Interobserver variability in MRI measurements of mesorectal invasion depth in rectal cancer.

PROPOSE: To assess the interobserver variability in MRI measurements of mesorectal invasion depth (MID) in rectal adenocarcinomas primarily staged as T3, by determining the level of interobserver agreement in the differentiation of individual T3 substages and of T3a-b vs. T3c-d disease, between readers with different levels of expertise. METHODS: A retrospective analysis of 60 patients classified by MRI as having T3 rectal cancers was performed. Each patient underwent MR examination in a 1.5 T machine and the standard imaging protocol included a high-resolution axial T2-weighted sequence in which the measurements were determined by independent radiologists (readers A and B, with 15 years and 1 year of experience, respectively). The rectum was further divided into quadrants and each reader selected the quadrant where the measurement was taken. The patients were grouped according to the MID (T3a < 1 mm; T3b 1-5 mm; T3c > 5-15 mm; T3d > 15 mm) and the interobserver reliability was tested using Cohen's kappa. RESULTS: Population included 40 males and 20 females with a median age of 65.9 years. Interobserver agreement on individual substage differentiation (T3 a, b, c and d) was moderate (K = 0.428) and in the quadrant evaluation the level of agreement was also moderate (K = 0.414). Nevertheless, the interobserver reliability for the differentiation between stages T3a-b vs. T3c-d was substantial (K = 0.697). CONCLUSIONS: There is no considerable interobserver variability when distinguishing T3a-b from T3c-d tumors, regardless of the quadrant where the MID is measured. Therefore, assessment of MID, for that purpose, is a reproducible MR parameter, irrespectively of the readers' experience.

Portal Venous Pressure Variation during Hepatectomy: A Prospective Study.

INTRODUCTION: Excessive portal venous pressure in the liver remnant is an independent factor in the occurrence of posthepatectomy liver failure and small-for-size syndrome. The baseline portal pressure prior to hepatectomy was not considered previously. The aim of this study is to assess the impact of portal pressure change during hepatectomy on the patient outcome. MATERIAL AND METHODS: Prospective observational study including 30 patients subjected to intraoperative measurement of portal pressure before and after hepatectomy. This variation was related to the patient outcome. Control group evaluation was assessed. Patient, disease and procedure features were considered. The optimal cut-off of portal pressure variation was determined. Linear regression or logistic regression was applied to identify predictors of the outcome. RESULTS: The univariate analysis showed that portal pressure increase after hepatectomy was associated with coagulation impairment in the first 30 postoperative days (p < 0.05), and with the occurrence of major complications (p = 0.01), namely hepatic failure (p = 0.041). The multivariate analysis showed that portal venous pressure increase ≥ 2 mmHg is an independent factor for worse outcomes. DISCUSSION: As in previous studies, this study concludes that, after hepatectomy, in addition to the functional liver remnant, other factors are responsible for deterioration of liver function and patient outcome, such as the portal pressure increase and the exposure to chemotherapy prior to hepatectomy. This work may influence the definition of future indications for portal influx modulation. CONCLUSION: Patient outcomes are influenced by the portal venous pressure increase: an increment ≥ 2 mmHg after hepatectomy seems to increase the risk of major complications.

Introdução: O aumento da pressão venosa portal para o remanescente hepático é um fator independente para falência hepática após hepatectomia e síndrome small-for-size. Estudos anteriores não consideram o valor de pressão portal prévio à hepatectomia. O objetivo deste estudo é analisar o impacto da variação da pressão portal durante a hepatectomia na evolução clínica pós-operatória. Material e Métodos: Estudo observacional prospetivo, incluindo 30 doentes submetidos a medição intraoperatória da pressão portal antes e após hepatectomia, relacionando esta variação com a evolução clínica pós-operatória. Avaliação similar foi efetuada num grupo de controlo. Fatores relacionados com o doente, doença e procedimento foram considerados. Determinou-se o valor ideal de variação da pressão portal. Regressão linear ou logística foram aplicadas para identificar fatores preditores de evolução clínica. Resultados: A análise univariada mostrou que um aumento de pressão portal após hepatectomia associa-se a deterioração da coagulação nos primeiros 30 dias após hepatectomia (p < 0,05), a complicações major (p = 0,01) como a falência hepática após hepatectomia (p = 0,041). A análise multivariada mostrou que um aumento de pressão portal ≥ 2 mmHg é um fator independente para a evolução clínica pós-operatória desfavorável. Discussão: Após hepatectomia, para além do remanescente hepático funcional, outros fatores são responsáveis pela deterioração da função hepática e pela morbimortalidade, como o aumento da pressão portal e a exposição prévia a quimioterapia. Este trabalho contribui para a definição futura das indicações para modulação do influxo portal. Conclusão: Um aumento de pressão portal ≥ 2 mmHg após hepatectomia parece agravar o risco de complicações major.

