CT-guided percutaneous drainage of abdominopelvic collections: a pictorial essay

The evolution of percutaneous abdominal abscess drainage: A review

Abdominal abscesses are commonly treated using percutaneous abscesses drainage (PAD). Despite PAD becoming commonplace in clinical practice, there are still unanswered questions and absent formal guidelines regarding its use. This narrative review discusses the evolution and different features of PAD, including the imaging modalities used in the process, catheter anatomy and sizes, placement techniques, the quantity of catheter side holes, and factors that determine the length of catheter stay and the usage of antibiotics for treating abdominal abscesses. Based on a retrospective review of the existing literature, this work is presented with an intent of identifying the most efficient design aspects and indications to optimize clinical success when performing PAD. This manuscript shows that there are still many unanswered questions and room for improvement regarding percutaneous drainage of abscesses.

ESR Essentials: image guided drainage of fluid collections-practice recommendations by the Cardiovascular and Interventional Radiological Society of Europe

This ESR Essentials article intends to provide detailed, step-by-step, information on the role of imaging in the diagnosis, procedural management, and follow-up of patients with fluid collections. Evidence-based medicine recommendations for the positioning of percutaneous drainages and/or for diagnostic/therapeutic aspiration of fluid collections are provided. Although medical history, clinical symptoms, physical examination, and laboratory tests can raise suspicions regarding a collection, an imaging assessment is usually necessary for the diagnosis. Radiologists can easily identify fluid collections that are clinically suspected by using a wide range of imaging modalities, such as ultrasound, CT, MRI, and cone-beam CT. Consequently, these imaging methods (either alone or combined), can be used to aspirate the collection or for the placement of a drainage catheter. The choice of imaging technique to be used is influenced by the location of the collection, operator preference, size, and content of the collection. In addition, it is of utmost importance to underline the role of the interventional radiologist in the management and follow-up of patients with percutaneous drains, in collaboration with surgeons, clinicians, and diagnostic radiologists. KEY POINTS: Indications for percutaneous imaging-guided drainage are supported by clinical findings, laboratory tests, and pre-procedural imaging. Deciding between aspiration or drain insertion should follow patient assessment and fluid collection characterization. The interventional radiologist should be part of the entire patient care process including follow-up.

Complicated diverticulitis: Diagnostic precision and surgical solutions in a patient with chronic kidney disease

Diverticulitis, an inflammation of diverticula in the colon, can lead to severe complications such as perforation and abscess formation. A 42-year-old female with polycystic kidney disease and chronic kidney disease stage III presented with severe abdominal pain, fever, and inability to tolerate oral intake. The patient was a previous smoker who smoked 0.5 packs per day for 25 years. Initial evaluation revealed leukocytosis and elevated creatinine. A CT scan identified pneumoperitoneum and mild sigmoid diverticulitis, suggesting a perforated viscus. She underwent urgent exploratory laparotomy, which confirmed the CT findings and resulted in an appendectomy, sigmoid colon resection, and ostomy creation. Postoperatively, the patient faced complications, including recurrent pneumoperitoneum and subcutaneous emphysema, detected through follow-up CT scans, leading to further surgical interventions. CT imaging was pivotal in diagnosing, monitoring, and guiding treatment, with noncontrast CT being beneficial given her renal impairment. Early diagnosis and CT imaging are crucial in managing complicated diverticulitis. Postoperative monitoring with CT scans is essential for detecting complications. Follow-up care should include regular colonoscopies to assess diverticular disease and dietary modifications to prevent recurrence. Combining clinical, surgical, and radiologic data ensures effective management and improves patient outcomes.

Ultrasound-Mediated Antibiotic Delivery to In Vivo Biofilm Infections: A Review

Bacterial biofilms are a significant concern in various medical contexts due to their resilience to our immune system as well as antibiotic therapy. Biofilms often require surgical removal and frequently lead to recurrent or chronic infections. Therefore, there is an urgent need for improved strategies to treat biofilm infections. Ultrasound-mediated drug delivery is a technique that combines ultrasound application, often with the administration of acoustically-active agents, to enhance drug delivery to specific target tissues or cells within the body. This method involves using ultrasound waves to assist in the transportation or activation of medications, improving their penetration, distribution, and efficacy at the desired site. The advantages of ultrasound-mediated drug delivery include targeted and localized delivery, reduced systemic side effects, and improved efficacy of the drug at lower doses. This review scrutinizes recent advances in the application of ultrasound-mediated drug delivery for treating biofilm infections, focusing on in vivo studies. We examine the strengths and limitations of this technology in the context of wound infections, device-associated infections, lung infections and abscesses, and discuss current gaps in knowledge and clinical translation considerations.

Source Control and Antibiotics in Intra-Abdominal Infections

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23-38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient's conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient's overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Investigating the accuracy of machine vision and augmented reality in percutaneous computed tomography-guided interventions: A phantom study

OBJECTIVES

This study aimed to evaluate the accuracy of percutaneous computed tomography (CT)-guided puncture based on machine vision and augmented reality in a phantom.

MATERIALS AND METHODS

The surgical space coordinate system was established, and accurate registration was ensured using the hierarchical optimization framework. Machine vision tracking and augmented reality display technologies were used for puncture navigation. CT was performed on a phantom, and puncture paths with three different lengths were planned from the surface of the phantom to the metal ball. Puncture accuracy was evaluated by measuring the target positioning error (TPE), lateral error (LE), angular error (AE), and first success rate (FSR) based on the obtained CT images.

RESULTS

A highly qualified attending interventional physician performed a total of 30 punctures using puncture navigation. For the short distance (4.5-5.5 cm), the TPE, LE, AE, and FSR were 1.90 ± 0.62 mm, 1.23 ± 0.70 mm, 1.39 ± 0.86°, and 60%, respectively. For the medium distance (9.5-10.5 cm), the TPE, LE, AE, and FSR were 2.35 ± 0.95 mm, 2.00 ± 1.07 mm, 1.20 ± 0.62°, and 40%, respectively. For the long distance (14.5-15.5 cm), the TPE, LE, AE, and FSR were 2.81 ± 1.17 mm, 2.33 ± 1.34 mm, 0.99 ± 0.55°, and 30%, respectively.

