EASL–EORTC Clinical Practice Guidelines (CPG) on the management of hepatocellular carcinoma (HCC) define the use of surveillance, diagnosis, and therapeutic strategies recommended for patients with this type of cancer. This is the first European joint effort by the European Association for the Study of the Liver (EASL) and the European Organization for Research and Treatment of Cancer (EORTC) to provide common guidelines for the management of hepatocellular carcinoma. These guidelines update the recommendations reported by the EASL panel of experts in HCC published in 2001 [1]. Several clinical and scientific advances have occurred during the past decade and, thus, a modern version of the document is urgently needed. The purpose of this document is to assist physicians, patients, health-care providers, and health-policy makers from Europe and worldwide in the decision-making process according to evidencebased data. Users of these guidelines should be aware that the recommendations are intended to guide clinical practice in circumstances where all possible resources and therapies are available. Thus, they should adapt the recommendations to their local regulations and/or team capacities, infrastructure, and cost– benefit strategies. Finally, this document sets out some recommendations that should be instrumental in advancing the research and knowledge of this disease and ultimately contribute to improve patient care. The EASL–EORTC CPG on the management of hepatocellular carcinoma provide recommendations based on the level of evidence and the strength of the data (the classification of evidence is adapted from National Cancer Institute [2]) (Table 1A) and the strength of recommendations following previously reported systems (GRADE systems) (Table 1B).

http://www.bclc.cat/download/easl-guidelines.pdf

EASL-EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma European Association for the Study of the Liver ⇑ , European Organisation for Research and Treatment of Cancer

Local-regional treatments play a key role in the management of hepatocellular carcinoma (HCC). Image-guided tumor ablation is recommended in patients with early-stage HCC when surgical options are precluded and can replace resection in selected patients. Radiofrequency (RF) ablation has shown superior anticancer effects and greater survival benefit with respect to the seminal percutaneous technique, ethanol injection, in meta-analyses of randomized controlled trials and is currently established as the standard method for local tumor treatment. Novel thermal and nonthermal techniques for tumor ablation, including microwave ablation and irreversible electroporation, seem to have potential to overcome the limitations of RF ablation and warrant further clinical investigation. Transcatheter arterial chemoembolization (TACE) is the standard of care for patients with asymptomatic noninvasive multinodular tumors in intermediate-stage disease. Embolic microspheres that have the ability to release a drug in a controlled and sustained fashion have been shown to substantially increase the safety and efficacy of TACE in comparison to conventional ethiodized oil-based regimens. The available data for radioembolization with yttrium 90 suggest that this is a potential new option for patients with HCC, and future studies should be devoted to assessments of the role of radioembolization in the treatment algorithm for HCC.

Local-Regional Treatment of Hepatocellular Carcinoma

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.23725

Loco-regional treatment of hepatocellular carcinoma.

EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma

https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.27548

Multicenter randomized controlled trial of percutaneous cryoablation versus radiofrequency ablation in hepatocellular carcinoma.

The purpose of this study was to retrospectively determine the safety and effectiveness of percutaneous cryoablation, monitored with computed tomography (CT) and ultrasonographic (US) guidance, for the treatment of hepatocellular carcinoma (HCC). Four patients with small HCCs underwent one percutaneous cryoablation treatment session monitored with CT and US guidance. All patients underwent pretreatment blood chemistry testing and imaging evaluation. We treated lesions with simultaneous insertion of multiple 17-G cryoprobes (two or three) and defined technical success when the extension of a visible iceball was beyond 5 mm from the tumor margin. Intralesional enhancement or tumoral size increase was defined as local progression compared with that on images obtained immediately after ablation. We evaluated complications and follow-up (at 1, 3, and 6 months). All patients survived without short- or long-term complications. Cryoablation was technically successful in all patients at the end of the procedure. During follow-up two patients developed disease recurrence. One patient developed local tumor progression on the margin of the lesion; the other, a new HCC. In the case of local tumor progression a new elevation of alpha-fetoprotein (alphaFP) levels occurred at first follow-up control. In the other case levels of alphaFP remained stable during the first 3 months after the procedure, then demonstrated a progressive increase in alphaFP levels beginning at the fourth month, without tumor evidence during CT control at 3 months. We conclude that percutaneous cryotherapy with US guidance and CT monitoring is a feasible, safe, and effective for treatment of HCC. If local ablative procedures of hepatic lesions are to be performed, percutaneous cryoablation, not laparotomic, should be discussed as an alternative therapeutic measure. Longer follow-up should provide proof of the effectiveness of this technique.

Percutaneous cryoablation of small hepatocellular carcinoma with US guidance and CT monitoring: initial experience.

