Large regenerative nodules in a patient with Budd-Chiari syndrome after TIPS positioning while on the liver transplantation list diagnosed by Gd-EOB-DTPA MRI

BACKGROUND:Large regenerative nodules (LRNs) are hyperplastic benign nodules most commonly associated with Budd-Chiari syndrome (BCS),caused by outflow obstruction of the hepatic veins or vena cava.To our knowledge,no cases of LRNs arising in BCS after transjugular intrahepatic portosystemic shunt (TIPS) positioning and detected by GdEOB-DTPA MRI have been reported in the literature.METHODS:A 58-year-old woman with BCS,on the liver transplantation (LT) list,underwent a follow-up enhanced MRI.Two years earlier,a TIPS had been placed.In 2008,recurrent hepaticoencephalopathy resistant to medical treatment fulfilled the LT criteria for BCS treated with TIPS and the patient was therefore added to the LT list.CT performed before TIPS had not detected any hepatic lesions.CT performed six months after TIPS showed its complete patency but documented two indeterminate hypervascular liver lesions.RESULTS:MRI performed with Gd-EOB-DTPA revealed additional hypervascular lesions with uptake and retention of the medium in the hepatobiliary phase,thus reflecting a benign behavior of hepatocellular composition.These MRI features were related to LRNs as confirmed by histopathologic analysis.CONCLUSIONS:Gd-EOB-DTPA-enhanced MRI is potentially superior to standard imaging using gadolinium chelates or spiral CT,especially for the differential diagnosis of hypervascular lesions.Gd-EOB-DTPA MRI may become the imaging method of choice for evaluating LT list patients with BCS after TIPS placement.

Non-cirrhotic portal hypertension with large regenerative nodules: A diagnostic challenge

Non-cirrhotic portal hypertension is a poorly understood condition characterized by portal hypertension in the absence of conventional hepatic cirrhosis and described in association with blood coagulation disorders, myeloproliferative and immunological diseases and with exposure to toxic drugs. Very recently, precise classification criteria have been proposed in order to define four distinct subcategories. The present case highlights how the clinical presentation, the confounding results from imaging studies, and the difficulties in the histological evaluation often render cases of non-cirrhotic portal hypertension a real diagnostic challenge. It also underscores the classification problems which can be faced once this diagnosis is performed. Indeed, the different subcategories proposed result from the prevalent subtypes in a spectrum of hepatic regenerative responses to a variety of injuries determining microcirculatory dis-turbances. More flexibility in classification should derive from this etiopathogenic background.

Classification tool for the systematic histological assessment of hepatocellular carcinoma, macroregenerative nodules, and dysplastic nodules in cirrhotic liver

AIM： To design a classification tool for the histological assessment of hepatocellular carcinoma （HCC）, dysplastic nodules （DN）, and macroregenerative nodules （MRN） in cirrhotic liver. METHODS： Two hundred and twelve hepatocellular nodules （106 HCC; 74 IRN, 32 DN） were assessed systematically, quantitatively, and semiquantitatively as appropriate for 10 histological features that have been described as helpful in distinguishing small HCC, DN, and MRN in cirrhotic livers. The data were analyzed by multiple correspondence analysis （MCA）. RESULTS： HCA distributed HCC, DN, and HRN as defined by traditional histological evaluation as well as the individual histological variables, in a ＂malignancy scale＂. Based on the MCA data representation, we created a classification tool, which categorizes an individual nodular lesion as MRN, DN, or HCC based on the balance of all histological features （i.e., vascular invasion, capsular invasion, tumor necrosis, tumor heterogeneity, reticulin loss, capillarization of sinusoids, trabecular thickness, nuclear atypia, and mitotic activity）. The classification tool classified most （83%） of a validation set of 47 nodules in the same way as the routine histological assessment. No discrepandes were present for DN and MRN between the routine histological assignment and the dassification tool. Of 25 HCC assigned by routine assessment in the validation set, 8 were assigned to the DN category by the classification tool. CONCLUSION： We have designed a classification tool for the histological assessment of HCC and its putative precursors in cirrhotic liver. Application of this toolsystematically records histological features of diagnostic importance in the evaluation of small HCC.

