Appearance of hepatocellular adenomas on gadoxetic acid-enhanced MRI

OBJECTIVE

The purpose of this study was to evaluate enhancement characteristics of hepatocellular adenomas (HCAs) using gadoxetic acid as a hepatocyte-specific MR contrast agent.

METHODS

Twenty-four patients with histopathologically proven HCAs were retrospectively identified. MRI consisted of T1- and T2-weighted (w) sequences with and without fat saturation (fs), multiphase dynamic T1-w images, and fs T1-w images during the hepatobiliary phase. Standard of reference was surgical resection (n = 19) or biopsy (n = 5). Images were analysed for morphology and contrast behaviour including signal intensity (SI) measurement on T1-w images normalised to the pre-contrast base line.

RESULTS

In total 34 HCAs were evaluated. All HCAs showed enhancement in the arterial phase; 38 % of HCAs showed reduced contrast enhancement ("wash-out") in the venous phase. All HCAs showed enhancement (SI increase, 56 ± 53 %; P <0.001) in the hepatobiliary phase, although liver uptake was stronger (96 ± 58 %). Thus, 31 of all HCAs (91 %) appeared hypointense to the surrounding liver in the hepatobiliary phase, while 3 out of 34 lesions were iso-/hyperintense.

CONCLUSIONS

Gadoxetic acid accumulates in HCAs in the hepatobiliary phase, although significantly less than in surrounding liver. Thus, HCA appears in the vast majority of cases as a hypointense lesion on hepatobiliary phase images.

KEY POINTS

• Magnetic resonance-specific contrast agents are now available for hepatic imaging. • Hepatocellular adenomas enhance with gadoxetic acid as in previous CT/MRI experience. • Enhancement during the hepatobiliary phase is less in HCAs than in liver. • Typical HCAs appear as hypointense lesions on T1-w hepatobiliary phase images. • True hyperintense HCA enhancement can occasionally occur during the hepatobiliary phase.

Impact of neoadjuvant transarterial chemoembolization on tumor recurrence and patient survival after liver transplantation for hepatocellular carcinoma: a retrospective analysis

Transarterial chemoembolization (TACE) has gained wide acceptance as a bridge to liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Aim of this analysis was to compare long-term results with and without neoadjuvant TACE and to identify subgroups, which particularly benefit from TACE. Patients with HCC transplanted at our center were retrospectively analyzed. The following were excluded to increase consistency: incidental-HCC, Child-C, living-related-LT, other HCC-specific-treatment. Of 336 patients, 177 were subject of this analysis, 71 received TACE and 106 no HCC therapy. Patients with and without TACE showed similar five-yr survival (73/67%) and recurrence rates (23/29%). Progression on the waiting list was associated with a higher recurrence rate in the TACE (50 vs.12%) and the non-TACE group (40 vs. 22%). HCC recurrence was reduced in patients inside Milan (0.053) and UCSF (0.037) criteria by neoadjuvant TACE but not outside UCSF (0.99). Also a trend towards an improved survival was seen within these criteria. Our large single center experience suggests that TACE lowers the HCC recurrence rate in patients inside the Milan and UCSF criteria. Moreover, the response to TACE is a good indicator of low recurrence rates. The effect of TACE might be more pronounced in patients with longer waiting time than in this cohort (mean, 4.6 months).

[Percutaneous CT-guided high-dose brachytherapy (CT-HDRBT) ablation of primary and metastatic lung tumors in nonsurgical candidates]

PURPOSE

To evaluate the safety and efficacy of CT-guided high-dose brachytherapy (CT-HDRBT) ablation of primary and metastatic lung tumors.

MATERIALS AND METHODS

Between November 2007 and May 2010, all consecutive patients with primary or metastatic lung tumors, unsuitable for surgery, were treated with CT-HDRBT. Imaging follow-up after treatment was performed with contrast-enhanced CT at 6 weeks, 3 months and every 6 months after the procedure. The endpoints of the study were local tumor control and time to progression. The Kaplan-Meier method was used to estimate survival functions and local tumor progression rates.

