Original contribution
Hepatic nodules in liver transplantation candidates: MR imaging and underlying hepatic disease

https://doi.org/10.1016/j.mri.2005.02.001Get rights and content

Abstract

Objective

To assess by MR imaging the frequency of hepatic nodules in patients waiting on the liver transplant list and to determine whether certain underlying hepatic diseases were more often associated with the development of such hepatic nodules.

Material and Methods

We reviewed the MR and clinical records in all patients seen by the liver transplant service at our center since its inception in January 1998 until September 2002. A total of 371 patients (207 men and 164 women, age range 18–68 years, mean 45 years) were included in the study. The presence of hepatic nodules, size, number and underlying hepatic diseases were determined in all patients. Magnetic resonance imaging was performed on a 1.5-T MR imager using T1-weighted, T2-weighted and multi-phase gadolinium-enhanced sequences. Odds ratio (OR) and 95% confidence intervals (CIs) were computed to evaluate the association between the underlying hepatic disease and the development of hepatic nodule.

Results

Among 371 liver transplantation candidates, the most common underlying hepatic disease was hepatitis C virus (HCV) infection, either alone (n=93; 25%) or associated with other hepatic diseases (n=40; 10.8%). Of all patients, 33 (8.9%) had regenerative nodules (RNs), 40 (10.7%) dysplastic nodules (DNs) and 57 (15.3%) hepatocellular carcinomas (HCCs). Hepatocellular carcinoma was observed in 35.3% of patients with HCV infection and alcohol abuse combined, 24.5% with cryptogenic cirrhosis, 25% with hemochromatosis and 19% with alcohol abuse. Patients who had either DNs or HCC were 2.5 times more likely to have either alcohol abuse or HCV, alone or combined, as the substrate of their liver disease (OR 2.54, 95% CI 1.56–4.13). Our data suggest a supra-additive interaction between HCV infection and ethanol in their association with MR imaging detected lesions.

Conclusion

Patients with cryptogenic cirrhosis, alcohol abuse, HCV infection (alone or combined) and hemochromatosis had the greatest likelihood of having HCC, with the combination of HCV infection and alcohol abuse having the highest of all.

Introduction

Liver transplantation has been shown to be an alternative procedure for cirrhotic patients with the diagnosis of hepatocelullar carcinoma (HCC) [1]. Most of these patients are not suitable to undergo liver resection because of a limited hepatic reserve.

It is well established that HCC has the greatest propensity to arise in specific underlying liver diseases. Among all of them, hepatitis C (HCV) and hepatitis B (HBV) viral infections are the most frequent ones [2], [3]. In the United States, HCV is reportedly the most common chronic infectious hepatic disease. Prevalence analyses based on modeling studies and extrapolation from studies such as the National Health and Nutrition Examination Survey report that 3.9 million Americans have been infected with HCV and 2.7 million have resultant chronic hepatitis [4].

The shortage of liver donors and the long length of time waiting on the liver transplant list are pressing cirrhotic patients to be screened more often to depict premalignant nodules or early-stage malignancies. The detection of high-grade dysplastic nodules (DNs) or small HCCs is crucial because many institutions have available ablative therapies that may cure or lengthen patient's survival. Magnetic resonance imaging is more accurate and has higher sensitivity than CT in the detection and characterization of focal liver lesions. The superiority of MRI is achieved by the combination of multiplanar T1- and T2-weighted images, and the serial dynamic imaging after gadolinium administration [5], [6], [7].

The purpose of our study was to assess the frequency of hepatic nodules in cirrhotic patients on the liver transplant list. Moreover, to provide insight into which underlying hepatic diseases are more likely to develop HCCs and therefore may require a greater frequency of MR examinations to survey for malignancy.

Section snippets

Patients

Between January 1998 and September 2002, 440 consecutive patients were evaluated for liver transplantation at our center, representing our complete experience from the inception of the liver transplant service. From this population, 40 pediatric patients (1–17 years old) and 28 adult patients were excluded because the laboratory data or MR images were missing. Consequently, a total of 371 patients (207 men, 164 women, age range 18–68 years, mean 45 years) were included in the study. Eventually,

Results

The most common etiology of underlying hepatic disease was HCV infection. Only HCV infection was present in 25% (93/371) of patients, HCV infection combined with alcohol abuse in 9.1% (34/371), HCV infection combined with alcohol abuse and PSC in 0.5% (2/371), HCV infection combined with HBV infection in 0.5% (2/371) and HCV infection combined with HBV infection and alcohol abuse 0.2% (1/371). The following most frequent underlying disease was alcohol abuse alone in 15.6% of patients (58/371),

Discussion

Our study demonstrated that HCV infection was the most frequent underlying disease evaluated for liver transplantation in our center. In addition, the highest frequency of HCC was in the setting of HCV infection alone and combined with alcohol abuse or HBV infection. Our results were comparable to the descriptions of other liver transplantation institutions in North America [17], [18], [19]. Moreover, our study findings concur with other reports showing synergism between virus infection and

References (34)

  • M.M. Hassan et al.

    Rising prevalence of hepatitis C virus infection among patients recently diagnosed with hepatocellular carcinoma in the United States

    J Clin Gastroenterol

    (2002)
  • B.P. Yawn et al.

    Diagnosis and 10-year follow up of a community-based hepatitis C cohort

    J Fam Pract

    (2002)
  • Y. Yamashita et al.

    Small hepatocellular carcinoma in patients with chronic liver damage: prospective comparison of detection with dynamic MR imaging and helical CT of the whole liver

    Radiology

    (1996)
  • R.C. Semelka et al.

    Liver lesion detection, characterization, and effect on patient management: comparison of single-phase spiral CT and current MR techniques

    J Magn Reson Imaging

    (1997)
  • R.C. Semelka et al.

    Focal liver lesions: comparison of dual-phase CT and multisequence multiplanar MR imaging including dynamic gadolinium enhancement

    J Magn Reson Imaging

    (2001)
  • E.S. Siegelman et al.

    Idiopathic hemochromatosis: MR imaging findings in cirrhotic and precirrhotic patients

    Radiology

    (1993)
  • J.S. Wenzel et al.

    Primary biliary cirrhosis: MR imaging findings and description of MR imaging periportal halo sign

    AJR Am J Roentgenol

    (2001)

    • Cited by (0)

    1

    Current address: Department of Clinical Medicine, University “La Sapienza”, Rome, Italy.

    2

    Curent address: Department of Radiology Services, Gifu University Hospital, Gifu, Japan.

    View full text
    Copyright © 2005 Elsevier Inc. All rights reserved.