Case report: Uncommon manifestations of Rosai-Dorfman disease in the liver mimicking HCC.

Rosai-Dorfman-Destombes disease (RDD) is a rare non-Langerhans cell histiocytosis (LCH) disorder characterized by systemic extranodal lesions. Common cases include skin lesions, whereas liver lesions are rare. This study presents a case of a 66-year-old woman with a solitary extranodal liver lesion who underwent successful surgical treatment followed by glucocorticoid therapy. The patient did not experience any symptoms before surgery. The liver lesion was incidentally discovered during a routine ultrasound examination. Enhanced CT scan revealed the lesion with the characteristic of washout, similar to primary hepatic cancer (HCC). CT scans of the head, neck, chest, and abdominal pelvis revealed no lymph node or other organ lesions. After surgery, the liver lesion was diagnosed as RDD, and subsequent whole-body examinations did not reveal any skin lesions. The definitive diagnosis was solid liver RDD in adults. Although there were no typical cases of bilateral cervical lymph node lesions, ultrasound and CT examinations promptly detected liver lesions, leading to the correct diagnosis through surgical resection. The findings from this case indicate that RDD can occur in rare extrasegmental areas, and the imaging characteristics of liver lesions are not specific, indicating the importance of avoiding delayed diagnosis.

MRI Radiomics in Imaging of Focal Hepatic Lesions: A Narrative Review.

Magnetic resonance imaging (MRI) is generally used to identify, describe, and evaluate treatment responses for focal hepatic lesions. However, the diagnosis and differentiation of such lesions require considerable input from radiologists. In order to reduce these difficulties, radiomics is an artificial intelligence (AI)-based quantitative method that employs the extraction of image features to reliably detect and differentiate focal hepatic lesions. MRI radiomics is a novel technique for the characterization of focal hepatic lesions. It can aid in preoperative evaluation, treatment approach, and forecast microvascular invasion. Although many studies have illustrated its efficiency there are certain limitations such as the absence of a large diverse dataset, comparison with other AI models, integration with histopathological findings, clinical utility, and feasibility.

Liver Histopathological and Immunohistochemical Evaluation from Fasciola hepatica Experimentally Infected and Reinfected Sheep.

Fasciolosis is an important economic disease of livestock. There is a global interest in the development of protective vaccines since the current anthelmintic therapy is no longer sustainable. A better knowledge of the host-parasite interaction is needed to design effective vaccines. To date, few studies have evaluated host-parasite interaction by comparing infected and reinfected animals. The present study evaluates the microscopical hepatic lesions in sheep infected and reinfected with Fasciola hepatica during the acute and chronic stages of infection. The histopathological study revealed the presence of necrotizing foci (NF1) associated with larvae migration during the early stages of infection in the primoinfected (PI) and reinfected (RI) groups. In the late stages of infection of the PI group and at the early and late stages of infection in the RI groups, extensive necrotizing/hemorrhagic foci (NF2) were found in the vicinity of enlarged bile ducts, some containing adult flukes, suggesting parasites may have caused NF2 while feeding. The immunohistochemical study revealed an increase in Foxp3+ T cells in both PI and RI groups with respect to the UC group and in the infiltrates adjacent to NF1 in the RI groups with respect to the PI group, suggesting the F. hepatica induce Foxp3 T cell expansion to facilitate parasite survival. In addition, in both the PI and RI groups, and during acute and chronic stages of the infection, a poor expression of iNOS was found accompanied by a strong expression of CD163, suggesting a marked M2 activation of macrophages in the hepatic lesions, which may be related with healing processes, and it also may facilitate parasite survival. The main differences between PI and RI animals were the more severe infiltration of eosinophils and Foxp3+ T cells, whereas RI did not modify M2 activation of macrophages which occurs since the early stages of primoinfection.

Gastric Neuroendocrine Tumor With Cystic Hepatic Metastases Mimicking Hepatic Echinococcosis: A Case Report.

Metastatic gastrointestinal neuroendocrine tumors classically appear as contrast-enhancing lesions on computed tomography. However, in a small percentage of patients, these lesions can be cystic in nature, leading to false diagnoses of benign or infectious lesions such as echinococcosis. Hence, every cystic lesion of the liver must be carefully investigated before making the treatment plan. We report a patient with hematemesis caused by a large gastric ulcer with multiple cystic lesions in the left lobe of the liver abutting the stomach. The liver lesions were misdiagnosed as hepatic echinococcosis, and the patient was started on medical therapy. However, when medical therapy failed, the patient underwent surgical excision and the histopathology showed cystic metastases of a gastric neuroendocrine tumor.