RESULTS

34 procedures were carried out on 33 lesions in 22 patients. The mean diameter of the tumors was 33.3 mm (SD = 20.4). The first contrast-enhanced CT showed that complete ablation was achieved in all lesions. The mean minimal tumor enclosing dose was 18.9 Gy (SD = 2). Three patients developed a pneumothorax after the procedure. The mean follow-up time was 13.7 (3 - 29) months. 2 of 32 lesions (6.25 %) developed a local tumor progression. 8 patients (36.3 %) developed a distant tumor progression. After 17.7 months, 13 patients were alive and 9 patients had died.

CONCLUSION

CT-HDRBT ablation is a safe and attractive treatment option for patients with lung malignancies and allows targeted destruction of tumor tissue with simultaneous preservation of important lung structures. Furthermore, CT-HDRBT is independent of the size of the lesion and its location within the lung parenchyma.

Hepatocellular carcinoma: computed-tomography-guided high-dose-rate brachytherapy (CT-HDRBT) ablation of large (5-7 cm) and very large (>7 cm) tumours

OBJECTIVES

Evaluate the clinical outcome of CT-guided high-dose-rate-brachytherapy (CT-HDRBT) of hepatocellular carcinoma (HCC) larger than 5 cm in diameter with the goal of local tumour control (LTC).

METHODS

Thirty-five patients with 35 unresectable HCCs ranging in size from 5 to 12 cm (mean: 7.1 cm) were treated with CT-HDRBT. Tumours were classified into two groups according to diameter: "large lesions" (5-7 cm) and "very large lesions" (>7 cm). Tumour response was evaluated by Gd-EOB-DTPA-enhanced liver magnetic resonance imaging (MRI) performed before, 6 weeks after, and then every 3 months after treatment. Endpoints included local tumour control (LTC), progression-free survival (PFS) and overall survival (OS).

RESULTS

Nineteen tumours were classified as "large" and 16 as "very large". Complete tumour enclosure was achieved in all patients after the first CT-HDRBT session. Five patients were lost to follow-up. At a mean follow-up of 12.8 months, two patients had local progression (6.7%), one in each group. Nine patients (30%) experienced distant progression, five (26.3%) in the "large" and four (25%) in the "very large" group. No patients died during the follow-up period. No major complications were recorded.

CONCLUSIONS

CT-HDRBT is a promising therapy for HCCs that exceed indications for thermal ablation.

KEY POINTS

• Computed Tomography guided high-dose-rate brachytherapy offers new therapeutic options for hepatocellular carcinoma • CT-HDRBT can be safely practised in HCCs exceeding 5 cm in diameter • CT-HDRBT offers high rate of local control where thermal ablation is impossible • CT-HDRBT could be a valid alternative to TACE for intermediate stage HCC.

Well-differentiated neuroendocrine carcinoma mimicking an echinococcus cyst of the liver in CT-MRI findings with hepatocyte specific contrast material

Gastroenteropancreatic neuroendocrine tumors and their metastases have an inconsistent appearance with only a small percentage of lesions appearing as cystic masses in computed tomography (CT) and magnetic resonance imaging (MRI) and can therefore be mistaken as benign or infectious lesions, leading to a false diagnosis with delayed and inadequate treatment. We report a patient with upper abdominal pain lasting for several months, caused by a huge cystic neuroendocrine carcinoma of the liver which was mistakenly interpreted as an echinococcus cyst and present the findings in the initial CT and the subsequently performed MRI under application of hepatocyte specific contrast material, which led to distinct differential diagnoses and therefore had a capacious impact on the therapeutic strategy.

Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma

PURPOSE

Long-term results after liver resection for hilar cholangiocarcinoma are still not satisfactory. Previously, we described a survival advantage of patients who undergo combined right trisectionectomy and portal vein resection, a procedure termed "hilar en bloc resection." The present study was conducted to analyze its oncological effectiveness compared to conventional hepatectomy.

PATIENTS

During hilar en bloc resection, the extrahepatic bile ducts were resected en bloc with the portal vein bifurcation, the right hepatic artery, and liver segments 1 and 4 to 8. With this "no-touch" technique, preparation of the hilar vessels in the vicinity of the tumor was avoided. The long-term outcome of 50 consecutive patients who underwent curative (R0) hilar en bloc resection between 1990 and 2004 was compared to that of 50 consecutive patients who received curative conventional major hepatectomy for hilar cholangiocarcinoma (perioperative deaths excluded).