CONCLUSION

The augmented reality and machine vision-based CT-guided puncture navigation system allows for precise punctures in a phantom. Further studies are needed to explore its clinical applicability.

Safety and clinical contribution of computed tomography-guided biopsy for cervical spine lesion

INTRODUCTION

The purpose is to clarify the safety and clinical contribution of computed tomography (CT)-guided percutaneous needle-biopsy for patients with cervical spine lesion.

MATERIAL AND METHODS

Between June 2015 and August 2022, CT-guided percutaneous needle biopsies were performed for 15 cervical spine lesions of 15 patients (8 male, 7 female; 2-81 years old). The technical success, clinical contribution, and safety were evaluated. Technical success was defined as the completion of the biopsy procedure. Clinical contribution was defined as any contribution to the therapeutic strategy. Safety was assessed by the Common Terminology Criteria for Adverse Events, version 5.0.

RESULTS

The technical success rate was 100%. In all 15 patients, nontarget organs (e.g., major vessels, spinal cord) could be avoided. The post-biopsy histological diagnoses were myeloma (n = 2), metastatic adenocarcinoma (n = 2), chordoma (n = 2), Langerhans cell histiocytosis (n = 3), and one case each of malignant lymphoma, schwannoma, pyogenic spondylitis, non-pyogenic spondylitis, degenerative change, and non-pathological fracture. All of these diagnoses contributed to the therapeutic strategy decisions. One case of grade 2 pain was observed, but no complications with grade 3 or more were observed during or after the biopsies.

CONCLUSION

CT-guided percutaneous needle biopsies for cervical spine lesions were safe and clinically beneficial.

Evaluating Imaging Techniques for Diagnosing and Drainage Guidance of Psoas Muscle Abscess: A Systematic Review

Background: Psoas muscle abscess (PMA) is an uncommon yet severe condition characterized by diagnostic and therapeutic challenges due to its varied etiology and nonspecific symptoms. This study aimed to evaluate the effectiveness and accuracy of various imaging techniques used in the image-guided percutaneous drainage (PD) of PMA. Methods: A systematic review was conducted following the PRISMA guidelines. We searched PubMed, Google Scholar, and Science Direct for studies published in English from 1998 onwards that reported on the use of PD in treating PMA, detailing outcomes and complications. Imaging modalities guiding PD were also examined. Results: We identified 1570 articles, selecting 39 for full review. Of these, 23 met the inclusion criteria; 19 were excluded due to unspecified PMA, absence of imaging guidance for PD, or inconclusive results. Eleven studies utilized computed tomography (CT) for PD, with six also using magnetic resonance imaging (MRI). Ten studies implemented ultrasound (US)-guided PD; variations in diagnostic imaging included combinations of US, CT, and MRI. A mixed approach using both CT and US was reported in two articles. Most studies using CT-guided PD showed complete success, while outcomes varied among those using US-guided PD. No studies employed MRI-guided PD. Conclusions: This review supports a multimodal approach for psoas abscess management, using MRI for diagnosis and CT for drainage guidance. We advocate for Cone Beam CT (CBCT)-MRI fusion techniques with navigation systems to enhance treatment precision and outcomes, particularly in complex cases with challenging abscess characteristics.

Use of fibrinolytics for percutaneous drainage of intrabdominal hematoma: a case report

Background

Intrabdominal hematoma can be managed with angioembolization, surgical drainage, or percutaneous drainage depending on the patient factors, underlying pathology, and size and stability of hematoma. During the past decades, advancements have been made in the percutaneous management of intrapleural fluid collections using fibrinolytics. However, intrabdominal hematoma resolution with the help of fibrinolytic-assisted percutaneous drainage has not been as widely studied as intrapleural fibrinolytics. Our case presents a scenario where effective percutaneous drainage of abdominal fluid collection using fibrinolytics avoided an operative intervention in a patient with a history of multiple abdominal surgeries. This case report in essence can help navigate future studies into exploring non-operative management options in patients with a history of multiple abdominal surgeries.

Case Description

In this report, we present a 51-year-old female status post hiatal hernia repair with jejunostomy tube (J-tube) exchange complicated by walled off intraabdominal hematoma who presented with persistent abdominal pain and leakage around her J-tube. Due to her past history of multiple abdominal surgeries including multiple hiatal hernia repairs, distal esophagectomy with Roux-en-Y, and revision of the said Roux-en-Y complicated by wound dehiscence, surgical drainage was deferred in favor of trialing fibrinolytic administration via catheters. For this purpose, we employed the protocol for fibrinolytic administration used by the Second Multicenter Intrapleural Sepsis Trial (MIST2).

Conclusions

Use of tissue plasminogen activator (t-PA) and deoxyribonuclease (DNase) as per MIST2 protocol was safely replicated for intrabdominal walled off hematoma and resulted in a near complete resolution of the hematoma in 1 week. The patient was eventually discharged with no complications. This case highlights safe and efficacious use of fibrinolytics for non-operative management of intrabdominal hematomas.

Technical and Clinical Outcome of Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement in Abdominal Fluid Collections after Liver Transplantation: A 16-Year Retrospective Analysis of 50 Consecutive Patients

PURPOSE

Evaluation of the effectiveness of CT-guided drainage (CTD) placement in managing symptomatic postoperative fluid collections in liver transplant patients. The assessment included technical success, clinical outcomes, and the occurrence of complications during the peri-interventional period.

METHODS

Analysis spanned the years 2005 to 2020 and involved 91 drain placement sessions in 50 patients using percutaneous transabdominal or transhepatic access. Criteria for technical success (TS) included (a) achieving adequate drainage of the fluid collection and (b) the absence of peri-interventional complications necessitating minor or prolonged hospitalization. Clinical success (CS) was characterized by (a) a reduction or normalization of inflammatory blood parameters within 30 days after CTD placement and (b) the absence of a need for surgical revision within 60 days after the intervention. Inflammatory markers in terms of C-reactive protein (CRP), leukocyte count and interleukin-6, were evaluated. The dose length product (DLP) for various intervention steps was calculated.

