Hepatic adrenal rest tumor in a patient with multifactorial liver cirrhosis: a case report with CT and MRI findings and pathologic correlation

AbstractBackgroundAdrenal rest tumor is an ectopic collection of adrenocortical cells in an extra-adrenal site, more frequently located around the kidney, retroperitoneum, spermatic cord, para-testicular region and broad ligament, but very rarely occurring also in the liver. Hepatic adrenal rest tumor poses a diagnostic challenge in differentiating it from hepatocellular carcinoma, particularly in a cirrhotic liver.Case presentationAn 83-years-old male was referred to our hospital by his family doctor for hepatological evaluation due to multifactorial liver cirrhosis. Ultrasound revealed a centimetric hypoechoic nodule in the VI hepatic segment in the context of a liver with signs of cirrhosis and steatosis. The patient first underwent MRI and then CT, which showed a fat containing focal liver lesion in the subcapsular location of the right lobe, strictly adjacent to the homolateral adrenal gland. The nodule was hypervascular in the arterial phase, washed out in the portal-venous and transitional phases, resulting hypointense in the hepato-biliary phase at MR imaging. In the suspicion of a hepatocellular carcinoma, the nodule was surgically removed, and the patient's postoperative course was unremarkable. The final histopathological diagnosis was of adrenal rest tumor of the liver.ConclusionsHepatic adrenal rest tumor is an extremely rare hepatic tumor, often without any clinical manifestation, that can also occur in the cirrhotic liver as in our case. Although there are not specific imaging findings, the possible diagnosis of HART should be considered when we observe a well-defined lesion in the subcapsular location of the right lobe, with fat containing, hypervascularity after contrast medium injection and vascular supply from the right hepatic artery

Just Friends? : Richard Rolle and the Possibility of Christian Friendship Between Men and Women

Tutkimus käsittelee Richard Rollen (k. 1349), englantilaisen erakon ja uskonnollisen kirjailijan, käsityksiä ystävyydestä yleensä ja erityisesti hengellisestä ystävyydestä miesten ja naisten välillä. Rolle kirjoitti useita latinan- ja keskienglanninkielisiä tutkielmia ja hengellisiä oppaita, joissa hän sivusi ystävyyden tematiikkaa sekä omaelämäkerrallisesta että teoreettisesta näkökulmasta. Tutkimuksen pääasiallisina lähteinä käytetään seitsemää Rollen omaa teosta sekä kanonisoinnin toivossa hänestä laadittua pyhimyselämäkertaa. Tutkimus esittelee Rollen ystävyysteoriaa ja suhteuttaa sen 1300-luvun Yorkshiren historialliseen kontekstiin, Rollen kirjallisiin esikuviin sekä hänen ajatteluunsa yleensä. Rolle näyttää tunteneen sekä Ciceron (k. 43 eaa.) että Aelred Rievaulxlaisen (k. 1167) teokset ystävyydestä, mutta sovelsi näiden näkemyksiä omintakeisesti. Rollen maailmankuvalle oli ominaista jyrkkä kaksijakoisuus maailman ja Jumalan rakkauden välillä, minkä vuoksi ero pyhän ja maallisen ystävyyden välillä oli ehdoton. Vääränlainen ystävyys oli vaarallista etenkin kontemplatiivista elämää harjoittaville erakoille ja anakoreeteille, joita Rolle opasti välttämään ihmiskontakteja. Jyrkkyydestään huolimatta Rolle erosi edeltäjistään ja 1300-luvun valtavirrasta puolustamalla sukupuolten välisen pyhän ystävyyden mahdollisuutta. Tutkimuksen keskeinen löytö on, että Rolle määritteli sukupuolten välisen ystävyyden hengelliseksi ohjaukseksi ja perusteli siten sen tarpeellisuutta; naiset tarvitsivat pyhien miesten neuvoja pelastuakseen. Tällainen opetusystävyys ei ollut tasa-arvoinen suhde, vaan miehen tuli opastaa ja oikaista naista tämän omaksi parhaaksi. Toisaalta Rolle uskoi naisten mahdollisuuksiin saavuttaa hengellisen elämän korkeimmat asteet. Lähteet paljastavat, että Rolle tosiasiassa opasti naisia esittämänsä mallin mukaan. Tutkimus osoittaa, että yksittäisille naisille laaditut kansankieliset opaskirjeet sisältävät opetusystävyyden keskeisiä piirteitä ja noudattavat sen hierarkista logiikkaa: Rolle esiintyy välittäjänä Jumalan ja lukijan välillä houkutellen, moittien ja neuvoen lukijaa, jotta tämä saavuttaisi yhä korkeamman pyhyyden asteen. Rollen ja anakoreetti Margaret Kirkebyn välinen suhde, jota on keskiajalla ja myöhemmin pidetty esimerkkinä pyhästä ystävyydestä, näyttää myös muiden lähteiden valossa olleen hierarkkinen opetussuhde. Tutkimuksessa argumentoidaan, että Rollen kirjoittamista motivoi tarve itsepuolustukseen ja toiminnan oikeuttamiseen; hänen kontaktinsa naisiin herättivät epäilyksiä. Rolle halusi olla hengellinen auktoriteetti, mutta hänellä ei ollut luostarisääntökunnan, kerjäläisveljestön tai pappisviran tuomaa virallista tukea, joten hänen paras mahdollisuutensa itsepuolustukseen oli kirjallinen toiminta. Oikeuttaakseen toimintansa naisten parissa Rolle esitti mallin Jumalan rakkauden elävöittämästä pyhästä elämästä, johon kuului velvollisuus opettaa naisia ystävinä. Lisäksi Rollen tuli osoittaa, että hänen oma elämänsä edusti hänen puolustamaansa mallia, jonka edellytyksenä oli välinpitämättömyys maallisia houkutuksia kohtaan. Kaiken tämän takana näyttää olleen toive tasavertaisen ystävän löytämisestä: Rolle ei ollut löytänyt vertaistaan ystävää, joka olisi jakanut hänen hengelliset kokemuksensa, joten hän pyrki hengellisen ohjauksen avulla nostamaan edes yhden oppilaistaan tasolleen. On huomionarvoista, että Rolle näyttää pitäneen naisia kelvollisina kandidaatteina tällaiseen suhteeseen

