Simplified liver imaging reporting and data system for the diagnosis of hepatocellular carcinoma on gadoxetic acid-enhanced magnetic resonance imaging

BACKGROUND The liver imaging reporting and data system(LI-RADS)diagnostic table has 15 cells and is too complex.The diagnostic performance of LI-RADS for hepatocellular carcinoma(HCC)is not satisfactory on gadoxetic acid-enhanced magnetic resonance imaging(EOB-MRI).AIM To evaluate the ability of the simplified LI-RADS(sLI-RADS)to diagnose HCC on EOB-MRI.METHODS A total of 331 patients with 356 hepatic observations were retrospectively analysed.The diagnostic performance of sLI-RADS A-D using a single threshold was evaluated and compared with LI-RADS v2018 to determine the optimal sLIRADS.The algorithms of sLI-RADS A-D are as follows:The single threshold for sLI-RADS A and B was 10 mm,that is,classified observations≥10mm using an algorithm of 10-19 mm observations(sLI-RADS A)and≥20 mm observations(sLI-RADS B)in the diagnosis table of LI-RADS v2018,respectively,while the classification algorithm remained unchanged for observations<10 mm;the single threshold for sLI-RADS C and D was 20 mm,that is,for<20 mm observations,the algorithms for<10 mm observations(sLI-RADS C)and 10-19 mm observations(sLI-RADS D)were used,respectively,while the algorithm remained unchanged for observations≥20 mm.With hepatobiliary phase(HBP)hypointensity as a major feature(MF),the final sLI-RADS(F-sLI-RADS)was formed according to the optimal sLI-RADS,and its diagnostic performance was evaluated.The times needed to classify the observations according to F-sLIRADS and LI-RADS v2018 were compared.RESULTS The optimal sLI-RADS was sLI-RADS D(with a single threshold of 20 mm),because its sensitivity was greater than that of LI-RADS v2018(89.8%vs 87.0%,P=0.031),and its specificity was not lower(89.4%vs 90.1%,P>0.999).With HBP hypointensity as an MF,the sensitivity of F-sLI-RADS was greater than that of LI-RADS v2018(93.0%vs 87.0%,P<0.001)and sLI-RADS D(93.0%vs 89.8%,P=0.016),without a lower specificity(86.5%vs 90.1%,P=0.062;86.5%vs 89.4%,P=0.125).Compared with that of LI-RADS v2018,the time to classify lesions according to FsLI-RADS was shorter(51±21 s vs 73±24 s,P<0.001).CONCLUSION The use of sLI-RADS with HBP hypointensity as an MF may improve the sensitivity of HCC diagnosis and reduce lesion classification time.

Hepatomegaly and jaundice as the presenting symptoms of systemic light-chain amyloidosis: A case report

BACKGROUND Light chain(AL)amyloidosis is a plasma cell dyscrasia characterized by the pathologic production and extracellular tissue deposition of fibrillar proteins derived from immunoglobulin AL fragments secreted by a clone of plasma cells,which leads to progressive dysfunction of the affected organs.The two most commonly affected organs are the heart and kidneys,and liver is rarely the dominant affected organ with only 3.9%of cases,making them prone to misdia-gnosis and missed diagnosis.CASE SUMMARY A 65-year-old woman was admitted with a 3-mo history of progressive jaundice and marked hepatomegaly.Initially,based on enhanced computed tomography scan and angiography,Budd-Chiari syndrome was considered and balloon dilatation of significant hepatic vein stenoses was performed.However,addi-tional diagnostic procedures,including liver biopsy and bone marrow-exami-nation,revealed immunoglobulin kapa AL amyloidosis with extensive liver involvement and hepatic vascular compression.The disease course was progre-ssive and fatal,and the patient eventually died 5 mo after initial presentation of symptoms.CONCLUSION AL amyloidosis with isolated liver involvement is very rare,and can be easily misdiagnosed as a vascular disease.