RESULTS

The TS rate was 93.4%. CS rates were 64.3% for CRP, 77.8% for leukocytes, and 54.5% for interleukin-6. Median time until successful decrease was 5.0 days for CRP and 3.0 days for leukocytes and interleukin-6. Surgical revision was not necessary in 94.0% of the cases. During the second half of the observation period, there was a trend (p = 0.328) towards a lower DLP for the entire intervention procedure (median: years 2013 to 2020: 623.0 mGy·cm vs. years 2005 to 2012: 811.5 mGy·cm). DLP for the CT fluoroscopy component was significantly (p = 0.001) lower in the later period (median: years 2013 to 2020: 31.0 mGy·cm vs. years 2005 to 2012: 80.5 mGy·cm).

CONCLUSIONS

The TS rate of CT-guided drainage (CTD) placement was notably high. The CS rate ranged from fair to good. The reduction in radiation exposure over time can be attributed to advancements in CT technology and the growing expertise of interventional radiologists.

Building an Efficient Peritoneal Surface Malignancies Program Despite the Lower-Middle-Income Barriers: Ukraine Experience

PURPOSE

Cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) programs are often limited to centers in developed countries because of extensive requirements. We aimed to analyze efficacy and challenges of CRS/HIPEC centers in lower-middle-income settings in the Ukraine example.

METHODS

A multicenter descriptive study was conducted using data sets (2008-2022) from Kyiv, Lviv, and Odesa centers. Patients with appendiceal neoplasm (AN); colorectal cancer (CRC); malignant peritoneal mesothelioma (MPM); and epithelial ovarian, fallopian tube, and primary peritoneal cancer (EOC) treated with CRS ± HIPEC were included. Overall survival (OS) was analyzed for N ≥ 20 cohorts using the Kaplan-Meier method.

RESULTS

We included 596 patients. At Kyiv and Lviv centers, 37 and 28 patients with AN had completeness of cytoreduction (CC-0/1) rates of 84% and 71%, respectively. Thirty-day major morbidity stood at 24% and 18%, respectively. Median OS was not reached (NR) at both centers. Nineteen patients with CRC from Kyiv, 11 from Lviv, and 156 from Odesa had CC-0/1 rates of 84%, 91%, and 86%, respectively. Thirty-day major complications occurred in 16%, 18%, and 8%, respectively. Median OS in the Odesa cohort was 35 (95% CI, 32 to 38) months. Among 15 Kyiv, five Lviv, and six Odesa patients with MPM, CC-0/1 rates were 67%, 80%, and 100%, respectively, while major complications occurred in 13%, 0%, and 17%, respectively. OS was not analyzed because of small MPM cohorts. At Kyiv, Lviv, and Odesa centers, 91, 40, and 89 patients, respectively, had primary EOC. CC-0/1 rates were 79%, 100%, and 80%, and 30-day major morbidity rates were 23%, 5%, and 6%, respectively. Median OS was NR, 71 (95% CI, 32 to 110), and 67 (95% CI, 61 to 73) months, respectively.

CONCLUSION

CRS/HIPEC programs in lower-middle-income environment can achieve safety and survival that meet global standards. Our discussion highlights common obstacles in such settings and proposes effective overcoming strategies.

Effectiveness of endoscopic ultrasound-guided simple puncture-aspiration (non-stenting) in the management of abdominal collections

Background

Endoscopic management of abdominal collections includes endoscopic ultrasound (EUS)-guided transmural drainage, transpapillar via endoscopic retrograde cholangiopancreatography (ERCP), and EUS-guided simple puncture-aspiration (SPA). The latter is little reported, and there are some doubts about its real usefulness.

Objectives

The aim of this study was to assess the effectiveness of EUS-guided SPA as a first-line approach for treatment in selected abdominal collections.

Design

Retrospective observational study performed in two tertiary centers (Barcelona area).

Methods

Inclusion of all consecutive patients with abdominal collections that underwent EUS-guided SPA from July 2007 to July 2021. The decision was based on endoscopist criteria and collection characteristics. Clinical success was defined as avoidance of an additional interventional approach (endoscopic stenting, percutaneous drainage, surgery).

Results

Of 241 patients with abdominal collections treated endoscopically, 55 were included for analysis (mean age, 56 ± 12 years). Collection features: mean size 63.3 ± 24.8 mm; positive culture in 22 (40%) and pancreatic nature in 45 (81.8%). EUS-SPA was performed successfully in all cases, and clinical success was achieved in 76.3% (95% confidence interval (CI), 65.5-87.3) of cases (n-42/55). The most frequently used needle size was 19 Ga (85%). A nonsignificant trend for success was detected for noninfected collections (84.8 vs 63.6; p = 0.07) and lower size (mean ± SD; 60.2 ± 22.9 vs 73.8 ± 29 mm; p = 0.09). Two related adverse events were detected: one bleeding and one abdominal pain. Recurrence was detected in five pseudocysts after clinical success. Median follow-up was 629 days (IQR 389-877).

Conclusion

EUS-SPA of selected abdominal collections seems to be a safe and effective technique, avoiding a more aggressive strategy such as transmural stenting. EUS-SPA may be a viable alternative in collections with limited size and preferably noninfected.

Graphical abstract

Abdominal compartment syndrome: what radiologist needs to know

The intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) are life-threatening conditions with a significant rate of mortality; therefore, early detection is paramount in their optimal management. IAH is diagnosed when the intra-abdominal pressure (IAP) is more than 12 mmHg. It can occur when the intra-abdominal volume increases (ileus, ascites, trauma, pancreatitis, etc.) and/or the abdominal wall compliance decreases. IAH can cause decreased venous flow, low cardiac output, renal impairment, and decreased respiratory compliance. Consequently, these complications can lead to multiple organ failure and induce the abdominal compartment syndrome (ACS) when IAP rises above 20 mmHg. The diagnosis is usually made with intravesical pressure measurement. However, this measurement was not always possible to obtain; therefore, alternative diagnostic techniques should be considered. In this setting, computed tomography (CT) may play a crucial role, allowing the detection and characterization of pathological conditions that may lead to IAH. This review is focused on the pathogenesis, clinical features, and radiological findings of ACS, because their presence allows radiologists to raise the suspicion of IAH/ACS in critically ill patients, guiding the most appropriate treatment.

