Nuclear imaging for functional evaluation and theragnosis in liver malignancy and transplantation

Currently, nuclear imaging such as positron emission tomography (PET) and single photon emission computed tomography (SPECT) is increasingly used in the management of liver malignancy. 18F-fluorodeoxyglucose (FDG)-PET is the most widely used nuclear imaging in liver malignancy as in other cancers, and has been reported to be effective in diagnosis, response monitoring, recurrence evaluation, and prognosis prediction. Other PET imaging such as 11C-acetate PET is also used complementarily to FDG-PET in diagnosis of liver malignancy. Additionally, image-based evaluation of regional hepatic function can be performed using nuclear imaging. Those imaging modalities are also effective for candidate selection, treatment planning, and perioperative evaluation in liver surgery and transplantation. Recently, nuclear imaging has been actively adopted in the transarterial radioembolization therapy of liver malignancy, according to the concept of theragnosis. With the development of new hybrid imaging technologies such as PET/magnetic resonance imaging and SPECT/CT, nuclear imaging is expected to be more useful in the management of liver malignancy, particularly regarding liver surgery and transplantation. In this review, the efficacy and roles of nuclear imaging methods in diagnosis, transplantation and theragnosis are discussed.

Application of Cone-beam Computed Tomography in Interventional Therapies for Liver Malignancy:A Consensus Statement by the Chinese College of Interventionalists

Despite its crucial role in interventional therapies for liver malignancy,cone-beam computed tomography(CBCT)has not yet been fully integrated into clinical practice due to several complicating factors,including nonstandardized operations and limited recognition of CBCT among interventional radiologists.In response,the Chinese College of Interventionalists has released a consensus statement aimed at standardizing and promoting the application of CBCT in the interventional therapies for liver malignancy.This statement summarizes CBCT scanning techniques,and operational standards,and highlights its potential applications in clinical practice.

Laparoscopic liver resection for malignancy:A review of the literature

AIM: To review the published literature about laparoscopic liver resection for malignancy.

Ex vivo liver resection and auto-transplantation as an alternative for the treatment of liver malignancies: Progress and challenges

Hepatectomy is still the major curative treatment for patients with liver malignancies.However,it is still a big challenge to remove the tumors in the central posterior area,especially if their location involves the retrohepatic inferior vena cava and hepatic veins.Ex vivo liver resection and auto-transplantation(ELRA),a hybrid technique of the traditional liver resection and transplantation,has brought new hope to these patients and therefore becomes a valid alternative to liver transplantation.Due to its technical difficulty,ELRA is still concentrated in a few hepatobiliary centers that have experienced surgeons in both liver resection and liver transplantation.The efficacy and safety of this technique has already been demonstrated in the treatment of benign liver diseases,especially in the advanced alveolar echinococcosis.Recently,the application of ELRA for liver malignances has gained more attention.However,standardization of clinical practice norms and international consensus are still lacking.The prognostic impact in these oncologic patients also needs further evaluation.In this review,we summarized the principles and recent progresses on ELRA.

Selective internal radiation therapy segmentectomy:A new minimally invasive curative option for primary liver malignancies?

Transarterial radioembolization or selective internal radiation therapy(SIRT)has emerged as a minimally invasive approach for the treatment of tumors.This percutaneous technique involves the local,intra-arterial delivery of radioactive microspheres directly into the tumor.Historically employed as a palliative measure for liver malignancies,SIRT has gained traction over the past decade as a potential curative option,mirroring the increasing role of radiation segmentectomy.The latest update of the BCLC hepatocellular carcinoma guidelines recognizes SIRT as an effective treatment modality comparable to other local ablative methods,particularly well-suited for patients where surgical resection or ablation is not feasible.Radiation segmentectomy is a more selective approach,aiming to deliver high-dose radiation to one to three specific hepatic segments,while minimizing damage to surrounding healthy tissue.Future research efforts in radiation segmentectomy should prioritize optimizing radiation dosimetry and refining the technique for super-selective administration of radiospheres within the designated hepatic segments.

