Treatment of hepatocellular carcinoma with portal venous tumor thrombosis: A comprehensive review

The natural history of hepatocellular carcinoma(HCC)with portal vein tumor thrombosis(PVTT)is dismal(approximately 2-4 mo),and PVTT is reportedly found in 10%-40%of HCC patients at diagnosis.According to the Barcelona Clinic Liver Cancer(BCLC)Staging System(which is the most widely adopted HCC management guideline),sorafenib is the standard of care for advanced HCC(i.e.,BCLC stage C)and the presence of PVTT is included in this category.However,sorafenib treatment only marginally prolongs patient survival and,notably,its therapeutic efficacy is reduced in patients with PVTT.In this context,there have been diverse efforts to develop alternatives to current standard systemic chemotherapies or combination treatment options.To date,many studies on transarterial chemoembolization,3-dimensional conformal radiotherapy,hepatic arterial chemotherapy,and transarterial radioembolization report better overall survival than sorafenib therapy alone,but their outcomes need to be verified in future prospective,randomized controlled studies in order to be incorporated into current treatment guidelines.Additionally,combination strategies have been applied to treat HCC patients with PVTT,with the hope that the possible synergistic actions among different treatment modalities would provide promising results.This narrative review describes the current status of the management options for HCC with PVTT,with a focus on overall survival.

Radiologic evaluation of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease(NAFLD)is a frequent cause of chronic liver diseases,ranging from simple steatosis to nonalcoholic steatohepatitis(NASH)-related liver cirrhosis.Although liver biopsy is still the gold standard for the diagnosis of NAFLD,especially for the diagnosis of NASH,imaging methods have been increasingly accepted as noninvasive alternatives to liver biopsy.Ultrasonography is a well-established and costeffective imaging technique for the diagnosis of hepatic steatosis,especially for screening a large population at risk of NAFLD.Ultrasonography has a reasonable accuracy in detecting moderate-to-severe hepatic steatosis although it is less accurate for detecting mild hepatic steatosis,operator-dependent,and rather qualitative.Computed tomography is not appropriate for general population assessment of hepatic steatosis given its inaccuracy in detecting mild hepatic steatosis and potential radiation hazard.However,computed tomography may be effective in specific clinical situations,such as evaluation of donor candidates for hepatic transplantation.Magnetic resonance spectroscopy and magnetic resonance imaging are now regarded as the most accurate practical methods of measuring liver fat in clinical practice,especially for longitudinal followup of patients with NAFLD.Ultrasound elastography and magnetic resonance elastography are increasingly used to evaluate the degree of liver fibrosis in patients with NAFLD and to differentiate NASH from simple steatosis.This article will review current imaging methods used to evaluate hepatic steatosis,including the diagnostic accuracy,limitations,and practical applicability of each method.It will also briefly describe the potential role of elastography techniques in the evaluation of patients with NAFLD.

Interventional management of tracheobronchial strictures

Tracheobronchial balloon dilation and stent placement have been well used in the treatment of patients with benign and/or malignant diseases.Balloon dilation is the first option in the treatment of benign airway stenosis.Although balloon dilation is simple and fast,recurrence rate is high.Stent placement promptly relieves acute airway distress from malignant extraluminal and intraluminal airway obstruction.Temporary stent placement may be an alternative for benign airway strictures refractory to balloon dilation.This article reviews the indications,pre-procedure evaluation,technique,outcomes and complications of balloon dilation and stent placement with regard to benign and malignant tracheobronchial stenoses.

CT colonography in the diagnosis and management of colorectal cancer:Emphasis on pre-and post-surgical evaluation

This article addresses the use of computed tomographic colonography (CTC) for the diagnosis and management of colorectal cancer, focusing on presurgical evaluation of the colon proximal to an occlusive cancer and surveillance after cancer resection surgery. The key evidences accumulated in the literature and future work needed are summarized. CTC is a technically robust and the most practical method to evaluate the colon proximal to an occlusive cancer, which prevents colonoscopic examination past the occlusion, either before or after metallic stent placement. The high sensitivity of CTC for detecting cancers and advanced adenomas in the proximal colon can help prevent additional surgical procedures in patients showing negative results. However, the accuracy of CTC for distinguishing intramural cancers from adenomas is low, and the technique is limited in guiding management when a medium-sized lesion that do not show invasive features such as pericolic extension or nodal metastasis is found in the proximal colon. A maximal diameter ≥ 15 mm has been proposed as a criterion for surgical removal of proximal lesions. However, this needs to be verified in a larger cohort. In addition, the influence of presurgical CTC results on the current post-cancer resection colonic surveillance timeline remains to be determined. CTC can be readily added to the routine abdominopelvic CT in the form of contrast-enhanced CTC, which can serve as an effective stand-alone tool for post-cancer resection surveillance of both the colorectum and extracolonic organs. Although the accuracy of CTC has been demonstrated, its role in the current colonoscopy-based postoperative colonic surveillance protocols remains to be determined. Readers of CTC also need to be knowledgeable on the colonic lesions that are unique to the postoperative colon.

