Assessment of drainage vein of focal nodular hyperplasia using contrast-enhanced ultrasound.

PURPOSE: Identification of drainage vessels is useful for differential diagnosis of hepatic tumors. Direct drainage to the hepatic vein has been reported to occur in focal nodular hyperplasia (FNH), but studies evaluating the drainage veins of FNH are limited. We aimed to investigate the detection rate of the FNH drainage vein and the factors related to visualization of the drainage vein on contrast-enhanced ultrasound (CEUS). METHODS: Fifty consecutive patients with 50 FNH lesions were retrospectively evaluated in this study. We calculated and compared the detection rate of the FNH drainage vein on CEUS, contrast-enhanced magnetic resonance imaging (CEMRI), and contrast-enhanced computed tomography (CECT), and identified the factors correlated with visualization of the FNH drainage vein on CEUS by using multivariate logistic regression analyses. RESULTS: Visualization of the drainage vein was confirmed in 31 of 50 lesions (62%) using CEUS, three of 44 lesions (6.8%) using CEMRI, and one of 18 lesions (5.6%) using CECT. The detection rate of the FNH drainage vein on CEUS was significantly higher than that on CEMRI and CECT (p < 0.001). Multivariate analysis identified lesion size (≥ 25 mm) and detection of the spoke-wheel pattern on Doppler US as independent factors for drainage vein detection in FNH. CONCLUSION: Our study showed that rapid FNH drainage to the hepatic vein was observed at a relatively high rate on CEUS, suggesting that CEUS focusing on detection of drainage veins is important for diagnosing FNH.

Contrast-enhanced ultrasonography for blood flow detection in hepatocellular carcinoma during lenvatinib therapy.

PURPOSE: Blood flow reduction after initiation of lenvatinib therapy may not always indicate tumor necrosis. This study aimed to compare the blood flow detectability of contrast-enhanced ultrasonography (CEUS), contrast-enhanced computed tomography (CT), and contrast-enhanced magnetic resonance imaging (MRI) in hepatocellular carcinoma (HCC) during lenvatinib therapy. METHODS: A total of 12 cases underwent CEUS and contrast-enhanced CT/MRI within 2 weeks during lenvatinib therapy. Vascularity on CEUS and CT/MRI was compared. RESULTS: At the time of CEUS examination, the median period from the start of lenvatinib was 227 ± 210 (31-570) days. CEUS showed hyperenhancement in eight cases (66.7%), hypoenhancement in two cases (16.7%), and no enhancement in one case (8.3%), while CT/MRI showed hyperenhancement in one case (8.3%), ring enhancement in three cases (25.0%), and hypoenhancement in eight cases (66.7%) (p = 0.007). Transarterial chemoembolization (n = 3), radiofrequency ablation (n = 2), and stereotactic body radiation therapy (n = 2) were performed after blood flow detection by CEUS. CONCLUSIONS: The viability of the HCC should be confirmed using CEUS when contrast-enhanced CT/MRI reveals lesion hypoenhancement during lenvatinib therapy.

Comparison of local recurrence in transcatheter arterial chemoembolization of hepatocellular carcinoma with or without accumulation of iodized oil beyond corona enhancement area: Short-term results.

BACKGROUND: Local tumor recurrence of hepatocellular carcinoma (HCC) often occurs in blood drainage areas. Corona enhancement is determined by computed tomography during hepatic arteriography (CTHA) and is considered to represent the blood drainage area. This study aimed to investigate the relationship between embolization of corona enhancement area and local tumor recurrence of patients with HCC who underwent transcatheter arterial chemoembolization (TACE). PATIENTS AND METHODS: The study retrospectively selected 53 patients with 60 HCC nodules that showed corona enhancement area on late-phase CTHA and showed homogenous accumulation of iodized oil throughout the nodule on non-contrast-enhanced CT performed immediately after TACE. We divided the nodules into two groups, according to whether the accumulation of iodized oil covered the entire corona enhancement area (group A) or not (group B). Local tumor recurrence was compared between the two groups. RESULTS: The cumulative local tumor recurrence rates for group A (n = 36) were 2.8%, 2.8%, 8.3% at 3, 6, and 12 months, respectively, whereas the recurrence rates for group B (n = 24) were 20.8%, 45.8%, 75% at 3, 6, and 12 months, respectively. The cumulative local tumor recurrence rates for group A were significantly lower than those for group B (hazard ratio, 0.079; 95% confidence interval, 0.026-0.24; p < 0.001). CONCLUSIONS: The results of the study suggest that the corona enhancement area may be an accurate safety margin in TACE which should be performed until the embolic area covers the entire corona enhancement area.

