Hepatocellular Carcinoma Demonstrates Heterogeneous Growth Patterns in a Multicenter Cohort of Patients With Cirrhosis.

BACKGROUND AND AIMS: There are limited data on hepatocellular carcinoma (HCC) growth patterns, particularly in Western cohorts, despite implications for surveillance, prognosis, and treatment. Our study's aim was to quantify tumor doubling time (TDT) and identify correlates associated with indolent and rapid growth. APPROACH AND RESULTS: We performed a retrospective multicenter cohort study of patients with cirrhosis diagnosed with HCC from 2008 to 2017 at six US and European health systems with two or more contrast-enhanced imaging studies performed ≥ 30 days apart prior to HCC treatment. Radiologists independently measured tumors in three dimensions to calculate TDT and specific growth rate (SGR). We used multivariable ordinal logistic regression to identify factors associated with indolent (TDT > 365 days) and rapid (TDT < 90 days) tumor growth. In the primary cohort (n = 242 patients from four centers), median TDT was 229 days (interquartile range [IQR], 89-627) and median SGR was 0.3% per day (IQR, 0.1%-0.8%). Over one-third (38%) of HCCs had indolent growth, 36.8% intermediate growth, and 25.2% rapid growth. In multivariable analysis, indolent growth was associated with larger tumor diameter (odds ratio [OR], 1.15, 95% confidence interval [CI], 1.03-1.30) and alpha-fetoprotein < 20 ng/mL (OR, 1.90; 95% CI, 1.12-3.21). Indolent growth was more common in nonviral than viral cirrhosis (50.9% versus 32.1%), particularly in patients with T1 HCC (OR, 3.41; 95% CI, 1.08-10.80). Median TDT (169 days; IQR 74-408 days) and SGR (0.4% per day) were similar in an independent cohort (n = 176 patients from two centers). CONCLUSIONS: In a large Western cohort of patients with HCC, we found heterogeneous tumor growth patterns, with one-fourth exhibiting rapid growth and over one-third having indolent growth. Better understanding different tumor growth patterns may facilitate a precision approach to prognostication and treatment.

A Randomized Phase II Open-Label Multi-Institution Study of the Combination of Bevacizumab and Erlotinib Compared to Sorafenib in the First-Line Treatment of Patients with Advanced Hepatocellular Carcinoma.

OBJECTIVES: To investigate the clinical efficacy and tolerability of the combination of bevacizumab (B) and erlotinib (E) compared to sorafenib (S) as first-line treatment for patients with advanced hepatocellular carcinoma (HCC). METHODS: A total of 90 patients with advanced HCC, Child-Pugh class A-B7 cirrhosis, and no prior systemic therapy were randomly assigned (1: 1) to receive either 10 mg/kg B intravenously every 14 days and 150 mg E orally daily (n = 47) (B+E) or 400 mg S orally twice daily (n = 43). The primary endpoint was overall survival (OS). Secondary endpoints included event-free survival (EFS), objective response rate based on Response Evaluation Criteria in Solid Tumors (RECIST 1.1), time to progression, and safety and tolerability. RESULTS: The median OS was 8.55 months (95% CI: 7.00-13.9) for patients treated with B+E and 8.55 months (95% CI: 5.69-12.2) for patients receiving S. The hazard ratio (HR) for OS was 0.92 (95% CI: 0.57-1.47). The median EFS was 4.37 months (95% CI: 2.99-7.36) for patients receiving B+E and 2.76 months (95% CI: 1.84-4.80) for patients receiving S. The HR for EFS was 0.67 (95% CI: 0.42-1.07; p = 0.09), favoring B+E over S. When OS was assessed among patients who were Child-Pugh class A, the median OS was 11.4 months (95% CI: 7.5-15.7) for patients treated with B+E (n = 39) and 10.26 months (95% CI: 5.9-13.0) for patients treated with S (n = 38) (HR = 0.88; 95% CI: 0.53-1.46). CONCLUSIONS: There was no difference in efficacy between the B+E and S arms, although the safety and tolerability profile tended to favor B+E over S based on competing risk analysis.