Negative impact of hepatitis B surface seroclearance on prognosis of hepatitis B-related primary liver cancer

AIM To assess the impact of hepatitis B surface(HBs Ag) seroclearance on survival outcomes in hepatitis B-related primary liver cancer.METHODS Information from patients with hepatitis B-related liver cancer admitted in our hospital from 2008-2017 was retrieved. Cases diagnosed with HBs Ag(-) and HBc Ab(+) liver cancer were included in the HBs Ag seroclearance(SC) group. HBs Ag(+) liver cancer patients strictly matched for liver cancer stage(AJCC staging system, 8 th edition), Child-Pugh score, and first diagnosis/treatment method(surgery, ablation and TACE) were assigned to the HBsA g non-seroclearance(NSC) group. Then, clinical, pathological and survival data in both groups were assessed.RESULTS The SC and NSC groups comprised of 72 and 216 patients, respectively. Patient age(P < 0.001) and platelet count(P = 0.001) in the SC group were significantly higher than those of the NSC group. SC group patients who underwent surgery had more intrahepatic cholangiocarcinoma(ICC) and combined HCC-CC(CHC) cases than the NSC group, but no significant differences in tumor cell differentiation and history of liver cirrhosis were found between the two groups. The numbers of interventional treatments were similar in both groups(4.57 vs 5.07, P > 0.05). Overall survival was lower in the SC group than the NSC group(P = 0.019), with 1-,3-, and 5-year survival rates of 82.1% vs 85.1%, 43.2%vs 56.8%, and 27.0% vs 45.2%, respectively. Survival of patients with AJCC stage Ⅰ disease in the SC group was lower than that of the NSC group(P = 0.029).CONCLUSION Seroclearance in patients with hepatitis B-related primary liver cancer has protective effects with respect to tumorigenesis, cirrhosis, and portal hypertension but confers worse prognosis, which may be due to the frequent occurrence of highly malignant ICC and CHC.

Isolated gastric variceal bleeding related to non-cirrhotic portal hypertension following oxaliplatin-based chemotherapy:A case report

BACKGROUND Sinusoidal obstruction syndrome has been reported after oxaliplatin-based chemotherapy,but liver fibrosis and non-cirrhotic portal hypertension(NCPH)are rarely reported.CASE SUMMARY Here,we describe the case of a 64-year-old woman who developed isolated gastric variceal bleeding 16 mo after completing eight cycles of oxaliplatin combined with capecitabine chemotherapy after colon cancer resection.Surprisingly,splenomegaly and thrombocytopenia were not accompanied by variceal bleeding,which has been reported to have predictive value for gastric variceal formation.However,a liver biopsy showed fibrosis in the portal area,suggesting NCPH.The patient underwent endoscopic treatment and experienced no further symptoms.CONCLUSION It is necessary to guard against long-term complications after oxaliplatin-based chemotherapy.Sometimes splenic size and platelet level may not always accurately predict the occurrence of portal hypertension.

Primary hepatic angiosarcoma manifesting as hepatic sinusoidal obstruction syndrome:A case report

BACKGROUND Primary hepatic angiosarcoma(PHA)is a rare malignancy with a poor prognosis.It is difficult to diagnose PHA because of the lack of specific symptoms or tumour markers,and it rapidly progresses and has a high mortality.To our knowledge,PHA has not been reported to mimic hepatic sinusoidal obstruction syndrome.Herein,we present a case of PHA manifesting as hepatic sinusoidal obstruction syndrome,diagnosed using transjugular liver biopsy,that resulted in the death of the patient.CASE SUMMARY A 71-year-old man was admitted with the primary complaint of abdominal distension,decreased appetite,fatigue in the previous month,and loss of 10 kg of weight in the past 2 years.Both the liver and spleen were enlarged,and the liver had a medium-hard texture on percussion.Laboratory examinations were performed,and abdominal plain computed tomography(CT)and contrastenhanced CT showed hepatomegaly and splenomegaly,as well as diffuse lowdensity shadows distributed in the liver and spleen.Contrast-enhanced CT revealed diffuse,hypodense,nodular or flake shadows in the liver and heterogeneous enhancement in the spleen.A transjugular liver biopsy was performed.Based on the pathology results,the patient was diagnosed with hepatic sinusoidal obstruction syndrome secondary to PHA.The patient’s status further deteriorated and he developed serious hepatic failure.The patient was discharged,and died 3 d later.CONCLUSION PHA is rare and has a poor prognosis;however,transjugular liver biopsy can be safely performed to aid in diagnosis.

ALPPS in the treatment of liver cancer with insufficient future liver remnant

To the Editor:In 2007,Schlitt firstly reported that the rapid compensatory increase of future liver remnant (FLR) after surgery can be achieved in a very short time which is known as a revolutionary breakthrough of liver surgery for huge or multiple liver cancer therapy^([1]).de Santibanes and Clavien later proposed the medical term"ALPPS"^([2]).