Comparison of Milan and UCSF criteria for liver transplantation to treat hepatocellular carcinoma

AIM:To assess the validity of the Milan and University of California San Francisco(UCSF) criteria and examine the long-term outcome of orthotopic liver transplantation(OLT) in patients with hepatocellular carcinoma(HCC) in a single-center study.METHODS:This study is a retrospective review of prospectively collected data.Between 1998 and 2009,56 of 356 OLTs were performed in patients with HCC.Based on pathological examination of liver explants,patients were retrospectively categorized into 3 groups:Milan +(n = 34),Milan-/UCSF +(n = 7) and UCSF-(n = 14).RESULTS:Median follow-up period was 39.5(1-124) mo.The 5-year overall survival rates in the Milan +,Milan-/UCSF + and UCSF-groups were 87.7%,53.6% and 33.3%,respectively(P < 0.000).Within these groups,tumor recurrence was determined in 5.8%,14.3% and 40% of patients,respectively(P < 0.011).Additionally,the presence of microvascular invasion within the explanted liver had a negative effect on the 5-year disease free survival(74.7% vs 46.7%,P < 0.044).CONCLUSION:The Milan criteria are reliable in the selection of suitable candidates for OLT for the treatment of HCC.For cases of OLT involving living donors,the UCSF criteria may be applied.

Epithelioid Hemangioendothelioma of the Liver -Case Report

EH （Epithelioid hemangioendothelioma） is a rare vascular malignant neoplasm. Only 434 cases had been reported until 2006. Symptoms may be nonspecific, but it atso can involve hepatic veins resulting in Budd-Chiari syndrome. The main differential diagnosis is cholangiocarcinoma, sometimes only distinguishable through immunohistochemistry study. We report a case of a young woman diagnosed with hepatic EH and listed for liver transplantation.

Epithelioid hemangioendothelioma of the liver as a rare indication for liver transplantation

AIM: To investigate the indications and outcomes of liver transplantation for hepatic epithelioid hemangioendothelioma (HEHE).

Doege-Potter syndrome by malignant solitary fibrous tumor of the liver: A case report and review of literature

BACKGROUND Solitary fibrous tumor of the liver (SFTL) is a rare occurrence with a low number of cases reported in literature. SFTL is usually benign but, 10%-20% cases are reported to be malignant with a tendency to metastasize. The majority of malignant SFTL cases are associated with a paraneoplastic hypoglycaemia defined as Doege-Potter syndrome. Surgery is the best therapeutic treatment, however, long- life follow-up is recommended. CASE SUMMARY A 74-year-old man, was admitted to the emergency department after a syncopal episode with detection of hypoglycaemia resistant to medical treatment. The computed tomography revealed a solid mass measuring 15 cm of the left liver. An open left hepatectomy was performed with complete resection of tumor. Histopathological analyses confirmed a malignant SFTL. CONCLUSION Large series with long-term follow-up have not been published neither have clinical trials been undertaken. Consequently, the methodical long-term followup of surgically treated SFTLs is strongly recommended.

Therapeutic usability of two different fiducial gold markers for robotic stereotactic radiosurgery of liver malignancies:A pilot study

AIM: To assess how the application of different types of markers affects the tracking accuracy of Cyber Knife's.METHODS: Fifteen patients were recruited and subjected to the ultrasound-guided placement of markers. Two different type of needles 25 gauge(G) and 17 G containing two different fiducial marker, gold notched flexible anchor wire 0.28 mm × 10 mm(25 G needle) and gold cylindrical grain 1 mm × 4 mm(17 G), were used. Seven days after the procedure, a Cyber Knife planning computed tomography(CT) for the simulation of radiation treatment was performed on all patients.A binary CT score was assigned to the fiducial markers visualization. Also, the CT number was calculated for each fiducial and the values compared with a specific threshold.RESULTS: For each patient from 1 to 5, intra-hepatic markers were placed(one in 2 patients, three in 8 patients, four in 3 patients, and five in 2 patients). A total of 48 needles were used(thirty-two 17 G and sixteen 25 G) and 48 gold markers were placed(32 Grain shaped markers and 16 Gold Anchor). The result showed that the CT visualization of the grain markers was better than the anchor markers(P = 5 × 10^(-9)). Furthermore, the grain markers were shown to present minor late complications(P = 3 × 10^(-6)), and the best CT threshold number(P = 0.0005). CONCLUSION: The study revealed that the Gold Anchor fiducial marker is correlated with a greater number of late minor complications and low visualization by the CT.

