Quantitative radiomics and qualitative LI-RADS imaging descriptors for non-invasive assessment of ß-catenin mutation status in hepatocellular carcinoma.

PURPOSE: Gain-of-function mutations in CTNNB1, gene encoding for ß-catenin, are observed in 25-30% of hepatocellular carcinomas (HCCs). Recent studies have shown ß-catenin activation to have distinct roles in HCC susceptibility to mTOR inhibitors and resistance to immunotherapy. Our goal was to develop and test a computational imaging-based model to non-invasively assess ß-catenin activation in HCC, since liver biopsies are often not done due to risk of complications. METHODS: This IRB-approved retrospective study included 134 subjects with pathologically proven HCC and available ß-catenin activation status, who also had either CT or MR imaging of the liver performed within 1 year of histological assessment. For qualitative descriptors, experienced radiologists assessed the presence of imaging features listed in LI-RADS v2018. For quantitative analysis, a single biopsy proven tumor underwent a 3D segmentation and radiomics features were extracted. We developed prediction models to assess the ß-catenin activation in HCC using both qualitative and quantitative descriptors. RESULTS: There were 41 cases (31%) with ß-catenin mutation and 93 cases (69%) without. The model's AUC was 0.70 (95% CI 0.60, 0.79) using radiomics features and 0.64 (0.52, 0.74; p = 0.468) using qualitative descriptors. However, when combined, the AUC increased to 0.88 (0.80, 0.92; p = 0.009). Among the LI-RADS descriptors, the presence of a nodule-in-nodule showed a significant association with ß-catenin mutations (p = 0.015). Additionally, 88 radiomics features exhibited a significant association (p < 0.05) with ß-catenin mutations. CONCLUSION: Combination of LI-RADS descriptors and CT/MRI-derived radiomics determine ß-catenin activation status in HCC with high confidence, making precision medicine a possibility.

Pancreatic quantitative sensory testing to predict treatment response of endoscopic therapy or surgery for painful chronic pancreatitis with pancreatic duct obstruction: study protocol for an observational clinical trial.

INTRODUCTION: Treatment for abdominal pain in patients with chronic pancreatitis (CP) remains challenging in the setting of central nervous system sensitisation, a phenomenon of remodelling and neuronal hyperexcitability resulting from persistent pain stimuli. This is suspected to render affected individuals less likely to respond to conventional therapies. Endotherapy or surgical decompression is offered to patients with pancreatic duct obstruction. However, the response to treatment is unpredictable. Pancreatic quantitative sensory testing (P-QST), an investigative technique of standardised stimulations to test the pain system in CP, has been used for phenotyping patients into three mutually exclusive groups: no central sensitisation, segmental sensitisation (pancreatic viscerotome) and widespread hyperalgesia suggestive of supraspinal central sensitisation. We will test the predictive capability of the pretreatment P-QST phenotype to predict the likelihood of pain improvement following invasive treatment for painful CP. METHODS AND ANALYSIS: This observational clinical trial will enrol 150 patients from the University of Pittsburgh, Johns Hopkins and Indiana University. Participants will undergo pretreatment phenotyping with P-QST. Treatment will be pancreatic endotherapy or surgery for clearance of painful pancreatic duct obstruction. PRIMARY OUTCOME: average pain score over the preceding 7 days measured by Numeric Rating Scale at 6 months postintervention. Secondary outcomes will include changes in opioid use during follow-up, and patient-reported outcomes in pain and quality of life at 3, 6 and 12 months after the intervention. Exploratory outcomes will include creation of a model for individualised prediction of response to invasive treatment. ETHICS AND DISSEMINATION: The trial will evaluate the ability of P-QST to predict response to invasive treatment for painful CP and develop a predictive model for individualised prediction of treatment response for widespread use. This trial was approved by the University of Pittsburgh Institutional Review Board. Data and results will be reported and disseminated in conjunction with National Institutes of Health policies. TRIAL REGISTRATION NUMBER: NCT04996628.

Unconventional Strategies for Solid Organ Transplantation and Special Transplantation Scenarios.

Solid organ transplantation is the only long-term therapeutic option for patients with end-organ failure but cadaveric and living donor transplant pools are unable to meet the demand for organ transplantation. Newer techniques, innovative strategies and altruistic donors can help bridge this wide gap between the number of organ donors and recipients. Domino liver transplantation, paired organ donation, and ABO incompatible transplants are some of the ways to ensure increased transplant organ availability. Split liver transplantation and ex vivo liver resection and auto transplantation are considered surgically challenging but are being done at tertiary transplant centers.