RESULTS

The 1-, 3-, and 5-year survival rates after hilar en bloc resection were 87%, 70%, and 58%, respectively, which was significantly higher than after conventional major hepatectomy. In the latter group, 1-, 3-, and 5-year survival rates were 79%, 40%, and 29%, respectively (P = 0.021). Tumor characteristics were comparable in both groups. A high number of pT3 and pT4 tumors and patients with positive regional lymph nodes were present in both groups. Multivariate analysis identified hilar en bloc resection as an independent prognostic factor for long-term survival (P = 0.036).

CONCLUSIONS

In patients with central bile duct carcinomas, hilar en bloc resection is oncologically superior to conventional major hepatectomy, providing a chance of long-term survival even in advanced tumors.

CT-guided high-dose-rate brachytherapy of metachronous ovarian cancer metastasis to the liver: initial experience

AIM

Hepatic resection for hepatic ovarian cancer metastases remains controversial. The purpose of this study was to evaluate the clinical outcome of CT-guided high dose rate brachytherapy (CT-HDRBT) for minimally invasive cytoreduction of isolated metachronous ovarian cancer metastases to the liver.

PATIENTS AND METHODS

Seven patients with 12 isolated ovarian cancer metastases to the liver were treated with CT-HDRBT. To evaluate tumor response a gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced liver MRI was performed before, six weeks after and every third month after treatment.

RESULTS

The mean MRI-follow-up period was 15.4 months. Tumors ranged from 13 to 120 mm in diameter. Complete ablation was achieved for all lesions. No complications occurred. No local progression was observed in any of the included patients. Overall survival was 100% after 12 months. Two patients died after 14 and 25 months, respectively.

CONCLUSION

CT-HDRBT is a safe and valid technique for performing minimally invasive cytoreduction of metachronous isolated liver metastases from ovarian cancer.

Matched-pair comparison of radioembolization plus best supportive care versus best supportive care alone for chemotherapy refractory liver-dominant colorectal metastases

PURPOSE

This study was designed to evaluate overall survival after radioembolization or best supportive care (BSC) in patients with chemotherapy-refractory liver-dominant metastatic colorectal cancer (mCRC).

METHODS

This was a matched-pair comparison of patients who received radioembolization plus BSC or BSC alone for extensive liver disease. Twenty-nine patients who received radioembolization were retrospectively matched with a contemporary cohort of >500 patients who received BSC from 3 centers in Germany. Using clinical databases, patients were initially matched for prior treatments and tumor burden and then 29 patients were consecutively identified with two or more of four matching criteria: synchronous/metachronous metastases, tumor burden, increased ALP, and/or CEA >200 U/ml. Survival was calculated from date of progression before radioembolization or BSC by using Kaplan-Meier analysis.

RESULTS

Of 29 patients in each study arm, 16 pairs (55.2%) matched for all four criteria, and 11 pairs (37.9%) matched three criteria. Patients in both groups had a similar performance status (Karnofsky index, median 80% [range, 60-100%]). Compared with BSC alone, radioembolization prolonged survival (median, 8.3 vs. 3.5 months; P < 0.001) with a hazard ratio of 0.3 (95% confidence interval, 0.16-0.55; P < 0.001) in a multivariate Cox proportional hazard model. Treatment-related adverse events following radioembolization included: grade 1-2 fatigue (n = 20, 69%), grade 1 abdominal pain/nausea (n = 14, 48.3%), and grade 2 gastrointestinal ulceration (n = 3, 10.3%). Three cases of grade 3 radiation-induced liver disease were symptomatically managed.

CONCLUSIONS

Radioembolization offers a promising addition to BSC in treatment-refractory patients for whom there are limited options. Survival was prolonged and adverse events were generally mild-to-moderate in nature and manageable.

Safety of liver resection and effect on quality of life in patients with benign hepatic disease: single center experience

BACKGROUND

Although liver resection has long been established for selected patients with benign hepatic disease, the success of surgical treatment of these patients cannot be evaluated exclusively through postoperative morbidity and mortality. Therefore, the aim of the study was to prove the safety of liver resection in the treatment of benign liver tumors and to evaluate the effect of surgical treatment on the patients' quality of life.

METHODS

A total of 146 patients who underwent liver resection because of benign liver tumors were included in this study. Postoperative outcome was assessed and patients evaluated their quality of life before surgery and at the present time using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ C-30).