The facile method developed for preparing polyvinylidene fluoride plasma separation membrane via macromolecular interaction

The design of membrane pore is critical for membrane preparation. Polyvinylidene fluoride(PVDF) membrane exhibits outstanding properties in the water-treatment field. However, it is a huge challenge to prepare PVDF macro-pore plasma separation membrane by non-solvent induced phase separation(NIPS). Herein, a facile strategy is proposed to prepare PVDF macro-pore plasma separation membrane via macromolecular interaction. ATR-FTIR and ^(1)H NMR showed that the intermolecular interaction existed between polyethylene oxide(PEO) and polyvinylpyrrolidone(PVP). It could significantly affect the PVDF macro-pore membrane structure. The maximum pore of the PVDF membrane could be effectively adjusted from small-pore/medium-pore to macro-pore by changing the molecular weight of PEO. The PVDF macro-pore membrane was obtained successfully when PEO-200 k existed with PVP. It exhibited higher plasma separation properties than the currently used plasma separation membrane.Moreover, it had excellent hemocompatibility due to the similar plasma effect, hemolysis, prothrombin time, blood effect and complement C_(3a) effect with the current utilized plasma separation membrane,implying its great potential application. The proposed facile strategy in this work provides a new method to prepare PVDF macro-pore plasma separation membrane by NIPS.

The mutation landscape of multiple cancer predisposition genes in Chinese familial/hereditary breast cancer families

Objective:Approximately 5%–10%of breast cancer(BC)patients display familial traits that are genetically inherited among the members of a family.The purpose of this study was to profile the germline mutations in 43 genes with different penetration rates and their correlations with phenotypic traits in Chinese familial BC families.Methods:Ion Torrent S5™-based next generation sequencing was conducted on 116 subjects from 27 Chinese familial BC families.Results:Eighty-one germline mutations in 27 BC predisposition genes were identified in 82.8%(96/116)of the cases.Among these,80.8%of the mutated genes were related to DNA damage repair.Fourteen possible disease-causing variants were identified in 13 of 27 BC families.Only 25.9%(7/27)of the BC families exhibited hereditary deficiency in BRCA1/2 genes,while 22.2%of the BC families exhibited defects in non-BRCA genes.In all,41.7%(40/96)of the mutation carriers had BRCA mutations,88.5%(85/96)had non-BRCA mutations,and 30.2%(29/96)had both BRCA and non-BRCA mutations.The BC patients with BRCA mutations had a higher risk of axillary lymph node metastases than those without mutations(P<0.05).However,the BC patients with non-BRCA mutations frequently had a higher occurrence of benign breast diseases than those without mutations(P<0.05).Conclusions:In addition to BRCA1/2,genetic variants in non-BRCA DNA repair genes might play significant roles in the development of familial/hereditary BC.Therefore,profiling of multiple BC predisposition genes should be more valuable for screening potential pathogenic germline mutations in Chinese familial/hereditary BC.

Acute myocardial infarction due to Kounis syndrome:A case report

BACKGROUND Acute myocardial infarction(AMI)can be induced by several factors.However,AMI induced by Kounis syndrome(an allergic reaction)is extremely rare and is highly susceptible to misdiagnosis.CASE SUMMARY A 70-year-old man presented after suffering an allergic reaction that caused chest pain triggered upon eating ice cream.Troponin I was found to be elevated,and an electrocardiogram showed ST-segment elevation.The diagnosis was AMI.He underwent two coronary angiographies,with one intravascular ultrasound during hospitalization showing no evidence of atherosclerotic coronary artery disease.The final diagnosis was vasospastic myocardial infarction due to Kounis syndrome.The patient was then treated with hydrocortisone and intravenous antihistamines,and his chest pain symptoms resolved.CONCLUSION Allergic reactions(such as Kounis syndrome)can cause serious damage to the heart.Physicians should be alert to the consequences and avoid misdiagnosis.

Nine-year survival of a 60-year-old woman with locally advanced pancreatic cancer under repeated open approach radiofrequency ablation:A case report

BACKGROUND Radiofrequency ablation(RFA)is gaining popularity as an additional therapy for pancreatic ductal adenocarcinoma.RFA appears to be an attractive treatment option for patients with unresectable,locally advanced and nonmetastatic pancreatic cancer.CASE SUMMARY A 60-year-old woman with 2 mo intermittent upper abdominal pains was admitted to hospital.She had undergone radical gastrectomy(Billroth II)for gastric antral cancer.Contrast-enhanced computed tomography(CECT)and abdominal ultrasound displayed a primary tumor in the neck of the pancreas.Pathological examination showed that the lesion was a pancreatic ductal adenocarcinoma.According to the results of the imaging,open approach RFA was selected to treat the primary tumor.Eight months later,CECT follow-up revealed local recurrence of the tumor,and another open RFA was performed.Although there is evidence that RFA for recurrence of other cancers such as hepatocellular carcinoma may prolong patient survival,it remains unclear whether repeat RFA for local recurrence of pancreatic cancer is feasible.The patient continued to enjoy 9 years of life following the first RFA.CONCLUSION RFA of locally advanced,nonresectable,nonmetastatic,pancreatic tumor is characterized by feasibility-based treatment giving rise to tumor reduction based on improvement of quality of life.