Complementary comments on metastatic liver lesions with exceptional and rare cases.

Liver metastases can appear in different forms in magnetic resonance imaging. Contrary to popular belief, while radiologists report hypovascular or hypervascular metastatic lesions, exceptional examples may be detected in various tumors. The aim of this article is to improve this review by presenting rare and atypical examples of liver metastasis, as well as cases that might potentially be misdiagnosed as metastases during the process of differential diagnosis.

Application of Intravoxel Incoherent Motion in Clinical Liver Imaging: A Literature Review.

Intravoxel incoherent motion (IVIM) modeling is a widely used double-exponential model for describing diffusion-weighted imaging (DWI) signal, with a slow component related to pure molecular diffusion and a fast component associated with microcirculatory perfusion, which compensates for the limitations of traditional DWI. IVIM is a noninvasive technique for obtaining liver pathological information and characterizing liver lesions, and has potential applications in the initial diagnosis and treatment monitoring of liver diseases. Recent studies have demonstrated that IVIM-derived parameters are useful for evaluating liver lesions, including nonalcoholic fatty liver disease (NAFLD), liver fibrosis and liver tumors. However, the results are not stable. Therefore, it is necessary to summarize the current applications of IVIM in liver disease research, identify existing shortcomings, and point out the future development direction. In this review, we searched for studies related to hepatic IVIM-DWI applications over the past two decades in the PubMed database. We first introduce the fundamental principles and influential factors of IVIM, and then discuss its application in NAFLD, liver fibrosis, and focal hepatic lesions. It has been found that IVIM is still unstable in ensuring the robustness and reproducibility of measurements in the assessment of liver fibrosis grade and liver tumors differentiation, due to inconsistent and substantial overlap in the range of IVIM-derived parameters for different fibrotic stages. In the end, the future direction of IVIM-DWI in the assessment of liver diseases is discussed, emphasizing the need for further research on the stability of IVIM-derived parameters, particularly perfusion-related parameters, in order to promote the clinical practice of IVIM-DWI. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 3.

Interpretation of Farnesoid X Receptor Immunohistochemical Expression in Discriminating Hepatocellular Carcinoma from Its Non-Neoplastic Mimics as an Adjunct to Glypican 3.

AIMS: Differentiating hepatocellular carcinoma (HCC) and non-neoplastic lesions may be challenging. Immunohistochemistry (IHC) can help in the comparative morphologic evaluation of HCC and its mimics. Farnesoid X receptor (FXR) is a nuclear metabolic receptor essential for bile salts homeostasis and other biological functions of liver cells. Preliminary studies have shown that FXR can be useful for diagnosing HCC. This study aimed to assess the role of Farnesoid X receptor (FXR) combined with Glypican 3 (GPC3) in differentiation between HCC and non-neoplastic hepatic lesions. MATERIAL AND METHODS: Immunohistochemistry of GPC3 and FXR was performed in 38 cases of primary hepatic lesions using an automated immunohistochemical stainer. The study included 17 primary HCC cases and 21 non-neoplastic hepatic lesions (5 cases were focal nodular hyperplasia, 7 were regenerative nodules and 9 were dysplastic nodules). RESULTS: The percentage of positive GPC3 and low or negative FXR expression was significantly higher in HCC cases than non-neoplastic hepatic lesions (P value <0.001). The sensitivity and specificity of GPC3 in differentiating HCC from non-neoplastic hepatic lesions were 70.6% and 85.7%, respectively, while the sensitivity and specificity of FXR were 58.8% and 100%, respectively. CONCLUSION: The present work revealed that FXR could be combined with GPC3 in distinguishing between HCC and non-neoplastic hepatic lesions with improved specificity rather than using an individual marker.

Joint liver and hepatic lesion segmentation in MRI using a hybrid CNN with transformer layers.