RESULTS

The rate of serious (> grade 2) complications was 4.1% with no postoperative death. The quality of life assessment revealed an overall improvement of general health status after resection (0.7 vs. 0.56, p < 0.001) and additionally a significant reduction of 6 out of 9 symptoms. Furthermore, compelling benefits in the patients' social and emotional coping could be detected after surgery.

CONCLUSIONS

Liver resection for benign liver disease is a safe procedure and leads to a significant improvement of quality of life in selected patients.

Assessment of the cerebellar arteries with multidetector computed tomography angiography benefits from submillimeter slice thickness

PURPOSE

To evaluate the accuracy of 64-row-multidetector computed tomography (MDCT) with different slice thickness (0.625 vs. 1.25 mm) in assessing the cerebellar arteries.

MATERIALS AND METHODS

A total of 21 consecutive patients who underwent computed tomography angiography (CTA) of the cervicocranial arteries (64-row MDCT; slice thickness, 0.625 mm) because of suspicion of cerebral ischemia were enrolled retrospectively. The MDCT data set was secondarily reconstructed to a slice thickness of 1.25 mm. The examinations were reviewed by three independent blinded observers. Recorded parameters for reconstructed slice thicknesses of 0.625 compared to 1.25 mm were visualization and edge enhancement (based on a developed phantom reference model) of the cerebellar arteries including anterior and posterior inferior cerebellar arteries and the superior cerebellar artery.

RESULTS

With 0.625-mm slices, significantly more vessel segments were visualized and edge enhancement was superior compared to 1.25-mm slices by the three readers, and a significant difference for the interaction between vessel segments and the slice thickness was found (P<.001). Furthermore, for a slice thickness of 1.25 mm, there was a significant difference in visualization (P=.0042) and edge enhancement (P=.0015) of vessel segments between the three readers, whereas for thinner slices (0.625 mm), no significant differences were found (P=.412, P=.465).

CONCLUSIONS

MDCT with slice thickness of 0.625 mm is superior to 1.25 mm reconstructed slice thickness regarding the visualization of cerebellar arteries, representative for smallest assessable arteries in CTA. This is paralleled by a sharper edge enhancement of the vessel contours resulting from a reduced partial volume effect. Conclusively, cranial CTA protocols should be routinely optimized to generate submillimeter slices for diagnostic purposes and digital storage as additional diagnostic value can be expected.

Repeated liver resection for recurrent hepatocellular carcinoma

BACKGROUND AND AIM

Tumor recurrence after liver resection occurs in the majority of patients with hepatocellular carcinoma (HCC). This study was conducted to clarify the safety and effectiveness of repeated liver resection as a curative option for intrahepatic HCC recurrence.

METHODS

Between July 1990 and January 2009, 483 patients underwent 514 curative hepatic resections for HCC in our institution. Among this collective, 27 patients underwent 31 repeated resections due to recurrent HCC (27 s resections, three third resections and one forth resection). The outcome of these patients was retrospectively reviewed using a prospective database.

RESULTS

Perioperative morbidity and mortality was 11% (three of 27) and 0%. Six patients showed multiple liver lesions, 23 underwent minor liver resections (fewer than three segments) and five patients underwent major resections (three or more segments). The majority of the patients showed no signs of chronic liver disease (16 of 27). The median tumor free margin was 1.5 mm (range: 0 to 20 mm). The median tumor diameter was 40 mm (range: 10 to 165 mm). Tumor dedifferentiations at time of tumor recurrence were not observed. The 1-, 3- and 5-year overall survival rates after second liver resection were 96%, 70% and 42%.

CONCLUSIONS

Repeated liver resection is a valid and safe curative therapy option for recurrent HCC and results in significant prolongation of survival in comparison to interventional treatment strategies in selected patients. However, due to impaired liver function, multifocal intrahepatic or extrahepatic recurrence repeated resection is only feasible in a minority of patients.