A Case of Pseudoprogression in Hepatocellular Carcinoma Treated With Atezolizumab Plus Bevacizumab.

A 74-year-old man was diagnosed with hepatocellular carcinoma. The tumor in the liver showed a complete response after transcatheter arterial chemoembolization, but lung, bone, and lymph node metastases were observed, so treatment with atezolizumab plus bevacizumab was initiated. After administration, the scans showed tumor growth, but after continuous administration of atezolizumab plus bevacizumab, the tumors finally reduced in size and showed a partial response. The transient growth of the tumors was considered to be pseudoprogression. Herein, we report a case of pseudoprogression in hepatocellular carcinoma treated with atezolizumab plus bevacizumab.

Ultrasonographic grayscale findings related to fibrosis in patients with non-alcoholic fatty liver disease: comparison with transient elastography and Fib-4 index.

PURPOSE: Fibrosis is a predictor of mortality in patients with non-alcoholic fatty liver disease (NAFLD). In our institution, abdominal ultrasonography has been performed based on a unified method consisting of 25 images. We investigated ultrasonographic grayscale findings related to fibrosis in patients with NAFLD. METHODS: This retrospective study comprised 41 cases of pathologically proven fatty liver between January 2015 and September 2020. A total of 26 ultrasonographic findings were subjectively evaluated. These findings, transient elastography (TE) with M probe, and FIB-4 index were compared with fibrosis stage. RESULTS: The frequency of roughness of the dorsal side of the surface (p < 0.001), heterogenicity of the parenchyma (p = 0.003), narrowing of the hepatic vein (p = 0.004), and splenomegaly (p < 0.001) were strongly correlated with the fibrosis stage. Logistic regression analysis for stage ≥ 3 showed narrowing of the hepatic vein (odds ratio [OR] 5.860, p = 0.031) and splenomegaly (OR 6.290, p = 0.028). Logistic regression analysis for stage 4 showed roughness of the ventral side of the surface (OR 42.0, p = 0.019). The AUROC for stage 3 and stage 4 with the number of positive ultrasonographic findings was 0.856, and 0.940, respectively. The AUROC for F3 and F4 with TE was 0.831 and 0.861, respectively. The AUROC for stage 3 and stage 4 with FIB-4 index was 0.815 and 0.806, respectively. CONCLUSIONS: Narrowing of the hepatic vein, roughness of the dorsal side of the surface, heterogenicity of the parenchyma, and splenomegaly and their combination could predict fibrosis in patients with NAFLD.

Renal vein measurement using ultrasonography in patients with cirrhotic ascites and congestive heart failure.

PURPOSE: Ascites can cause compression of the inferior vena cava (IVC), leading to increased renal venous pressure and renal congestion. Previously, the left renal vein diameter in liver cirrhosis patients with ascites was measured using computed tomography, showing that enlargement of the left renal vein diameter affects the prognosis. Herein, the diameter and flow velocity of the renal veins were measured using ultrasonography. METHODS: Abdominal ultrasonography was performed on 186 patients. The patients were divided into four groups: normal liver (n = 102), liver cirrhosis (LC) without ascites (n = 37), LC with ascites (n = 30), and congestive liver (n = 17). Ultrasonographic measurements for diameter and flow velocity of the IVC, left renal vein main trunk, and segmental renal vein were performed. RESULTS: The left renal vein diameter increased in the following order: normal liver, LC, LC with ascites, and congestive liver groups (P < 0.001). IVC flow velocity was lower and left renal vein diameter was larger in the congestive liver and LC with ascites groups. These results suggest that the two groups have different pathological conditions, but the mechanism of renal congestion is similar. In patients with LC, IVC compression due to ascites might cause blood stagnation and renal congestion. CONCLUSION: The left renal vein and IVC can be measured using ultrasonography. It might help in furthering our understanding of the pathophysiology of renal congestion in these patients.

Quantitative Ultrasound Image Analysis Helps in the Differentiation of Hepatocellular Carcinoma (HCC) From Borderline Lesions and Predicting the Histologic Grade of HCC and Microvascular Invasion.

