Background and objective Portal vein thrombosis (PVT) is a common complication in cirrhosis, and when complete, it increases morbidity and mortality in liver transplant candidates. The aim of the study was to assess the hemostatic status, as well as clinical characteristics of thrombus and patients, as predictors of therapeutic efficacy of anticoagulation for the treatment of PVT in cirrhotics. Patients and methods Patients with cirrhosis consecutively treated for PVT with enoxaparin were enrolled. All patients underwent evaluation of coagulation status and thrombophilia screening. Thrombus characteristics and extension were evaluated at baseline and during follow-up. Anticoagulation was continued until recanalization or up to 12 months. Variables correlated with the response to anticoagulation were used to create a predictive score that was validated in an external multicenter cohort. Results A total of 65 patients were included and had partial PVT in most cases (72%). Treatment with enoxaparin resulted in an overall response rate of 66% (43/65) after a median time of 4.4 months and 76% (33/43) within the first 6 months. At multivariate analysis, efficacy of anticoagulation correlated with the severity of liver disease, complete verus partial PVT, age of the thrombus, and time interval from treatment start (<6 months). The areas under the curve of the statistical model for predicting the response to anticoagulation were 0.84 and 0.76 for the training ( n =65) and validation ( n =60) cohorts, respectively. Conclusion Early diagnosis and early treatment are key factors for the successful management of PVT in cirrhosis, so that screening of PVT and prompt start of anticoagulant treatment should be mandatory.
Abstract Background & Aims To develop an individual prognostic calculator for patients with unresectable hepatocellular carcinoma ( HCC ) undergoing trans‐arterial chemo‐embolization ( TACE ). Methods Data from two prospective databases, regarding 361 patients who received TACE as first‐line therapy (2000–2012), were reviewed in order to refine available prognostic tools and to develop a continuous individual web‐based prognostic calculator. Patients with neoplastic portal vein invasion were excluded from the analysis. The model was built following a bootstrap resampling procedure aimed at identifying prognostic predictors and by carrying out a 10‐fold cross‐validation for accuracy assessment by means of Harrell's c‐statistic. Results Number of tumours, serum albumin, serum total bilirubin, alpha‐foetoprotein and maximum tumour size were selected as predictors of mortality following TACE with the bootstrap resampling technique. In the 10‐fold cross‐validation cohort, the model showed a Harrell's c‐statistic of 0.649 (95% CI : 0.610–0.688), significantly higher than that of the Hepatoma Arterial‐embolization Prognostic ( HAP ) score (0.589; 95% CI : 0.552–0.626; P = 0.001) and of the modified HAP ‐ II score (0.611; 95% CI : 0.572–0.650; P = 0.005). Akaike's information criterion for the model was 2520; for the mHAP ‐ II it was 2544 and for the HAP score it was 2554. A web‐based calculator was developed for quick consultation at http://www.livercancer.eu/mhap3.html . Conclusions The proposed individual prognostic model can provide an accurate prognostic prediction for each patient with unresectable HCC following treatment with TACE without class stratification. The availability of an online calculator can help physicians in daily clinical practice.
Introduzione: la trombosi del sistema venoso portale (PVT) rappresenta una complicanza frequente nel paziente con cirrosi epatica. La gestione terapeutica del paziente cirrotico con PVT non e chiara.
Obiettivi: analizzare retrospettivamente la storia naturale della trombosi portale e gli eventi emorragici in un gruppo di pazienti cirrotici trattati e non trattati con terapia anticoagulante.
Metodi: Da Gennaio 2008 a Dicembre 2015 abbiamo retrospettivamente individuato una coorte di 182 pazienti affetti da PVT. 81 pazienti sono stati trattati con terapia anticoagulante e 101 non hanno ricevuto terapia. Abbiamo valutato le caratteristiche demografiche, l’estensione della trombosi, l’eventuale trattamento anticoagulante, l’evoluzione della patologia e gli eventi emorragici.
Risultati: La trombosi e andata incontro a ricanalizzazione in 46 (56,8%) pazienti trattati e in 26 (25,7%) pazienti non trattati (p<0,001). La durata del trattamento (p=0,005) e la doppia somministrazione giornaliera (p=0,003) sono risultati essere gli unici fattori predittivi di ricanalizzazione nei pazienti trattati. Dopo la sospensione della terapia, dei 46 pazienti che hanno ottenuto la ricanalizzazione, 17(36%) hanno presentato una recidiva della trombosi. L’analisi di Kaplan-Meier ha mostrato un tasso di sopravvivenza maggiore nel gruppo dei pazienti trattati (p=0,010) e il trattamento anticoagulante e risultato essere l’unico fattore indipendente correlato alla sopravvivenza all’analisi multivariata (p=0,014).
Complicanze emorragiche si sono verificate in 22(21,8%) pazienti non trattati e in 16 (19,7%) pazienti trattati, solo in 4 casi dovute al trattamento anticoagulante.
Conclusioni: il trattamento anticoagulante e sicuro ed efficace nei pazienti cirrotici con PVT, raggiungendo dei tassi di ricanalizzazione completa e parziale del 56,8%. La durata del trattamento di almeno 12 mesi e la doppia somministrazione giornaliera sembrano associati a piu alti tassi di ricanalizzazione. Nei pazienti che hanno raggiunto la ricanalizzazione, l’interruzione della terapia e associata ad un alto rischio di recidiva. Il trattamento anticoagulante sembra migliorare la sopravvivenza dei pazienti cirrotici con PVT.