A matter of the heart: myocardial metastases in neuroendocrine tumors

The aim of the present study was to evaluate frequency, clinical spectrum, and treatment of myocardial metastases in patients with histologically proven neuroendocrine tumors by analysis of our database and literature review. The literature on cardiac metastases in patients with neuroendocrine tumors published from 1973 to the present was reviewed for age, sex, primary tumor localization, metastases, symptoms, complications, treatment, diagnostic methods, and histology. Patient records from our institution were analyzed retrospectively for cardiac metastases detected by any diagnostic means and detailed patient histories are given. 4 patients with myocardial metastases could be identified in our database (n=550) while literature review identified 41 published cases. Mean age at initial diagnosis was 57.5 years (females=13, males=28), primary tumor localizations were foregut (n=7), midgut (n=28), hindgut (n=1), or unknown (n=3). Carcinoid syndrome was reported for 28 patients. Cardiac involvement was right-ventricular only (n=10), left-ventricular only (n=11), or biventricular (n=10). Diagnosis was obtained by echocardiography (n=21), CT/MRI (n=12) and other methods (n=9), or by autopsy (n=9). We describe visualization of cardiac metastases by (68)Ga-DOTATOC-PET/CT for the first time. Clinical presentation ranged from asymptomatic patients to cardiac arrest. Follow-up times ranged from <1 month up to 12 years. Clinicians treating patients with neuroendocrine tumors should be aware of the heart as a possible site of metastatic disease. Echocardiography and MRI are the methods of choice for follow-up, while PET/CT might contribute to earlier and more frequent detection. Management of cardiac metastases requires close cooperation between specialists of internal medicine, nuclear medicine, and cardiac surgery.

Preoperative multidetector row computed tomography for evaluation and assessment of resection criteria in patients with pancreatic masses

BACKGROUND

preoperative assessment of pancreatic masses is still challenging as regards the characterization and assessment of irresectability. The opportunities of modern multidetector computed tomography (MDCT) with image postprocessing can be expected to enhance the diagnostic performance if accurate criteria are elaborated.

PURPOSE

to estimate the accuracy of MDCT and multiplanar image reconstructions with the use of standardized imaging criteria for preoperative evaluation of pancreatic masses with respect to irresectability.

MATERIAL AND METHODS

a total of 105 consecutive patients who underwent exploratory laparoscopy or pancreatic resection and had preoperative 3-phase MDCT (4-64 rows) were enrolled retrospectively. First, transverse sections and secondly additional 3Ds were reviewed by two independent blinded observers (O1/O2). Preoperative imaging findings were correlated with intraoperative and histopathologic results.

RESULTS

among all 105 patients, 70 malignant pancreatic tumors and 35 benign pancreatic diseases were found (accuracy of 93% for O1 and 91% for O2). For arterial tumor invasion, receiver operator characteristic (ROC) analysis (values averaged from the results of O1 and O2) revealed an area under the curve (AUC) of 0.931 for transverse sections and 0.986 for 3Ds. Regarding irresectability, positive predictive values were 97% (with 3Ds, 97%) for O1/O2; negative predictive values were 84% (with 3Ds, 89%) for O1 and 86% (with 3Ds, 91%) for O2.

CONCLUSION

MDCT with 3Ds was highly accurate for evaluation and assessment of irresectability criteria in patients with pancreatic masses. However, due to the limited specificity regarding arterial tumor infiltration, the indication for surgical exploration should be made generously in case of inconclusive findings.

Laparoscopic radiofrequency ablation of liver tumors: comparison of MR guidance versus conventional laparoscopic ultrasound for needle positioning in a phantom model

Laparoscopic radiofrequency ablation (LapRFA) is an established procedure for liver tumors in patients who are unsuitable for resection. A novel technique of magnetic resonance (MR) guided needle positioning during LapRFA was developed and compared to conventional ultrasound (US) guidance in a phantom model. MR-guided procedures were conducted in a 1.0 tesla high field open MR using an MR compatible endoscope and camera. The ultrasound-guided procedure was performed with a clinically established laparoscopy setup and a 2D laparoscopic US probe. During both techniques an identical monopolar non-ferromagnetic RFA needle and a silicon-based phantom model were applied. Finally needle positioning was performed by two surgeons and one interventionalist. Time to needle placement and number of trials were recorded and statistically analyzed. MR-guided needle positioning under laparoscopic control was technically feasible. Average time to correct needle placement was 2' 6″ in the LapUS group and 1' 54″ in the MR group. The number of trials was 3.2 in the LapUS group and 2.6 in the MR group. Image quality was assessed by all participants. MR images showed a better tissue to tumor contrast and allowed an improved orientation due to multiplanar visualization. MR-guided laparoscopic RFA is a promising technique offering multiplanar needle positioning with high soft tissue contrast with immediate therapy control. In a phantom model it showed comparable results regarding needle positioning to the established technique of laparoscopic US guidance.