OBJECTIVES: Quantitative image analysis is one of the methods to overcome the lack of objectivity of ultrasound (US). The aim of this study was to clarify the correlation between the features from a US image analysis and the histologic grade and microvascular invasion (MVI) of hepatocellular carcinoma (HCC) and differentiation of HCC smaller than 2 cm from borderline lesions. METHODS: We retrospectively analyzed grayscale US images with histopathologic evidence of HCC or a precancerous lesion using ImageJ version 1.47 software (National Institutes of Health, Bethesda, MD). RESULTS: A total of 148 nodules were included (borderline lesion, n = 31; early HCC [eHCC], n = 3; well-differentiated HCC [wHCC], n = 16; moderately differentiated HCC [mHCC], n = 79; and poorly differentiated HCC [pHCC], n = 19). A multivariate analysis selected lower minimum gray values (odds ratio [OR], 0.431; P = .003) and a higher standard deviation (OR, 1.880; P = .019) as predictors of HCC smaller than 2 cm. Median (range) minimum gray values of borderline lesions, eHCC, wHCC, mHCC, and pHCC were 29 (0-103), 7 (0-47), 6 (0-60), 10 (0-53), and 2 (0-38), respectively, and gradually decreased from borderline lesions to pHCC (P < 0.001). The multivariate analysis showed a higher aspect ratio (OR, 2.170; P = .001) and lower minimum gray value (OR, 0.475; P = .043) as predictors of MVI. An anechoic area diagnosed by a subjective evaluation was correlated with the minimum gray value (P < .0001). The proportion of the anechoic area gradually increased from eHCC to pHCC (P = .031). CONCLUSIONS: In a US image analysis, HCC smaller than 2 cm had features of greater heterogeneity and a lower minimum gray value than borderline lesions. Moderately differentiated HCC was smoother than borderline lesions, and the anechoic area correlated with histologic grading. Microvascular invasion was correlated with a slender shape and a lower minimum gray value.

New algorithm using L1 regularization for measuring electron energy spectra.

Retrieving the spectrum of physical radiation from experimental measurements typically involves using a mathematical algorithm to deconvolve the instrument response function from the measured signal. However, in the field of signal processing known as "Source Separation" (SS), which refers to the process of computationally retrieving the separate source components that generate an overlapping signal on the detector, the deconvolution process can become an ill-posed problem and crosstalk complicates the separation of the individual sources. To overcome this problem, we have designed a magnetic spectrometer for inline electron energy spectrum diagnosis and developed an analysis algorithm using techniques applicable to the problem of SS. An unknown polychromatic electron spectrum is calculated by sparse coding using a Gaussian basis function and an L1 regularization algorithm with a sparsity constraint. This technique is verified by using a specially designed magnetic field electron spectrometer. We use Monte Carlo simulations of the detector response to Maxwellian input energy distributions with electron temperatures of 5.0 MeV, 10.0 MeV, and 15.0 MeV to show that the calculated sparse spectrum can reproduce the input spectrum with an optimum energy bin width automatically selected by the L1 regularization. The spectra are reproduced with a high accuracy of less than 4.0% error, without an initial value. The technique is then applied to experimental measurements of intense laser accelerated electron beams from solid targets. Our analysis concept of spectral retrieval and automatic optimization of energy bin width by sparse coding could form the basis of a novel diagnostic method for spectroscopy.

The influence of esophagogastroduodenoscopy using carbon dioxide insufflation on abdominal ultrasonographic imaging efficiency.

PURPOSE: The ability to perform abdominal ultrasonography after esophagogastroduodenoscopy (EGD) is hypothesized to improve examination efficiency. Therefore, we performed abdominal ultrasonography before and after EGD to verify the effects of EGD on abdominal ultrasonographic imaging efficiency. METHODS: We performed abdominal ultrasonography before, immediately after, 30 min after, and 60 min after EGD with carbon dioxide (CO2) insufflation in 23 consecutive patients who visited our center between July 2015 and December 2016. We examined the visualization status of the head, body, and tail of the pancreas; extrahepatic bile duct; and inferior pole of the right kidney. RESULTS: The visualization status of the pancreas decreased immediately after EGD in approximately 50% of patients; however, at 30 min and after, the status was almost the same as for imaging performed before endoscopy. Visualization of the extrahepatic bile duct decreased slightly immediately after the procedure; however, 30 min and later, it was almost the same as before endoscopy. The inferior pole of the right kidney was observable from the dorsal side and could be visualized at all examination points in all patients. CONCLUSION: There was no difficulty in performing abdominal ultrasonography at 30 min or later following EGD with CO2 insufflation. Additionally, visualization of the head, body, and tail of the pancreas as well as the extrahepatic bile duct was improved in some patients.

Utility of Contrast-Enhanced Ultrasound for Early Therapeutic Evaluation of Hepatocellular Carcinoma After Transcatheter Arterial Chemoembolization.