Backgound and Objective: Deep learning-based segmentation of the liver and hepatic lesions therein steadily gains relevance in clinical practice due to the increasing incidence of liver cancer each year. Whereas various network variants with overall promising results in the field of medical image segmentation have been successfully developed over the last years, almost all of them struggle with the challenge of accurately segmenting hepatic lesions in magnetic resonance imaging (MRI). This led to the idea of combining elements of convolutional and transformer-based architectures to overcome the existing limitations. METHODS: This work presents a hybrid network called SWTR-Unet, consisting of a pretrained ResNet, transformer blocks as well as a common Unet-style decoder path. This network was primarily applied to single-modality non-contrast-enhanced liver MRI and additionally to the publicly available computed tomography (CT) data of the liver tumor segmentation (LiTS) challenge to verify the applicability on other modalities. For a broader evaluation, multiple state-of-the-art networks were implemented and applied, ensuring direct comparability. Furthermore, correlation analysis and an ablation study were carried out, to investigate various influencing factors on the segmentation accuracy of the presented method. RESULTS: With Dice similarity scores of averaged 98±2% for liver and 81±28% lesion segmentation on the MRI dataset and 97±2% and 79±25%, respectively on the CT dataset, the proposed SWTR-Unet proved to be a precise approach for liver and hepatic lesion segmentation with state-of-the-art results for MRI and competing accuracy in CT imaging. CONCLUSION: The achieved segmentation accuracy was found to be on par with manually performed expert segmentations as indicated by inter-observer variabilities for liver lesion segmentation. In conclusion, the presented method could save valuable time and resources in clinical practice.

Lantana camara poisoning in cattle that took refuge during a storm in a forest invaded by this plant.

An outbreak of poisoning by Lantana camara occurred in cattle when a herd sought refuge in a Eucalyptus forest heavily infested by this plant. The animals showed apathy, elevated serum activities of hepatic enzymes, severe photosensitivity, jaundice, hepatomegaly and nephrosis. After a clinical manifestation period of 2-15 days, 74 out of 170 heifers died. The main histological changes were random hepatocellular necrosis, cholestasis, biliary proliferation and, in one animal, centrilobular necrosis. Immunostaining for Caspase 3 detected scattered apoptotic hepatocytes.

RECURRENT SEPSIS IN A PATIENT WITH BILIARY HAMARTOMAS.

Biliary hamartomas or von Meyenburg complexes (VMCs) are hepatic tumour-like lesions related to congenital malformation of the ductal plate, and are part of the ciliopathy spectrum of disorders. The exact pathogenesis of VMCs is unclear and it remains controversial whether they have the potential for malignant transformation. Patients are often asymptomatic and VMCs are usually encountered as an incidental finding on imaging. We report a case of recurrent sepsis with an unidentified focus. It was later confirmed that biliary hamartomas were acting as a sanctuary for the persistent pathogenic agent. The authors hope to draw attention to the existence of this unusual focus of recurrent sepsis. LEARNING POINTS: Hepatobiliary sepsis is an unusual clinical presentation of biliary hamartomas.Clinicians should be aware of the infectious complications of these diffuse structural biliary ductal abnormalities.Early recognition of this atypical life-threatening clinical presentation is important for the prognosis.

A case of Leishmania infection with focal splanchnic involvement without systemic symptoms: a potential anti-inflammatory role for vitamin D.

CASE REPORT: We report the case of a 59 year-old woman with persistent nausea, hyporexia, fatigue and mild abdominal discomfort. The patient was hospitalized upon suspicion of malignancy due to multiple hepatic and splenic nodules found on an abdominal ultrasound. Hypercalcemia emerged at initial diagnostic workup, which was considered secondary to iatrogenic vitamin D intoxication. After an adequate management of hypercalcemia and normalization of serum calcium level, all symptoms presented by the patient completely regressed. In order to characterize splanchnic lesions, several biochemistry, microbiology and radiological tests were performed, including two bioptic specimens of a focal hepatic lesion. Eventually, a diagnosis of leishmanial infection was made. The patient started a specific anti-leishmanial treatment, and the focal hepatic and splenic lesions progressively disappeared. CONCLUSION: To our knowledge, this is the first reported case of asymptomatic leishmanial infection with a widespread focal splanchnic involvement. The anti-inflammatory effect of vitamin D could be related to this atypical presentation of visceral leishmaniasis without systemic symptoms.