Feasibility of hepatic radiofrequency ablation in patients with bilioenteric anastomoses

BACKGROUND/AIMS

Radiofrequency ablation (RFA) in the liver is contraindicated in the presence of bilioenteric anastomoses, because it predisposes to occasionally devastating infectious complications. The purpose of this single-center experience is to demonstrate the technical feasibility of such procedures.

METHODOLOGY

Patients with bilioenteric anastomoses were offered ultrasound-guided RFA, if an interdisciplinary tumor board endorsed this decision, or an intraoperative opportunity to achieve a tumor-free situation emerged. All procedures were carried out under general anesthesia in a surgical operation theatre. RFA was performed percutaneously (n=3) and open surgically (n=3) with two different types of monopolar devices. All patients received antibiotic prophylaxis with various different agents.

RESULTS

Six patients with seven tumor nodules were treated. The average age of the patients was 59 +/- 7 years. Mean size of the tumors was 20 +/- 7 mm. Median follow up was 15 months. No infectious complication including intrahepatic abscess occurred. No local recurrence was detected.

CONCLUSIONS

The presented data indicates the feasibility of RFA in patients with bilioenteric anastomoses, and infectious problems, namely intrahepatic abscess formation, do not inevitably occur. The role of antimicrobial prophylaxis remains unclear. The importance of ensuring an unobstructed and uninhibited biliary flow distally in the bilioenteric track is stressed.

Advances in image guided conventional and minimal invasive liver surgery

Technological developments, advances in perioperative medicine and ongoing scientific research have led to reduced rates of mortality and morbidity in patients undergoing major liver surgery. Under these conditions, the frontier of resectability is constantly in movement towards more complex cases with extended tumor spread and potentially minimized remnant liver volume. A promising technique to support oncological correct and safe liver surgery is the introduction of preoperative computer based planning models and intraoperative navigation systems. Whereas three-dimensional (3D) liver models are commercially available and have been clinically implemented, the use of navigation systems is currently under evaluation by different groups using a variety of techniques. This manuscript is meant to give the reader an overview on current developments, difficulties and future aspects of image guided liver surgery.

Comparison of F-18 FET-PET with F-18 FDG-PET for biopsy planning of non-contrast-enhancing gliomas

OBJECTIVE

The management of non-contrast-enhancing brain tumours largely depends on biopsy, which allows a differentiation of low-grade gliomas (LGG) from high-grade gliomas (HGG). The aim of this study was to compare positron emission tomography using 2-[(18)F]-fluoro-2-deoxy-D: -glucose (FDG-PET) and O-(2-[(18)F]-fluoroethyl)-L: -tyrosine (FET-PET) in terms of providing target regions for biopsies.

MATERIALS AND METHODS

Fifteen consecutive patients with newly diagnosed brain tumours (n = 11) or suspected recurrence of a known LGG (n = 4), in whom MRI demonstrated no contrast enhancement, were studied by both FET-PET and FDG-PET. FET-PET, FDG-PET and MRI data were fused, and then transferred to the neurosurgical navigation system, prior to neurosurgical interventions.

RESULTS

Histology showed HGG (WHO grade III) in 6/15 and LGG (WHO grade II) in 9/15 patients. FET-PET revealed an increased intratumoural tracer uptake in 8/9 LGG and in 5/6 HGG. FDG-PET depicted hypermetabolic spots in 2/9 LGG and in 4/6 HGG. In 6 patients we observed an increased intratumoural uptake of both tracers. In 4 of them, the area of highest FET accumulation in the tumour corresponded to the focus of increased FDG uptake.

CONCLUSIONS

FET-PET appears to be superior to FDG-PET for biopsy planning in non-contrast-enhancing brain tumours. FDG-PET does not provide any additional information in this issue.

