[Contribution of spiral CT for the early diagnosis of hepato-cellular carcinoma in cirrhotic patients]. / Intérêt du scanner hélicoïdal dans le diagnostic précoce des carcinomes hépatocellulaires sur cirrhose.

PURPOSE: To evaluate the specificity of spiral CT for early diagnosis of small hepato-cellular carcinoma. PATIENTS AND METHODS: One or several hepatic hypervascular nodules, with a diameter smaller than or equal to 3cm and suspected of corresponding to small hepato-cellular carcinoma, were detected during the arterial phase of spiral CT in 55 patients. The diagnosis of the main nodule could be established in 31 patients by pathologic examination, elevated alpha-foeto-protein level or follow-up examination. RESULTS: Among the 31 studied nodules, 19 were hepato-cellular carcinomas (61%) and 12 were benign (39%). Seven (78%) of the 9 nodules>20mm and 12 (54%) of the 22 nodules<=20mmm were hepato-cellular carcinomas. Three benign lesions (2 angiomas and 1 pseudo-nodule of hemodynamic origin) were showing typical radiological characteristics which retrospectively allowed their identification. On the other hand, the appearance of the 9 other benign nodules (29%) was exactly the same as the one of the hepato-cellular carcinoma. CONCLUSION: Although, in cirrhotic patients, hepato-cellular carcinoma is the most frequent cause of detected nodules during the arterial phase of the spiral CT, 29% of hypervascular lesions<=3cm were benign in this study. In some cases, only follow-up examinations are able to confirm the diagnosis.

[Leiomyosarcoma and stromal tumor of the pancreas]. / Léiomyosarcome et tumeur stromale du pancréas.

A tumor of the head of pancreas was an incidental finding on US of two patients aged 52 and 61 years presenting with abdominal pain. The tumor was studied by computed tomography, MRI and endoscopic ultrasonography. Surgical biopsy of a liver lesion was performed in one case and partial duodenopancreatectomy was performed in the other case. Histological evaluation, including immunohistochemistry, showed leiomyosarcoma and stromal tumor respectively. Whatever the site of origin, most mesenchymal pancreatic tumors are hypervascular, heterogeneous and have a necrotic center.

Comparing contrast-enhanced breath-hold MR angiography and conventional angiography in the evaluation of mesenteric circulation.

OBJECTIVE: Our aim was to compare the results of gadolinium-enhanced breath-hold MR angiography with those of conventional angiography for the study of mesenteric circulation. SUBJECTS AND METHODS: MR angiography and digital subtraction angiography were prospectively performed in 33 patients referred for hepatic, pancreatic, or mesenteric disease. MR angiography was performed with four three-dimensional acquisitions at 0, 30, 60, and 90 sec after injection of 0.1 mmol/kg of gadolinium. Selective conventional angiography was used as the standard of reference. RESULTS: A pure arterial angiogram (one on which veins could not be visualized) was obtained in 27 patients during the second or third acquisition. By subtracting the arterial phase from an arteriovenous phase (third or fourth acquisition) we obtained a pure venous angiogram (one on which arteries could not be visualized) in 28 patients. Agreement was good or excellent for the hepatic artery (kappa = 0.78), the superior mesenteric artery (kappa = 0.65), the splenic artery (kappa = 0.70), the portal vein (kappa = 1.0), the superior mesenteric vein (kappa = 0.88), and the splenic vein (kappa = 0.75). Agreement was poor, and vessels were better shown by conventional angiography, for the intrahepatic arteries (kappa = 0.006) and the branches of the superior mesenteric artery (kappa = 0.14). MR angiography and conventional angiography revealed 29 and 27 portosystemic collaterals, respectively. CONCLUSION: Dynamic breath-hold contrast-enhanced MR angiography compared favorably with conventional angiography in preoperative assessment of the proximal mesenteric arteries and in the evaluation of portal hypertension; however, conventional angiography is still necessary to evaluate distal arteries.

Biliary leaks: treatment by means of percutaneous transhepatic biliary drainage.

PURPOSE: To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks. MATERIALS AND METHODS: Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect. RESULTS: In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma. CONCLUSION: Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.