Total serum bile acids predict therapy for HBeAg-negative chronic hepatitis B patients with borderline ALT and high HBV DNA.

INTRODUCTION: The introduction of antiviral therapy in chronic hepatitis B (CHB) infection depends on precise evaluation of hepatic lesions. Total serum bile acids (TSBAs) are highly sensitive in monitoring liver dysfunction. We evaluated the predictive role of TSBAs for hepatic lesions in CHB patients with borderline alanine aminotransferase (ALT) and high level of hepatitis B virus (HBV) DNA copies. METHODOLOGY: 328 CHB patients were enrolled, 241 were hepatitis B e antigen (HBeAg)-positive and 87 were HBeAg-negative. Patients were further divided into two entities according to inflammation/fibrosis evaluated by liver biopsy, low-grade (inflammation grade < 2 and fibrosis stage < 2) and high-grade (inflammation grade ≥ 2 or/and fibrosis stage ≥ 2) cohorts. TSBAs were compared with noninvasive tools including aspartate aminnotransferase (AST)-to-platelet ratio index (APRI), fibrosis-4 (FIB-4) and red cell distribution width (RDW)-to-platelet ratio (RPR) to predict high-grade hepatic lesions in CHB subgroups. RESULTS: TSBAs, APRI, FIB-4 and RPR were statistically different between low- and high-grade patients in HBeAg-positive cohort. Only TSBAs showed significant difference between low and high grade in HBeAg-negative patients. Similarly, APRI, FIB-4 and RPR were correlated with different division of inflammation/fibrosis only in HBeAg-positive while TSBAs were correlated with inflammation/fibrosis levels in both HBeAg-positive and HBeAg-negative groups. Of the four indicators, the receiver operating characteristic (ROC) curve analysis showed that TSBAs have the maximum AUC (area under the curve) in HBeAg-negative group but the minimum in HBeAg-positive cohort. CONCLUSIONS: TSBAs can be used for predicting antiviral therapy in CHB patients with HBeAg-negative, borderline ALT and high HBV DNA.

Response assessment methods for patients with hepatic metastasis from rare tumor primaries undergoing transarterial chemoembolization.

PURPOSE: This study assessed the response to conventional transarterial chemoembolization (cTACE) in patients with liver metastases from rare tumor primaries using one-dimensional (1D) and three-dimensional (3D) quantitative response assessment methods, and investigate the relationship of lipiodol deposition in predicting response. MATERIALS AND METHODS: This retrospective bicentric study included 16 patients with hepatic metastases from rare tumors treated with cTACE between 2002 and 2017. Multi-phasic MR imaging obtained before and after cTACE was used for assessment of response. Response evaluation criteria in solid tumors (RECIST) and modified-RECIST (mRECIST) were utilized for 1D response assessment, and volumetric RECIST (vRECIST) and enhancement-based quantitative European Association for Study of the Liver EASL (qEASL) were used for 3D response assessment. The same day post-cTACE CT scan was analyzed to quantify intratumoral lipiodol deposition (%). RESULTS: The mean and standard deviation (SD) of diameter of treated lesions per targeted area was 7.5 ± 5.4 cm, and the mean and SD of number of metastases in each targeted area was 4.2 ± 4.6. cTACE was technically successful in all patients, without major complications. While RECIST and vRECIST methods did not allocate patients with partial response, mRECIST and qEASL identified patients with partial response. Intratumoral lipiodol deposition significantly predicted treatment response according qEASL (R2 = 0.470, p < 0.01), while no association was shown between lipiodol deposition within treated tumor area and RECIST or mRECIST (p > 0.212). CONCLUSION: 3D quantitative volumetric response analysis can be used for stratification of response to cTACE in patients with hepatic metastases originating from rare primary tumors. Lipiodol deposition could potentially be used as an early surrogate to predict response to cTACE.

Effects of post-mortem inspection techniques change on the detection capability of low public health impact diseases of slaughtered pigs: A quasi-experimental study.