This study investigates the diagnostic performance of a new T1 imaging series, generated by the digital subtraction of the opposed phase from in phase T1 weighted images, in MRI for renal angiomyolipoma (AML) evaluation.This retrospective study involved 96 patients, 63 (65.6%) with at least one renal AML and 33 (34.4%) healthy patients. Two radiologists having different experience retrospectively reviewed two MR imaging series, starting with in and out-phase T1 weighted images and then the new subtracted T1 images, in which AML appeared white on black background. The presence, number, location, and dimensions of the AMLs, and reading time were collected separately for the two kidneys. Statistical analysis was carried out using the appropriate tests.The number of lesions identified and the evaluation of lesion dimension did not statistically differ between the different MR imaging series evaluated, without interobserver variability. Both percentage agreement of the total number of observations and the κ coefficient showed very good agreement between the radiologists. The median time for the diagnosis was statistically lower when using the subtracted T1 imaging series for both observers with a median gain from 6.5 to 15 s per identified lesion, resulting in a total time-saving of more than half (52.9%), in both patients with and without AMLs, and in patients with a single or with more than one AML (p < 0.001).The new subtracted T1 imaging series proved to be reliable in identifying fat-containing renal lesions, by both expert and non-expert radiologists, resulting in a saving of both time and money. Moreover, this new subtracted T1 imaging series could be an effective tool in non-dedicated kidney examinations in which a faster reading is advisable.The opportunity of using a single set of MRI images in kidney evaluation for identifying fat-containing lesions, considerably reducing reading time, resulting in cost-effectiveness.
Knowledge regarding biliary anatomy and its variations, including the cystic duct (CD), is important in the pre-surgical setting and for predicting biliary diseases. However, no large series has focused on CD evaluation using a quantitative analysis. The primary aim of this prospective study was to create a 'taxonomic' classification of CD anatomy in a large cohort of subjects who underwent magnetic resonance cholangiopancreatography (MRCP). The secondary aim was to evaluate the correlations between extrahepatic bile duct (EHBD) variants and biliary diseases. We enrolled patients who underwent MRCP for different clinical indications from January 2017 to May 2019. Demographical, anatomical and clinical data were evaluated using statistical analyses, as appropriate. The anatomical assessment of EHBD was performed using the standard classification for CD in low, medium, and high insertions, and the lengths of CD to the duodenal papilla (DP), and EHBD was determined to conduct a new quantitative analysis. The final study population comprised 1004 subjects. A new classification for EHBD as per the percentile distribution of the ratio CDDP/EHBD was designed, and the following categories were obtained: type 1 (below the 25th percentile) for CDDP/EHBD ratio ≤ 50%; type 2 (25th to 75th percentile) for CDDP/EHBD ratio 51–75% and type 3 (above the 75th percentiles) for CDDP/EHBD ratio > 75%. Type 1 of the new classification of CD implantation was significantly superior in terms of the detection of low, medial and intra-pancreatic CD that was significantly correlated with a high risk of choledochal lithiasis in comparison with the standard classification (P < 0.001). The new classification of CD implantation enables identification of the vast majority of intra-pancreatic CDs that are correlated with a high risk of choledochal lithiasis in a single category (type 1) that is easy to identify using imaging.
Abstract To evaluate the potential variability of Manganese (Mn 2+ ) in commercial pineapple juice (PJ) produced in different years and to identify the optimal Mn 2+ concentration in the correct amount of PJ to be administered prior to Magnetic Resonance Cholangiopancreatography (MRCP) in order to suppress the gastroduodenal (GD) liquid signal. The Mn 2+ concentration in PJ produced in different years was defined using Atomic Absorption Spectrometry. The optimal Mn 2+ concentration and the amount of PJ, were estimated in an in-vitro analysis, and were then prospectively tested in a population of patients who underwent MRCP. The results were compared with those achieved with the previous standard amount of PJ used in a similar population. The concentrations of Mn 2+ in commercial PJ produced in different years did not differ. A total amount of 150 ml (one glass) of PJ having a high Mn 2+ content (2.37 mg/dl) was sufficient for the suppression of the GD liquid signal, despite the additional dilution caused by GD liquids since it led to a final concentration of Mn 2+ of 0.5–1.00 mg/dl. The optimized single-dose oral administration of 150 ml (approximately one glass) of PJ having a high Mn 2+ concentration prior to MRCP was adequate to guarantee the correct amount of Mn 2+ to suppress the GD signal.
Abstract Changes in body composition are associated with poor outcomes in cancer patients including hepatocellular carcinoma (HCC). Sarcopenia, defined as the loss of skeletal muscle mass, quality and function, has been associated with a higher rate of complications and recurrences in patients with cirrhosis and HCC. The assessment of patient general status before HCC treatment, including the presence of sarcopenia, is a key-point for achieving therapy tolerability and to avoid short- and long-term complications leading to poor patients’ survival. Thus, we aimed to review the current literature evaluating the role of sarcopenia assessment related to HCC treatments and to critically provide the clinicians with the most recent and valuable evidence. As a result, sarcopenia can be predictive of poor outcomes in patients undergoing liver resection, transplantation and systemic therapies, offering the chance to clinicians to improve the muscular status of these patients, especially those with high-grade sarcopenia at high risk of mortality. Further studies are needed to clarify the predictive value of sarcopenia in other HCC treatment settings and to evaluate its role as an additional staging tool for identifying the most appropriate treatment. Besides, interventional studies aiming at increasing the skeletal muscle mass for reducing complications and increasing the survival in patients with HCC are needed.