Treatment of hepatocellular carcinoma by transcatheter arterial chemoembolization: comparison of planned periodic chemoembolization and chemoembolization based on tumor response.

OBJECTIVE: The purpose of our study was to assess the efficacy of transcatheter arterial chemoembolization in the treatment of hepatocellular carcinoma using two different infusion schedules. MATERIALS AND METHODS: Chemoembolization with lipiodol-mediated injection of doxorubicin was performed in 160 patients. In the first group of 80 patients, conventional chemoembolization was initially planned to be repeated at least three times at 2-month intervals. In the second group of 80 patients, chemoembolization was used selectively and repeated only when necessary on the basis of follow-up CT or MR imaging. According to the Okuda classification, 72 patients were stage 1, 33 belonging to group 1 (subgroup 1, Okuda 1) and 39 belonging to group 2 (subgroup 2, Okuda 1). Eighty-eight patients were stage 2, 47 belonging to group 1 (subgroup 1, Okuda 2) and 41 belonging to group 2 (subgroup 2, Okuda 2). RESULTS: Complications of transcatheter arterial chemoembolization occurred in 19 patients from group 1 and six patients from group 2 (p < .001). The mean time between the first and the third courses was significantly different between group 1 (4 months) and group 2 (14 months) (p < .001). The 1-year, 2-year, and 3-year survival rates were significantly different between subgroup 1, Okuda 1, (58%, 28%, 11%) and subgroup 2, Okuda 1 (89%, 68%, 39%) (p <. 001), and between subgroup 1, Okuda 2 (19%, 0%, 0%), and subgroup 2, Okuda 2 (48%, 31%, 15%) (p < .001). CONCLUSION: The efficacy and tolerability of chemoembolization increase when it is used selectively and repeated only when necessary. Such technical considerations might explain some of the discrepancies of the results of chemoembolization in published data.

MR cholangiography in primary sclerosing cholangitis.

OBJECTIVE: The purpose of this study was to evaluate the ability of MR cholangiography to reveal the characteristics of biliary abnormalities found in primary sclerosing cholangitis. CONCLUSION: Our results suggest that MR cholangiography could be useful in the diagnosis of primary sclerosing cholangitis. Slightly dilated peripheral bile ducts unconnected to the central ducts in several hepatic segments are a characteristic MR sign of primary sclerosing cholangitis. However, other studies are necessary to establish the usefulness of MR cholangiography in relation to other imaging techniques for evaluating primary sclerosing cholangitis.

Caroli's disease: a magnetic resonance cholangiopancreatography diagnosis.

Magnetic resonance cholangiopancreatography (MRCP) has received much attention in the recent literature as a noninvasive alternative to endoscopic retrograde cholangiography, primarily for biliary calculus disease, but also for the less common indication of evaluation of biliary anomalies. We present a case of Caroli's disease in which the diagnosis can be clearly inferred by MRCP. The findings of MRCP and endoscopic retrograde cholangiopancreatography are similar. This new procedure could be a noninvasive alternative to direct cholangiography and perhaps will become the first-choice imaging technique for diagnosing Caroli's disease.

Congenital hepatic fibrosis: findings at MR cholangiopancreatography.

OBJECTIVE: This study describes the MR imaging features of congenital hepatic fibrosis in four children who were examined with MR cholangiopancreatography. CONCLUSION: MR cholangiopancreatography effectively reveals biliary cysts, dilatation of intrahepatic bile ducts, and polycystic kidney disease, findings often associated with congenital hepatic fibrosis. This diagnosis should be suspected when these biliary and renal abnormalities are associated with hepatosplenomegaly in a patient with normal liver function.

Transjugular intrahepatic portosystemic shunt in an infant.

A 15-month-old girl, who presented with biliary cirrhosis secondary to cystic fibrosis with refractory ascites and recurrent intestinal bleeding, underwent percutaneous transjugular intrahepatic portosystemic shunting. Immediately following the procedure the ascites disappeared and no further bleeding occurred. The stent shunt was patent on Doppler ultrasound until the 22nd day. The patient died on day 22 because of liver failure due to a low-flow syndrome with severe hepatic ischaemia, but with no recurrence of bleeding or ascites.

