Comparison between CT volumetry, technetium99m galactosyl-serum-albumin scintigraphy, and gadoxetic-acid-enhanced MRI to estimate the liver fibrosis stage in preoperative patients.

OBJECTIVES: To compare the efficacy of computed tomography volumetry (CTV), technetium99m galactosyl-serum-albumin (99mTc-GSA) scintigraphy, and gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic-acid-enhanced MRI (EOB-MRI) in estimating the liver fibrosis (LF) stage in patients undergoing liver resection. METHODS: This retrospective study included 91 consecutive patients who had undergone preoperative dynamic CT and 99mTc-GSA scintigraphy. EOB-MRI was performed in 76 patients. CTV was used to measure the total liver volume (TLV), spleen volume (SV), normalised to the body surface area (BSA), and liver-to-spleen volume ratio (TLV/SV). 99mTc-GSA scintigraphy provided LHL15, HH15, and GSA indices. The liver-to-spleen ratio (LSR) was calculated in the hepatobiliary phase of EOB-MRI. Hyaluronic acid and type 4 collagen levels were measured in 65 patients. Logistic regression and receiver operating characteristic (ROC) analyses were performed to identify useful parameters for estimating the LF stage and laboratory data. RESULTS: According to the multivariable logistic regression analysis, SV/BSA (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.003-1.02; p = 0.011), LSR (OR, 0.06; 95%CI, 0.004-0.70; p = 0.026), and hyaluronic acid (OR, 1.01; 95%CI, 1.001-1.02; p = 0.024) were independent variables for severe LF (F3-4). Combined SV/BSA, LSR, and hyaluronic acid correctly estimated severe LF, with an AUC of 0.91, which was significantly larger than the AUCs of the GSA index (AUC = 0.84), SV/BSA (AUC = 0.83), or LSR (AUC = 0.75) alone. CONCLUSIONS: Combined CTV, EOB-MRI, and hyaluronic acid analyses improved the estimation accuracy of severe LF compared to CTV, EOB-MRI, or 99mTc-GSA scintigraphy individually. CLINICAL RELEVANCE STATEMENT: The combined analysis of spleen volume on CT volumetry, liver-to-spleen ratio on gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic-acid-enhanced MRI, and hyaluronic acid can identify severe liver fibrosis associated with a high risk of liver failure after hepatectomy and recurrence in patients with hepatocellular carcinoma. KEY POINTS: • Spleen volume of CT volumetry normalised to the body surface area, liver-to-spleen ratio of EOB-MRI, and hyaluronic acid were independent variables for liver fibrosis. • CT volumetry and EOB-MRI enable the detection of severe liver fibrosis, which may correlate with post-hepatectomy liver failure and complications. • Combined CT volumetry, gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic-acid-enhanced MRI (EOB-MRI), and hyaluronic acid analyses improved the estimation of severe liver fibrosis compared to technetium99m galactosyl-serum-albumin scintigraphy.

Extracellular volume by dual-energy CT, hepatic reserve capacity scoring, CT volumetry, and transient elastography for estimating liver fibrosis.

Our purpose was to compare the efficacy of liver and splenic volumetry (LV and SV), extracellular volume (ECV) on dual-layer spectral-detector CT scoring systems for estimating liver fibrosis (LF) in 45 patients with pathologically staged LF. ECV measured on CT value (HU-ECV), iodine density (ID-ECV), atomic number (Zeff-ECV), and electron density (ED-ECV), LV or SV/body surface area (BSA), albumin bilirubin grade (ALBI), model for end-stage liver disease (MELD) score, aspartate aminotransferase platelet ratio index (APRI), and fibrosis index based on the four factors (FIB-4) were recorded. Transient elastography was measured in 22 patients, and compared to ECV. No correlation was found between transient elastography and all ECVs. Area under the curve (AUC) for estimating F4 on transient elastography was 0.885 (95% CI 0.745-1.000). ALBI was weakly associated with LF (p = 0.451), while MELD (p < 0.001), APRI (p = 0.010), and FIB-4 (p = 0.010) were significantly associated with LF. SV/BSA had a higher AUC than MELD, APRI, and FIB-4 for estimating F4 (AUC = 0.815, 95% CI 0.63-0.999), but MELD (AUC = 0.799, 95% CI 0.634-0.965), APRI (AUC = 0.722, 95% CI 0.561-0.883), and FIB-4 (AUC = 0.741, 95% CI 0.582-0.899) had higher AUCs than ALBI. SV/BSA significantly contributed to differentiation for estimating F4; odds ratio (OR) was 1.304-1.353 (Reader 1-2; R1-R2), whereas MELD significantly contributed to the differentiation between F0-2 and F3-4; OR was 1.528-1.509 (R1-R2). AUC for SV/BSA and MELD combined was 0.877 (95% CI 0.748-1.000). In conclusion, SV/BSA allows for a higher estimation of liver cirrhosis (F4). MELD is more suitable for assessing severe LF (≥ F3-4). The combination of SV/BSA and MELD had a higher AUC than SV/BSA alone for liver cirrhosis (F4).

Comparison between Intravoxel Incoherent Motion and Splenic Volumetry to Predict Hepatic Fibrosis Staging in Preoperative Patients.

