Clinical and histological features of different types of Budd-Chiari syndrome: a comparison of 4 cases.

Budd-Chiari syndrome (BCS) is a rare condition characterized by hepatic venous outflow obstruction. In this report, we present 4 cases of BCS with complete and incomplete obstruction of the inferior vena cava (IVC) and hepatic vein (HV). Each case showed different and unique features of liver damage, which were attributed to the site and degree of obstruction. Interestingly, improved liver functions such as increased serum albumin levels, decreased hyaluronic acid levels and a normal indocyanine green clearance test were evident within 1 month of the balloon angioplasty. Pericellular fibrosis and hypervascular regenerative nodules were also reversible after obstruction removal. Therefore, it is very important to manage this rare disease before it progresses to liver cirrhosis.

Contrast behavior of high-spatial-resolution T1-weighted MR imaging at 3.0 T vs. 1.5 T.

Twenty-four volunteers were examined at T1-weighted images with thin sections using gradient-based sequences with a possible short and same TR at 3.0 and 1.5 T. Pancreas-to-spleen contrast measurements and scores for visual assessments of image contrast were significantly worse at 3.0 T than at 1.5 T on both sequences. The image contrast of high-spatial-resolution T1-weighted images at 3.0 T is decreased compared to that of images with the same and possible short TR at 1.5 T.

Diffusion tensor MRI of the kidney at 3.0 and 1.5 Tesla.

BACKGROUND: Diffusion tensor imaging (DTI) at 3 T provides information on the microstructure and pathophysiology of tissues that is not available from conventional imaging with an advantage of high signal to noise ratio (SNR). PURPOSE: To evaluate the feasibility of DTI of the normal kidney at 3.0 T compared to results obtained at 1.5 T. MATERIAL AND METHODS: DTI of the normal kidney of 15 healthy volunteers obtained with 3.0 and 1.5 T scanners using respiration-triggered acquisition was examined. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of both the renal cortex and the medulla and SNRs were measured (b-values 0 and 400 s/mm², diffusion direction of 6). The image quality of FA and ADC maps was also compared subjectively. RESULTS: The FA values of the renal cortex were 0.15 ± 0.03 at 3.0 T and 0.14± 0.03 at 1.5 T on average. This difference was not significant. The FA values of the renal medulla were 0.49 ±0.04 at 3.0 T and 0.42 ± 0.05 at 1.5 T. ADC values of the renal cortex were 2.46 x 10⁻³± 0.09 mm<²/s at 3.0 T and 2.20 x 10⁻³±0.11 mm²/s at 1.5 T. The ADC values of the renal medulla were 2.08 x 10⁻³ ± 0.08 mm²/s at 3.0 T and 1.90 x 10⁻³± 0.11 mm²/s at 1.5 T. These FA and ADC values were consistent with previous publications. The difference was significant for the FA value of the medulla (P< 0.01) and ADC values in both cortex and medulla (P < 0.01). The subjective image quality of the FA map with the 3.0 T scanner was significantly superior to that with the 1.5 T scanner (P< 0.01), but not significant for the ADC map (P = 0.18). There was a significant difference in SNR between 3.0 T (48.8 ± 6.6) and 1.5 T images (32.8 ± 5.0). CONCLUSION: The feasibility of renal DTI with a 3.0 T magnet resulting in improved SNR was demonstrated.

High spatial resolution 3D MR cholangiography with high sampling efficiency technique (SPACE): comparison of 3T vs. 1.5T.