Intravesical Contrast-Enhanced MRI: A Potential Tool for Bladder Cancer Surveillance and Staging.

This review article gives an overview of the current state of the art of bladder cancer imaging and then discusses in depth the scientific and technical merit of a novel imaging approach, tracing its evolution from murine cancer models to cancer patients. While the poor resolution of soft tissue obtained by widely available imaging options such as abdominal sonography and radiation-based CT leaves them only suitable for measuring the gross tumor volume and bladder wall thickening, dynamic contrast-enhanced magnetic resolution imaging (DCE MRI) is demonstrably superior in resolving muscle invasion. However, major barriers still exist in its adoption. Instead of injection for DCE-MRI, intravesical contrast-enhanced MRI (ICE-MRI) instills Gadolinium chelate (Gadobutrol) together with trace amounts of superparamagnetic agents for measurement of tumor volume, depth, and aggressiveness. ICE-MRI leverages leaky tight junctions to accelerate passive paracellular diffusion of Gadobutrol (604.71 Daltons) by treading the paracellular ingress pathway of fluorescein sodium and of mitomycin (<400 Daltons) into bladder tumor. The soaring cost of diagnosis and care of bladder cancer could be mitigated by reducing the use of expensive operating room resources with a potential non-surgical imaging option for cancer surveillance, thereby reducing over-diagnosis and over-treatment and increasing organ preservation.

Pancreatic-Portal Vein Fistula: a Rare Diagnosis with Wide-Ranging Complications-13-Year Experience of a Pancreas Center of Excellence.

PURPOSE: To determine factors affecting mortality, and long-term patency of portal vein, in patients with pancreatic-portal vein fistula (PPVF). METHODS: Consecutive cases of PPVF at the University of Pittsburgh Medical Center from 2008 to 2020 were retrospectively identified. Clinical history, imaging studies, management strategies, complications, and long-term outcomes were analyzed. RESULTS: Fourteen patients, representing the largest PPVF cohort reported to date (mean age 58.6 years, 64.3% women, median follow-up 10 months [1-98 months]) were identified. Underlying chronic pancreatitis was seen in 9 (64.3%) patients, while 5 (35.7%) developed PPVF with first attack of acute pancreatitis. PPVF involved proximal main portal vein (MPV) in 10 (78.6%) patients. Of the 5 patients (35.7%) who died, all had occlusive (n=4) or near-occlusive (n=1) PPVF-associated filling defect (FD) in the MPV. Conversely, 7 of 9 survivors (87.5%) had subocclusive FD and patent MPV. In patients with sepsis (n=5), 1 underwent surgical necrosectomy and survived, while 3 of 4 (75%) patients without debridement died. CONCLUSION: Occlusive/near-occlusive PPVF-associated MPV FD, and sepsis, are associated with high mortality rates, while subocclusive MPV FD is associated with survival and long-term MPV patency. PPVF is a potentially life-threatening, and possibly under-diagnosed, entity that warrants early clinical suspicion for timely diagnosis, to facilitate optimal management.

Imaging and Pathologic findings of Hepatic Small Vessel Hemangioma.

Hepatic small vessel hemangioma represents a distinct yet very rare pathologic entity of the liver. The entity has also been in the past referred to as adult capillary hemangioma of the liver and congenital noninvoluting hemangioma. Imaging findings are not definitive and biopsy or resection is ultimately necessary. Pathologically these represent vasoformative abnormalities with infiltrative margins that can potentially mimic hepatic angiosarcoma. Immunohistochemistry can help differentiate hepatic small vessel hemangioma from angiosarcoma. Given the infiltrative growth pattern and unknown outcomes, resection and or close follow up has been recommended. Recently the term hepatic small vessel neoplasm has been coined in view of the unknown outcomes and some concerning findings on molecular analysis. We report 2 cases of this unusual entity and describe its imaging, gross pathologic, histopathologic, and immunohistochemical features.

Thyroid nodules (≥4 cm): can ultrasound and cytology reliably exclude cancer?