Oral administration of a low-cost negative contrast agent: a three-year experience in routine practice.

A low cost, well tolerated, and effective gastrointestinal contrast agent is needed for abdominal MRI. The authors tested, in vitro and in routine practice, a mixture of 192 g of barium sulfate (Micropaque HD oral, Guerbet, France) diluted in 500 ml of gastric antacid (Maalox, Rohrer, Fort Washington, PA). Its T1 and T2 relaxation times were 324 and 14 msec, respectively (.2 T). This contrast agent was used in routine practice in 789 patients (.5 T). It had a low signal intensity in 86% and 82% of the cases on T1- and T2-weighted sequences, respectively. No side effect due to magnetic susceptibility was seen, even with gradient-echo sequences. The dilution of barium sulfate in gastric antacid, instead of water, causes a low signal intensity on all sequences for a low barium sulfate concentration (38% w/v). This product is an effective and low cost contrast agent in routine practice.

Hepatic iron overload: diagnosis and quantification with MR imaging.

OBJECTIVE: The aim of this study was to assess the sensitivity of MR imaging in the diagnosis of liver hemochromatosis and its ability to quantify hepatic iron concentration (HIC). SUBJECTS AND METHODS: MR images were prospectively obtained in 58 patients suspected to have hemochromatosis. We used a scanner with a 0.5-T magnet and two sequences: gradient-echo T1-weighted (400/12 [TR/TE], 90 degrees flip angle) and gradient-echo T2*-weighted (700/30, 30 degrees flip angle) sequences. Measurement of the liver-to-muscle signal-intensity ratio was compared with the HIC value measured at biopsy for each patient. RESULTS: Both MR sequences showed significant correlation between decreased signal-intensity ratios and increased HIC (r = -.87 for T1-weighted sequences and r = -.74 for T2*-weighted sequences). The sensitivity and specificity of the T2*-weighted sequence (signal-intensity ratio < 0.8) to detect iron overload (HIC > 36 mumol/g) were 91% and 88%, respectively. The best correlation was obtained with T2*-weighted sequences, when patients had an HIC less than 100 mumol/g (r = -.71); with T1-weighted sequences, the best correlation was obtained when patients had an HIC of 100-324 mumol/g (r = -.67). We found a significant correlation between the HIC revealed on MR images, calculated from both sequences, and that measured at biopsy when patients had an HIC of less than 300 mumol/g (r = -.93, p < .01). CONCLUSION: MR imaging shows promise in differentiating normal from abnormal hepatic iron concentration and in grossly quantifying moderate degrees of hepatic iron overload.

[MR cholangiopancreatography]. / Cholangio-wirsungographie par IRM.

MR cholangiopancreatography (MRCP) is a new technique allowing noninvasive investigation of the bile ducts and pancreatic duct. Due to the extremely intense signal of water on T2-weighting, MR sequences can be obtained only demonstrating liquids. The bile and pancreatic ducts can therefore be studied spontaneously even in the case of major cholestasis. The contraindications of MR cholangiography are exclusively those of MR. MRCP can visualize the level of a bile duct obstruction and often the nature of this obstruction (stone, tumour). Complementary axial T1- and T2-weighted sequences can also visualize the parenchyma around the ducts. MR cholangiography therefore appears to be a technique of the future for noninvasive investigation of the bile ducts.

[Percutaneous biliary prostheses. Type of material and indications]. / Les prothèses biliaires percutanées. Type de matériel et indications.

The results of percutaneous transhepatic endoprosthesis in the treatment of biliary stenosis are discussed on the basis of the reports of the literature and a personal experience of more than 400 patients treated for about 15 years. Advantages and disadvantages of conventional stents as compared with metal endoprosthesis are discussed, the latter being now preferred by most authors. However they do not prove to be more efficient than conventional stents which are suitable for those patients who have a relatively short life expectancy. Percutaneous treatment of benign biliary stenosis has grown as well but the choice of the best procedure remains difficult. Metal endoprostheses are controversial because the risk of delayed obstruction has not yet been clearly evaluated. However it might become an interesting therapeutic procedure in the future.