últimos anos. ˜ La evidencia científica en el tratamiento del carcinoma hepatocelular se ha evaluado de acuerdo con las recomendaciones del National Cancer Institute (www.cancer.gov) y la fuerza de la recomendación se basa en el sistema GRADE.

Impact of contrast-enhanced ultrasound in the study of hepatic artery hypoperfusion shortly after liver transplantation: contribution to the diagnosis of artery steal syndrome.

OBJECTIVE: To assess the value of contrast-enhanced ultrasound (CEUS) in the absence of hepatic artery signal on Doppler ultrasound (DUS) in the immediate postoperative period after liver transplant. METHODS: This prospective study included 675 consecutive liver transplants. Patients without hepatic artery signal by DUS within 8 days post-transplant were studied with CEUS. If it remained undetectable, a thrombosis was suspected. In patent hepatic artery, a DUS was performed immediately after CEUS; if low resistance flow was detected, an arteriography was indicated. Patients with high resistance waveform underwent DUS+/CEUS follow-up. Arteriography was indicated when abnormal flow persisted for more than 5 days or liver dysfunction appeared. RESULTS: Thirty-four patients were studied with CEUS. In 11 patients CEUS correctly diagnosed hepatic artery thrombosis. In two out of 23 non-occluded arteries, a low resistance flow lead to a diagnosis of stenosis/proximal thrombosis. Twenty-one patients had absence of diastolic flow, which normalized in the follow-up in 13 patients. In the remaining eight patients, splenic artery steal syndrome (ASS) was diagnosed. CONCLUSIONS: CEUS allows us to avoid invasive tests in the diagnostic work-up shortly after liver transplant. It identifies the hepatic artery thrombosis and points to a diagnosis of ASS. KEY POINTS: • CEUS is useful in the diagnostic work-up shortly after liver transplant • CEUS identifies the hepatic artery thrombosis with reliability • There is little information about DUS and CEUS findings in the ASS • DUS and CEUS offer functional information useful in the diagnosis of ASS.

Doppler ultrasound findings in the hepatic artery shortly after liver transplantation.

OBJECTIVE: The purpose of this article is to describe the Doppler waveform findings in the hepatic artery in the early posttransplantation period, both in the absence and presence of arterial complications. CONCLUSION: The presence of transient high-resistance Doppler waveforms in normal hepatic arteries is a common finding after grafting. Hepatic artery thrombosis and stenosis, and arterial steal syndromes can be diagnosed by Doppler in the early liver transplantation period.

Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis.

OBJECTIVES: We aimed to develop a model based on noninvasive variables for the prediction of clinically significant portal hypertension (CSPH) and of esophageal varices (EV) in patients with compensated liver disease. METHODS: Sixty patients with compensated liver cirrhosis diagnosed by histology were included in the training set. All patients had physical examination, laboratory tests, abdominal color-Doppler ultrasound, upper digestive tract endoscopy, and measurement of hepatic venous pressure gradient. Predictive models for the presence of CSPH and of EV were calculated. The models were validated in an independent series of 74 patients with compensated liver disease. RESULTS: Clinical and laboratory variables were selected in the final models, while ultrasonography did not add statistical power for the prediction of CSPH and EV. The model for prediction of CSPH included albumin, INR, and ALT. The best cutoff had 93% sensitivity and 61% specificity in the training set, and correctly classified 77% of patients in the validation set. Spider angiomas, ALT, and albumin predicted EV. The best cutoff of the model in the training set had a sensitivity of 93% and a specificity of 37% and correctly classified 72% of cases in the validation set. CONCLUSIONS: Noninvasive prediction of EV in well-compensated cirrhotic patients is not accurate. However, a model obtained by combining simple laboratory variables has a high sensitivity to predict CSPH in this population and may be useful to select the subset of patients requiring screening endoscopy. By this method, endoscopic screening could be obviated in about 40% of patients.

Value of Doppler sonography for predicting clinical outcome after renal artery revascularization in atherosclerotic renal artery stenosis.