Management of Rectal Wall Abscess: A Rare Case Report

A 34-year-old male presented with spontaneous rectal pain. He was diagnosed with a posterior rectal wall abscess 7 cm proximal to the anal verge that was confirmed on an MRI (magnetic resonance imaging) pelvis. This abscess was drained through a transrectal route. Rectal wall abscess is an exceedingly rare pathology compared to perianal abscess; therefore, this case highlights the key aspects of its management.

Computed tomography texture analysis to discriminate fungal and non-fungal infected fluid collections

Purpose

Texture analysis of computed tomography (CT) can aid in characterization of fluid collections providing biomarkers. The present study tested whether texture analysis can discriminate between fungal or non-fungal infection in patients undergoing CT-guided percutaneous drainage treatment.

Approach

Overall, 214 patients [(n = 76 females, 35.5%); mean age 62 ± 14 years and range 20 to 94 years] with 255 fluid collections were included in the analysis. All patients underwent CT-guided drainage treatment and were evaluated with microbiological analysis. CT texture analysis was performed with the MaZda package.

Results

Only three of the investigated CT texture features were statistically significant different between the groups, namely kurtosis (p = 0.04 ), S(3,3)InvDfMom (p = 0.02 ), and S(5,-5)DifEntrp (p = 0.003 ). These texture features were further investigated by the receiver operating characteristic curve. S(3,3)InvDfMom achieved the highest accuracy with an area under the curve of 0.62, resulting in a sensitivity of 0.66 and a specificity of 0.57.

Conclusion

Some CT texture features were different between fungal and non-fungal infected fluid collections. The diagnostic overlap is large, which could reduce the clinical benefit. Further studies are needed to identify the possible diagnostic benefit of texture analysis in these patients.

Computed Tomography-guided Drainage with Modified Trocar Technique Using a Drainaway Drainage Kit

Purpose

Image-guided percutaneous drainage for abscesses is known as a safe and effective treatment. The computed tomography-guided percutaneous drainage kit Drainaway (SB Kawasumi Co., Ltd.), developed on the basis of a modified trocar method, has made it possible to complete the procedure only under computed tomography guidance without radiographic fluoroscopy. This study investigated the feasibility and safety of Drainaway for abscess drainage.

Material and Methods

In this retrospective observational study, 28 procedures in 27 patients (18 men and 9 women; age 67.0 ± 12.3 years) who underwent computed tomography-guided drainage using Drainaway between March and December 2021 at seven affiliated hospitals were analyzed. Patients with symptomatic, puncturable on computed tomography and refractory abscesses were included. Technical success (successful drainage with computed tomography alone), primary clinical success (successful drainage with Drainaway alone), secondary clinical success (avoidance of surgery), and complications were evaluated.

Results

The sites of the abscesses were the intraperitoneal, retroperitoneal, and thoracic cavities in 19, 5, and 2 patients, respectively, and subcutaneous tissue in 1 patient. The mean size of the abscesses was 7.1 ± 3.4 cm. The technical success rate was 96.4%; the ligament of the puncture route could not be penetrated in one case. The primary clinical success rate was 77.8%, whereas the secondary clinical success rate of catheter upsizing or replacement was 96.3%. Complications included one case of biliary pleurisy that required drainage.

Conclusions

Drainaway is a useful device that allows abscess drainage using only computed tomography guidance without radiographic fluoroscopy.

Metastatic Seeding of Abdominal Wall After Drainage of Perforated Colorectal Cancer in a Presumed Complicated Diverticular Disease

A 37-year-old male presented multiple times for abdominal pain with a persistent diverticular abscess on imaging that was managed previously with antibiotics and percutaneous drainages. Due to unrelenting abdominal pain and multiple presentations of unresolved acute complicated diverticulitis, the patient underwent an exploratory laparotomy. A colonic mass was discovered, and the patient had a colonic resection. Pathology revealed invasive transverse colonic adenocarcinoma with perforation and involvement of the stomach. Imaging showed no distant metastatic disease and chemotherapy was started. Months after treatment, the patient developed skin lesions and a palpable mass at the previous drain site. Biopsy showed metastatic adenocarcinoma consistent with colonic origin. Colonic adenocarcinoma with metastasis to the abdominal wall after drainage of presumed diverticular abscess is rare. Clinicians should consider malignancy when a patient has a recurrent diverticular abscess that has failed medical management and multiple drainages. Clinicians should remain vigilant of the risk of seeding colonic adenocarcinoma to the abdominal wall when repeated drainage is performed.

Accuracy of computed tomography in staging acute appendicitis and its impact on surgical outcome and strategy: a multi-center retrospective case-control study

INTRODUCTION

The aims of this study were to evaluate the concordance between AAST-CT appendicitis grading criteria, first published in 2014, and surgical findings and to assess the impact of CT staging on the choice of surgical approach.

METHODS

This was a multi-center retrospective case-control study including 232 consecutive patients undergoing surgery for acute appendicitis and who had undergone preoperative CT evaluation between 1 January 2017 and 1 January 2022. Appendicitis severity was classified in 5 grades. For each degree of severity, the surgical outcome between patients undergoing open and surgical approach was compared.

RESULTS

An almost perfect agreement (k = 0.96) was found between CT and surgery in staging acute appendicitis. The vast majority of patients with grade 1 and 2 appendicitis underwent laparoscopic surgical approach and showed low morbidity rate. In patients with grade 3 and 4 appendicitis, laparoscopic approach was adopted in 70% of cases and was associated, if compared to open, with a higher prevalence of postoperative abdominal collections (p = 0.05; fisher's exact test) and a significantly lower prevalence of surgical site infections (p = 0.0007; fisher's exact test). All the patients with grade 5 appendicitis were treated by laparotomy.

CONCLUSIONS

AAST-CT appendicitis grading system seems to show a relevant prognostic value and a potential impact on the choice of surgical strategy, directing toward a laparoscopic approach in patients with grade 1 and 2, an initial laparoscopic approach, replaceable by the open one, for grade 3 and 4 and an open approach in patients with grade 5.

