Liver Transplantation for Budd-Chiari Syndrome With Large Solitary Focal Nodular Hyperplasia of the Liver in a Patient With Essential Thrombocythemia: Case Report. [Corrected]

Living donor liver transplantation for idiopathic portal hypertension with focal nodular hyperplasia

The patient was a 61-year-old woman with a history of diabetes mellitus who had undergone ileocecal resection for ascending colon carcinoma 5 years earlier, followed by a postoperative adjuvant chemotherapy with XELOX (capecitabine + oxaliplatin). During follow-up, the liver gradually atrophied, and radiological imaging showed suspicious findings of 20 × 14 mm hepatocellular carcinoma (HCC) in the right lobe of the liver. The patient also underwent endoscopic variceal ligation for the esophageal varices. She was referred to our hospital for living donor liver transplantation (LDLT) due to decompensated liver cirrhosis with HCC. The patient did not have hepatitis B or C, and history of alcohol, suggesting that her liver cirrhosis was caused by a non-alcoholic steatohepatitis. The Child-Pugh score was 10 points (class C) and the Model for End-Stage Liver Disease (MELD) score was 8 points. The possibility of HCC could not be ruled out, and LDLT was performed. Postoperative pathological examination revealed idiopathic portal hypertension (IPH), and the mass lesion was diagnosed as focal nodular hyperplasia (FNH). The postoperative course was uneventful and the patient was discharged on postoperative day 14. This is the first case of liver transplantation for IPH with FNH.

A case of inferior right hepatic vein-right hepatic vein bypass with interrupted inferior vena cava compressed by focal nodular hyperplasia in caudate lobe

Focal nodular hyperplasia (FNH) is a relatively common benign liver tumor with rare indications to surgery. Budd-Chiari syndrome is a rare condition caused by interrupted hepatic venous outflow in the hepatic veins and inferior vena cava (IVC). A 42-year-old woman was referred to our department with a hepatic tumor. Patient's chief complaint was leg edema. Because of this symptom, it was difficult for the patient to stand for more than 20 min in the evening. Computed tomography (CT) showed a hypervascular mass compressing IVC in the caudate lobe of the liver. Fine needle aspiration was performed, and preoperative diagnosis was focal nodular hyperplasia (FNH). Hepatic resection of the right caudate lobe was performed. Postoperative histological examination revealed that the tumor was FNH. After surgery, the patient's leg edema disappeared, and postoperative CT revealed that severe IVC stenosis was improved. Although there have been several reports of giant FNH causing Budd-Chiari syndrome, this case shows the stenosis of IVC below the root of hepatic veins causing Budd-Chiari-like syndrome without portal hypertension. The location of the tumor considerably attributed to the congestion of venous flow in IVC causing various symptoms and intrahepatic inferior right hepatic vein-right hepatic vein bypass. The surgical indication of FNH is limited in most cases; however, the current report alerts that the location of FNH should be taken into account when monitoring it.

Comparison of 3.0T MRI with 3D LAVA sequence and digital subtraction angiography for the assessment of accessory hepatic veins in Budd-Chiari syndrome

PURPOSE

To compare 3D liver acceleration volume acquisition (LAVA) and digital subtraction angiography (DSA) for evaluating the presence of accessory hepatic veins (AHV) in Budd-Chiari syndrome (BCS).

MATERIALS AND METHODS

This was a retrospective study in 228 patients with BCS who underwent 3.0T magnetic resonance imaging (MRI) with the 3D LAVA sequence. Two reviewers noted AHV: openings located in the inferior vena cava (IVC), caliber, and the angle of entering into the IVC. MRI results were compared to DSA. Kappa statistics were calculated to quantify intrareader variability in detecting AHVs.

RESULTS

On MRI, 63 patients demonstrated no AHV on LAVA images, 70 had one AHV, 62 had two AHVs, 26 patients had three AHVs, six patients had four AHVs, and one patient had five AHVs (P < 0.05 vs. DSA). The mean caliber of the AHVs was 8.3 ± 4.0 mm compared to 9.9 ± 3.2 for DSA (P < 0.001). Among the 301 AHVs, there were 140 with acute angles (46.5%), 71 with right angles (23.6%), and 90 with obtuse angles (29.8%). The prevalence of AHVs on DSA was 54.8% (125/228), while MRI demonstrated 301 AHVs in 165 patients, for a prevalence of 72.4% (165/228) compared to 54.8% for DSA (P = 0.001). The two methods were concordant in only 116/228 (50.9%) patients. The kappa coefficient demonstrated good intrareader consistency for all documented MRI findings of AHVs (κ = 0.626 for caliber and κ = 0.65 for angles).

CONCLUSION

More AHVs were visible on MRI LAVA sequences than on conventional DSA.

LEVEL OF EVIDENCE

4 J. Magn. Reson. Imaging 2017;45:401-409.