PURPOSE: The aim of this study was to evaluate image quality of 3D MR cholangiography (MRC) using high sampling efficiency technique (SPACE) at 3T compared with 1.5T. METHODS AND MATERIALS: An IRB approved prospective study was performed with 17 healthy volunteers using both 3 and 1.5T MR scanners. MRC images were obtained with free-breathing navigator-triggered 3D T2-weighted turbo spin-echo sequence with SPACE (TR, >2700ms; TE, 780ms at 3T and 801ms at 1.5T; echo-train length, 121; voxel size, 1.1mmx1.0mmx0.84mm). The common bile duct (CBD) to liver contrast-to-noise ratios (CNRs) were compared between 3 and 1.5T. A five-point scale was used to compare overall image quality and visualization of the third branches of bile duct (B2, B6, and B8). The depiction of cystic duct insertion and the highest order of bile duct visible were also compared. The results were compared using the Wilcoxon signed-ranks test. RESULTS: CNR between the CBD and liver was significantly higher at 3T than 1.5T (p=0.0006). MRC at 3T showed a significantly higher overall image quality (p=0.0215) and clearer visualization of B2 (p=0.0183) and B6 (p=0.0106) than at 1.5T. In all analyses of duct visibility, 3T showed higher scores than 1.5T. CONCLUSION: 3T MRC using SPACE offered better image quality than 1.5T. SPACE technique facilitated high-resolution 3D MRC with excellent image quality at 3T.

A comparative study of pathological staging systems in predicting recurrent hepatocellular carcinoma after liver transplantation.

BACKGROUND/PURPOSE: The applicability of the staging systems of hepatocellular carcinoma (HCC) to liver transplantation (LT) has not been fully evaluated. Therefore, we compared the HCC recurrence after LT as predicted by various staging systems, including the American Joint Committee on Cancer (AJCC) system 5th edition, the AJCC system 6th edition, the American Liver Tumor Study Group (ALTSG) system, and the Liver Cancer Study Group of Japan (LCSGJ) system. METHODS: A total of 108 patients who had HCC were classified according to these systems. We compared cumulative recurrence curves, recurrence-free survival curves, and overall survival curves of the systems estimated by Kaplan-Meier method. We compared cumulative event rates among different stages with the log-rank test for each staging system. RESULTS: The log-rank test showed that the cumulative recurrence rates were different among different stages with a statistical significance for the staging systems except for the AJCC 5th edition system. Cumulative recurrence curves by the AJCC 6th edition system and the LCSGJ system showed better visual separation than the other two systems. With respect to recurrence-free survival and overall survival, no staging systems showed significant discriminative power. CONCLUSIONS: The current AJCC tumor-node-metastasis staging and the LCSGJ system are superior in predicting HCC recurrence after LT.

Hepatic lesions: improved image quality and detection with the periodically rotated overlapping parallel lines with enhanced reconstruction technique--evaluation of SPIO-enhanced T2-weighted MR images.

PURPOSE: To evaluate the effectiveness of the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) technique for superparamagnetic iron oxide (SPIO)-enhanced T2-weighted magnetic resonance (MR) imaging with respiratory compensation with the prospective acquisition correction (PACE) technique in the detection of hepatic lesions. MATERIALS AND METHODS: The institutional human research committee approved this prospective study, and all patients provided written informed consent. Eighty-one patients (mean age, 58 years) underwent hepatic 1.5-T MR imaging. Fat-saturated T2-weighted turbo spin-echo images were acquired with the PACE technique and with and without the PROPELLER method after administration of SPIO. Images were qualitatively evaluated for image artifacts, depiction of liver edge and intrahepatic vessels, overall image quality, and presence of lesions. Three radiologists independently assessed these characteristics with a five-point confidence scale. Diagnostic performance was assessed with receiver operating characteristic (ROC) curve analysis. Quantitative analysis was conducted by measuring the liver signal-to-noise ratio (SNR) and the lesion-to-liver contrast-to-noise ratio (CNR). The Wilcoxon signed rank test and two-tailed Student t test were used, and P < .05 indicated a significant difference. RESULTS: MR imaging with the PROPELLER and PACE techniques resulted in significantly improved image quality, higher sensitivity, and greater area under the ROC curve for hepatic lesion detection than did MR imaging with the PACE technique alone (P < .001). The mean liver SNR and the lesion-to-liver CNR were higher with the PROPELLER technique than without it (P < .001). CONCLUSION: T2-weighted MR imaging with the PROPELLER and PACE technique and SPIO enhancement is a promising method with which to improve the detection of hepatic lesions. (c) RSNA, 2009.

Diffusion tensor imaging of kidneys with respiratory triggering: optimization of parameters to demonstrate anisotropic structures on fraction anisotropy maps.