A robust microsatellite instability detection model for unpaired colorectal cancer tissue samples

Background:Microsatellite instability(MSI)is a key biomarker for cancer immunotherapy and prognosis.Integration of MSI testing into a next-generation-sequencing(NGS)panel could save tissue sample,reduce turn-around time and cost,and provide MSI status and comprehensive genomic profiling in single test.We aimed to develop an MSI calling model to detect MSI status along with the NGS panel-based profiling test using tumor-only samples.Methods:From January 2019 to December 2020,a total of 174 colorectal cancer(CRC)patients were enrolled,including 31 MSI-high(MSI-H)and 143 microsatellite stability(MSS)cases.Among them,56 paired tumor and normal samples(10 MSI-H and 46 MSS)were used for modeling,and another 118 tumor-only samples were used for validation.MSI polymerase chain reaction(MSI-PCR)was performed as the gold standard.A baseline was built for the selected microsatellite loci using the NGS data of 56 normal blood samples.An MSI detection model was constructed by analyzing the NGS data of tissue samples.The performance of the model was compared with the results of MSI-PCR.Results:We first intersected the target genomic regions of the NGS panels used in this study to select common microsatellite loci.A total of 42 loci including 23 mononucleotide repeat sites and 19 longer repeat sites were candidates for modeling.As mononucleotide repeat sites are more sensitive and specific for detecting MSI status than sites with longer length motif and the mononucleotide repeat sites performed even better than the total sites,a model containing 23 mononucleotide repeat sites was constructed and named Colorectal Cancer Microsatellite Instability test(CRC-MSI).The model achieved 100%sensitivity and 100%specificity when compared with MSI-PCR in both training and validation sets.Furthermore,the CRC-MSI model was robust with the tumor content as low as 6%.In addition,8 out of 10 MSI-H samples showed alternations in the four mismatch repair genes(MLH1,MSH2,MSH6,and PMS2).Conclusion:MSI status can be accurately determined along the targeted NGS panels using only tumor samples.The performance of mononucleotide repeat sites surpasses loci with longer repeat motif in MSI calling.

Autotaxin:An Early Warning Biomarker for Acute-on-chronic Liver Failure

Background and Aims:Recent accumulating evidence indicates the biological actions of autotaxin(ATX)in liver disease.However,the relationship between ATX and liver failure has not been reported.The present study aimed to examine alterations of serum ATX in acute-on-chronic liver failure(ACLF)and evaluate whether serum ATX could be useful as an early warning biomarker of ACLF.Methods:Serum ATX was measured in 50 patients with hepatitis B-related ACLF,14 patients with alcohol-related ACLF,11 patients with hepatitis B-related pre-ACLF,11 patients with alcohol-related Child-Pugh A cirrhosis,39 patients with hepatitis B-related Child-Pugh A cirrhosis,26 patients with chronic hepatitis B,and 38 healthy volunteers by enzyme-linked immunosorbent assay.Results:Serum ATX level was significantly higher in the pre-ACLF group than in the Child-Pugh A cirrhosis and chronic hepatitis B groups but lower than in the ACLF group;furthermore,patients with pre-ACLF deteriorated to ACLF had significantly higher serum ATX levels than pre-ACLF patients that did not progress to ACLF.Serum ATX levels were significantly higher among male ACLF patients with preclinical infection,spontaneous bacterial peritonitis or pneumonia,as compared to patients with ACLF but no spontaneous bacterial peritonitis or pneumonia.Serum ATX levels were well correlated with serum biochemical parameters of liver function and model for end-stage liver disease score.Serum ATX≥584.1 ng/mL was a poor prognostic factor for ACLF(hazard ratio of 4.750,95%confidence interval of 1.106-20.392,p=0.036).Conclusions:Serum ATX level may be a useful early warning biomarker for ACLF.

Prognostic value of the extravascular lung water and pulmonary vascular permeability indices in severe adult respiratory distress syndrome managed with extracorporeal membrane oxygenation

Severe acute respiratory distress syndrome(ARDS)is commonly seen in intensive care units(ICUs).It is characterized by capillary endothelium and alveolar epithelium damage that results in significant increases in capillary permeability and extravascular lung water.