Biliary complications following orthotopic liver transplantation: May contrast-enhanced MR Cholangiography provide additional information?

Purpose: To assess whether contrast-enhanced T1-weighted MR Cholangiography may provide additional information in the evaluation of biliary complications in orthotopic liver transplant recipients. Material and methods: Eighty liver transplant patients with suspicion of biliary adverse events underwent MR imaging at 1.5 T scanner. After acquisition of axial T1-/T2-weighted images and conventional T2-weighted MR Cholangiography (image set 1), 3D gradient-echo T1-weighted fat-suppressed LAVA (Liver Acquisition with Volume Acceleration) sequences were obtained about 30 min after intravenous infusion of mangafodipir trisodium (Mn-DPDP,Teslascan®) (image set 2). The diagnostic value of mangafodipir trisodium-enhanced MR Cholangiography in the detection of biliary complications was tested by separate analysis results of image set 1 alone and image set 1 and 2 together. MRI results were correlated with direct cholangiography in 46 patients, surgery in 14 and/or clinical-radiological follow-up in the remaining 20 cases. Results: The level of confidence in the assessment of biliary adverse events was significantly increased by the administration of mangafodipir trisodium (p < 0.05). Particularly, contrast-enhanced T1-weighted LAVA sequences tended to out-perform conventional T2-weighted MR Cholangiography in the delineation of anastomotic and non-anastomotic biliary strictures and in the diagnosis of biliary leak. Conclusions: Contrast-enhanced T1-weighted MR Cholangiography may improve the level of diagnostic confidence provided by conventional T2-weighted MR Cholangiography in the evaluation of biliary complications after orthotopic liver transplantation. Keywords: Liver transplantation, Biliary complications, MR Cholangiography, Contrast-enhanced MR Cholangiography, Mangafodipir trisodium (Mn-DPDP

Techniques of parenchyma-sparing hepatectomy for the treatment of tumors involving the hepatocaval confluence: A reliable way to assure an adequate future liver remnant volume