Accuracy of magnetic resonance cholangiopancreatography in identifying pancreatic duct disruption.

GOALS: Endoscopic retrograde pancreatography is the gold standard diagnostic study for pancreatic duct (PD) pathology but carries significant risks. Our aim was to assess the ability of magnetic resonance cholangiopancreatography (MRCP) to delineate PD disruption. BACKGROUND: PD disruption is a significant clinical event and portends a more severe clinical course after acute pancreatitis or other pancreatic injury. Knowledge of such a disruption can direct a more aggressive medical therapy early in the disease course and might also select those patients likely to benefit from early endoscopic intervention. MRCP has been evaluated abundantly in the context of biliary disease. Conversely, the role of MRCP in the investigation of PD pathology has been little studied. STUDY: A retrospective analysis identified consecutive patients between 2000 and 2008 undergoing endoscopic retrograde cholangiopancreatography (ERCP) for the indication of pancreatitis. Records were then reviewed to subselect only those patients with proximate ERCP and MRCP. The radiologist reviewing the MRCP was blinded to all clinical and imaging data except a brief clinical synopsis provided by the other authors. RESULTS: Thirty-one patients had MRCP within 7 days of the ERCP. MRCP preceded ERCP in 84% (26/31) patients, with ERCP performed a median 2.2 (range, 0 to 7) days after MRCP. PD disruption was found at ERCP in 74% (23/31) of patients; MRCP confirmed 91% (21/23) of the duct disruptions. In the 8 patients with intact PD at ERCP, MRCP correctly reported an intact PD. CONCLUSIONS: MRCP performed for a suspected PD fistula is highly accurate in assessing the integrity of the PD.

Ultrasound evaluation of gallbladder dyskinesia: comparison of scintigraphy and dynamic 3D and 4D ultrasound techniques.

OBJECTIVE: The purpose of this study was to determine the efficacy of 3D and 4D ultrasound in correlation with hepatoiminodiacetic acid (HIDA) scanning for calculating gallbladder ejection fraction (EF). SUBJECTS AND METHODS: A prospective study was conducted with 40 adult patients with suspected gallbladder dyskinesia. Cholecystokinin-provoked (99m)Tc-HIDA scintigraphy was performed, and concurrent 3D and 4D ultrasound images of the gallbladder were obtained before cholecystokinin infusion and 20, 30, and 40 minutes after infusion. The EF values calculated from the ultrasound images and HIDA scan were compared. RESULTS: The gallbladder EF values (mean ± standard error of the mean) calculated 20 minutes after cholecystokinin infusion from HIDA scans and 3D and 4D ultrasound images were 54.1% ± 5.0%, 58.9% ± 6.3%, and 62.8% ± 5.5%. Thirty minutes after infusion the EF values were 56.3% ± 4.7%, 56.9% ± 5.7%, and 59.1% ± 4.6%. The numbers of patients with an EF less than 50% were 14, 12, and 13, and the numbers with an EF less than 35% were 10, seven, and eight. For the patients with an EF less than 50%, the kappa agreement between HIDA scanning and 3D ultrasound was 0.89 (95% CI, 0.73-1.00), between HIDA scanning and 4D ultrasound was 0.83 (95% CI, 0.65-1.00), and between 3D and 4D ultrasound was 0.83 (95% CI, 0.64-1.00). CONCLUSION: Both 3D and 4D ultrasound techniques correlate well with HIDA scanning for calculating gallbladder EF in patients with suspected biliary dyskinesia.

An overview of renal transplantation: current practice and use of ultrasound.