Slaughtered animals are regularly submitted to post-mortem inspection to ensure that all the edible parts are fit for human consumption. According to Regulation (EU) No 219/2014, pig carcasses inspection is exclusively visual as palpation and incision could lead to cross-contamination and spread of relevant zoonotic agents. However, when compared to incision and palpation, the visual method is characterized by low sensitivity; thus, the omission of incision and palpation could lead to a reduced detection capability of organic lesions. This study aims to assess the effectiveness of exclusively visual inspection to mark pulmonary and hepatic lesions associated with low public health impact diseases in pork carcasses. A quasiexperimental- before/after research protocol has been used. All the post-mortem inspections have been carried out in a slaughterhouse located in the province of Teramo (IT), on 7,764 swine from 2011 to 2017. Carcasses undergone the only visual inspection have shown a statistically significant reduction (pvalue <0.0001) in the diagnosis of hepatic (decrease of 59%) and pulmonary diseases (decrease of 38. 5%). To overcome the limits of the low sensitivity of the visual inspection, as well as the inter-operator diagnostic variability, the high number of carcasses examined is proposed as a factor conferring external validity to the study, which provides quantitative evidence in support of the causal association between the modified inspection technique and the reduced diagnostic capacity. A further support derives from the assessment of the prevalence of hepatic and pulmonary diseases in species for whom the inspection technique is not changed.

Percutaneous microwave ablation of hepatic lesions near the heart.

BACKGROUND: Early stage liver cancer is often treated with hepatic resection or transplantation for curative intent. Microwave ablation (MWA) is often performed in patients who are poor surgical candidates, patients with limited multifocal disease, disease close to hepatic vasculature, but can also be performed with curative intent in case of small lesions. The purpose of this study is to evaluate safety and efficacy of MWA of liver tumors with final ablation zone ≤5 mm from the heart. METHODS: A retrospective review was conducted on patients with hepatic cancer who underwent MWA between 1/2015 and 6/2019. Patients with a final ablation zone ≤5 mm to the heart were included. For these patients, imaging obtained prior, during and after procedure along with procedure reports were used to identify tumor and ablation characteristics, and electronic medical records were used to identify patient demographics and disease status. RESULTS: A total of 17 patients had liver tumors with ablation zone ≤5 mm to the heart. Mean lesion size was 18.2 mm (range, 10-33 mm) and mean follow-up period was 10.4 months. Of note 82% of patients had multifocal disease at time of MWA of lesion close to the heart. Two patients had pneumothorax, one of which required chest tube placement. None of the patients had cardiac arrhythmias or other complications. Overall 12/17 of the patients had disease progression within the liver at different sites from ablated lesions. One patient had residual disease and one had local recurrence. In addition, 4/17 patients, had no disease progression or recurrence and one underwent liver transplantation prior to follow-up imaging. CONCLUSIONS: MWA of liver lesions with ablation zone ≤5 mm to the heart is safe and effective, however, it can be technically challenging.

Focal hepatic lesions in acid sphingomyelinase deficiency: Differential diagnosis between foamy macrophages aggregates and malignancy.

Acid sphingomyelinase deficiency (ASMD) is a rare metabolic disorder due to biallelic mutation in the SMPD1 gene. The defect leads to the accumulation of sphingomyelin within the cells of the reticulo-endothelial system, particularly in the spleen, liver, lungs, and bone marrow causing hepato-splenomegaly, lung disease and hematological abnormalities. At present, data on abdominal imaging in ASMD are limited. Here we describe the characteristics of focal liver lesions observed in a 30 years old female. During the Magnetic Resonance follow up an increase in number and size of the lesions, showing T1 hypointensity and T2 hyperintensity with contrast enhancement, was observed. Contrast enhanced ultrasound evidenced rapid wash-in and steady isoecogenicity without appreciable wash-out at 80 seconds. The main lesion was biopsied to rule out the presence of a hepatocellular carcinoma, and showed to be a benign foamy macrophages aggregate. In this report, we discuss the possible pathogenesis of focal hepatic lesions in ASMD and their differential diagnosis.

Extramedullary Multiple Myeloma with Hepatic Involvement.

Hepatic involvement with space-occupying lesions seen in patients with multiple myeloma (MM) is a rare phenomenon. We present two cases of extramedullary multiple myeloma (EMM), with different presentations to highlight the diversity of clinical presentation. Clinically relevant hepatic involvement of myeloma is uncommon and can pose management problems. Hepatic involvement of EMM is indicative of a poor prognosis. Early recognition can help stage and prognosticate the disease.