Background: Parenchyma-sparing hepatectomy techniques allow a lesser volume resection (<3 adjacent segments) for tumors involving the hepatic veins at the hepatocaval confluence, assuring adequate volume of the future liver remnant. We report the ability to perform parenchyma-sparing hepatectomy as planned from the preoperative imaging and the type of vascular intervention used to preserve hepatic outflow. Methods: We analyzed 60 consecutive parenchyma-sparing hepatectomies in 54 patients for 7 primary and 53 metastatic tumors (48 colorectal), located in segments I, VII, VIII, or IVa and involving the hepatocaval confluence. Patients had a median of 2 (range: 1-18) lesions with median diameter of 4 cm (range: 1.2-16.5), which were bilateral in 43%. Results: A parenchyma-sparing hepatectomy was performed in all of the 60 cases, only one case required the resection of 3 adjacent segments. In 16 (27%) hepatic veins-resections, the outflow was assured by preservation of the inferior-right-hepatic veins in 3 (5%), of the communicating-veins in 4 (7%), of the middle-hepatic veins in 3 (4%; middle-hepatic veins patch-reconstruction in 2 cases), by polytetrafluoroethylene-grafts in 4 (7%), and by hepatic veins-anastomosis in 2 (3%). In 15 (25%) cases, the hepatic veins were resected tangentially and reconstructed by direct suture venorraphy. In 29 (48%) cases, the hepatic veins were skeletonized from the tumor. Grade IIIb to IV complications occurred in 7%, median hospital-stay was 9 days, and 90-day mortality occurred in one cirrhotic patient. Median overall and disease-free survivals were 72 and 16 months (median follow-up: 34 months). Conclusion: A lesser volume parenchyma-sparing hepatectomy rather than a formal major hepatectomy for tumors involving the hepatocaval confluence can be performed with a low rate of major complications (7%). Parenchyma-sparing hepatectomy should be considered in highly selected patients when evaluating liver resection for tumors involving the hepatocaval confluence based on appropriate and accurate preoperative imaging

PTFE Graft as a “Bridge” to Communicating Veins Maturation in the Treatment of an Intrahepatic Cholangiocarcinoma Involving the 3 Hepatic Veins. The Minor-but-Complex Liver Resection

Background: Parenchyma-sparing liver surgery allows resecting hepatic veins (HV) at the hepatocaval confluence with minor (<3 adjacent segments) liver resections. PTFE graft can be used as a bridge to communicating-veins maturation to ensure the correct outflow of the spared liver. We present a video of an intrahepatic cholangiocarcinoma (IC) involving the three HV at the hepatocaval confluence treated with this approach. Methods: In a 50-year old obese (BMI 44.8) male a 6-cm IC involving the hepatocaval confluence was identified during the follow-up for a kidney malignancy. At the preoperative CT scan the left HV was not detectable, the middle HV was incorporated within the tumor, and right HV had a 3-cm contact with the tumor. No communicating veins were evident at preoperative imaging. Results: After a J-shape thoracophrenolaparotomy, the resection of segments II–III–IVa was partially extended to segment VIII–VII and I. The right HV was detached from the tumor, and the middle HV was reconstructed with a 7-mm ringed-armed PTFE graft anastomosed to V8. Surgery lasted 20 h and 55 min with an estimated blood loss of 3500 ml, but the postoperative course was uneventful and the patient was discharged on the 14th postoperative day. One month later the CT scan showed a patent PTFE graft with the maturation of communicating-veins. One year later a complete thrombosis of the PTFE graft was observed with normal liver perfusion and function, and the patient was disease-free. Conclusions: PTFE-based parenchyma-sparing liver resection is a new tool to treat tumors located at the hepatocaval confluence exploiting the maturation of intrahepatic communicating-veins between main HV

Cystic Lesions of the Pancreas: Is Apparent Diffusion Coefficient Value Useful at 3 T Magnetic Resonance Imaging?