Colorectal liver metastases patients prognostic assessment: prospects and limits of radiomics and radiogenomics

In this narrative review, we reported un up-to-date on the role of radiomics to assess prognostic features, which can impact on the liver metastases patient treatment choice. In the liver metastases patients, the possibility to assess mutational status (RAS or MSI), the tumor growth pattern and the histological subtype (NOS or mucinous) allows a better treatment selection to avoid unnecessary therapies. However, today, the detection of these features require an invasive approach. Recently, radiomics analysis application has improved rapidly, with a consequent growing interest in the oncological field. Radiomics analysis allows the textural characteristics assessment, which are correlated to biological data. This approach is captivating since it should allow to extract biological data from the radiological images, without invasive approach, so that to reduce costs and time, avoiding any risk for the patients. Several studies showed the ability of Radiomics to identify mutational status, tumor growth pattern and histological type in colorectal liver metastases. Although, radiomics analysis in a non-invasive and repeatable way, however features as the poor standardization and generalization of clinical studies results limit the translation of this analysis into clinical practice. Clear limits are data-quality control, reproducibility, repeatability, generalizability of results, and issues related to model overfitting.

Dose Reduction Strategies for Pregnant Women in Emergency Settings

In modern clinical practice, there is an increasing dependence on imaging techniques in several settings, and especially during emergencies. Consequently, there has been an increase in the frequency of imaging examinations and thus also an increased risk of radiation exposure. In this context, a critical phase is a woman's pregnancy management that requires a proper diagnostic assessment to reduce radiation risk to the fetus and mother. The risk is greatest during the first phases of pregnancy at the time of organogenesis. Therefore, the principles of radiation protection should guide the multidisciplinary team. Although diagnostic tools that do not employ ionizing radiation, such as ultrasound (US) and magnetic resonance imaging (MRI) should be preferred, in several settings as polytrauma, computed tomography (CT) nonetheless remains the examination to perform, beyond the fetus risk. In addition, protocol optimization, using dose-limiting protocols and avoiding multiple acquisitions, is a critical point that makes it possible to reduce risks. The purpose of this review is to provide a critical evaluation of emergency conditions, e.g., abdominal pain and trauma, considering the different diagnostic tools that should be used as study protocols in order to control the dose to the pregnant woman and fetus.

Management of Non-Melanoma Skin Cancer: Radiologists Challenging and Risk Assessment

Basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma are the three main types of nonmelanoma skin cancers and their rates of occurrence and mortality have been steadily rising over the past few decades. For radiologists, it is still difficult to treat patients with advanced nonmelanoma skin cancer. Nonmelanoma skin cancer patients would benefit greatly from an improved diagnostic imaging-based risk stratification and staging method that takes into account patient characteristics. The risk is especially elevated among those who previously received systemic treatment or phototherapy. Systemic treatments, including biologic therapies and methotrexate (MTX), are effective in managing immune-mediated diseases; however, they may increase susceptibility to NMSC due to immunosuppression or other factors. Risk stratification and staging tools are crucial in treatment planning and prognostic evaluation. PET/CT appears more sensitive and superior to CT and MRI for nodal and distant metastasis as well as in surveillance after surgery. The patient treatment response improved with advent and utilization of immunotherapy and different immune-specific criteria are established to standardized evaluation criteria of clinical trials but none of them have been utilized routinely with immunotherapy. The advent of immunotherapy has also arisen new critical issues for radiologists, such as atypical response pattern, pseudo-progression, as well as immune-related adverse events that require early identification to optimize and improve patient prognosis and management. It is important for radiologists to have knowledge of the radiologic features site of the tumor, clinical stage, histological subtype, and any high-risk features to assess immunotherapy treatment response and immune-related adverse events.

Post-Surgical Imaging Assessment in Rectal Cancer: Normal Findings and Complications

Rectal cancer (RC) is one of the deadliest malignancies worldwide. Surgery is the most common treatment for RC, performed in 63.2% of patients. The type of surgical approach chosen aims to achieve maximum residual function with the lowest risk of recurrence. The selection is made by a multidisciplinary team that assesses the characteristics of the patient and the tumor. Total mesorectal excision (TME), including both low anterior resection (LAR) and abdominoperineal resection (APR), is still the standard of care for RC. Radical surgery is burdened by a 31% rate of major complications (Clavien-Dindo grade 3-4), such as anastomotic leaks and a risk of a permanent stoma. In recent years, less-invasive techniques, such as local excision, have been tested. These additional procedures could mitigate the morbidity of rectal resection, while providing acceptable oncologic results. The "watch and wait" approach is not a globally accepted model of care but encouraging results on selected groups of patients make it a promising strategy. In this plethora of treatments, the radiologist is called upon to distinguish a physiological from a pathological postoperative finding. The aim of this narrative review is to identify the main post-surgical complications and the most effective imaging techniques.

Risk Assessment and Cholangiocarcinoma: Diagnostic Management and Artificial Intelligence

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver tumor, with a median survival of only 13 months. Surgical resection remains the only curative therapy; however, at first detection, only one-third of patients are at an early enough stage for this approach to be effective, thus rendering early diagnosis as an efficient approach to improving survival. Therefore, the identification of higher-risk patients, whose risk is correlated with genetic and pre-cancerous conditions, and the employment of non-invasive-screening modalities would be appropriate. For several at-risk patients, such as those suffering from primary sclerosing cholangitis or fibropolycystic liver disease, the use of periodic (6-12 months) imaging of the liver by ultrasound (US), magnetic Resonance Imaging (MRI)/cholangiopancreatography (MRCP), or computed tomography (CT) in association with serum CA19-9 measurement has been proposed. For liver cirrhosis patients, it has been proposed that at-risk iCCA patients are monitored in a similar fashion to at-risk HCC patients. The possibility of using Artificial Intelligence models to evaluate higher-risk patients could favor the diagnosis of these entities, although more data are needed to support the practical utility of these applications in the field of screening. For these reasons, it would be appropriate to develop screening programs in the research protocols setting. In fact, the success of these programs reauires patient compliance and multidisciplinary cooperation.