Successful hemostasis of intractable rectal variceal bleeding using variceal embolization

Portal hypertension causes portosystemic shunting along the gastrointestinal tract,resulting in gastrointestinalvarices.Rectal varices and their bleeding is a rare complication,but it can be fatal without appropriate treatment.However,because of its rarity,no established treatment strategy is yet available.In the setting of intractable rectal variceal bleeding,a transjugular intravenous portosystemic shunt can be a treatment of choice to enable portal decompression and thus achieve hemostasis.However,in the case of recurrent rectal variceal bleeding despite successful transjugular intravenous portosystemic shunt,alternative measures to control bleeding are required.Here,we report on a patient with liver cirrhosis who experienced recurrent rectal variceal bleeding even after successful transjugular intravenous portosystemic shunt and was successfully treated with variceal embolization.

Contrast-enhanced ultrasonography for the evaluation of liver fibrosis after biliary obstruction

AIM:To investigate perfusion change in contrastenhanced ultrasonography(CEUS) to evaluate liver fibrosis based on biliary obstruction using an animal model.METHODS:New Zealand white rabbits(3-4 kg) underwent bile duct ligation to form a biliary obstruction model.We performed liver CEUS and laboratory tests on the day before the operation(day 0) and every 7 postoperative days until the rabbits were sacrificed.After CEUS,signal intensity of liver parenchyma with a time-intensity curve was analyzed.Perfusion parameters were automatically calculated from regionof-interests,including peak signal intensity,mean transit time,area under the curve and time to peak.Histological grades of liver fibrosis were assessed according to the Metavir score system immediately after sacrifice.Generalized estimating equations were used to analyze the association between liver fibrosis grades and perfusion parameters for statistical analysis.The perfusion parameters were measured on the last day and the difference between day 0 and the last day were evaluated.RESULTS:From the nine rabbits,histological grades of liver fibrosis were grade 1 in one rabbit,grade 2 and 3 in three rabbits each,and grade 4 in two rabbits.Among the four CEUS parameters,only the peak signal intensity measured on the last day demonstrated a significant association with liver fibrosis grades(OR =1.392,95%CI:1.114-1.741,P =0.004).The difference in peak signal intensity between day 0 and the last dayalso demonstrated an association with liver fibrosis(OR =1.191,95%CI:0.999-1.419,P =0.051).The other parameters tested,including mean transit time,area under the curve,and time to peak,showed no significant correlation with liver fibrosis grades.CONCLUSION:This animal study demonstrates that CEUS can be used to evaluate liver fibrosis from biliary obstruction using peak signal intensity as a parameter.

Multidetector computed tomography features of pancreatic metastases from leiomyosarcoma: Experience at a tertiary cancer center

AIM: To describe the multidetector computed tomography features of pancreatic metastasis from leiomyosarcoma(LMS).METHODS: Between January 1995 and December 2012, 13 consecutive patients(11 women, 2 men; mean age of 57 years; range, 38-78 years) with pancreatic metastases from LMS were included in our study. Imaging features including location, number, largest dimension, tumor attenuation and enhancement characteristics, presence of necrosis, pancreatic ductal dilatation, common bile duct(CBD) dilatation, presence of pancreatitis, and atrophy were documented.RESULTS: The most common site of origin of the pancreatic metastases from LMS was uterus(38.5%), followed by retroperitoneum(30.8%) and extremity(23.1%). None of the patients in our study had pancreas as the first site of metastasis. All patients developed pancreatic metastases at a median interval of 24 mo. Pancreatic metastases from LMS were solitary in 8/13 patients and multiple in 5/13 patients, had no predilection for any part of the pancreas, were hypovascular on arterial phase in 10/13 patients and associated with pancreatic duct dilatation in 3/13 patients. None had CBD dilatation. None of the pancreatic metastases in LMS cohort caused pancreatitis, and atrophy. Median duration of follow-up was 19 mo for LMS cohort during which two patients underwent resection of metastasis(median survival 45 mo) while the remaining underwent systemic therapy(median survival 13 mo).CONCLUSION: Pancreatic metastases from LMS are often solitary and hypovascular masses and less commonly associated with pancreatic ductal dilatation, CBD dilatation, pancreatitis or pancreatic atrophy. Surgical resection of solitary LMS pancreatic metastasis can be considered due to the long survival of these patients.

