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Background: Laparoscopic right hemihepatectomy (L-RHH) is still considered a technically complex procedure, which should only be performed by experienced surgeons in specialized centers. Future liver remnant modulation (FLRM) strategies, including portal vein embolization (PVE), and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), might increase the surgical difficulty of L-RHH, due to the distortion of hepatic anatomy, periportal inflammation, and fibrosis. Therefore, this study aims to evaluate the safety and feasibility of L-RHH after FLRM, when compared with ex novo L-RHH. Methods: All consecutive right hemihepatectomies performed by a single surgeon in the period between October 2007 and March 2023 were retrospectively analyzed. The patient characteristics and perioperative outcomes of L-RHH after FLRM and ex novo L-RHH were compared. Results: A total of 59 patients were included in the analysis, of whom 33 underwent FLRM. Patients undergoing FLRM prior to L-RHH were most often male (93.9% vs. 42.3%, p < 0.001), had an ASA-score >2 (45.5% vs. 9.5%, p = 0.006), and underwent a two-stage hepatectomy (45.5% vs. 3.8% p < 0.001). L-RHH after FLRM was associated with longer operative time (median 360 vs. 300 min, p = 0.008) and Pringle duration (31 vs. 24 min, p = 0.011). Intraoperative blood loss, unfavorable intraoperative incidents, and conversion rates were similar in both groups. There were no significant differences in length of hospital stay and 30-day overall and severe morbidity rates. Radical resection margin (R0) and textbook outcome rates were equal. One patient who underwent an extended RHH in the FLRM group deceased within 90 days of surgery, due to post-hepatectomy liver failure. Conclusion: L-RHH after FLRM is more technically complex than L-RHH ex novo, as objectified by longer operative time and Pringle duration. Nevertheless, this procedure appears safe and feasible in experienced hands.

Objectives: To determine the reproducibility of the National Comprehensive Cancer Network (NCCN) resectability status classification for pancreatic cancer. Background: The NCCN classification defines 3 resectability classes (resectable, borderline resectable, locally advanced), according to vascular invasion. It is used to recommend different approaches and stratify patients during clinical trials. Methods: Prospective, multicenter, observational study (trial ID: NCT03673423). Main outcome measure was the interobserver agreement of tumor assignment to different resectability classes and quantification of vascular invasion degrees. Agreement was measured by Fleiss' k (k = 1 perfect agreement; k = 0 agreement by chance). Sixty-nine computed tomography (CT) scans of pathologically confirmed pancreatic adenocarcinoma were independently reviewed in a blinded fashion by 22 observers from 11 hospitals (11 surgeons and 11 radiologists). Rating differences between surgeons or radiologists and between hospitals with different volumes (≥60 or 180° (k range: 0.619-0.756). Neither reviewers' specialty nor hospital volume influenced the agreement. Conclusions: There is high variability in the assignment to resectability categories, which may compromise the reliability of treatments recommendations and the evidence of trials stratifying patients in resectability classes. Criteria should be revised to allow a reproducible classification.

Benign biliary diseases include a large spectrum of congenital and acquired disorders, which have different prognosis and require different treatment management. The diagnosis may be challenging since some benign disorders may mimic malignancy. Imaging has an important role in the diagnostic process, for treatment decision and planning and in patient follow up. Magnetic resonance (MR) with magnetic resonance cholangiopancreatography (MRCP) sequences is the imaging modality of choice for biliary diseases and has demonstrated high diagnostic accuracy. Moreover, the use of a hepato-specific MR contrast agent allows morphological and functional assessment of the liver and the biliary tree improving the diagnostic performance.

OBJECTIVE. The purpose of this article is to review current image acquisition and interpretation for whole-body MRI, clinical applications, and the emerging roles in oncologic imaging, especially in the assessment of bone marrow diseases. CONCLUSION. Whole-body MRI is an emerging technique used for early diagnosis, staging, and assessment of therapeutic response in oncology. The improved accessibility and advances in technology, including widely available sequences (Dixon and DWI), have accelerated its deployment and acceptance in clinical practice.

Benign focal liver lesions can origin from all kind of liver cells: hepatocytes, mesenchymal and cholangiocellular line. Their features at imaging may sometimes pose difficulties in differential diagnosis with malignant primary and secondary lesions. In particular, the use of MDCT and MRI with extracellular and hepatobiliary Contrast Agents may non invasively help in correct interpretation and definition of hepatocellular or mesenchymal and inflammatory nature, allowing to choose the best treatment option. The peculiarities of main benign liver lesions at US, CT and MRI are described, with special attention to differential diagnosis and diagnostic clues.

Purpose: To compare the diagnostic accuracies of diffusion-weighted imaging (DWI), T2-weighted imaging (T2WI), and the combination of both sequences in discriminating benign from malignant focal liver lesions (FLLs). Materials and Methods: In all, 166 patients with 269 FLLs (153 benign and 116 malignant) were retrospectively evaluated. Two abdominal readers visually assessed the DWI, T2WI, and the combined (DWI+T2WI) image sets in an independent and blinded manner. The diagnostic abilities of each image set in discriminating the benign from the malignant FLLs set were compared using a binary logistic regression model. Pathologic results, consensus reading, and follow-up imaging were used as the reference standard. Results: The overall characterization accuracy in all lesions of the combined set (80.3%) was significantly higher than those of the T2WI set (68.8%) and DWI set (73.2%) (combined vs. T2WI, P < 0.001; combined vs. DWI, P = 0.001), while there was no significant difference between the T2WI and DWI sets (P = 0.058). All image sets were more accurate in the characterization of malignant FLLs than of benign FLLs (P < 0.001). Conclusion: T2WI and DWI are complementary in discriminating benign from malignant FLLs; their combination improves diagnostic confidence. J. Magn. Reson. Imaging 2012;35:1388–1396. © 2012 Wiley Periodicals Inc.