OBJECTIVES: We aimed to investigate whether contrast-enhanced ultrasound (CEUS) could be useful for early evaluation of the treatment response to transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma (HCC). METHODS: This study retrospectively selected HCCs in which homogeneous retention of iodized oil was confirmed on non-contrast-enhanced computed tomography performed immediately after TACE. Therapeutic responses of HCCs were evaluated by CEUS 1 to 2 days after TACE and by contrast-enhanced computed tomography (CECT) approximately 4 weeks after TACE. We investigated the noninferiority of CEUS 1 to 2 days after TACE to CECT approximately 4 weeks after TACE in terms of the diagnostic accuracy of the therapeutic response to TACE on HCC. RESULTS: Eighty-nine HCCs were enrolled in this study between April 2014 and June 2016. A complete response was observed in 57 of 89 nodules (64.0%), and an incomplete response was observed in the remaining 32 nodules (36.0%). The accuracy rates for CEUS 1 to 2 days after TACE and CECT approximately 4 weeks after TACE in the therapeutic effect of TACE on HCCs were 83.1% (95% confidence interval, 73.7%-90.2%) and 83.1% (95% confidence interval, 73.7%-90.2%), respectively. The difference in diagnostic accuracy between methods was 0%, which was below the predetermined noninferiority limit of 15%, and CEUS 1 to 2 days after TACE was noninferior to CECT approximately 4 weeks after TACE. CONCLUSIONS: Our results suggest that CEUS is a useful modality for early therapeutic evaluation of TACE for HCC, and we can thus plan the next treatment strategies for HCC within a few days after TACE.

Hepatic hemangioma supplied by abnormal portal vein: A case report.

Hepatic hemangioma is the most common hepatic tumor with a prevalence of approximately 3%. It is typically supplied by the hepatic artery as evident from findings of abdominal angiography, contrast-enhanced ultrasonography (CEUS), contrast-enhanced computed tomography (CT), and contrast-enhanced magnetic resonance imaging. However, few cases of hepatic hemangioma supplied by the portal vein have been reported. In this paper, we report a rare case of hepatic hemangioma supplied by the portal vein as shown on CEUS and CT arterioportography.

Renal vein dilation predicts poor outcome in patients with refractory cirrhotic ascites.

AIM: Renal venous hypertension is known to be associated with worsening of renal function in patients with decompensated heart failure. Intra-abdominal hypertension including cirrhotic ascites also leads to renal venous hypertension. We aimed to clarify the effect of renal venous hypertension on cirrhotic ascites. METHODS: Two hepatologists measured the left renal vein diameter in 142 consecutive patients with refractory cirrhotic ascites using non-contrast computed tomography. The renal vein diameter was measured at the renal vein main trunk and upstream of the confluence of collateral veins. RESULTS: The inter-observer agreements were high for the measurements of the left renal vein (r = 0.918, P < 0.001). The median overall survival for patients with renal vein diameter ≥11 mm was less than that for patients with renal vein diameter <11 mm (P < 0.001; 2.5 vs. 32.0 months). One-year survival rates were 15.3% versus 66.4%. Multivariate analysis revealed renal vein diameter ≥11 mm (hazard ratio, 2.94; P < 0.001; 95% confidence interval, 1.67-5.20) and a high Model for End-stage Liver Disease score combined with serum sodium level (MELD-Na) (hazard ratio, 3.39; P < 0.001; 95% confidence interval, 2.00-5.74) were significant independent predictors of mortality. CONCLUSIONS: Renal vein dilation is a risk factor of mortality in patients with refractory cirrhotic ascites, independent of the MELD-Na score.

Solitary Variceal Rupture in the Small Intestine.

A 70-year-old man was referred to our hospital to undergo treatment for hepatocellular carcinoma. In hospital, he complained of hematochezia and a laboratory analysis revealed a decreased level of hemoglobin. Abdominal computed tomography revealed a tumor in the small intestine, with slow enhancement of the dorsal region. Double-balloon enteroscopy revealed a submucosal tumor with a depression in the jejunum. Partial enterectomy was performed and a pathological examination demonstrated the presence of a solitary varix. Solitary varix in the small intestine has not been reported previously. We herein report an extremely rare case of solitary varix in the jejunum.

Focal nodular hyperplasia: our experience of 53 Japanese cases.