MR Features of Regenerative Nodules and Dysplastic Nodules in the Cirrhotic Liver

Summary： In order to study MR features of the regenerative nodule （RN） and dysplastic nodule （DN） of the cirrhotic liver, 26 cases of cirrhotic liver with RNs and DNs, of which 8 cases accompanied with hepatocellular carcinoma, were subjected to MRI. Eighteen of 26 cases underwent additional enhanced MRI with administration of Gd-DTPA on T1WI and 10 of the 18 cases did additional SPIO （Feridex） enhancement on T2W1. Clinical data showed normal level of α-fetoprotein in 18 cases except 8 cases accompanied with HCC. The results showed that 12 cases had RNs with nodules measuring 〈1 cm. The MR appearance of those RNs showed isointensity on T1WI and hypointensity on T2WI. The intensity of those RNs was isointense to the surrounding hepatic parenchyma on enhanced MRI with administration of Gd-DTPA or SPIO. Among the 14 cases of DNs, 8 cases had nodules measuring 1-3 cm in size and 6 had macroregenerative nodule measuring 〉3 cm. In 8 cases with DNs measuring 1-3 cm in size, 5 cases appeared hyperintense on T1W1 and hypointense on T2W1 as well as the enhancement as that of nodules with （1 cm in size; and the remaining 3 cases appeared hypointense on T1WI and hyperintense on T2WI, and were not isointense to the surrounding hepatic parenchyma on enhanced MRI but hyperintense on SPIO enhanced MRI. In 6 cases of macroregenerative nodule measuring 2〉3 cm in size, 2 cases appeared hyperintense to the surrounding hepatic parenchyma on T1, T2WI and enhanced MRI; 4 cases showed hyperintense on TlWI, and hypointense on T2WI and enhanced MRI. Sometimes, normal vessels were seen to pass through the surface of macroregenerative nodules. It was suggested that RNs of cirrhosis had features on MRI that usually allow distinction from hepatocellular carcinoma but not always from dysplastic nodules （DNs）. A helpful distinction between HCC and DNs is that the latter are almost never hyperintense on T2WI. Additionally, low grade DNs appear hypoimense on SPIO enhanced MR1.

Giant Hepatic Regenerative Nodule in a Patient With Hepatitis B Virus-related Cirrhosis

Hepatic regenerative nodules are reactive hepatocellular proliferations that develop in response to liver injury.Giant hepatic regenerative nodules of 10 cm or more are extremely rare and have only been reported in patients with biliary atresia or Alagille syndrome.A 50-year-old man presented with a pathologically confirmed giant 11.3×9.4×11.2 cm hepatic regenerative nodule and hepatitis B virus-related cirrhosis.Imaging of intrahepatic nodule included mild hyperenhancement in the portal phase of contrast-enhanced CT and the hepatobiliary phase in the gadoxetic acid-enhanced MRI scan,as well as the portal vein crossing through sign in the setting of liver cirrhosis.This case highlights the imaging characteristics of giant hepatic regenerative nodules in hepatitis cirrhosis.

Evaluation of contrast-enhanced ultrasound for diagnosis of dysplastic nodules with a focus of hepatocellular carcinoma in liver cirrhosis patients

Objective： To compare the enhancement features of dysplastic nodnles with a focus of hepatocellular carcinoma （DN-HCC） versus HCC and regenerative nodules （RN） in cirrhotic patients. Methods： One hundred and ninety-three cirrhotic patients were enrolled in this study; they had 215 focal liver lesions, 1.0-3.5 cm in size, which were examined using contrast-enhanced ultrasound （CEUS） with SonoVue and diagnosed as HCC, RN or DN-HCC by biopsy. Samples were obtained using 18-gauge needles in the different enhanced areas. The enhancement features of DN-HCC, HCC and RN were evaluated. Results： There were 86 HCC lesions, 102 RN lesions, and 27 DN-HCC lesions diagnosed by biopsy. Of 86 HCC lesions, 87.2% （75/86） showed complete enhancement during the arterial phase, and 12.8% （11/86） had inhomogeneous enhancement, with no enhancement in the central area during the arterial phase; 100% （86/86） exhibited washout during the late phase. Of 102 RN lesions, 95.1% （97/102） had delayed or simultaneous enhancement during the arterial phase, and 4.9% （5/102） displayed slight enhancement during the arterial phase; 26.5% （27/102） exhibited washout and 73.5% （75/102） exhibited no washout during the late phase. In 27 DN-HCC lesions, only part of the lesions enhanced during the arterial phase and washed out during the late phase; the other areas had delayed or simultaneous enhancement during the arterial phase, and 29.6% （8/27） exhibited slight washout in the late phase. In 86 HCCs, the pathological feature was HCC in the enhanced area of 75 lesions, hepatocellular fatty degeneration in the slightly enhanced area of 7 lesions, and hepatocellular necrosis in the unenhanced area and HCC in the enhanced area of 4 lesions. In 102 RNs, the pathological diagnosis was hepatocyte proliferation with or without fatty degeneration. In 27 DN-HCCs, the pathological feature was HCC in the enhanced area and hepatocye regeneration in the unenhanced area. Conclusions： CEUS is useful for the diagnosis of focal liver lesions in cirrhotic patients. CEUS can help determine the progression from RN to DN-HCC to HCC by analyzing the hemodynamics. CEUS can promote the diagnostic accuracy of a biopsy by providing more accurate information on the site of the biopsy.