PURPOSE: To demonstrate the feasibility of diffusion tensor imaging (DTI) of kidneys with respiratory triggering, and determine the optimal imaging parameters for fraction anisotropy (FA) maps. MATERIALS AND METHODS: DTI of kidneys from 16 healthy volunteers was performed using a 1.5T scanner. Five different sequences with different parameters including respiration-triggered acquisition or multiple breath-holding, slice thicknesses of 3 or 5 mm, and different numbers of signal averaging and b values were compared. FA and apparent diffusion coefficients (ADCs) of the cortex and medulla were measured. Measurement error within the same and repeated examination was examined using within-individual standard deviation (Sw). RESULTS: FAs of the renal cortex were lower than the medulla (mean value of a sequence ranging 0.148-0.224, 0.433-0.476) and the ADCs of the cortex were higher than the medulla (2.26-2.69x10(-3) mm2/s, 1.77-2.19x10(-3) mm2/s) in all sequences (P<0.001). The renal cortex-medulla difference was the largest, with respiratory trigger- ing including a 3-mm slice thickness, three signal averages,and a b-value=0, 200, or 400 s/mm2 (P<0.001). Sw tended to be smaller in the sequence with a b-value of 400 s/mm2. CONCLUSION: DTI of kidneys with respiratory triggering is feasible with excellent cortex-medulla differentiation.

Non-contrast-enhanced MR angiography for selective visualization of the hepatic vein and inferior vena cava with true steady-state free-precession sequence and time-spatial labeling inversion pulses: preliminary results.

PURPOSE: To selectively visualize the hepatic vein and inferior vena cava (IVC) using three-dimensional (3D) true steady-state free-precession (SSFP) MR angiography with time-spatial labeling inversion pulse (T-SLIP), and to optimize the acquisition protocol. MATERIALS AND METHODS: Respiratory-gated 3D true SSFP scans were conducted in 23 subjects in combination with two different T-SLIPs (one placed in the thorax to suppress the arterial signal and the other in the abdomen to suppress the portal venous signal). One of the most important factors was the inversion time (TI) of abdominal T-SLIP, and the image quality was evaluated at four different TIs of 800, 1200, 1600, and 2000 msec in terms of relative signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and mean visualization scores. RESULTS: No significant difference was observed in SNR and CNR between each TI. However, IVC visualization scores were better at TIs of 1600 and 2000 msec, and overall image quality was better at TIs of 1200 and 1600 msec. Therefore, the TI of 1600 msec was considered to provide the optimal balance between IVC visualization and signal suppression of the portal vein in our protocol. CONCLUSION: True SSFP scan with T-SLIPs enabled selective visualization of the hepatic vein and IVC without an exogenous contrast agent.

Non-contrast-enhanced hepatic MR angiography with true steady-state free-precession and time spatial labeling inversion pulse: optimization of the technique and preliminary results.

OBJECTIVE: To selectively visualize the hepatic arteries using the respiratory-triggered three-dimensional (3D) true steady-state free-precession (SSFP) projection magnetic resonance angiographic sequence with time spatial labeling inversion pulse (T-SLIP), and describe the optimization of this protocol. MATERIALS AND METHODS: Twenty healthy volunteers were examined in this study. A respiratory-triggered 3D true SSFP combined with T-SLIP was performed. Among several key factors that affect the image quality, the most important is the inversion time (TI). Therefore, according to the difference in TI, four image groups: group A (TI of 800 ms), group B (TI of 1000 ms), group C (TI of 1200 ms), and group D (TI of 1400 ms), were assigned and compared to detect the optimal TI for hepatic artery visualization. For quantitative assessment, the relative signal intensity, i.e., Cv-l (vessel-to-liver contrast) of the right hepatic artery was measured. For qualitative evaluation, the quality of vessel visualization and the order of identified hepatic artery branches were evaluated by two radiologists. RESULTS: Selective and high-contrast visualization of the hepatic arteries was acquired in all cases. Regarding the quantitative assessment, Cv-l decreased in group D due to background signal recovery, but there was no significant difference between groups (p-value >0.05). Regarding the qualitative evaluation, there were significant differences between group A and the other groups (p-value <0.01) and between groups B and C (p-value <0.05). In group C, both the image quality score and mean value for the order of the hepatic artery branches were highest, and a TI of 1200 ms was thought to be optimal regarding the balance between vessel-to-liver contrast and peripheral hepatic artery visualization. CONCLUSION: The MR angiographic technique using true SSFP with T-SLIP enabled the selective visualization of hepatic arteries without the need for an exogenous contrast agent or breath-hold.