[Distal pancreatectomy with splenectomy and en bloc resection of the celiac trunk for locally advanced cancer of the pancreatic body with infiltration of the celiac trunk]

BACKGROUND

Locally advanced cancer of the body of the pancreas with infiltration of the celiac trunk and its branches is often considered an unresectable disease. Distal pancreatectomy with resection of the celiac trunk was described as a new concept for the curative treatment of these tumors.

CASE REPORT

The case of a 61-year-old female patient is reported, who underwent distal pancreatectomy with splenectomy and resection of the celiac trunk for locally advanced cancer of the pancreatic body with infiltration of the celiac trunk. The celiac trunk was embolized preoperatively in order to assure arterial perfusion of the liver.

CONCLUSION

Distal pancreatectomy with en bloc resection of the celiac trunk offers a high resectability rate and thus a curative option for locally advanced cancer of the pancreatic body with vascular invasion. The optimization of patient selection and the development of effective adjuvant chemotherapy could significantly improve the survival of patients subjected to this operation.

Evolving experience with prevention and treatment of splenic artery syndrome after orthotopic liver transplantation

Impaired hepatic arterial perfusion after orthotopic liver transplantation (OLT) may lead to ischemic biliary tract lesions and graft-loss. Hampered hepatic arterial blood flow is observed in patients with hypersplenism, often described as arterial steal syndrome (ASS). However, arterial and portal perfusions are directly linked via the hepatic arterial buffer response (HABR). Recently, the term 'splenic artery syndrome' (SAS) was coined to describe the effect of portal hyperperfusion leading to diminished hepatic arterial blood flow. We retrospectively analyzed 650 transplantations in 585 patients. According to preoperative imaging, 78 patients underwent prophylactic intraoperative ligation of the splenic artery. In case of postoperative SAS, coil-embolization of the splenic artery was performed. After exclusion of 14 2nd and 3rd retransplantations and 83 procedures with arterial interposition grafts, SAS was diagnosed in 28 of 553 transplantations (5.1%). Twenty-six patients were treated with coil-embolization, leading to improved liver function, but requiring postinterventional splenectomy in two patients. Additionally, two patients with SAS underwent splenectomy or retransplantation without preceding embolization. Prophylactic ligation could not prevent SAS entirely (n = 2), but resulted in a significantly lower rate of complications than postoperative coil-embolization. We recommend prophylactic ligation of the splenic artery for patients at risk of developing SAS. Post-transplant coil-embolization of the splenic artery corrected hemodynamic changes of SAS, but was associated with a significant morbidity.

Imaging of hypoxic-ischemic penumbra with (18)F-fluoromisonidazole PET/CT and measurement of related cerebral metabolism in aneurysmal subarachnoid hemorrhage

This study aimed to characterize hypoxic, but salvageable, tissue imaged by (18)F-fluoromisonidazole ((18)F-FMISO), combining with perfusion-computed tomography (PCT) for regional cerebral blood flow (rCBF) measurement and metabolism by microdialysis (MD) in aneurysmal subarachnoidal hemorrhage (SAH) patients. (18)F-FMISO positron-emission tomography (PET)/CT was performed within the period of possible vasospasm (day 6.8+/-3 after SAH) in seven SAH patients. In parallel, rCBF was determined within the MD region of interest (MD-ROI) (n=5). The MD catheter was inserted into the brain parenchyma with highest risk for ischemia; extracellular levels of glutamate and energy metabolites were registered at time of PET and hourly for 10 days. Twelve-month outcome was evaluated. In asymptomatic patients (n=3) no hypoxia was detected and glutamate levels were low (<10 mmol/L), whereas symptomatic patients had higher glutamate concentrations (P<0.001). Increased (18)F-FMISO uptake within the MD-ROI (n=3) was related to higher glutamate levels, while rCBF was above the ischemic range. Hypoxia (increased (18)F-FMISO uptake) was present in symptomatic patients and associated with relevant metabolic derangement of extracellular glutamate levels, whereas energy metabolism and rCBF were preserved. This technique has the potential to improve our understanding of the role of cellular hypoxia in aneurysmal SAH.

Impact of Multiphase 68Ga-DOTATOC-PET/CT on therapy management in patients with neuroendocrine tumors

AIM

Retrospective evaluation of the impact of integrated positron emission tomography/computed tomography (PET/CT) using (68)Ga-DOTA(0)-Phe(1)-Tyr(3)-octreotide ((68)Ga-DOTATOC) on the therapeutic management of patients with neuroendocrine tumors (NET).