Liver Multiacinar Regenerative Nodules: Imaging Findings and Clinical Implications.

INTRODUCTION: Multiacinar regenerative nodules are benign hepatocellular nodules related to vascular disturbances of the liver. They strongly resemble conventional focal nodular hyperplasia but are connected to different clinical settings, typically chronic liver disease. The purpose of the present study was to describe the key imaging features of these lesions and compare them with a control arm of focal nodular hyperplasia. MATERIAL AND METHODS: A blinded consensus review of liver magnetic resonance consisting of 26 cases of multiacinar regenerative nodules and 25 cases of focal nodular hyperplasia was performed. Lesion size, shape, margins, structure, T1 and T2 signal intensity, diffusion and contrast-enhanced features (including hepatobiliary phase), presence of a central scar and of a peripheral hypointense rim were compared between the two groups. RESULTS: Significant differences between multiacinar regenerative nodules and focal nodular hyperplasia included size (median 2.35 cm, IQR: 2.13, vs 6.00 cm, IQR: 5.20, respectively, p < 0.001), presence of a peripheral hypointense rim after contrast (n = 9 vs n = 2 cases, p = 0.038) and of a central scar (n = 9 vs n = 20, p = 0.002). There were no other significant differences. DISCUSSION: Overall multiacinar regenerative nodules and focal nodular hyperplasia have very similar imaging features but lack of a central scar and presence of a hypointense rim should suggest a diagnosis of multiacinar regenerative nodules. CONCLUSIONS: Recognition of the imaging findings of multiacinar regenerative nodules can explain some atypical cases of focal nodular hyperplasia, avoiding unnecessary biopsies. They may also be the trigger to investigate an unsuspected underlying liver vascular abnormality.

Introdução: Nódulos regenerativos multiacinares são nódulos hepatocelulares benignos relacionados com alterações vasculares hepáticas. São muito semelhantes à hiperplasia nodular focal mas ocorrem num contexto diferente de doença hepática crónica. O objectivo deste trabalho foi descrever os achados imagiológicos principais destes nódulos e compará-los com um grupo controlo de hiperplasia nodular focal. Material e Métodos: Foi efectuada uma revisão cega de estudos por ressonância magnética de 26 casos de nódulos regenerativos multiacinares e 25 de hiperplasia nodular focal, sendo os dois grupos comparados quanto à dimensão das lesões, morfologia, margens, estrutura, aspecto em T1, T2, difusão e após contraste (incluindo na fase hepatobiliar), presença de cicatriz central e halo hipointenso. Resultados: Foram encontradas diferenças significativas entre nódulos regenerativos multiacinares e hiperplasia nodular focal quanto às dimensões das lesões (mediana 2,35 cm AIQ: 2,13 vs 6,00 cm AIQ: 5,20 respectivamente, p < 0,001), presença de halo hipointenso após contraste (n = 9 vs n = 2, p = 0,038) e de cicatriz central (n = 9 vs n = 20, p = 0,002). Não se observaram outras diferenças significativas. Discussão: Nódulos regenerativos multiacinares e hiperplasia nodular focal são globalmente muito semelhantes mas a ausência de cicatriz central e a presença de halo hipointenso deve sugerir o diagnóstico de nódulos regenerativos multiacinares. Conclusão: O reconhecimento dos achados imagiológicos de nódulos regenerativos multiacinares pode explicar alguns dos casos atípicos de hiperplasia nodular focal e prevenir biopsias desnecessárias. Pode também desencadear uma investigação mais aprofundada de anomalias vasculares hepáticas subjacentes eventualmente desconhecidas.

Imaging Findings of Metaplastic Carcinoma of the Breast with Pathologic Correlation.