Loss of heterozygosity on 10q23 is involved in metastatic recurrence of hepatocellular carcinoma.

We performed loss of heterozygosity (LOH) analysis on five chromosomal arms (1p, 3p, 9p, 10q, 17p) in hepatocellular carcinoma (HCC). Univariate analyses of 80 patients who underwent liver transplantation demonstrated significant correlations between cancer recurrence and the following variables: LOH on 3p26, LOH on 10q23, LOH on 17p13, tumor diameter > or = 5 cm, number of tumors > or = 4, histologic Grade 3, alpha-fetoprotein (AFP) > or = 400 ng/mL, American Joint Committee on Cancer (AJCC) pT classification, and portal invasion. Patients with LOH on 10q23 exhibited a significantly higher 3-year recurrence rate (38.9%vs 11.9%, P = 0.0009). Multivariate analysis identified LOH on 10q23, histologic Grade 3, tumor nodules > or = 4, and AFP > or = 400 ng/mL as the risk factors of advanced HCC recurrence. These results suggest that LOH on 10q23 is associated with metastatic recurrence of HCC.

F-18 fluorodeoxyglucose uptake in a solid pseudopapillary tumor of the pancreas mimicking malignancy.

Solid pseudopapillary tumors (SPTs), predominantly affecting young women, are rare pancreatic tumors. It is reported that imaging features of SPT are solid and cystic components, and there is intratumoral hemorrhage and calcification. However, findings of positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG) with pathologic correlation have not been fully evaluated. We present a case of SPT that mimicked malignancy on FDG-PET.

MRI artifact reduction and quality improvement in the upper abdomen with PROPELLER and prospective acquisition correction (PACE) technique.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER [BLADE in the MR systems from Siemens Medical Solutions]) with a respiratory compensation technique for motion correction, image noise reduction, improved sharpness of liver edge, and image quality of the upper abdomen. SUBJECTS AND METHODS: Twenty healthy adult volunteers with a mean age of 28 years (age range, 23-42 years) underwent upper abdominal MRI with a 1.5-T scanner. For each subject, fat-saturated T2-weighted turbo spin-echo (TSE) sequences with respiratory compensation (prospective acquisition correction [PACE]) were performed with and without the BLADE technique. Ghosting artifact, artifacts except ghosting artifact such as respiratory motion and bowel movement, sharpness of liver edge, image noise, and overall image quality were evaluated visually by three radiologists using a 5-point scale for qualitative analysis. The Wilcoxon's signed rank test was used to determine whether a significant difference existed between images with and without BLADE. A p value less than 0.05 was considered to be statistically significant. RESULTS: In the BLADE images, image artifacts, sharpness of liver edge, image noise, and overall image quality were significantly improved (p < 0.001). CONCLUSION: With the BLADE technique, T2-weighted TSE images of the upper abdomen could provide reduced image artifacts including ghosting artifact and image noise and provide better image quality.

Contrast behavior and image quality of magnetic resonance cholangiopancreatography imaging using variable echo times at 3.0 T.

Twenty-five volunteers were examined at three different echo times (TE) using magnetic resonance cholangiopancreatography (MRCP) images obtained with half-Fourier-acquired single-shot turbo spin echo (HASTE) thick-slab and multislice HASTE to identify the optimal TE at 3.0 T. No significant difference in the overall image quality was found comparing three different TEs within commonly used ranges. We observed an almost identical duct visibility with different TEs, while we found a trend toward superior visibility of the cystic duct at shorter TE.

High-spatial-resolution three-dimensional MR cholangiography using a high-sampling-efficiency technique (SPACE) at 3T: comparison with the conventional constant flip angle sequence in healthy volunteers.