Serum midkine levels for the diagnosis and assessment of response to interventional therapy in patients with hepatocellular carcinoma

Objective:To explore the clinical significance of serum midkine(MDK) levels for the diagnosis of hepatocellular carcinoma(HCC) and evaluate the efficacy of interventional therapy.Methods:Eighty-four patients with HCC were enrolled in this retrospective study.They received an interventional treatment.A follow-up was performed every 2 months,using magnetic resonance imaging,to determine whether the treatment should be continued.Serum alpha-fetoprotein(AFP) and MDK levels were measured at the first diagnosis and during the follow-ups,and the HCC detection rates based on the cutoff values of these two measurements were compared.The relationships between AFP and MDK and the clinical tumor characteristics and changes in APK and MDK before and after treatment were also compared using a rank sum test and χ2 test,respectively.The prognostic significance of MDK for HCC was determined through regression analysis.A twosided P <0.05 was considered statistically significant.Results:MDK expression was detected in 95.24% of the cases.Subgroup analysis revealed MDK expression in95.35%,95.12%,85.19%,86.67%,and 83.33% of the AFP-positive,AFP-negative,stage A Barcelona clinic liver cancer(BCLC-A),BCLC-A/AFP-positive,and BCLC-A/AFP-negative cases,respectively.MDK expression after the interventional treatment(66.7%) was significantly lower than that before the treatment(95.2%).The mean posttreatment MDK level was 0.67 ng/mL in patients with a positive response to therapy as compared with 3.66 ng/mL in those with no positive response.All patients were followed up for 18 months,and those positive for MDK expression before the intervention were more likely to relapse than patients without MDK expression.Subgroup analysis revealed the highest recurrence rate for patients who were positive for MDK expression before and after treatment.Conclusions:Serum MDK may serve as a powerful complement to AFP in the diagnosis of HCC.MDK measurement may improve the detection rate of BCLC-A and AFP-negative HCC.Serum MDK may help to determine the vascular invasion and poor clinical staging of HCC tumors.Patients with MDK-positive HCC before treatment may be more prone to postoperative tumor progression.

Effect of intra-arterial infusion with triolein emulsion on rabbit liver

AIM: To determine whether intra-arterial infusion of triolein emulsion has biochemical and histopathologic effect on rabbit liver.

Embolization of pancreatic arteriovenous malformation:A case report

BACKGROUND Pancreatic arteriovenous malformation(AVM)is a rare disease with a number of different reported treatment methods,but there are as yet no established or definite treatments for the disease.CASE SUMMARY A 43-year-old man visited the hospital due to periumbilical pain.The patient underwent imaging study and laboratory testing for evaluation of cause.Pancreatic AVM associated with pancreatitis was suspected on computed tomography and magnetic resonance imaging.The patient was diagnosed with pancreatic AVM with pancreatitis on imaging study and angiography.Transcatheter arterial embolization with various embolic materials was performed.Follow-up computed tomography scan revealed progressive regression of AVM and improvement of pancreatitis.At two-year follow-up,the patient showed no recurrence of symptom or pancreatitis.CONCLUSION Transcatheter arterial embolization can be considered an effective treatment modality for selective cases of pancreatic AVM.