Purpose: To evaluate whether using MR fluoroscopic triggering technique and slow rate injection improves the quality of arterial phase images in gadoxetic acid-DTPA-enhanced (Gd-EOB-DTPA) MR imaging because of proper acquisition timing and reduction of artifacts. Materials and Methods: Two hundred sixteen patients undergoing examination for liver diseases were retrospectively reviewed. All MR images were obtained with two Gd-EOB-DTPA injection protocols: (i) a combination protocol, in which the MR fluoroscopic triggering technique and slow rate injection (1 mL/s) were used; and for comparison, (ii) a conventional protocol, in which adjusted fixed scan delay and ordinary rate injection (2 mL/s) were adopted. Signal-to-noise ratio (SNR) of aorta, portal vein, and liver parenchyma on arterial phase images were calculated. Two blinded readers independently evaluated the obtained arterial phase images in terms of acquisition timing and degree of artifacts. Results: The SNRs of aorta and portal vein on arterial phase images were significantly higher in the combination protocol group (aorta/portal: 221.9 ± 91.9/197.1 ± 89.8) than that in the conventional protocol group (aorta/portal: 169.8 ± 97.4/92.7 ± 48.5) (P < 0.05). The acquisition timing for arterial phase images with the combination protocol was significantly better than that with the conventional protocol (P < 0.01). The image quality of the combination protocol was significantly higher than that of the conventional protocol (P < 0.01). The occurrence rate of moderate or severe degree of artifacts in the conventional protocol (38.0%) was more prominent than that in the combination protocol (18.5%). Conclusion: The combination of the MR fluoroscopic triggering technique and slow rate injection provides proper arterial phase images and reduces the artifacts in Gd-EOB-DTPA MR imaging. J. Magn. Reson. Imaging 2010;32:334–340. © 2010 Wiley-Liss, Inc.

The objective of this study was to assess the clinical role of apparent diffusion coefficient (ADC) analysis in noncystic focal liver lesion (FLL) classification/characterization. Six hundred liver magnetic resonances with multi-b (b = 50, 400, 800 s/mm2) diffusion-weighted imaging (DwI) were retrospectively reviewed. Mean ADC was measured in 388 lesions (195 benign and 193 malignant) excluding internal necrotic areas. Cystic benign lesions were excluded from analysis. Sensitivity and specificity in distinguishing benign from malignant lesions were calculated. Analysis of variance was performed to detect differences among subgroups of solid lesions. Mean ADC of malignant lesions was 0.980 × 10−3 mm2/s, significantly (P 1/3 (39.5%) presented values lower than 1 × 10−3 mm2/s, with 90.0% chance of malignancy. Above 1.5 × 10−3 mm2/s (about 20% of all lesions) chance of malignancy was 9.5%. DwI cannot assist in noncystic FLL characterization, but can help in FLL classification in about half the cases.

Alpha1‐antitrypsin deficiency (A1ATD) is usually linked to chronic lung dysfunction and chronic liver disease. Recent evidence have shown involvement also of the cardiovascular system. Indeed, dissection of the thoracic aorta or of the coronary arteries, and intra-cerebral aneurysms has been shown to represent concomitant vascular adverse events and apparently related to the impaired vascular wall integrity, strictly related to the elastase levels which are usually modulated by the A1AT. The case herein reported describes a patient affected by A1ATD associated with a large pseudoaneurysm of the left ventricle without any known predisposing factors to pseudoaneurysm development (coronary artery disease, acute myocardial infarction, taruma and myocarditis) indicating that the connective tissue impairment documented in A1ATD may also affect the myocardial structure, ultimately leading to weakened wall integrity, sudden rupture and pseudoaneurysm formation successfully managed by a surgical approach.

Purpose: To assess the value of hepatobiliary phase gadoxetic acid (EOB)-enhanced magnetic resonance imaging (MRI) for the diagnosis of early stage hepatocellular carcinoma (HCC) (

Gardner syndrome is an autosomal dominant disease characterized by the presence of colonic polyposis, osteomas and soft tissue tumors. We present a case of a man who was admitted for a relapse of adenocarcinoma of the rectum. CT-staging showed multiple locations of desmoid tumors and osteomas, with final diagnosis of Gardner syndrome. The follow-up CT, after surgery and chemotherapy, showed a relapse of the lesions with hydronephrosis due to ureteral compression.

This is a systematic review to evaluate the accuracy of contrast-enhanced ultrasonography (CEUS) performed with "SonoVue" (sulphur hexafluoride) in the detection of hepatic metastases. The MEDLINE, EMBASE and COCHRANE Databases were searched, regardless of language, for relevant articles published before December 2009. Two reviewers independently assessed study eligibility using a standardized form and methodological quality using the quality assessment of diagnostic accuracy studies (QUADAS) Checklist. Sensitivity estimates were calculated on a per-patient and/or per-lesion basis. The search for published articles yielded 718 potentially relevant abstracts. Of these, 14 papers were eligible but only three articles fulfilled the inclusion criteria, which comprised a total of 450 patients (patient sample number: range 12 to 365; cancer prevalence: 14.8 to 71.2%). Estimated per-patient sensitivity ranged from 79-100%. Although the quality assessment of diagnostic accuracy studies checklist showed the papers were of good quality, a meta-analysis was not applicable because of the lack of eligible studies. In conclusion, CEUS seems to be promising in the detection of liver metastases; however, there have not been enough studies to conduct meta-analysis. Further studies are required before this promising method can be widely used.