BACKGROUND: Whether a threshold nodule size should prompt diagnostic thyroidectomy remains controversial. We examined a consecutive series of patients who all had thyroidectomy for a ≥4 cm nodule to determine (1) the incidence of thyroid cancer (TC) and (2) if malignant nodules could accurately be diagnosed preoperatively by ultrasound (US), fine needle aspiration biopsy (FNAB) cytology and molecular testing. METHODS: As a prospective management strategy, 361 patients with 382 nodules ≥4 cm by preoperative US had thyroidectomy from 1/07 to 3/12. RESULTS: The incidence of a clinically significant TC within the ≥4 cm nodule was 22 % (83/382 nodules). The presence of suspicious US features did not discriminate malignant from benign nodules. Moreover, in 86 nodules ≥4 cm with no suspicious US features, the risk of TC within the nodule was 20 %. US-guided FNAB was performed for 290 nodules, and the risk of malignancy increased stepwise from 10.4 % for cytologically benign nodules, 29.6 % for cytologically indeterminate nodules and 100 % for malignant FNAB results. Molecular testing was positive in 9.3 % (10/107) of tested FNAB specimens, and all ten were histologic TC. CONCLUSIONS: In a large consecutive series in which all ≥4 cm nodules had histology and were systematically evaluated by preoperative US and US-guided FNAB, the incidence of TC within the nodule was 22 %. The false negative rate of benign cytology was 10.4 %, and the absence of suspicious US features did not reliably exclude malignancy. At minimum, thyroid lobectomy should be strongly considered for all nodules ≥4 cm.

Computed tomographic cholangiography in living liver transplant donors: factors determining the degree of contrast enhancement.

OBJECTIVE: To determine factors affecting liver and bile duct contrast enhancement during computed tomographic cholangiography (CTC) in living-donor transplant candidates. METHODS: Forty-four candidates underwent preoperative triphasic CT followed by intravenous infusion of 20 mL of iodipamide for CTC. Body size indices and liver volume were correlated to parenchymal and biliary enhancement. Bile duct visibility was compared to duct enhancement. RESULTS: Poorly visualized first- and second-order bile ducts demonstrated diminished enhancement (P < 0.015). Both CTC parenchymal and biliary enhancement correlated inversely with body surface area, height, and weight (P < 0.001); inverse correlation was also seen between liver volume and parenchymal enhancement (P < 0.001). A moderately positive correlation was noted between CTC biliary and parenchymal portal venous enhancement (r = 0.421; P = 0.004). CONCLUSIONS: Computed tomographic cholangiography parenchymal and biliary enhancement diminishes with increased body size and liver volume, supporting a need for adjustable contrast dosing. Portal venous parenchymal enhancement may serve as a preinfusion indicator.

Thyroid ultrasound part 1: technique and diffuse disease.

Technical advances in high-resolution ultrasound have brought ultrasound to the forefront of thyroid imaging. Despite the seeming similarity in the imaging appearance of diffuse thyroid diseases, the radiologist should be able to identify patients with diffuse thyroid abnormality, be aware of the spectrum of the imaging appearance of common thyroid conditions, suggest a clinically relevant differential diagnosis, and exclude nodular disease when present. This article presents an overview of recent developments in ultrasound and discusses techniques for performing a neck ultrasound. The clinical and imaging features of the most common diffuse diseases affecting the thyroid gland are reviewed.

Multiple hepatic adenomas associated with liver steatosis at CT and MRI: a case-control study.

OBJECTIVE: The objective of our study was to investigate the relationship between hepatic adenoma and liver steatosis. MATERIALS AND METHODS: Radiology and pathology records from January 1999 to March 2007 were reviewed to identify 24 patients (22 women and two men; mean age, 40 years) with a pathology-proven diagnosis of hepatic adenoma (mean size +/- SD, 7.2 +/- 3.7 cm) who underwent helical contrast-enhanced CT (n = 23) and/or gadolinium-enhanced MRI (n = 8). The control group was composed of 24 patients of similar age and sex (21 women and three men; mean age, 43 years) with hepatic hemangioma who underwent CT or MR evaluation during the same time period. Two radiologists independently interpreted the imaging studies to determine the number of lesions and whether steatosis was present. The difference in prevalence of steatosis between the adenoma group versus the control group and the difference between patients with a single hepatic adenoma versus those with multiple hepatic adenomas were assessed (chi-square test). RESULTS: Hepatic steatosis was present in 14 of 24 patients (58%) with hepatic adenoma versus seven of 24 patients (29%) with hemangioma (p = 0.042). Steatosis was more common in patients with multiple hepatic adenomas (9/11, 82%) than in those with a single hepatic adenoma (5/13, 38%) (p = 0.047). CONCLUSION: Hepatic adenomas occur more frequently and more often are multiple in patients with hepatic steatosis.