The rat eustachian tube:Anatomical, histological, and radiological features

Purpose: This study investigated the anatomical and histological characteristics of the rat Eustachian tube(E-tube)and the feasibility of Eustachian tubography in a rat model.Materials and methods: Fifteen male Wistar rats were used in this study, and the bilateral E-tubes of each rat were examined. Ten E-tubes were used for anatomical studies, another ten for histological analysis, and the other ten for Eustachian tubography. Five rats were euthanized and decapitated, and ten E-tubes were dissected to describe the anatomy of the E-tube. Ten E-tube specimens obtained from five other rats were sectioned to investigate Etube histology. Eustachian tubography was performed on the bilateral E-tubes of the other five rats using the trans-tympanic approach.Results: The rat E-tubes consisted of bony and membranous parts. Cartilage and bone tissue covered only the bony part. The E-tubes’ mean diameter and overall length were 2.97 mm and 4.96 mm, respectively. The tympanic orifices’ mean diameter was 1.21 mm. The epithelium of E-tubes was mainly composed of pseudostratified ciliated and goblet cells. Eustachian tubography was successfully performed on both sides of the E-tube for each rat.The technical success rate was 100%, the average running time was 4.9 min, and no procedure-related complications occurred. On tubography images, the E-tube, tympanic cavity, and nasopharynx could be identified because of the visualization of bony landmarks.Conclusion: In this study, we described the anatomical and histological features of rat E-tubes. With the aid of these findings, E-tube angiography was successfully performed using a transtympanic approach. These results will facilitate further investigation of E-tube dysfunction.

典型与不典型原发中枢淋巴瘤的MRI及1H-MRS特征研究

目的 ：探讨典型与不典型原发中枢淋巴瘤（primary central nervous system lymphoma,PCNSL）的MRI及1H-MRS特征。方法：回顾性分析48例经病理证实的PCNSL常规MRI及1H-MRS资料,定性分析典型与不典型PCNSL的常规MRI特征,定量分析胆碱（Cho）/肌酸（Cr）、Cho/N-乙酰天门冬氨酸（NAA）值及脂质-乳酸峰（lip-lac）等级,并将两者进行对比。结果：典型PCNSL 27例,呈等或稍低信号,增强后呈显著均匀结节样强化;不典型PCNSL 21例,信号混杂,出现坏死（9例）、出血（6例）,增强后7例呈环形强化,11例呈斑片样强化,2例呈线样强化,1例无强化。典型与不典型PCNSL的1H-MRS均可见Cho峰升高、NAA峰降低、不同等级的lip-lac峰。但典型PCNSL的Cho/Cr值较不典型PCNSL高（P=0.02）;高耸的5级lip-lac峰是PCNSL的特征性表现。结论：典型与不典型PCNSL的MRI及1H-MRS有一定特征,两者结合对PCNSL的诊断具有重要价值。

Transarterial chemoembolization in hepatocellular carcinoma treatment: Barcelona clinic liver cancer staging system

Hepatocellular carcinoma(HCC),the fifth most common cancer that predominantly occurs in liver cirrhosis patients,requires staging systems to design treatments. The barcelona clinic liver cancer staging system(BCLC) is the most commonly used HCC management guideline. For BCLC stage B(intermediate HCC),transarterial chemoembolization(TACE) is the standard treatment. Many studies support the use of TACE in early and advanced HCC patients. For BCLC stage 0(very early HCC),TACE could be an alternative for patients unsuitable for radiofrequency ablation(RFA) or hepatic resection. In patients with BCLC stage A,TACE plus RFA provides better local tumor control than RFA alone. TACE can serve as bridge therapy for patients awaiting liver transplantation. For patients with BCLC B,TACE provides survival benefits compared with supportive care options. However,because of the substantial heterogeneity in the patient population with this stage,a better patient stratification system is needed to select the best candidates for TACE. Sorafenib represents the first line treatment in patients with BCLC C stage HCC. Sorafenib plus TACE has shown a demonstrable effect in delaying tumor progression. Additionally,TACE plus radiotherapy has yielded better survival in patients with HCC and portal venous thrombosis. Considering these observations together,TACE clearly has a critical role in the treatment of HCC as a stand-alone or combination therapy in each stage of HCC. Diverse treatment modalities should be used for patients with HCC and a better patient stratification system should be developed to select the best candidates for TACE.