Imaging has played a major role in monitoring the well-being of the renal graft. Ultrasound, in particular, has been extremely helpful for the detection of postoperative complications related to the transplant kidney. From an imaging perspective, the complications of renal transplantation can be categorized into vascular complications, complications related to the collecting systems (urological complications), perinephric fluid collections, and parenchymal complications. Additionally, there are some complications that may occur, secondary to a transplant renal biopsy. To be able to correctly identify the complications associated with renal transplants, one should have a comprehensive understanding of various aspects of the transplant procedure and be familiar with the normal or expected findings after a transplant. This article provides an overview of renal transplantation and discusses the use of various imaging modalities in its evaluation. The various complications associated with renal transplant as well as renal biopsy are elaborated in this article with special emphasis on the use of ultrasound.

Intussusception of the appendix mimicking appendicitis during pregnancy: a case report.

BACKGROUND: Intussusception occurs when a segment of bowel and its associated mesentery telescopes into the lumen of the adjacent distal bowel. Appendiceal intussusception is a rare form of ileocoloc intussusception, is rarely diagnosed preoperatively, can mimic appendicitis and has not been previously reported during pregnancy. CASE: A 31-year-old gravid woman at 27 1/7 weeks' gestation presented with symptoms suggestive of acute appendicitis and was found at laparoscopy to have complete appendiceal intussusception. CONCLUSION: The list of causes of abdominal pain in pregnancy is very long, but the presence of right-sided abdominal tenderness with guarding and rebound are highly suggestive of acute appendicitis. Regardless of preoperative imaging, because the morbidity, and even mortality, from appendicitis is the morbidity of delay, early surgical intervention is recommended. This is a case of complete appendiceal intussusception mimicking acute appendicitis, but the treatment of both conditions is appendectomy.

Can the smallest depth of ascitic fluid on sonograms predict the amount of drainable fluid?

PURPOSE: To investigate the correlation between the 'smallest fluid depth' (SFD) measured on sonography (US) at the 'paracentesis pocket' with the amount of fluid drained in patients referred for US-guided large-volume paracentesis. METHODS: US examinations performed to guide 60 paracenteses in 29 patients with large-volume ascites were reviewed and the SFD measured at the site of the paracentesis. The SFD was measured from the most superficial bowel loop to the abdominal wall. The SFD measurements were compared with the drained fluid volume (DFV) measurements. RESULTS: The average DFV per paracentesis was 5.2 L with an average SFD measurement of 5.4 cm. For every 1-cm increase in the measured SFD, there was an average 1-L increase in the DFV. After applying this relationship to the measured depth in each case, the comparison between the estimated fluid volume (EFV) on US and the DFV demonstrated a <1-L difference in 38 of 60 paracenteses (63.3%) and a <2-L difference in 51 of 60 paracenteses (85%). CONCLUSION: The SFD measured at the site of paracentesis shows a correlation with the drained fluid volume and can be used for fluid volume estimation on US.

Imaging of abdominal lymphoma.

This article discusses the radiologic appearances of solid organ involvement with Hodgkin and non-Hodgkin lymphoma in the abdominopelvic region. The most common radiologic patterns of involvement are illustrated. The imaging characteristics of lymphomatous involvement of abdominal organs overlap with several other disorders and the specific features pertaining to lymphoma are highlighted. In patients who have known lymphomas, other important management considerations, such as staging, response to therapy, malignant transformation, and identification of recurrent disease, are also discussed. The emerging role of fluorodeoxyglucose positron emission tomography is briefly outlined.

A review of sonographic evaluation of renal transplant complications.