OBJECTIVE: The purpose of this study was to prospectively evaluate the usefulness of Doppler sonography for predicting blood pressure and renal function improvement after percutaneous renal angioplasty in patients with unilateral atherosclerotic renal artery stenosis. METHODS: Thirty-six patients with successfully revascularized unilateral atherosclerotic renal artery stenosis were included. Patients were evaluated by Doppler sonography before treatment, with the resistive index (RI) and acceleration being measured in both kidneys. Blood pressure, number of antihypertensive drugs, and serum creatinine concentration were assessed before treatment and thereafter during a 23 +/- 15-month (mean +/- SD) period. RESULTS: In 20 of the 36 patients (55%), the RI was less than 0.80 before revascularization. After treatment, blood pressure improved in 17 (85%) of those 20 patients and improved in 8 (50%) of 16 patients with an RI of greater than 0.80 (P < .05). Twenty-five patients had renal insufficiency pretreatment, and 11 (44%) had a baseline RI of less than 0.80. Improvement in renal function after angioplasty was shown in 5 (45%) of these 11 patients and in 4 (28.5%) of 14 in the group with high RI (P > .05, not significant). On analysis of acceleration, blood pressure improved in 9 (69%) of 13 patients with acceleration of greater than 3 m/s(2) and in 16 (69.5%) of 23 with acceleration of less than 3 m/s(2) (P > .05). In patients with renal insufficiency, 5 (50%) of 10 cases with normal baseline acceleration and 4 (27%) of 15 with low acceleration showed improvement in renal function (P > .05). CONCLUSIONS: An elevated RI should not exclude patients from a revascularization procedure because, although renal RI does correlate with blood pressure response to revascularization, it is not a useful parameter in predicting renal function outcome. Acceleration has no prognostic value.

Ecografía con contraste de segunda generación (SonoVue) en la valoración del tratamiento percutáneo del carcinoma hepatocelular. Comparación con la TC multifásica / Second-generation ultrasound contrast agents (SonoVue) in the evaluation of percutaneous treatment of hepatocellular carcinoma: comparison with multiphase CT

Objetivo: Determinar la eficacia de la ecografía con contraste (EC) de segunda generación en la valoración del tratamiento percutáneo del carcinoma hepatocelular (CHC), tanto de una forma precoz (< 24 h), como al mes después del tratamiento. Asimismo, se analiza la utilidad de la tomografía computarizada (TC) en la valoración inmediata después del tratamiento, hecho cuestionado hasta el momento. Material y métodos: Se han incluido en el estudio 30 pacientes afectados de CHC de pequeño tamaño, no tributarios de resección quirúrgica, tratados mediante alcoholización o radiofrecuencia. Antes del tratamiento, pasadas menos de 24 h de tratamiento, y 1 mes postratamiento efectuaron una EC (con software especial de contrastes y bajo índice mecánico) y una TC multifásica. Se compararon los hallazgos de las exploraciones a las 24 h (EC y TC) y los de la EC 1 mes postratamiento con los de la TC al mes (gold standar).Resultados: Valorado con TC al mes, el tratamiento percutáneo obtuvo una respuesta completa en 22 de los 30 pacientes. La EC y la TC realizadas antes de las 24 h postratamiento obtuvieron, respectivamente, los siguientes resultados: sensibilidad (S), 12,5 (28,5%); especificidad (E), 95,4 (95,4%); rentabilidad diagnóstica (RD), 73,3 (79,3%); valor predictivo positivo (VPP), 50 (66%); valor predictivo negativo (VPN), 75 (80,6%). Los resultados de la EC realizada al mes postratamiento fueron: S, 87,5%; E, 95,4%; RD, 93,3%; VPP, 87,5%, y VPN, 95,4%.Conclusión: La EC y la TC realizadas antes de las 24 h postratamiento tienen escasa utilidad para detectar la persistencia tumoral valorada de forma inmediata postratamiento. Dados los buenos resultados de la EC realizada al mes postratamiento, esta exploración podría sustituir a la TC para valorar la necesidad de nuevos tratamientos