METHODS

The (68)Ga-DOTATOC-PET/CT data of 66 patients (31 male, 35 female; age: 29-79, mean age: 56 years) with known or suspected NET were included. Imaging data (PET and triple-phase contrast-enhanced CT) were evaluated in consensus by two readers for the visualization of NET manifestations. Combined PET/CT, clinical and imaging follow-up as well as histopathology (if available) served as the reference standard. In order to assess the impact of the respective submodalities on the therapeutic strategy chosen, the results were compared to the treatment decision made by the interdisciplinary NET tumor board of our institution.

RESULTS

Two of the initial 66 patients included did not suffer from NET according to further immunohistopathological examination. In 50 of the remaining 64 (78%) NET patients, a total of 181 NET manifestations were detected by PET/CT. 59/181 (32.6%) were detected by one submodality only (CT 17.1%, PET 15.5%, p for comparison of both = 0.459). Combined PET/CT reading had an impact on the therapeutic management in 24 of 64 (38%) NET patients: primary resection (n = 5), curative lymph node resection (n = 1), initiation/switch of chemotherapy (CTx) due to progressive disease (n = 10), no surgery due to systemic disease (n = 2), radiopeptide receptor therapy instead of CTx (n = 1), additional bisphosphonate therapy (n = 4), and hepatic brachytherapy (n = 1). In 12 of 24 (50%) of these patients, relevant findings were detected by a single submodality only: CT (n = 5), PET (n = 7); p for comparison = 0.774).

CONCLUSION

(68)Ga-DOTATOC-PET/CT influences therapeutic management in about one third of patients examined. CT and PET are comparably sensitive, deliver complementary information and equally contribute to therapeutic decision-making. Thus, despite the merits of the PET modality, the CT component must not be neglected and an optimized multiphase CT protocol is recommended.

Grid based evaluation of a liver segmentation method for contrast enhanced abdominal MRI

Recent developments in MRI contrast agents give new perspectives in radiological diagnosis and therapy planning, but require specific image analysis methods. By employment of an academic research grid, we are currently validating and optimizing a recently developed fully automatic method for liver segmentation in Gd-EOB enhanced MRI. The grid enables extensive parameter scans and evaluation against expert's reference segmentation. The implementation layout and so far reached results are presented. Furthermore, experiences made in the production phase and consequences resulting for the exploitation of publicly funded research grids for Healthgrid applications are given.

Extended bile duct resection and [corrected] liver and transplantation in patients with hilar cholangiocarcinoma: long-term results

For patients with irresectable hilar cholangiocarcinoma, liver transplantation (LT) is currently being reassessed because of promising data for neoadjuvant radiochemotherapy. For increased radicality, hepatectomy in combination with pancreatic head resection [extended bile duct resection (EBDR)] was performed for irresectable hilar cholangiocarcinoma during our initial experience. EBDR and LT was performed in 16 patients between 1992 and 1998. No neoadjuvant or adjuvant treatment was performed. The Union Internationale Contre le Cancer stages were I (n = 6), IIA (5), IIB (3), and IV (2). To evaluate the suspected increase in surgical radicality, a matched pair analysis was performed with 8 patients undergoing LT for hilar cholangiocarcinoma without partial pancreatoduodenectomy. The 1-, 5-, and 10-year patient survival rates after EBDR were 63%, 38%, and 38%, respectively. Twelve patients died: 2 died because of postoperative complications, 8 died because of tumor recurrence, and 2 died while recurrence-free more than 10 years after transplantation. Among the 6 stage I patients, only 1 developed tumor recurrence, but 2 died because of postoperative complications. The following factors showed a trend toward inferior survival: distant metastases, positive lymph nodes, high carbohydrate antigen 19-9 levels, and preoperative percutaneous transhepatic cholangiodrainage. When all lymph node-negative patients were considered after the exclusion of perioperative deaths, 10-year survival was 56%. In conclusion, the overall long-term survival was relatively low in our inhomogeneous cohort but favorable in patients without metastases. However, because of the increased perioperative mortality, EBDR is not recommended as a standard procedure for hilar cholangiocarcinoma instead of LT alone. To further improve the results, other approaches such as (neo)adjuvant therapy have to be increasingly investigated.