Diagnostic Management of Gastroenteropancreatic Neuroendocrine Neoplasms: Technique Optimization and Tips and Tricks for Radiologists

Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) comprise a heterogeneous group of neoplasms, which derive from cells of the diffuse neuroendocrine system that specializes in producing hormones and neuropeptides and arise in most cases sporadically and, to a lesser extent, in the context of complex genetic syndromes. Furthermore, they are primarily nonfunctioning, while, in the case of insulinomas, gastrinomas, glucagonomas, vipomas, and somatostatinomas, they produce hormones responsible for clinical syndromes. The GEP-NEN tumor grade and cell differentiation may result in different clinical behaviors and prognoses, with grade one (G1) and grade two (G2) neuroendocrine tumors showing a more favorable outcome than grade three (G3) NET and neuroendocrine carcinoma. Two critical issues should be considered in the NEN diagnostic workup: first, the need to identify the presence of the tumor, and, second, to define the primary site and evaluate regional and distant metastases. Indeed, the primary site, stage, grade, and function are prognostic factors that the radiologist should evaluate to guide prognosis and management. The correct diagnostic management of the patient includes a combination of morphological and functional evaluations. Concerning morphological evaluations, according to the consensus guidelines of the European Neuroendocrine Tumor Society (ENETS), computed tomography (CT) with a contrast medium is recommended. Contrast-enhanced magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI), is usually indicated for use to evaluate the liver, pancreas, brain, and bones. Ultrasonography (US) is often helpful in the initial diagnosis of liver metastases, and contrast-enhanced ultrasound (CEUS) can solve problems in characterizing the liver, as this tool can guide the biopsy of liver lesions. In addition, intraoperative ultrasound is an effective tool during surgical procedures. Positron emission tomography (PET-CT) with FDG for nonfunctioning lesions and somatostatin analogs for functional lesions are very useful for identifying and evaluating metabolic receptors. The detection of heterogeneity in somatostatin receptor (SSTR) expression is also crucial for treatment decision making. In this narrative review, we have described the role of morphological and functional imaging tools in the assessment of GEP-NENs according to current major guidelines.

Radiofrequency Ablation, Cryoablation, and Microwave Ablation for the Treatment of Small Renal Masses: Efficacy and Complications

Over the last two decades the detection rate of small renal masses has increased, due to improving diagnostic accuracy, and nephron-sparing treatments have become the first-choice curative option for small renal masses. As a minimally invasive alternative, thermal ablation has increased in popularity, offering a good clinical outcome and low recurrence rate. Radiofrequency ablation, Cryoablation, and Microwave ablation are the main ablative techniques. All of them are mostly overlapping in term of cancer specific free survival and outcomes. These techniques require imaging study to assess lesions features and to plan the procedure: US, CT, and both of them together are the leading guidance alternatives. Imaging findings guide the interventional radiologist in assessing the risk of complication and possible residual disease after procedure. The purpose of this review is to compare different ablative modalities and different imaging guides, underlining the effectiveness, outcomes, and complications related to each of them, in order to assist the interventional radiologist in choosing the best option for the patient.

Immunotherapy Assessment: A New Paradigm for Radiologists

Immunotherapy denotes an exemplar change in an oncological setting. Despite the effective application of these treatments across a broad range of tumors, only a minority of patients have beneficial effects. The efficacy of immunotherapy is affected by several factors, including human immunity, which is strongly correlated to genetic features, such as intra-tumor heterogeneity. Classic imaging assessment, based on computed tomography (CT) or magnetic resonance imaging (MRI), which is useful for conventional treatments, has a limited role in immunotherapy. The reason is due to different patterns of response and/or progression during this kind of treatment which differs from those seen during other treatments, such as the possibility to assess the wide spectrum of immunotherapy-correlated toxic effects (ir-AEs) as soon as possible. In addition, considering the unusual response patterns, the limits of conventional response criteria and the necessity of using related immune-response criteria are clear. Radiomics analysis is a recent field of great interest in a radiological setting and recently it has grown the idea that we could identify patients who will be fit for this treatment or who will develop ir-AEs.

Imaging Features of Main Hepatic Resections: The Radiologist Challenging

Liver resection is still the most effective treatment of primary liver malignancies, including hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), and of metastatic disease, such as colorectal liver metastases. The type of liver resection (anatomic versus non anatomic resection) depends on different features, mainly on the type of malignancy (primary liver neoplasm versus metastatic lesion), size of tumor, its relation with blood and biliary vessels, and the volume of future liver remnant (FLT). Imaging plays a critical role in postoperative assessment, offering the possibility to recognize normal postoperative findings and potential complications. Ultrasonography (US) is the first-line diagnostic tool to use in post-surgical phase. However, computed tomography (CT), due to its comprehensive assessment, allows for a more accurate evaluation and more normal findings than the possible postoperative complications. Magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP) and/or hepatospecific contrast agents remains the best tool for bile duct injuries diagnosis and for ischemic cholangitis evaluation. Consequently, radiologists should be familiar with the surgical approaches for a better comprehension of normal postoperative findings and of postoperative complications.

Risk Assessment and Pancreatic Cancer: Diagnostic Management and Artificial Intelligence

Pancreatic cancer (PC) is one of the deadliest cancers, and it is responsible for a number of deaths almost equal to its incidence. The high mortality rate is correlated with several explanations; the main one is the late disease stage at which the majority of patients are diagnosed. Since surgical resection has been recognised as the only curative treatment, a PC diagnosis at the initial stage is believed the main tool to improve survival. Therefore, patient stratification according to familial and genetic risk and the creation of screening protocol by using minimally invasive diagnostic tools would be appropriate. Pancreatic cystic neoplasms (PCNs) are subsets of lesions which deserve special management to avoid overtreatment. The current PC screening programs are based on the annual employment of magnetic resonance imaging with cholangiopancreatography sequences (MR/MRCP) and/or endoscopic ultrasonography (EUS). For patients unfit for MRI, computed tomography (CT) could be proposed, although CT results in lower detection rates, compared to MRI, for small lesions. The actual major limit is the incapacity to detect and characterize the pancreatic intraepithelial neoplasia (PanIN) by EUS and MR/MRCP. The possibility of utilizing artificial intelligence models to evaluate higher-risk patients could favour the diagnosis of these entities, although more data are needed to support the real utility of these applications in the field of screening. For these motives, it would be appropriate to realize screening programs in research settings.

Primary retroperitoneal mucinous cystadenoma: A case report with review of literature

Introduction and importance

Primary Retroperitoneal mucinous cystadenoma (PRMC) is an extremely rare benign tumor, predominantly occurring in women, with unclear pathogenesis.