Nomogram based on inflammation-related markers for predicting survival of patients undergoing hepatectomy for hepatocellular carcinoma

BACKGROUND Previous nomograms for hepatocellular carcinoma(HCC)did not include the neutrophil-to-lymphocyte ratio(NLR)or platelet-to-lymphocyte ratio(PLR).This study aimed to establish an effective nomogram capable of estimating the association between preoperative inflammatory factors and overall survival(OS)of HCC patients after hepatectomy.AIM To analyse the factors affecting the prognosis of HCC and establish a nomogram.METHODS A total of 626 HCC patients(410 training set patients from the First Affiliated Hospital of Anhui Medical University and 216 validation set patients from the First Affiliated Hospital of University of Science and Technology of China)underwent hepatectomy from January 2014 to December 2017 and were followed up every 3–6 mo.The nomogram was based on OS-related independent risk factors identified by Cox regression analysis.The C-index,calibration curve,and area under the curve(AUC)were used to evaluate the nomogram’s accuracy.RESULTS The 1-,2-and 3-year OS rates were 79.0%,68.0%and 45.4%in the training cohort(median OS=34 mo)and 92.1%,73.9%and 51.2%in the validation cohort(median OS=38 mo).Higherα-fetoprotein[hazard ratio(HR)=1.812,95%confidence interval(CI):1.343–2.444],NLR(HR=2.480,95%CI:1.856–3.312)and PLR(HR=1.974,95%CI:1.490–2.616),tumour size≥5 cm(HR=1.323,95%CI:1.002–1.747),and poor differentiation(HR=3.207,95%CI:1.944–5.290)were significantly associated with shortened OS.The developed nomogram integrating these variables showed good reliability in both the training(C-index=0.71)and validation cohorts(C-index=0.75).For predicting 1-,2-and 3-year OS,the nomogram had AUCs of 0.781,0.743 and 0.706 in the training cohort and 0.789,0.815 and 0.813 in the validation cohort.The nomogram was more accurate in predicting prognosis than the AJCC TNM staging system.CONCLUSION The prognostic nomogram combining pathological characteristics and inflammation indicators could provide a more accurate individualized risk estimate for the OS of HCC patients with hepatectomy.

Can Emax and platelet count truly differentiate between benign and malignant liver lesions?

This letter critically evaluates Jiang et al's article on the differentiation of benign and malignant liver lesions using Emax and platelet count.Despite notable findings,significant methodological and interpretative limitations are identified.The study lacks detailed assay conditions for Emax measurement,employs inadequate statistical methods without robust multivariate analysis,and does not provide clinically relevant threshold values.The nomogram's reliance on Emax as a major diagnostic contributor is questionable due to attenuation in hepatocellular carcinoma patients with cirrhosis.Moreover,the study's limitations,such as selection bias and confounding factors,are not adequately addressed.Future research should adopt more rigorous methodologies,including prospective studies with larger cohorts and standardized protocols for biomarker measurement,to enhance validity and clinical applicability.

Advances and challenges in laparoscopic surgery in the management of hepatocellular carcinoma

Hepatocellular carcinoma is the fifth most common malignancy and the third most common cause of cancer-related mortality worldwide. From the wide variety of treatment options, surgical resection and liver transplantation are the only therapeutic ones. However, due to shortage of liver grafts, surgical resection is the most common therapeutic modality implemented. Owing to rapid technological development, minimally invasive approaches have been incorporated in liver surgery. Liver laparoscopic resection has been evaluated in comparison to the open technique and has been shown to be superior because of the reported decrease in surgical incision length and trauma, blood loss, operating theatre time, postsurgical pain and complications, R0 resection, length of stay, time to recovery and oral intake. It has been reported that laparoscopic excision is a safe and feasible approach with near zero mortality and oncologic outcomes similar to open resection. Nevertheless, current indications include solid tumors in the periphery < 5 cm, especially in segments Ⅱ through Ⅵ, while according to the consensus laparoscopic major hepatectomy should only be performed by surgeons with high expertise in laparoscopic and hepatobiliary surgery in tertiary centers. It is necessary for a surgeon to surpass the 60-cases learning curve observed in order to accomplish the desirable outcomes and preserve patient safety. In this review, our aim is to thoroughly describe the general principles and current status of laparoscopic liver resection for hepatocellular carcinoma, as well as future prospects.