Objective: to determine the efficacy of ultrasonography using second-generation contrast agents (CUS) in the evaluation of percutaneous treatment of hepatocellular carcinoma (HCC), both for early evaluation (< 24 hours) and for evaluation one month after treatment. Likewise, the usefulness of computerized tomography (CT) for evaluation immediately after treatment, to date controversial, is assessed. Material and methods: A total of 30 patients with small-sized HCC without indications for surgery treated by radiofrequency ablation or alcohol injection were included in the study. All patients underwent CUS (using special contrast software and low mechanical index) and multiphase CT prior to treatment, within 24 hours of treatment, and one month after treatment. CT findings one month after treatment were taken as the gold standard. Findings at CUS and CT examination within 24 hours of treatment and CUS findings at one month were compared with the gold standard. Results: CT performed one month after percutaneous treatment found a complete response in 22 of the 30 patients. Comparison of CUS and CT findings within 24 hours of treatment with the gold standard yielded the following results: (CUS/CT) Sensitivity (S) = 12.5/28.5%, specificity (SP) = 95.4/95.4%, diagnostic yield (DY) = 73.3/79.3%, positive predictive value (PPV) = 50/66%, negative predictive value (NPV) = 75/80.6%. The results of CUS performed one month after treatment were : S = 87.5%, SP = 95.4%, DY = 93.3%, PPV = 87.5% and NPV = 95.4%.Conclusion: CUS and CT performed within 24 hours of treatment are of little use in detecting tumor persistence immediately after treatment. Given the good results obtained using CUS one month after treatment, this technique could substitute CT to assess the need for retreatment

Significance of and contributing factors for a high resistive index on Doppler sonography of the hepatic artery immediately after surgery: prognostic implications for liver transplant recipients.

OBJECTIVE: The goal of our study was to investigate the contributing factors, clinical repercussions, and implications for prognosis of high-resistance flow at the hepatic artery detected on Doppler sonography during the period immediately after orthotopic liver transplantation. MATERIALS AND METHODS: We retrospectively studied the transplanted livers of 90 patients who had been examined on Doppler sonography within the first 3 days after grafting. Seventeen variables from organ donors, transplant recipients, graft characteristics, and surgical procedures were investigated. Early clinical evolution was also analyzed. Follow-up was performed for 5 years. RESULTS: Forty-one (45.6%) of the 90 patients showed a high resistive index at the hepatic artery during the first 72 hr after transplantation. Two factors showed a statistically significant effect on the occurrence of a high resistive index at the hepatic artery immediately after transplantation: an older liver donor (p = 0.008) and extended preservation time (p = 0.005). No relation with early graft function was detected. The incidence of bile duct complications, retransplantation, or death was not higher at follow-up in patients with high-resistance flow than in those with normal flow. CONCLUSION: High-resistance flow at the hepatic artery detected on Doppler sonography during the period immediately after transplantation is a frequent finding and is related to older donor age and prolonged period of ischemia. This finding has neither significant clinical repercussions nor prognosis implications for early and long-term follow-up.

Transrectal prostatic ultrasonography in acute bacterial prostatitis: findings and clinical implications.

To evaluate the role of transrectal ultrasonography (TRUS) in the diagnosis of acute bacterial prostatitis (ABP) and to analyse the possible relationship between sonographic findings and clinical presentation and evolution, a prospective study using TRUS in patients with ABP was conducted. 45 patients (aged 58.2 +/- 14.6 y; mean +/- SD) with a clinical diagnosis of ABP admitted to a university hospital were studied prospectively. Clinical, analytical and microbiological data were recorded. TRUS was performed on admission and after 1 month of antibiotic therapy. Findings were correlated with clinical and evolutive data. The mean prostatic volume on admission was 40.5 +/- 17.9 ml. 21 patients (46.6%) had sonographically demonstrable lesions in peripheral prostatic lobules. One month later, when treatment had ended, lesions had disappeared or improved in 61.1% of patients, and the mean prostatic volume was 24.3 +/- 10.5 ml (p < 0.0005). Clinical, analytical and microbiological data and evolution of ABP were not significantly different in patients with or without sonographically demonstrable lesions. TRUS does not need to be performed in every patient with suspicion of ABP; the only indication for TRUS in ABP is the exclusion of prostatic abscess.

Centro de diagnóstico por la imagen en un hospital de tercer nivel / Centre for Diagnosis by Images in a Third Level Hospital

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