Gallbladder agenesis (GA) is a rare congenital anomaly of the biliary system often associated with other congenital abnormalities. Patients become symptomatic in 23% of cases. GA is often misinterpreted as other diseases, therefore, leading to unnecessary surgery. We report a case of congenital GA associated to cystic duct absence and a biliary tract abnormality diagnosed by Magnetic Resonance with Cholangiopancreatography.

/pdf/gallbladder-agenesis-and-cystic-duct-absence-in-an-adult-4ihqcjt8v5.pdf

Gallbladder agenesis and cystic duct absence in an adult patient diagnosed by magnetic resonance cholangiography: report of a case and review of the literature.

We wanted to determine whether liver contrast-enhanced ultrasound (CEUS)–derived peak signal intensity (PSI) and peak signal intensity/time (PIT) predict liver fibrosis in chronic hepatitis C (CHC). Forty-nine patients with CHC (METAVIR classification) and 10 control subjects were included in the study. After a bolus of 2.4 mL SonoVue (Bracco Imaging, Milan, Italy) solution was injected into a peripheral vein, the right lobe of the liver containing the right portal vein was scanned in a transverse section. Two-dimensional sonography was performed using the Philips iU22 ultrasound system (Philips Healthcare, Best, the Netherlands). A 1.0–5.0-MHz (C5-1) wideband convex transducer was used, applying the following settings in all cases. Regions of interest were manually drawn over the right liver lobe and over the portal vein (PV). Liver parenchyma PSI (LPpsi) and PIT (LPpit), portal vein PSI (PVpsi) and PIT (PVpit) were automatically calculated. δPSI was defined as the difference between PVpsi and LPpsi. A significant correlation was observed between PA PSI and fibrosis scores. When patients were stratified according to their LPpsi, a significant difference was achieved only between patients with fibrosis score 0–1 vs. 2–3 and 2 vs. 4. Statistically significant differences between all fibrosis scores, except 0 vs. 1 and 3 vs. 4 were observed when δPSI was used to stratify patients. Overall diagnostic accuracy of LPpsi and δPSI measurement for severe fibrosis by area under the receiving operator characteristic curve analysis was, respectively, 0.87 and 0.88. We suggest that liver CEUS perfusion could have the potential to be used as a complementary tool for the evaluation of liver fibrosis. However, further large-scale studies are required to accurately assess its accuracy in the evaluation of liver fibrosis. (E-mail: aorlacchio@uniroma2.it )

/pdf/liver-contrast-enhanced-ultrasound-perfusion-imaging-in-the-2zeuwwv8he.pdf

Liver contrast enhanced ultrasound perfusion imaging in the evaluation of chronic hepatitis C fibrosis: preliminary results.

Congenital extrahepatic portosystemic shunt (CEPS) is an extremely rare anomaly. In these malformations splanchnic blood bypasses the liver and drains into the systemic circulation through the inferior vena cava (IVC) or the left renal vein (LRV). Extrahepatic shunts may be divided into type 1 [end-to-side mesenterico-caval fistula with congenital absence of the portal vein (PV)] and type 2 (partial portocaval shunt caused by side-to-side mesenterico-caval fistula with normal or hypoplasic PV). Type 2 shunts typically are wholly extrahepatic between the PV or its right branch and the retrohepatic IVC. This report describes an asymptomatic case of CEPS not previously documented and not classifiable as type 1 or 2. CT revealed a normal PV with communication between the inferior mesenteric vein (IMV) and the LRV. The inferior mesenteric vein appeared tortuous, abnormally long and with a large calibre, and presented a connection with the LRV, in addition to a normal confluence into the splenic vein. Colour Doppler revealed hepatopetal normal flow in the PV and superior mesenteric vein with mild portal hypertension and an inversion of flow in the IMV directed to the LRV. Biochemical parameters showed a normal liver function without hyperammonaemia.

New type of asymptomatic congenital portosystemic shunt

Negli ultimi anni si stanno diffondendo sempre piu nella ricerca e nella pratica clinica scanner whole-body ad alto campo con magnete a 3T (3 Tesla). L’uso di campi magnetici piu potenti consente di ottenere un piu alto rapporto segnale-rumore, con significativi vantaggi in termini di risoluzione spaziale, temporale e di contrasto.

Gabriele Bazzocchi

Papers

Percutaneous cryoablation of small hepatocellular carcinoma with US guidance and CT monitoring: initial experience.

Gallbladder agenesis and cystic duct absence in an adult patient diagnosed by magnetic resonance cholangiography: report of a case and review of the literature.

Liver contrast enhanced ultrasound perfusion imaging in the evaluation of chronic hepatitis C fibrosis: preliminary results.

New type of asymptomatic congenital portosystemic shunt

Vantaggi e limiti dei magneti ad alto campo (3T)