Objective: The objective of this study is to determine the role of apparent diffusion coefficient (ADC) value at 3T magnetic resonance imaging (MRI) in the characterization of pancreatic cystic lesions. Methods: We retrospectively selected a total number of 223 patients with a conclusive diagnosis of pancreatic cystic lesion, previously undergoing MR examination on a 3 T system. The MRI protocol first included axial T1/T2-weighted sequences and magnetic resonance cholangiopancreatography. Diffusion-weighted MRI was performed using a spin-echo echo-planar sequence with multiple b values (0, 150, 500, 1000, and 1500 s/mm2) in all diffusion directions, obtaining an ADC map. Contrast-enhanced T1-weighted sequences were performed during the initial work-up of a pancreatic cystic lesion and when signs of malignancy were suspected during the MRI follow-up. The ADC value of each pancreatic lesion was measured using a monoexponential curve fitting with all the multiple b. Results: The final diagnosis of our study group included the following: serous cystadenomas (n = 42), mucinous cystadenomas (n = 14), intraductal papillary mucinous neoplasms (IPMNs) (n = 121), IPMNs with signs of malignancy at histopathologic examination (n = 24), pseudocysts (n = 9), other cystic lesions (n = 13). A statistically significant difference was observed between the ADC values of malignant IPMNs and those of each other group of pancreatic lesions (P &lt; 0.001). The ADC value of benign IPMN was significantly higher than that of serous cystadenomas (P = 0.024). A statistically significant difference was observed between the ADCs of all mucinous cystic tumors (benign IPMNs together to mucinous cystadenomas) and the ADCs of serous cystadenomas (P = 0.014). Conclusions: Fitted ADC value obtained at 3T MRI may be helpful in the characterization of pancreatic cystic lesions with particular regards of differential diagnosis between mucinous and serous cystic tumors and between malignant and benign IPMNs

3T diffusion-weighted MRI in the response assessment of colorectal liver metastases after chemotherapy: Correlation between ADC value and histological tumour regression grading

Purpose The purpose of the study was to correlate the apparent diffusion coefficient (ADC) values of diffusion-weighted MR imaging (DW-MRI) by 3T device with the histological tumour regression grading (TRG) analysis of colorectal liver metastases after preoperative chemotherapy. Materials and methods Our study included thirty-five patients with colorectal liver metastases who had undergone MRI by 3T device (GE DISCOVERY MR750; GE Healthcare) after preoperative chemotherapy. DW-MRI was performed using a single-shot spin-echo echo-planar sequence with multiple b-values (0, 150, 500, 1000, 1500 s/mm2), thus obtaining an ADC map. For each liver lesion (more than 1 cm in diameter) the fitted ADC values were calculated by two radiologists in conference and three ROIs were drawn: around the entire tumour (ADCe), at the tumour periphery (ADCp) and at the tumour center (ADCc). All ADC values were correlated with histopathological findings after surgery. Hepatic metastases were pathologically classified into five groups on the basis of TRG. Statistical analysis was performed on a per-lesion basis utilizing the one-way analysis of variance (ANOVA). This retrospective study was approved by our institutional review board; written informed consent was obtained from all patients. Results A total of 106 colorectal liver metastases were included for image analysis. TRG1, TRG2, TRG3, TRG4 and TRG5 were observed in 4, 14, 36, 35 and 17 lesions, respectively. ADCeand ADCpvalues were significantly higher in lesions classified as TRG1 (2.40 ± 0.12 Ã\u97 10â\u88\u929 m2/s and 2.28 ± 0.26 Ã\u97 10â\u88\u929 m2/s, respectively) and as TRG2 (1.40 ± 0.31 Ã\u97 10â\u88\u929 m2/s and 1.44 ± 0.35 Ã\u97 10â\u88\u929 m2/s), compared to TRG3 (1.16 ± 0.13 Ã\u97 10â\u88\u929 m2/s and 1.01 ± 0.18 Ã\u97 10â\u88\u929 m2/s), TRG4 (1.10 ± 0.26 Ã\u97 10â\u88\u929 m2/s and 0.97 ± 0.24 Ã\u97 10â\u88\u929 m2/s), and TRG5 (0.93 ± 0.17 Ã\u97 10â\u88\u929 m2/s and 0.82 ± 0.28 Ã\u97 10â\u88\u929 m2/s). ADCe, ADCpand ADCcvalues were significantly different in TRG classes (p < 0.0001). Statistical correlations were found between the ADCe, ADCp, ADCcvalues and the TRG classes (Spearman correlation coefficient were â\u88\u920.568, â\u88\u920.542 and â\u88\u920.554, respectively). Conclusion Our study showed a significant correlation between ADC values of 3T DW-MRI and histological TRG of colorectal liver metastases after preoperative chemotherapy