In this article, we present an overview of renal transplantation with its complications and discuss the abilities and limitations of ultrasound in evaluating these complications. We included renal transplants performed at our institution between 1993 and 2006 and gathered data on more than 1,000 patients who developed graft dysfunction. We analyzed the ultrasound findings in different posttransplant complications and compared our findings with those in published literature. We present this review article that elaborates and categorizes various transplant complications from an ultrasound perspective. Based on imaging evaluation, the complications of renal transplantation can be divided into four major categories: peri-renal, renal parenchymal, renal collecting system, and renal vascular complications. Common complications included acute tubular necrosis, graft rejection, drug nephrotoxicity, hematoma, lymphocele, urinoma, hydronephrosis, and vascular complications. Ultrasound has a key role in identification and management of most of these complications. However, some parenchymal complications may only be diagnosed on renal biopsy. Ultrasound is a very powerful screening tool to assess renal transplant dysfunction and has a primary role in early diagnosis and management of structural and vascular complications, which may need surgical intervention to save the graft.

Cholecystoenteric Fistula Masquerading as a Bleeding Subepithelial Mass.

An 82-year-old man was referred for endoscopic ultrasound of an ulcerated subepithelial mass in the duodenal sweep. The mass was initially identified during upper endoscopy for coffee-ground emesis. During endoscopic ultrasound, a 21-mm hypoechoic ulcerated subepithelial mass with a duct-like structure was identified. During suction to appose the lesion against the tip of the echoendoscope, the ulceration opened into a fistulous tract with drainage of bile and stones. Subsequent abdominal imaging demonstrated that the mass-like duodenal lesion abutted the gallbladder, which had an air-fluid level. We report a cholecystoenteric fistula masquerading as a subepithelial duodenal mass.

Imaging of hepatocellular carcinoma: new approaches to diagnosis.

The currently accepted major diagnostic criteria for identifying hepatocellular carcinoma (HCC) on dynamic cross-sectional imaging consist of diffuse arterial phase hyperenhancement within the lesion, portal venous or delayed phase washout, and the presence and appearance of a capsule; also included in this criteria is interval threshold growth. Ancillary features such as intralesional fat, blood products, and mosaic architecture also favor a diagnosis of HCC. Tumor in a portal or hepatic vein is a definitive finding for an HCC even if a parenchymal mass is not clearly seen.

Role of secretin-enhanced magnetic resonance cholangiopancreatography in the evaluation of patients following pancreatojejunostomy.

OBJECTIVE: This study was conducted to assess the role of secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) in the evaluation of patients following pancreatico-jejunal anatomosis. MATERIALS AND METHODS: S-MRCP studies (n = 83) performed at Brigham and Women's Hospital between 1/2005 and 7/2005 were retrospectively reviewed. Among these, there were 13 patients (10 females, 3 males; mean age = 45 years, range = 18-74 years) who were evaluated with S-MRCP following pancreatojejunal anatomosis. Single-shot fast spin-echo T2-weighted thick slab dynamic MRCP images obtained before and every minute (for 10 min) after IV injection of secretin (2 mcg/kg body weight of SecreFloTM IV over 1 min) were reviewed retrospectively and independently by 3 readers. Image analysis included measurement of the main pancreatic duct (MPD) diameter and subjective assessment of the grade of visualization of the MPD remnant. The amount of jejunal fluid and visualization of the pancreatico-jejunal anatomosis pre-and post-secretin were also documented. Direct correlation with endoscopic retrograde cholangiopancreatography (ERCP) finding was available in six of the 13 cases. RESULTS: The MPD diameter and MPD remnant visualization improved post-secretin for 1/3 readers. The number of pancreatico-jejunal anastomoses and the amount of jejunal fillings pre-and post-secretin was seen to improve significantly for 1 of the 3 readers. For Reader 1, the mean MPD diameter in the body of the pancreas, on the pre-and post-secretin image, was 3.2 ± 1.3 mm and 3.8 ± 1.9 mm, respectively. There was no statistical difference in the values pre- and post-secretin in the MPD diameter (P = 0.07), MPD visualization (P = 0.16) and the number of pancreatico-jejunal anastomoses seen (P = 0.125 5/13 pre- and 9/13 post-secretin). Statistical significance was seen in the amount of jejunal filling (P = 0.01) after secretin. For Reader 2, the MPD diameter pre-and post-secretin was 4 ± 2 and 3.9 ± 2.1 mm, respectively (P = 0.89). The MPD visualization (P = 0.19) and degree of jejunal filling (P = 0.7) did not improve significantly. There were 3/13 pancreatico-jejunostomy anastomoses seen pre- and 8/13 seen post-secretin (P = 0.06). The values for Reader 3 reached a statistical significance for the measurement of MPD (P = 0.032). In addition, MPD visualization (P = 0.038), the number of anastomoses seen (P = 0.016) and jejunal filling (P = 0.006) were also significantly improved. CONCLUSION: The addition of intravenous secretin to an MRCP study in the evaluation of patients following pancreatojejunal anastomosis does not significantly impact the visualization of the pancreatic duct. However, secretin may improve the assessment of the pancreatico-jejunal anastomosis.