PURPOSE: To evaluate the image quality of high-spatial-resolution three-dimensional magnetic resonance cholangiography (MRC) with a high-sampling-efficiency technique (sampling perfection with application optimized contrasts using different flip angle evolutions [SPACE]) in comparison with a conventional constant flip angle (FA) sequence at 3T. MATERIALS AND METHODS: Eighteen volunteers were examined on a 3T MR unit using MRC imaging performed with three different free-breathing three-dimensional T2-weighted turbo spin-echo (TSE) sequences: 1) SPACE (spatial resolution, 1.1x1.0x0.84 mm), 2) constant FA (1.1x1.0x0.84 mm), and 3) SPACE at a higher resolution (SPACE HR; 1.0x0.9x0.644 mm). A five-point scale was used to compare overall image quality and visualization of the third branches of the bile duct (B2, B6, and B8). Depictions of cystic duct insertion and the highest order of bile duct visible were also compared. RESULTS: MRC with SPACE and SPACE HR sequences produced significantly better overall image quality than the constant FA sequence. In all analyses of duct visibility, SPACE and SPACE HR sequences showed higher scores than the constant FA sequence. CONCLUSION: High-resolution three-dimensional MRC with SPACE at 3T allows high-quality imaging of the biliary tract, and has the ability to depict nondilated intrahepatic bile ducts (IHBD) in healthy volunteers.

Evaluation of motion correction effect and image quality with the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) (BLADE) and parallel imaging acquisition technique in the upper abdomen.

PURPOSE: To evaluate motion correction effect and image quality in the upper abdomen with the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) (BLADE) and parallel imaging acquisition technique. MATERIALS AND METHODS: A total of 50 consecutive patients underwent abdominal MR imaging. Fat-saturated T2-weighted turbo spin-echo sequences were obtained by respiratory triggering. The subjects were examined with three different conditions of echo train length (ETL), blade width, and percent k-space coverage in the same scanning time: 19/30/100%, 30/30/100%, and 30/52/175%, which were designated as L/C(1), L/C(2), and L/C(3), respectively. The parallel imaging acquisition technique was used to either reduce ETL from 30 to 19 in L/C(1) or increase k-space coverage from 100% to 175% in L/C(3) compared with L/C(2). Motion and streak artifacts, and overall image quality were evaluated visually by two radiologists, independently. RESULTS: Motion and streak artifacts were mostly reduced in L/C(3) condition. The L/C(3) image also gave the best overall image quality compared with other conditions (P < 0.001). The inter-rater reliability for each evaluation agreed well. CONCLUSION: In upper abdominal BLADE MRI, it was possible to reduce image artifacts and obtain better image quality by increasing the k-space coverage with parallel imaging in the same scanning time.

Hepatocellular carcinoma in patients undergoing living-donor liver transplantation. Accuracy of multidetector computed tomography by viewing images on digital monitors.

OBJECTIVE: To compare 8-detector row helical computed tomography (CT) findings with histopathology in patients with hepatocellular carcinoma (HCC) who had undergone living-donor liver transplantation (LDLT). MATERIALS AND METHODS: This institutional review board-approved prospective study was performed between February 12, 2003 and November 12, 2004; of the 78 candidates for LDLT due to HCC who underwent preoperative multidetector CT (MDCT), 48 transplant recipients met our criteria and in 41 of them, HCCs were diagnosed with <15 lesions on MDCT; these patients represented the study population. Results of preoperative CT were correlated with histopathological results after 5-mm sagittal slicing of the explanted liver. Following the injection of contrast medium (2 ml/kg body weight of 300 mg I/ml), triple-phase contrast-enhanced images were obtained. CT was performed using the following parameters: detector row configuration, 8 x 1 mm, reconstruction interval, 1 mm, 200 mA s and 120 kVp. Image analysis was performed in consensus by three abdominal radiologists using 1-mm-thick slices with 0.5-mm overlap with paging as well as multiplanar reformatting (MPR; i.e. axial, coronal and sagittal images). RESULTS: A total of 134 HCCs were identified by pathological examination. The mean lesion size was 21 mm. Sensitivity, positive predictive value and accuracy for HCC detection were 87, 96 and 84% for all lesions, respectively, and 99, 100 and 97% for lesions >1 cm, respectively, but only 46, 76 and 41% for tumors <1 cm, respectively (n = 28). There were 12 false-negative lesions but only 5 false-positive findings. CONCLUSION: MDCT combined with the paging method and MPR images is very effective in the detection of HCCs >1 cm in diameter with a very low false-positive rate.

