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"International Liver Disease-Hepatic Vascular Disease Column" is an academic column jointly initiated by Dr. Qi Xingshun from the Department of Gastroenterology of the Northern Theater General Hospital at the invitation of the editorial department of "International Liver Disease", which regularly collects and sorts out the research progress in the field of hepatovascular disease, and selects an important literature every two weeks (Wednesday) for intensive reading and discussion, hoping to help readers know what it is, why it is true, inspire clinical research thinking, and apply what they have learned.
Brief description of the article
布加综合征（BCS）是指肝静脉到右心房-下腔静脉（IVC）交界处的肝流出道阻塞，分为原发性布加综合征（P-BCS）和继发性布加综合征（S-BCS）。 继发性布加综合征常由恶性肿瘤等外部因素引起（Hitawala AA, et al. StatPearls Publishing (2023); Valla DC, et al. J Hepatol (2009) 50(1):195–203），原发性布加综合征常由静脉血栓形成或静脉炎引起，伴有高凝状态（DeLeve LD, et al. Hepatology (2009) 49(5):1729–64）。 布加综合征引起的慢性肝脏充血可能导致组织学改变，如结节性再生增生（NRH）、肝硬化和肝脏局灶性结节，在影像学上可能被误诊为小肝癌（s-HCC）（Cazals-Hatem D. Hepatology (2003) 37(3):510–9）。 长期随访研究表明，17.6%的布加综合征患者可进展为肝癌。 然而，尚缺乏可以有效区分布加综合征良性肝细胞病变和小肝癌的相关数据（Ren W, et al. Eur J Gastroenterol Hepatol (2013) 25(7):830–41.）。 因此，鉴别上述两种疾病仍具有挑战性。
In November 2023, the journal Frontiers in Oncology officially published an article titled "Multiparametric MR Imaging to Distinguish Benign Hepatocellular Lesions Associated with Small Hepatocellular Carcinoma (<3 cm) and Budd-Chiari Syndrome", aiming to explore the value of MR imaging in distinguishing benign hepatocellular lesions from patients with small liver cancer and Budd-Chiari syndrome.
Ghazal et al. selected patients diagnosed with Budd-Chiari syndrome from February 2005 to June 2018 at Johns Hopkins Hospital, and included a total of 12 patients with Budd-Chiari syndrome with benign hepatocellular lesions. In addition, 32 patients diagnosed with small liver cancer (<3 cm) were included. Compared with the small hepatocellular carcinoma group, there were significant differences in the T1 signal intensity/liver T1 signal intensity, T2 signal intensity/liver T2 signal intensity, and diffusion coefficient and diffusion coefficient of lesions/liver diffusion coefficient in the Benign Hepatocellular Lesion Group (P<0.001, P<0.001 and P=0.045, respectively). There were also significant differences in the enhancement signal of lesion sites in the venous phase and delayed phase between the benign hepatocellular lesion group and the small hepatocellular carcinoma group (P=0.001). ROC analysis showed that the logistic model established by combining T1 signal ratio, T2 signal ratio and portal vein enhancement signal ratio had an area under the curve of 0.94, which had a good ability to distinguish benign lesions.
Taken together, specific MR imaging features help distinguish benign hepatocellular lesions from small hepatocellular carcinoma and Budd-Chiari syndrome.
Analysis of important study results and their clinical significance
1. Incorporate a flow chart of the population
(Picture from the literature)
Of the 32 patients with small liver carcinoma (<3 cm), 14 (14/32, 43.8%) were diagnosed with small liver carcinoma by histopathology, and the remaining 18 patients were diagnosed based on imaging features and elevated serum AFP levels.
Excluding patients with Budd-Chiari syndrome who had no MR or MR that did not suggest liver lesions, a total of 12 patients with Budd-Chiari syndrome and benign hepatocellular lesions with 35 liver lesions were included, of which 4 lesions were histopathologically confirmed as benign (4/35) with unclear imaging features, and the remaining 31 lesions showed no significant change after at least one year of follow-up (median follow-up of 60 months [12–168]), with an alpha-fetoprotein (AFP) value of <15 ng/mL, and imaging features consistent with benign findings, so they were identified as benign lesions.
2. Baseline characteristics of the study population
(Table from literature)
There was no significant difference in gender between the two groups. Serum AFP > 15 ng/mL in 59% of patients with small hepatocellular carcinoma, while no patients in the benign hepatocellular lesion group had a serum AFP > 15 ng/mL (P<0.001). The lesion size was similar between the two groups (P=0.135). The venous elution rate of small hepatocellular carcinoma lesions (22/32, 68.8%) was higher than that of benign hepatocellular lesions (4/35, 11.4%, P<0.001), and benign hepatocellular lesions were more common with central scar (40% vs. 3%, P<0.001) than small hepatocellular carcinoma lesions.
3. Summary statistics of parameters between benign and malignant lesion groups
(Table from literature)
两组间，病变T1、T2信号强度、弥散系数无显著差异（P值分别为0.069、0.359、0.236）。 与良性病变组相比，小肝癌组病灶T1比值更低（中位数0.86 [IQR：0.79-1.14] vs. 1.25 [IQR：1.14-1.42]，P<0.001）、T2比值更高（中位数1.49 [IQR：1.29-2.01] vs. 0.88 [IQR：0.73-0.96]，P<0.001）、弥散系数比值更低（0.98±0.17 vs. 1.08±0.18，P=0.045）。
4. ROC curve analysis
(Picture from the literature)
In Figure a, the T1 ratio cut-off value is 1.05, the correct classification rate is 81.03%, and the sensitivity is 92.3%. The area under the ROC curve of the T1 ratio was 0.81, which could better identify benign lesions.