Safety study of Folfox-HAIC in relieving bed restriction

Objective:To investigate the safety of relieving bed restriction in hepatic arterial infusion chemotherapy(HAIC)and its effects on patient comfort.Methods:A prospective study was conducted.Patients with malignant liver tumors,who met the enrollment criteria,were randomly divided into experimental and control groups.During HAIC treatment,the patients in the experimental group,who were not confined to bed and could get out of bed,used electronic injection pumps to infuse chemotherapy drugs.The patients in the control group,who were strictly confined to bed and prohibited from getting out of bed,used infusion pumps to infuse chemotherapy drugs.The complications of the two groups were observed.The Christenson standard improved method was used to evaluate the bleeding and hematoma of limbs on the operation side.The Kolcaba General Comfort Questionnaire(GCQ)and Barthel Index(BI)were used to evaluate the two groups.Results:Ninety patients with malignant liver tumors were enrolled,including 53 with primary liver cancer and 37 with colorectal liver metastasis.There were 70 males and 20 females,aged 41-81 years old,with an average age of 61.6±9.248 years old.There were 60 patients in the experimental group and 30 patients in the control group.All patients underwent HAIC.The study showed that,during the treatment period,there were 3 cases of postoperative puncture point hematoma formation in the two groups,including 2 cases in the experimental group(2/60,3.3%)and 1 case in the control group(1/30,3.3%).The difference was not statistically significant(p>0.05).There were 5 cases of postoperative puncture point bleeding,including 4 cases in the experimental group(4/60,6.7%)and 1 case in the control group(1/30,3.3%),and the difference was not statistically significant(p>0.05).A total of 23 cases,with 6 cases in the experimental group(6/60,10%)and 17 cases in the control group(17/30,56.7%),complained of back pain after the operation,and the difference was statistically significant(p<0.05).Twenty-one cases complained of poor defecation after the operation,including 10 cases in the experimental group(10/60,16.7%)and 11 cases in the control group(11/30,36.7%).The difference was statistically significant(p<0.05).During the period of infusion chemotherapy,the two groups of patients had there was a significant difference between the two groups in terms of comfort status(GCQ)(88.78±6.705,78.47±9.519,p<0.001)and self-care ability(BI)(74.25±9.152,66.83±6.628,p<0.001).Conclusion:During HAIC treatment,getting out of bed is safe and reliable and can increase the patients’comfort and self-care ability.Hence,it merits clinical application.

The Human Microbiota in Health and Disease

Trillions of microbes have evolved with and continue to live on and within human beings. A variety of environmental factors can affect intestinal microbial imbalance, which has a close relationship with human health and disease. Here, we focus on the interactions between the human microbiota and the host in order to provide an overview of the microbial role in basic biological processes and in the development and progression of major human diseases such as infectious diseases, liver diseases, gastrointestinal cancers, metabolic diseases, respiratory diseases, mental or psychological diseases, and autoimmune diseases. We also review important advances in techniques associated with microbial research, such as DNA sequencing, metabonomics, and proteomics combined with computation-based bioinformatics.Current research on the human microbiota has become much more sophisticated and more comprehensive.Therefore, we propose that research should focus on the host-microbe interaction and on causeeffect mechanisms, which could pave the way to an understanding of the role of gut microbiota in health and disease, and provide new therapeutic targets and treatment approaches in clinical practice.

Contrast-enhanced ultrasound manifestations of synchronous combined hepatocellular-cholangiocarcinoma and hepatocellular carcinoma:A case report

BACKGROUND Synchronous combined hepatocellular-cholangiocarcinoma(CHC)and hepatocellular carcinoma(HCC)is very rare,with few literature reports and poor clinical outcomes associated with the disorder.Surgical resection is the main treatment,which makes the preoperative diagnosis very important.However,due to imaging manifestations overlapping with HCC,diagnosis of this type of synchronous cancer is challenging and it tends to be misdiagnosed as multiple HCC.Herein,we report the contrast-enhanced ultrasound(CEUS)manifestations of a case of synchronous CHC and HCC,aiming at adding to the understanding of this disease.CEUS displayed exquisite vascularity and tissue perfusion in real time with good spatial and temporal resolution and more accurately reflect tumor washin and washout times than contrast-enhanced computed tomography(CT)in this case.CASE SUMMARY The patient was a 69-year-old female with a 20-year history of chronic hepatitis B.Due to months of epigastric pain and anorexia,she reffered to our hospital for treatment.Five days before hospitalization,abdominal magnetic resonance imaging performed at another hospital detected a space-occupying lesion in the liver.After her hospitalization,laboratory tests showed elevated alpha-fetoprotein and carbohydrate antigen 19-9 level.Two suspicious liver lesions located in S4 and S6,respectively,were identified in a cirrhotic background by abdominal contrast-enhanced CT(CECT).Furthermore,the lesion in S4 and S6 were detected by CEUS and assigned to CEUS LI-RADS 5 and M categories,respectively.The patient underwent tumor radical resections.Post-operative pathology confirmed the S4 and S6 lesions to be HCC and CHC,respectively.A newly-found suspicious liver nodule with potential malignancy was detected in liver S1 by both CEUS and CECT 7 mo after operation.CONCLUSION The CEUS characteristics of CHC and HCC are different.CEUS features in combination with clinical information could help in effective diagnosis,clinical decision-making and better prognosis.