OBJECTIVES: To review the imaging findings of a series of cases of metaplastic carcinoma of the breast, a rare and aggressive form of breast cancer with variable imaging features. MATERIALS AND METHODS: Retrospective review of multimodality imaging features of eleven cases of metaplastic carcinoma of the breast retrieved from a single hospital institution database. Clinical and pathologic data were also documented. RESULTS: The median age of presentation was 65 years. Four cases had axillary lymphadenopathies, and two had distant metastases. An oval mass was the most common sonographic finding (7/11; 64%). Lesions displayed circumscribed/partially circumscribed margins (6/11; 55%) or non-circumscribed margins (5/11; 45%). Most lesions had a heterogeneous echo structure (9/11; 82%) and posterior acoustic enhancement (6/11; 55%). In nine patients, mammographies were available. An oval dense mass was the most common mammographic finding (5/9; 56%). The majority of cases had non-circumscribed margins (6/9; 67%), and nearly half displayed calcifications (4/9; 44%). CONCLUSIONS: Mammographic findings were not different from the usual features of more prevalent types of breast cancer, though the majority of metaplastic carcinoma of the breast showed possible distinctive sonographic features, such as circumscribed margins or complex echogenicity, reflecting the histologic background.

Bioenergetic adaptations of the human liver in the ALPPS procedure - how liver regeneration correlates with mitochondrial energy status.

BACKGROUND: The Associating Liver Partition and Portal Ligation for Staged Hepatectomy (ALPPS) depends on a significant inter-stages kinetic growth rate (KGR). Liver regeneration is highly energy-dependent. The metabolic adaptations in ALPPS are unknown. AIMS: i) Assess bioenergetics in both stages of ALPPS (T1 and T2) and compare them with control patients undergoing minor (miHp) and major hepatectomy (MaHp), respectively; ii) Correlate findings in ALPPS with volumetric data; iii) Investigate expression of genes involved in liver regeneration and energy metabolism. METHODS: Five patients undergoing ALPPS, five controls undergoing miHp and five undergoing MaHp. Assessment of remnant liver bioenergetics in T1, T2 and controls. Analysis of gene expression and protein content in ALPPS. RESULTS: Mitochondrial function was worsened in T1 versus miHp; and in T2 versus MaHp (p < 0.05); but improved from T1 to T2 (p < 0.05). Liver bioenergetics in T1 strongly correlated with KGR (p < 0.01). An increased expression of genes associated with liver regeneration (STAT3, ALR) and energy metabolism (PGC-1α, COX, Nampt) was found in T2 (p < 0.05). CONCLUSION: Metabolic capacity in ALPPS is worse than in controls, improves between stages and correlates with volumetric growth. Bioenergetic adaptations in ALPPS could serve as surrogate markers of liver reserve and as target for energetic conditioning.

Liver MRI: From basic protocol to advanced techniques.

Liver MR is a well-established modality with multiparametric capabilities. However, to take advantage of its full capacity, it is mandatory to master the technique and optimize imaging protocols, apply advanced imaging concepts and understand the use of different contrast media. Physiologic artefacts although inherent to upper abdominal studies can be minimized using triggering techniques and new strategies for motion control. For standardization, the liver MR protocol should include motion-resistant T2-w sequences, in-op phase GRE T1 and T2-w fast spin echo sequences with fat suppression. Diffusion-weighted imaging (DWI) is mandatory, especially for detection of sub-centimetre metastases. Contrast-enhanced MR is the cornerstone of liver MR, especially for lesion characterization. Although extracellular agents are the most extensively used contrast agents, hepatobiliary contrast media can provide an extra-layer of functional diagnostic information adding to the diagnostic value of liver MR. The use of high field strength (3T) increases SNR but is more challenging especially concerning artefact control. Quantitative MR belongs to the new and evolving field of radiomics where the use of emerging biomarkers such as perfusion or DWI can derive new information regarding disease detection, prognostication and evaluation of tumour response. This information can overcome some of the limitations of current tests, especially when using vascular disruptive agents for oncologic treatment assessment. MR is, today, a robust, mature, multiparametric imaging modality where clinical applications have greatly expanded from morphology to advanced imaging. This new concept should be acknowledged by all those involved in producing high quality, high-end liver MR studies.

Symptomatic bilateral coronary artery fistula to pulmonary artery in elderly patient.

We report the imaging findings of an uncommon coronary vascular termination anomaly, with fistula to the pulmonary artery. This 70 year old female patient presented unstable angina, showing a coronary artery fistula depicted in coronary angiogram from the left coronary to the pulmonary artery, with no significant atherosclerotic pathology. Due to development of ventricular tachycardia in stress echocardiogram examination, she was proposed for coronary fistula closure. Coronary CT was performed for procedure planning and allowed the identification of a second unsuspected fistula from the right coronary to the right pulmonary artery. Congenital coronary anomalies are a possible cause of symptomatic coronary pathology in patients of any age. In older patients, coronary artery fistulas are rare, especially when symptomatic. Adequately performed CT examinations, using its post processing capabilities, with 3D and MIP reconstructions are invaluable in delineating coronary anatomy, essential for further treatment planning.