Intravoxel incoherent motion (IVIM) and splenic volumetry (SV) for hepatic fibrosis (HF) prediction have been reported to be effective. Our purpose is to compare the HF prediction of IVIM and SV in 67 patients with pathologically staged HF. SV was divided by body surface area (BSA). IVIM indices, such as slow diffusion-coefficient related to molecular diffusion (D), fast diffusion-coefficient related to perfusion in microvessels (D*), apparent diffusion-coefficient (ADC), and perfusion related diffusion-fraction (f), were calculated by two observers (R1/R2). D (p = 0.718 for R1, p = 0.087 for R2) and D* (p = 0.513, p = 0.708, respectively) showed a poor correlation with HF. ADC (p = 0.034, p = 0.528, respectively) and f (p < 0.001, p = 0.007, respectively) decreased as HF progressed, whereas SV/BSA increased (p = 0.015 for R1). The AUCs of SV/BSA (0.649-0.698 for R1) were higher than those of f (0.575-0.683 for R1 + R2) for severe HF (≥F3-4 and ≥F4), although AUCs of f (0.705-0.790 for R1 + R2) were higher than those of SV/BSA (0.628 for R1) for mild or no HF (≤F0-1). No significant differences to identify HF were observed between IVIM and SV/BSA. SV/BSA allows a higher estimation for evaluating severe HF than IVIM. IVIM is more suitable than SV/BSA for the assessment of mild or no HF.

Management of acute pulmonary embolism with sequential hybrid therapy of surgical thrombectomy and rivaroxaban intensive therapy: a case report.

Acute pulmonary embolism (PE) is often associated with rapid hemodynamic deterioration or death. Therefore, early therapeutic intervention is important. A 45-year-old man was diagnosed with intermediate-high risk PE, and sequential hybrid therapy consisting of surgical thrombectomy and rivaroxaban intensive therapy was administered. During the course of treatment, echocardiography revealed improvement in pulmonary artery systolic pressure, and thrombus volume analysis by computed tomography revealed a drastic reduction in the size of the thrombus. Sequential hybrid therapy for acute PE not only stabilizes hemodynamics, but may also prevent conversion to chronic thromboembolic pulmonary hypertension by sufficiently reducing the volume of the thrombus.

Pathological Appearance of Focal Liver Reactions after Radiotherapy for Hepatocellular Carcinoma.

We studied five pathological specimens from five patients at 1.5, 3.0, 4.0, 13.5, and 14.0 months after radiotherapy for HCC. Four needle biopsies were obtained to investigate liver parenchyma of focal liver reaction (FLR) around treated HCC, when patients had newly developed HCC or local recurrence appeared in the liver. Liver resection was performed in one case where insufficient radiotherapy effect for HCC was suspected. In all patients, FLR was recognized as a hypervascular area around the HCC on enhanced CT and enhanced Gd-EOB-DTPA (EOB-MRI). Liver specimens were analyzed to assess the pathological characteristics of FLR. FLR was recognized as prolonged liver enhancement in enhanced CT and EOB-MRI. From pathological understanding, sinusoidal dilatation with degeneration and desquamation was caused by direct endothelial cell injury following radiotherapy. Hepatocytes and endothelium fell off, and so the portal tract came close, and hepatic arteries increase simultaneously, resulting in FLR around HCC after radiotherapy. In conclusion, the prolapse of hepatocytes and sinusoidal endothelium induced neovascularization of hepatic arteries due to the repair mechanisms; in addition, these prolapse may shorten the distance between each portal region and the hepatic arteries flowing through the portal region become more prominent in FLR.

Comparison between CT volumetry and extracellular volume fraction using liver dynamic CT for the predictive ability of liver fibrosis in patients with hepatocellular carcinoma.

OBJECTIVES: To compare the predictive ability of liver fibrosis (LF) by CT-volumetry (CTV) for liver and spleen and extracellular volume fraction (ECV) for liver in patients undergoing liver resection. METHODS: We retrospectively analysed 90 consecutive patients who underwent CTV and ECV. Manually placed region-of-interest ECV (manual-ECV), rigid-registration ECV (rigid-ECV), and nonrigid-registration ECV (nonrigid-ECV) were calculated as ECV(%) = (1-haematocrit) × (ΔHUliver/ΔHUaorta), where ΔHU = subtraction of unenhanced phase from equilibrium phase (240 s). Manual-ECV was compared with CTV for the estimation of LF. The total liver volume to body surface area (TLV/BSA), splenic volume to BSA (SV/BSA), ratio of TLV to SV (TLV/SV), ratio of right liver volume to SV (RV/SV), and liver segmental volume ratio (LSVR) were measured. ROC analyses were performed for ECV and CTV. RESULTS: After excluding 10 patients, seventy-eight (97.5%) out of 80 patients had a Child-Pugh score of 5 points, and two (2.5%) patients had a Child-Pugh score of 6 points. AUC of ECV showed no significant difference among manual-ECV, rigid-ECV, and nonrigid-ECV. TLV/BSA, SV/BSA, TLV/SV, and RV/SV had a higher correlation with LF grades than manual-ECV. AUC of SV/BSA was significantly higher than that of manual-ECV in F0-1 vs F2-4 and F0-2 vs F3-4. AUC of SV/BSA (0.76-0.83) was higher than that of manual-ECV (0.61-0.75) for all LF grades, although manual-ECV could differentiate between F0-3 and F4 at high AUC (0.75). CONCLUSIONS: In patients undergoing liver resection, SV/BSA is a better method for estimating severe LF grades, although manual-ECV has the ability to estimate cirrhosis (≥ F4). KEY POINTS: The splenic volume is a better method for estimating liver fibrosis grades. The extracellular volume fraction is also a candidate for the estimation of severe liver fibrosis.