Colorectal cancer: role of CT colonography in preoperative evaluation after incomplete colonoscopy

To evaluate computed tomographic (CT) colonography in patients with clinical suspicion of colorectal cancer and in whom colonoscopy was incomplete. After incomplete colonoscopy, 34 patients underwent CT colonography before and after intravenous injection of iodinated contrast agent, in supine and prone positions. Twenty patients with no evidence of colon cancer after complete colonoscopy were included as a control group. Sensitivity and specificity of CT colonography were determined for detection of cancers, polyps, and metastases to liver. In 29 patients, surgery revealed 30 colorectal cancers (three synchronous cancers) and two ischemic lesions of the descending colon. Colonoscopy missed 10 colorectal cancers and three synchronous cancers; all were detected with CT colonography. Sensitivity and specificity for detection of colorectal cancer were 56% and 92%, respectively, for incomplete colonoscopy and 100% and 96%, respectively, for CT colonography (P <.01). Sensitivity and specificity of CT colonography in detection of polyps were 86% and 70%, respectively, for diameters of 5 mm or less; 100% and 80%, respectively, for 5-10-mm diameters; and 100% for diameters greater than 10 mm. Spiral CT of the liver revealed four metastases (2-5 cm); sensitivity and specificity were 100% and 43% for nonenhanced scans and 100% for contrast-enhanced scans (P <.01). In this selected group of patients, CT colonography provided complete information to properly address surgery of colorectal cancer and treatment of liver metastases

Staging of pelvic lymph nodes in patients with prostate cancer: Usefulness of multiple b value SE-EPI diffusion-weighted imaging on a 3.0T MR system

AbstractPurposeTo evaluate the usefulness of diffusion-weighted imaging (DWI) with a multiple b value SE-EPI sequence on a 3.0T MR scanner for staging of pelvic lymph nodes in patients with prostate cancer candidate to radical prostatectomy and extended pelvic lymph node dissection (PLND).Materials and methodsInstitutional review board approval was obtained and written informed consent was taken from all enrolled subjects. A series of 26 patients with pathologically proven prostate cancer (high or intermediate risk according to D’Amico risk groups) scheduled for radical prostatectomy and PLND underwent 3T MRI before surgery. DWI was performed using an axial respiratory-triggered spin-echo echo-planar sequence with multiple b values (500, 800, 1000, 1500s/mm2) in all diffusion directions. ADC values were calculated by means of dedicated software fitting the curve obtained from the corresponding ADC for each b value. Fitted ADC measurements were performed at the level of proximal and distal external iliac, internal iliac, and obturator nodal stations bilaterally. Lymph node appearance was also assessed in terms of short axis, long-to-short axis ratio, node contour and intranodal heterogeneity of signal intensity.ResultsA total of 173 lymph nodes and 104 nodal stations were evaluated on DWI and pathologically analysed. Mean fitted ADC values were 0.79±0.14×10−3mm2/s for metastatic lymph nodes and 1.13±0.29×10−3mm2/s in non-metastatic ones (P<0.0001). The cut-off for fitted ADC obtained by ROC curve analysis was 0.91×10–3mm2/s. A two-point-level score was assigned for each qualitative parameter, and the mean grading score was 6.09±0.61 for metastastic lymph nodes and 5.42±0.79 for non-metastatic ones, respectively (P=0.001). Using a score threshold of 4 for morphological, structural, and dimensional MRI analysis and a cut-­off value of 0.91 × 10–3 mm2/s for fitted ADC measurements of pelvic lymph nodes, per-­station sensitivity, specificity, PPV, NPV and diagnostic accuracy were 100%, 7.9%, 15.6%, 100% and 21.3%, and 84.6%, 89.5%, 57.9%, 97.1% and 88.8%, respectively.Conclusions3.0T DWI with a multiple b value SE-EPI sequence may help distinguish benign from malignant pelvic lymph nodes in patients with prostate cancer