Differentiation of pyogenic hepatic abscesses from malignant mimickers using multislice-based texture acquired from contrast-enhanced computed tomography

BACKGROUND： Pyogenic hepatic abscess may mimic primary or secondary carcinoma of the liver on contrast-enhanced computed tomography（CECT）. The present study was to explore the usefulness of the analysis of multislice-based texture acquired from CECT in the differentiation between pyogenic hepatic abscesses and malignant mimickers.METHODS： This retrospective study included 25 abscesses in 20 patients and 33 tumors in 26 subjects who underwent CECT. To make comparison, we also enrolled 19 patients with hepatic single simple cyst. The images from CECT were analyzed using a Laplacian of Gaussian band-pass filter（5 filter levels with sigma weighting ranging from 1.0 to 2.5）. We also quantified the uniformity, entropy, kurtosis and skewness of the multislice-based texture at different sigma weightings. Statistical significance for these parameters was tested with oneway ANOVA followed by Tukey honestly significant difference（HSD） test. Diagnostic performance was evaluated using the receiver operating characteristic（ROC） curve analysis.RESULTS： There were significant differences in entropy and uniformity at all sigma weightings（P〈0.001） among hepatic abscesses, malignant mimickers and simple cysts. The significant difference in kurtosis and skewness was shown at sigma 1.8 and 2.0 weightings（P=0.002-0.006）. Tukey HSD testshowed that the abscesses had a significantly higher entropy and lower uniformity compared with malignant mimickers（P=0.000-0.004）. Entropy（at a sigma 2.0 weighting） had the largest area under the ROC curve（0.888） in differentiating abscesses from malignant mimickers, with a sensitivity of 81.8% and a specificity of 88.0% when the cutoff value was set to 3.64.CONCLUSION： Multislice-based texture analysis may be useful for differentiating pyogenic hepatic abscesses from malignant mimickers.

Pure Laparoscopic Liver Resection for Malignant Liver Tumor： Anatomic Resection Versus Nonanatomic Resection

Background： Laparoscopic liver resection （LLR） has been considered to be safe and feasible. However, few studies focused on the comparison between the anatomic and nonanatomic LLR. Therefore, the purpose of this study was to compare the perioperative factors and outcomes of the anatomic and nonanatomic LLR, especially the area of liver parenchymal transection and blood loss per unit area. Methods： In this study, surgical and oncological data of patients underwent pure LLR procedures for malignant liver tumor were prospectively collected. Blood loss per unit area of liver parenchymal transection was measured and considered as an important parameter. All procedures were conducted by a single surgeon. Results： During nearly 5 years, 84 patients with malignant liver tumor received a pure LLR procedure were included. Among them, 34 patients received anatomic LLR and 50 received nonanatomic LLR, respectively. Patients of the two groups were similar in terms of demographic features and tumor characteristics, despite the tumor size was significantly larger in the anatomic LLR group than that in the nonanatomic LLR group （4.77 ± 2.57 vs. 2.87 ± 2.10 cm, P = 0.001）. Patients who underwent anatomic resection had longer operation time （364.09 ± 131.22 vs. 252.00±135.21 min, P 〈 0.001） but less blood loss per unit area （7.85 ± 7.17 vs. 14.17 ± 10.43 ml/cm2, P = 0.018）. Nonanatomic LLR was associated with more blood loss when the area of parenchymal transection was equal to the anatomic LLR. No mortality occurred during the hospital stay and 30 days alter the operation. Moreover, there was no difference in the incidence of postoperative complications. The disease-free and overall survival rates showed no significant differences between the anatomic LLR and nonanatomic LLR groups. Conclusions： Both anatomic and nonanatomic pure LLR are safe and feasible. Measuring the area of parenchymal transection is a simple and effective method to estimate the outcomes of the liver resection surgery＇. Blood loss per unit area is an important parameter which is comparable between the anatomic LLR and nonanatomic LLR groups.