In panel b, the T2 ratio cut-off value is 1.07, the correct classification rate is 91.4%, and the sensitivity is 93.8%. The area under the ROC curve of the T2 ratio was 0.92, which could better identify malignant lesions.
5. MR imaging in patients with Budd-Chiari syndrome, benign hepatocellular lesions and patients with small liver cancer
(Picture from the literature)
On T1-weighted imaging (T1WI), benign hepatocellular lesions in Budd-Chiari syndrome showed uniform or peripheral hyperintensity, while small hepatocarcinoma showed uniform hypointensity (Fig. a, g).
On T2-weighted imaging (T2WI), Budd-Chiari syndrome benign hepatocellular lesions showed uniform or peripheral hypointensity, while small hepatocarcinoma showed uniform hyperintensity (Panels b, h).
On diffusion-weighted imaging (DWI), the diffusion coefficient of benign hepatocellular lesions in Budd-Chiari syndrome was higher than that of small hepatocellular carcinoma (Fig. c, i).
Benign hepatocellular lesions in Budd-Chiari syndrome often appear hyperintense in the arterial phase and uniformly hyperintense in the venous and delayed phases (Fig. D-F). Patients with small HCC exhibit heterogeneous hyperintensity in the arterial phase and hypointensity in the venous and delayed phases (Fig. J-L).
Summary and outlook
In this study, specific MR imaging features were identified to distinguish between small liver carcinoma (<3 cm) and benign liver lesions associated with Budd-Chiari syndrome. However, it is unclear how MR imaging differs between patients with small liver cancer with or without Budd-Chiari syndrome. Long-term radiographic follow-up is needed in the future to evaluate MR imaging features in patients with Budd-Chiari syndrome with small liver cancer.
Multicenter study unit recruitment on the prevalence of portal vein thrombosis in cirrhosis
Portal vein thrombosis (PVT), particularly in completely obstructive PVT, increases portal venous pressure in patients with cirrhosis, which in turn increases the risk of ascites and bleeding from esophagogastric varices. At present, proper management of portal vein thrombosis in liver cirrhosis is still a difficult clinical problem. In addition, the prevalence of PVT in liver cirrhosis is still unclear, and there is a lack of large-scale epidemiological studies in China to clarify this problem. To this end, Dr. Qi Xingshun from the Department of Gastroenterology of the Northern Theater General Hospital is preparing to launch a national multicenter study to determine the prevalence of PVT in patients with liver cirrhosis based on the results of enhanced CT examination, and further retrospective analysis of relevant risk factors. Doctors from gastroenterology, hepatology, infectious diseases, radiology and other related specialties are cordially invited to participate. If you are interested in this study, you can contact us for more detailed information about the study.
Contact: Dr. Li
Email: [email protected]
WeChat: lqq52708
Translator
Xiao Yao, Department of Gastroenterology, General Hospital of the Northern Theater of Operations, Graduate School of Liaoning University of Traditional Chinese Medicine.
Initiator and reviewer of the column "International Liver Disease - Hepatovascular Disease".
Qi Xingshun, Director of the Department of Gastroenterology of the Northern Theater General Hospital, part-time master's supervisor of China Medical University, Shenyang Pharmaceutical University, Dalian Medical University and Jinzhou Medical University, part-time doctoral supervisor of Northeastern University and China Medical University, and postdoctoral cooperative supervisor of the Postdoctoral Research Workstation of the Northern Theater General Hospital. Top 10 representatives of China Association for Science and Technology. He is the vice chairman of the Special Committee on the Integration of Precancerous Lesions between China and the West of the Chinese Anti-Cancer Association, a member of the 11th Committee of the Chinese Society of Gastroenterology, a member of the Hepatobiliary Disease Group, a member of the Minimally Invasive Intervention Collaboration Group, a member of the Liver Disease Related Digestive Disease Collaboration Group of the Chinese Medical Association, and a member of the Standing Committee of the 11th Committee of the Gastroenterology Branch of the Liaoning Medical Association. He is currently a Senior Editorial Board Member of BMC Gastroenterology, an Editorial Board Member of Therapeutic Advances in Gastroenterology, and an Academic Member of Canadian Journal of Gastroenterology and Hepatology Editor。 In 2016, he was awarded the Outstanding Doctoral Dissertation of the Army. He was selected as one of the Top Ten Talents of the 12th Liaoning Youth Science and Technology Award in 2019, the list of Elsevier's 2021, 2022 and 2023 China Highly Cited Scholars, the 2022 Joint Logistics Support Force Discipline Backbone Talent, the 2022 Military High-level Science and Technology Innovation Talent Project Young Science and Technology Talent, and the 2022 "Xingliao Talent Program" Young Top-notch Talent. According to Scopus, the H-index is 48, with a total of 8060 citations.
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Source: Editorial Board of International Liver Disease