PURPOSE: Contrast-enhanced ultrasound (CEUS) is a very sensitive diagnostic tool in characterizing liver tumors. It is especially useful in the diagnosis of focal nodular hyperplasia (FNH) of the liver. According to the previous reports, FNH is common in young women, and it is usually diagnosed by MRI. The majority of the previous reports come from European countries, and a very few studies of large series designed to describe the clinical features in Japanese patients have been reported. The aim of this study was to (a) describe the clinical features in 53 patients (59 lesions) diagnosed with CEUS and (b) compare the data with those from the previous reports. METHODS: The medical data from 53 patients diagnosed on the basis of typical CEUS findings at our institution and affiliated hospitals were reviewed, and their clinical data were analyzed. RESULTS: (1) The medical data from 53 cases showed a slight male predilection, with 30 male cases (57 %) and 23 female cases (43 %), although the occurrence in both sexes was equal. FNH cases were distributed throughout all generations in both sexes, mostly concentrated in the age of 30-60 years old, and metabolic cases were more common in men than in women (4 vs 0). (2) The lesions were small (mean: 23 mm) and distributed throughout the whole liver. (3) Lesion size was not influenced by age in either sex. (4) A rapid draining to the hepatic vein was recognized in five out of 59 lesions (8 %). CONCLUSIONS: Our data indicate that FNH occurs slightly more frequently in men than in women in Japan. It occurs also at any age in both sexes, but the mean lesion size was smaller in our series than in the previous reports. Metabolic disease was seen only in male FNH patients. A direct communication between the FNH lesion and the hepatic vein is diagnostically worth noting.

Contrast-enhanced ultrasonographic findings of serum amyloid A-positive hepatocellular neoplasm: Does hepatocellular adenoma arise in cirrhotic liver?

Hepatocellular adenoma (HCA) was recently classified into four pathological subtypes. There have been few studies describing the findings of contrast-enhanced ultrasonography (CEUS) of each type. Our case concerns a 78-year-old man who had undergone routine medical check-ups for hepatitis C for 11 years. Abdominal ultrasonography showed a 28 mm, hypo-echoic mass in the segment 4 of the liver. His integrating amount of drinking was 670 kg convert into ethanol. CEUS with Sonazoid demonstrated mild uniform hypo-enhancement with inflow of microbubbles from the periphery of the tumor in the arterial phase, and heterogeneously hypo-enhancement in the post vascular phase. Because the mass increased in size within 3 mo, a well differentiated hepatocellular carcinoma was suspected, and hepatic resection was performed. Microscopic findings showed homogeneous cell proliferation with low grade atypia, infiltration of inflammatory cells, ductular reactions, fatty deposit in part, and sinusoidal dilation. Immunohistochemistry revealed geographic positive for serum amyloid A (SAA), focal positive for glutamine synthetase, diffuse and strong positive for C-reactive protein, and positive for liver-type fatty acid binding protein. These pathological features corresponded to that of an inflammatory HCA. However, we could not make a clear diagnosis, because HCAs were defined as not to arise in cirrhotic liver. Finally, this tumor was diagnosed as a SAA positive hepatocellular neoplasm.

Onset of Tuberculosis from a Pulmonary Latent Tuberculosis Infection during Antiviral Triple Therapy for Chronic Hepatitis C.

A 62-year-old man was diagnosed with the onset of tuberculosis (Tb) from a pulmonary latent tuberculosis infection (LTBI) during triple therapy with pegylated interferon α2a, ribavirin, and telaprevir for a chronic hepatitis C infection in 2013 before interferon (IFN)-free anti-viral therapy was introduced in Japan. A liver biopsy before IFN treatment revealed the presence of epithelioid cell granulomas (ECGs). IFN may also be employed for chronic hepatitis B infection and malignant tumors, thus, special attention must be paid to the development of Tb from a LTBI when ECGs are observed before treatment. It is also necessary to review the significance of the liver biopsy.

Sarcomatoid Hepatocellular Carcinoma with Spontaneous Intraperitoneal Bleeding.

An 80-year-old woman was admitted to our hospital with right hypochondralgia. Abdominal ultrasonography showed a well-circumscribed round lesion in segments 5 and 6 of the liver. Contrast-enhanced ultrasonography (CEUS) indicated that the tumor was enhanced in the arterial phase, changing to hypo-enhanced 30 seconds following contrast injection. After admission, the patient complained of epigastralgia, and CEUS subsequently demonstrated extravasation from the tumor. Although abdominal angiography was successful for achieving hemostasis, the tumor grew rapidly and the patient died. An autopsy revealed the presence of sarcomatoid hepatocellular carcinoma (HCC). The literature is lacking in details regarding CEUS findings for sarcomatoid HCC and rupture. We herein report a rare case of sarcomatoid HCC.