Late occurring ectopic pregnancy in a posthysterectomy patient.

The incidence of ectopic pregnancy after hysterectomy is extremely rare with only 56 cases reported in the medical literature. Due to its rare occurrence, this diagnosis may not be initially considered when such a patient presents with abdominopelvic pain. It is an important diagnosis to keep in mind since a delay in diagnosis may lead to death. The case presented below describes this extremely unusual diagnosis of an ectopic pregnancy which occurred six years after a supracervical hysterectomy.

Ovarian cystic lesions: a current approach to diagnosis and management.

The primary imaging modality for evaluation of ovarian cystic lesions is pelvic ultrasonography. Most ovarian cysts are benign and demonstrate typical sonographic features that support benignity. However, some ovarian cystic lesions have indeterminate imaging features, and the approach to management varies. This article discusses how to recognize and diagnose different types of ovarian cystic lesions, including an approach to management. The learning objective is to recognize imaging features of ovarian cystic lesions.

Current role of ultrasound in chronic liver disease: surveillance, diagnosis and management of hepatic neoplasms.

Ultrasound (US) has been used to evaluate liver disease for many decades. Despite certain inherent limitations in evaluating chronic liver disease on routine gray-scale US, it is still widely used for the initial evaluation in patients suspected of liver disease as well as for hepatocellular carcinoma (HCC) screening in patients with known cirrhosis. Due to recent advances in digital technology and US imaging software, various new computer protocols have been incorporated in the new US equipment. This in turn has resulted in a great improvement in image quality and image resolution. Consequently, the increased ability of US to better characterize the liver texture in general has enabled the sonographers to identify subtle changes in the liver texture and delineate smaller masses in the liver with greater success.

Imaging of hepatocellular carcinoma: practical guide to differential diagnosis.

Hepatocellular carcinoma (HCC) is most commonly seen in patients with cirrhosis. Criteria for diagnosis include arterial-phase enhancement, venous-phase washout, and a capsule on delayed sequences. Tiny HCC are best detected with magnetic resonance imaging using the new hepatocyte-specific gadolinium agents; otherwise, short-term follow up versus biopsy is considered. Diffuse HCC can be difficult to diagnose because of the inherent heterogeneous hepatic parenchyma in cirrhosis, however, portal vein expansion due to thrombosis is a helpful sign.

Ultrasound for pelvic pain II: nongynecologic causes.

Acute pelvic pain in women is a common presenting complaint that can result from various conditions. Because these conditions can be of gynecologic or nongynecologic origin, they may pose a challenge to the diagnostic acumen of physicians, including radiologists. A thorough workup should include clinical history, physical examination, laboratory data, and appropriate imaging studies, all of which should be available to the radiologist for evaluation. Ultrasound is the primary imaging modality in women with acute pelvic pain because of its high sensitivity, low cost, wide availability, and lack of ionizing radiation, particularly when a gynecologic disorder is suspected as the underlying cause. However, other modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) may be very helpful, especially when a nongynecologic condition is suspected.