Case presentation

A 31-year-old woman, with no medical or surgical history, presented with left flank pain.

Clinical discussion

An abdominal computed tomography (CT) scan revealed an 11cm retroperitoneal cyst. Due to its large size, percutaneous CT-guided drainage followed by a laparotomy surgical resection, were performed. Post-operative course was uneventful. Histological and immunohistochemical findings were consistent with PRMC. The patient was disease-free after a 6-month follow-up.

Conclusion

Mucinous cystadenoma is a very odd finding in the retroperitoneum. Multiple differential diagnoses are to be considered beforehand, as most of cystic lesions in this anatomical region are malignant and require a different surgical approach. Radical resection, by laparotomy or laparoscopy, is the treatment of choice.

Management of cutaneous melanoma: radiologists challenging and risk assessment

Melanoma patient remains a challenging for the radiologist, due to the difficulty related to the management of a patient more often in an advanced stage of the disease. It is necessary to determine a stratification of risk, optimizing the means, with diagnostic tools that should be optimized in relation to the type of patient, and improving knowledge. Staging and risk assessment procedures are determined by disease presentation at diagnosis. Melanoma staging is a critical tool to assist clinical decision-making and prognostic assessment. It is used for clinical trial design, eligibility, stratification, and analysis. The current standard for regional lymph nodes staging is represented by the sentinel lymph node excision biopsy procedure. For staging of distant metastases, PET-CT has the highest sensitivity and diagnostic odds ratio. Similar trend is observed during melanoma surveillance. The advent of immunotherapy, which has improved patient outcome, however, has determined new issues for radiologists, partly due to atypical response patterns, partly due to adverse reactions that must be identified as soon as possible for the correct management of the patient. The main objectives of the new ir-criteria are to standardize the assessment between different trials. However, these ir-criteria do not take into account all cases of atypical response patterns, as hyperprogression or dissociated responses. None of these criteria has actually been uniformly adopted in routine. The immune-related adverse events (irAEs) can involve various organs from head to toe. It is crucial for radiologists to know the imaging appearances of this condition, to exclude recurrent or progressive disease and for pneumonitis, since it could be potentially life-threatening toxicity, resulting in pneumonitis-related deaths in early phase trials, to allow a proper patient management.

Multimodality Imaging Assessment of Desmoid Tumors: The Great Mime in the Era of Multidisciplinary Teams

Desmoid tumors (DTs), also known as desmoid fibromatosis or aggressive fibromatosis, are rare, locally invasive, non-metastatic soft tissue tumors. Although histological results represent the gold standard diagnosis, imaging represents the fundamental tool for the diagnosis of these tumors. Although histological analysis represents the gold standard for diagnosis, imaging represents the fundamental tool for the diagnosis of these tumors. DTs represent a challenge for the radiologist, being able to mimic different pathological conditions. A proper diagnosis is required to establish an adequate therapeutic approach. Multimodality imaging, including ultrasound (US), computed tomography (CT) and Magnetic Resonance Imaging (MRI), should be preferred. Different imaging techniques can also guide minimally invasive treatments and monitor their effectiveness. The purpose of this review is to describe the state-of-the-art multidisciplinary imaging of DTs; and its role in patient management.

Precision Imaging Guidance in the Era of Precision Oncology: An Update of Imaging Tools for Interventional Procedures

Interventional oncology (IO) procedures have become extremely popular in interventional radiology (IR) and play an essential role in the diagnosis, treatment, and supportive care of oncologic patients through new and safe procedures. IR procedures can be divided into two main groups: vascular and non-vascular. Vascular approaches are mainly based on embolization and concomitant injection of chemotherapeutics directly into the tumor-feeding vessels. Percutaneous approaches are a type of non-vascular procedures and include percutaneous image-guided biopsies and different ablation techniques with radiofrequency, microwaves, cryoablation, and focused ultrasound. The use of these techniques requires precise imaging pretreatment planning and guidance that can be provided through different imaging techniques: ultrasound, computed tomography, cone-beam computed tomography, and magnetic resonance. These imaging modalities can be used alone or in combination, thanks to fusion imaging, to further improve the confidence of the operators and the efficacy and safety of the procedures. This article aims is to provide an overview of the available IO procedures based on clinical imaging guidance to develop a targeted and optimal approach to cancer patients.

A Narrative Review on LI-RADS Algorithm in Liver Tumors: Prospects and Pitfalls

Liver cancer is the sixth most detected tumor and the third leading cause of tumor death worldwide. Hepatocellular carcinoma (HCC) is the most common primary liver malignancy with specific risk factors and a targeted population. Imaging plays a major role in the management of HCC from screening to post-therapy follow-up. In order to optimize the diagnostic-therapeutic management and using a universal report, which allows more effective communication among the multidisciplinary team, several classification systems have been proposed over time, and LI-RADS is the most utilized. Currently, LI-RADS comprises four algorithms addressing screening and surveillance, diagnosis on computed tomography (CT)/magnetic resonance imaging (MRI), diagnosis on contrast-enhanced ultrasound (CEUS) and treatment response on CT/MRI. The algorithm allows guiding the radiologist through a stepwise process of assigning a category to a liver observation, recognizing both major and ancillary features. This process allows for characterizing liver lesions and assessing treatment. In this review, we highlighted both major and ancillary features that could define HCC. The distinctive dynamic vascular pattern of arterial hyperenhancement followed by washout in the portal-venous phase is the key hallmark of HCC, with a specificity value close to 100%. However, the sensitivity value of these combined criteria is inadequate. Recent evidence has proven that liver-specific contrast could be an important tool not only in increasing sensitivity but also in diagnosis as a major criterion. Although LI-RADS emerges as an essential instrument to support the management of liver tumors, still many improvements are needed to overcome the current limitations. In particular, features that may clearly distinguish HCC from cholangiocarcinoma (CCA) and combined HCC-CCA lesions and the assessment after locoregional radiation-based therapy are still fields of research.