[Efficacy and toxicity of transcatheter arterial chemoembolization with Cisplatin suspended in lipiodol for unresectable hepatocellular carcinoma].

In this study we evaluated the efficacy and toxicity of transcatheter arterial chemoembolization (TACE) with Cisplatin (CDDP)-Lipiodol (LIP) suspension in 24 patients with advanced hepatocellular carcinoma (HCC). Eligibility criteria were as follows; unresectable HCC, age <75 years, performance status (PS) 0-2, Child-Pugh A or B and adequate heart and renal function. When TACE was performed, the catheter was placed selectively in feeding arteries of the tumors, and CDDP-LIP suspension (20 mg/mL) was injected followed by gelatin sponge particles. The direct and total effect on tumors were evaluated 3 and 6 months after TACE, respectively. As for a direct effect, complete and partial response rates were 54.2% and 25%, respectively. As for a total effect, complete and partial response rates were 41.7% and 4.1%, respectively. Grade 3/4 drug-related toxicities were as follows: thrombocytopenia (13%), appetite loss (8%) and nausea (4%). These severe side effects disappeared within 10 days after TACE. No renal and hepatic dysfunction was encountered, and no drug-related deaths occurred. TACE with CDDP suspended in LIP may provide some clinical benefits with relatively tolerable toxicities.

CT laparoscopy for detecting small superficial metastatic lesions of the liver surface: initial experience.

OBJECTIVE: The purpose of this study was to determine the efficacy of CT laparoscopy in the detection of superficial metastasis of the liver surface. SUBJECTS AND METHODS: From April 1, 2007, to July 1, 2007, a total of 34 consecutively registered patients (19 men, 15 women; median age, 55 years) with various intraabdominal malignant tumors underwent preoperative CT and composed the study population. All patients underwent superparamagnetic iron oxide-enhanced MRI and portal phase contrast-enhanced 64-MDCT, including CT laparoscopy. CT laparoscopy is a form of volume-rendering 3D imaging of the liver that depicts the liver surface in detail. RESULTS: Among 23 patients who underwent surgery for management of a primary tumor, four patients had seven superficial metastatic lesions of the liver surface. None of these lesions had been detected with preoperative axial CT or superparamagnetic iron oxide-enhanced MRI. In contrast, CT laparoscopy revealed four of seven lesions in four patients. On a lesion-by-lesion basis, the sensitivity was 57%, the positive predictive value was 100%, and the accuracy was 57%. CONCLUSION: Our initial experience proves that CT laparoscopy is a promising method for detecting small superficial metastatic lesions of the liver surface. The findings can influence decisions regarding tumor resectability.

Expansion of selection criteria for patients with hepatocellular carcinoma in living donor liver transplantation.

In the present study, the results of living donor liver transplantation (LDLT) for 125 hepatocellular carcinoma (HCC) patients were analyzed to determine optimal criteria exceeding the Milan criteria (MC) but still with predictably good outcomes. On the basis of pretransplant imaging studies, 70 patients met the MC, and 55 patients did not. Patients who exceeded the MC but presented with

Living donor liver transplantation for patients with HCC exceeding the Milan criteria: a proposal of expanded criteria.

BACKGROUND: Optimal indications for living donor liver transplantation (LDLT) for patients with hepatocellular carcinoma (HCC) have yet not been established. The aim of the present study was to determine optimal criteria including categories outside the Milan criteria (MC) and still with a predictably good outcome. PATIENTS AND METHODS: Between February 1999 and December 2007, 136 patients with HCC underwent LDLT. Based on preoperative imaging studies, 74 patients met the MC and 62 did not. RESULTS: Overall patient survival rate at 5 years was 70%. Patients who exceeded MC but presented with