肝纤维化分期的普美显增强MRI影像组学分析

目的应用钆塞酸增强MRI肝胆期影像,开发并验证基于影像组学的肝纤维化分期模型。材料与方法回顾性纳入2015年6月—2016年12月期间已行钆塞酸增强MRI并经病理证实的肝纤维化病人436例(年龄18~86岁,平均51岁),其中男319例(年龄18~86岁,平均51岁),女117例(年龄18~79岁,平均50岁)。

克罗恩病:CT小肠成像、MR小肠成像和小肠灌肠造影的比较

目的前瞻性比较CT和MR小肠成像及小肠灌肠造影3种检查方法发现克罗恩病病人活动性小肠炎症和肠外并发症的准确性。方法机构伦理审查委员会批准本研究计划,并所有参与者知情同意。对连续31例克罗恩病或疑有克罗恩病的病人行CT和MR小肠成像、小肠灌肠造影和回肠结肠镜检查。2位独立的阅片者回顾CT和MR小肠成像及小肠灌肠造影影像以确定活动性末端回肠炎和肠道外并发症的存在。以回结肠镜检查结果作为参考标准,利用受试者工作特性曲线方法来评估CT和MR小肠成像及小肠灌肠造影确定活动性末端回肠炎的准确度。

胶质瘤病人异柠檬酸脱氢酶(IDH)突变的成像预测:系统回顾和荟萃分析

目的研究异柠檬酸脱氢酶(IDH)突变型胶质瘤的影像特征,并评价MRI预测胶质瘤病人IDH突变的诊断效能。方法在Ovid-MEDLINE和EMBASE上系统检索截止至2017年10月10日的相关研究。

多层CT与经食管心动超声诊断卵圆孔未闭的比较

目的 通过与经食管心动超声（TEE）的比较，评价64层CT在诊断卵圆孔未闭（PFO）中的临床可行性和准确性。方法 此回顾性研究获审查委员会批准。对152例连续的脑卒中病人（男性98例，女性54例；平均年龄61．7岁）进行研究，均行多层CT和TEE检查。64层CT检查采用心电门控和盐水冲刷对比剂技术。

Sequential transcatheter arterial chemoembolization and portal vein embolization before right hemihepatectomy in patients with hepatocellular carcinoma

Background:Recent studies showed that sequential selective transcatheter arterial chemoembolization(TACE)and portal vein embolization(PVE)provided better future liver remnant(FLR)regeneration rate and disease-free survival following surgery compared with PVE alone.The present study aimed to clarify whether preoperative sequential TACE and PVE before right hemihepatectomy can reduce postoperative hepatocellular carcinoma(HCC)recurrence and improve long-term disease-free and overall survival.Methods:Recurrence and survival outcomes were retrospectively evaluated in 205 patients with HCC who underwent right hemihepatectomy by a single surgeon from November 1993 to November 2017.Patients were divided into four groups according to the procedure performed before the surgery:sequential TACE and PVE(TACE-PVE),PVE-only,TACE-only,or na?ve control groups.The baseline patient and tumor characteristics,postoperative outcomes,recurrence-free survival and overall survival were analyzed.Results:Baseline patient and tumor characteristics upon diagnosis were similar in all four groups,while sequential TACE and PVE were well tolerated.The TACE-PVE group had a higher mean increase in percentage FLR volume compared with that of the PVE-only group(17.46%±6.63%vs.12.14%±5.93%;P=0.001).The TACE-PVE group had significantly better overall and disease-free survival rates compared with the other groups(both P<0.001).Conclusions:Sequential TACE and PVE prior to surgery can be an effective therapeutic strategy for patients with HCC scheduled for major hepatic resection.The active application of preoperative sequential TACE and PVE for HCC would allow more patients with marginal FLR volume to become candidates for major hepatic resection by promoting compensatory FLR hypertrophy without the deterioration of basal hepatic functional reserve or tumor progression.

新生儿和婴儿胆道闭锁的彩色多普勒超声表现

目的描述胆道闭锁（BA）新生儿的肝脏彩色多普勒超声（US）表现．并同无BA的新生儿和正常对照组新生儿的肝脏US进行对照。材料与方法本研究经学术审核委员会的批准．可免除知情同意。回顾性分析64例胆汁淤积新生儿和19例正常对照新生儿的US和彩色多普勒US表现。BA与非BA确诊者分别为29例和35例。3名小儿放射科医生对US和彩色多普勒US表现进行评价，独立记录影像表现，有差异时协商取得一致意见。

在MR普美显增强下原发性肝癌的LI-RADS分型和预后

目的(a)评价各型肝脏影像报告和数据系统(LIRADS)原发性肝癌术后的预后意义;(b)确定2017版LIRADS在MR普美显增强中区分肝细胞肝癌(HCC)、肝内胆管细胞癌(IHCC)和肝细胞-胆管细胞混合型肝癌(cHCCCC)方面的作用。