Value of shear wave elastography with maximal elasticity in differentiating benign and malignant solid focal liver lesions.

BACKGROUND: It is important to differentiate benign and malignant focal liver lesions (FLLs) accurately. Despite the wide use and acceptance of shear wave elastography (SWE), its value for assessing the elasticity of FLLs and differentiating benign and malignant FLLs is still investigational. Previous studies of SWE for FLLs used mean elasticity as the parameter to reflect the stiffness of FLLs. Considering the inhomogeneity of tumor stiffness, maximal elasticity (Emax) might be the suitable parameter to reflect the stiffness of FLLs and to differentiate malignant FLLs from benign ones. AIM: To explore the value of SWE with Emax in differential diagnosis of solid FLLs. METHODS: We included 104 solid FLLs in 95 patients and 50 healthy volunteers. All the subjects were examined using conventional ultrasound (US) and virtual touch tissue quantification(VTQ) imaging. A diagnosis of benign or malignant FLL was made using conventional US. Ten VTQ values were acquired after 10 consecutive measurements for each FLL and each normal liver, and the largest value was recorded as Emax. RESULTS: There were 56 cases of malignant FLLs and 48 cases of benign FLLs in this study. Emax of malignant FLLs (3.29 ± 0.88 m/s) was significantly higher than that of benign FLLs (1.30 ± 0.46 m/s, P < 0.01) and that of livers in healthy volunteers (1.15 ± 0.17 m/s, P < 0.01). The cut-off point of Emax was 1.945, and the area under the curve was 0.978. The sensitivity and specificity of Emax were 92.9% and 91.7%, respectively, higher (but not significantly) than those of conventional US (80.4% for sensitivity and 81.3% for specificity). Combined diagnosis of conventional US and Emax using parallel testing improved the sensitivity to 100% with specificity of 75%. CONCLUSION: SWE is a convenient and easy method to obtain accurate stiffness information of solid FLLs. Emax is useful for differential diagnosis of FLLs, especially in combination with conventional US.

Understanding the Role of Gadoxetic Acid in MRI.

BACKGROUND: Radiological imaging methods used at a large scale in the assessment of hepatic lesions include: Ultrasound, computed tomography and magnetic resonance. To further characterize these lesions, specific contrast agents may be added, thus revealing the vascularity of the lesions. DISCUSSION: This review focuses on gadoxetic acid, which is a hepatospecific contrast agent used in MRI. The aim of the review is to briefly explain the mechanism of GA enhancement, describe the enhancement patterns of some benign and malignant hepatic lesions and discuss possible advantages of GA over standard contrast agents. CONCLUSION: The role of GA in functional MR cholangiography and the idea of accessing liver function by measuring parenchymal enhancement will also be explained.

Dynamic Telecytopathology-Guided Rapid On-Site Assessment of Percutaneous Image-Guided Fine-Needle Aspiration of Hepatic Lesions: An Institutional Review of 178 Cases.

Background: Rapid on-site evaluation (ROSE) of image-guided fine-needle aspiration (IGFNA) of hepatic lesions is necessary to ensure adequate sample collection and render preliminary diagnosis. We review our experience with utilization of telecytopathology for ROSE of IGFNA of liver lesions. Materials and Methods: Cytotechnologists at a remote site transmitted real-time images of Diff-Quik-stained cytology smears of hepatic lesions obtained using an Olympus DP70 digital camera via Ethernet to a pathologist. All live communications were conducted using the Vocera voice communication system. Preliminary telecytopathology ROSE diagnosis was compared with the final diagnosis for accuracy. Results: ROSE using telecytopathology of IGFNAs of hepatic lesion was performed on a total of 178 cases. Preliminary diagnosis of unsatisfactory, benign, suspicious for malignancy, and positive for malignancy was 2%, 28%, 15%, and 55%, respectively, for telecytopathology. The overall concordance between the preliminary and final cytology diagnoses was 94.4%. Nine of the cases were upgraded to suspicious/malignant final diagnosis contributing to an upgrade rate of 5%. One case with preliminary evaluation of positive for malignancy was downgraded to benign cytology on final diagnosis resulting in a downgrade rate of 0.1%. Conclusion: Utilization of telecytopathology is highly effective and accurate for ROSE of IGFNAs of hepatic lesions and may serve as a substitute for conventional microscopy.