Imaging Features of Main Posthepatectomy Complications: A Radiologist’s Challenge

In the recent years, the number of liver resections has seen an impressive growth. Usually, hepatic resections remain the treatment of various liver diseases, such as malignant tumors, benign tumors, hydatid disease, and abscesses. Despite technical advancements and tremendous experience in the field of liver resection of specialized centers, there are moderately high rates of postoperative morbidity and mortality, especially in high-risk and older patient populations. Although ultrasonography is usually the first-line imaging examination for postoperative complications, Computed Tomography (CT) is the imaging tool of choice in emergency settings due to its capability to assess the whole body in a few seconds and detect all possible complications. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for delineating early postoperative bile duct injuries and ischemic cholangitis that may arise in the late postoperative phase. Moreover, both MDCT and MRCP can precisely detect tumor recurrence. Consequently, radiologists should have knowledge of these surgical procedures for better comprehension of postoperative changes and recognition of the radiological features of various postoperative complications.

Complications Risk Assessment and Imaging Findings of Thermal Ablation Treatment in Liver Cancers: What the Radiologist Should Expect

One of the major fields of application of ablation treatment is liver tumors. With respect to HCC, ablation treatments are considered as upfront treatments in patients with early-stage disease, while in colorectal liver metastases (CLM), they can be employed as an upfront treatment or in association with surgical resection. The main prognostic feature of ablation is the tumor size, since the goal of the treatment is the necrosis of all viable tumor tissue with an adequate tumor-free margin. Radiofrequency ablation (RFA) and microwave ablation (MWA) are the most employed ablation techniques. Ablation therapies in HCC and liver metastases have presented a challenge to radiologists, who need to assess response to determine complication-related treatment. Complications, defined as any unexpected variation from a procedural course, and adverse events, defined as any actual or potential injury related to the treatment, could occur either during the procedure or afterwards. To date, RFA and MWA have shown no statistically significant differences in mortality rates or major or minor complications. To reduce the rate of major complications, patient selection and risk assessment are essential. To determine the right cost-benefit ratio for the ablation method to be used, it is necessary to identify patients at high risk of infections, coagulation disorders and previous abdominal surgery interventions. Based on risk assessment, during the procedure as part of surveillance, the radiologists should pay attention to several complications, such as vascular, biliary, mechanical and infectious. Multiphase CT is an imaging tool chosen in emergency settings. The radiologist should report technical success, treatment efficacy, and complications. The complications should be assessed according to well-defined classification systems, and these complications should be categorized consistently according to severity and time of occurrence.

Electrochemotherapy of Primary Colon Rectum Cancer and Local Recurrence: Case Report and Prospective Analysis

Purpose: Surgery, radiotherapy, and oncological treatment (chemotherapy and antineoplastic antibodies) are standard treatments of rectal cancer. ECT has shown its effectiveness and suitability in deep solid tumors conducted in both preclinical and clinical studies. We show here an update and preliminary results with locally advanced rectum cancer (LARC) treated with ECT. Methods: Two patients with major clinical response to restaging after neoadjuvant treatment for LARC were subjected to ECT 12 weeks after completing chemo-radiation therapy. One patient was subjected to ECT on a colorectal local recurrence formed after neoadjuvant treatment for LARC and surgery. Computed Tomography and Magnetic Resonance Imaging were used to assess ECT response. Results: The results showed stable disease in two of the three patients treated, while one patient achieved a complete response. The local control of disease is maintained in the patient follow-up. For each patient, a reduction in pain was observed and for the patient with local recurrence, a reduction in bleeding present before ECT was also achieved. Conclusion: Preliminary results showed that ECT is a safe and effective treatment in patients with a major clinical response or local recurrence after neoadjuvant therapy for LARC and allows a reduction in pain and bleeding with a consequent improvement to quality of life.

Complications after Thermal Ablation of Hepatocellular Carcinoma and Liver Metastases: Imaging Findings

Tumour ablation is a strategy of treatment of hepatic tumours in patients with small hepatocellular carcinoma (HCC) (<3 cm) or in patients unfit for surgical resection. Moreover, tumor ablation can be used as an adjuvant therapy or may be used in association with resection in case of patients with poor functional liver disease. These types of treatment usually could be performed percutaneously under image guidance. The most clinically verified and used ablation modalities are Radiofrequency Ablation (RFA) and microwave ablation (MWA). However, despite both of them are considered minimally invasive techniques, they could be related to post-procedural complications. The International Working Group on Image-Guided Tumor and the Society of Interventional Radiology (SIR) identified major and minor post-ablative complications. Major complications, as vascular complications, occur in 2.2% to 3.1% of cases and include all the high risk pathological conditions which could increase the level of care or result in hospital admission or substantially prolonged hospital stay (SIR classifications C−E). Minor complications, as biliary complications, occur in 5% to 8.9% and include self-limiting conditions that are considered to be of low risk for the patient’s outcome. The purpose of this review is to summarise the main pathological ultrasound (US) and Computed Tomography (CT) findings, that may arise after ablative treatment. To simplify the analysis, the pathological pictures are divided according to the site of damage into vascular, biliary and extrahepatic complications.

Combined Hepatocellular-Cholangiocarcinoma: What the Multidisciplinary Team Should Know

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare type of primary liver malignancy. Among the risk factors, hepatitis B and hepatitis C virus infections, cirrhosis, and male gender are widely reported. The clinical appearance of cHCC-CCA is similar to that of HCC and iCCA and it is usually silent until advanced states, causing a delay of diagnosis. Diagnosis is mainly based on histology from biopsies or surgical specimens. Correct pre-surgical diagnosis during imaging studies is very problematic and is due to the heterogeneous characteristics of the lesion in imaging, with overlapping features of HCC and CCA. The predominant histological subtype within the lesion establishes the predominant imaging findings. Therefore, in this scenario, the radiological findings characteristic of HCC show an overlap with those of CCA. Since cHCC-CCAs are prevalent in patients at high risk of HCC and there is a risk that these may mimic HCC, it is currently difficult to see a non-invasive diagnosis of HCC. Surgery is the only curative treatment of HCC-CCA. The role of liver transplantation (LT) in the treatment of cHCC-CCA remains controversial, as is the role of ablative or systemic therapies in the treatment of this tumour. These lesions still remain challenging, both in diagnosis and in the treatment phase. Therefore, a pre-treatment imaging diagnosis is essential, as well as the identification of prognostic factors that could stratify the risk of recurrence and the most adequate therapy according to patient characteristics.