[Biliary complications of liver transplant. Role of cholangiography with magnetic resonance]
Laghi A. Pavone P. Panebianco V. Catalano C. Messina A. Lobina L. Passariello R.
Istituto di Radiologia, Universita degli Studi La Sapienza, Roma.
INTRODUCTION: Orthotopic liver transplantation is considered the treatment of choice in several hepatic conditions. The five-year patient survival rate is approximately 75%, thanks to progress in both surgical techniques and postoperative medical treatment. Biliary complications are one of the commonest causes of failure and their prompt identification is difficult due to their insidious clinical pattern and to the poor predictive value of a negative US examination. To date, invasive contrast cholangiography (endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography) may be the only way to identify anatomic abnormalities and it is therefore a necessary examination when biliary obstruction is suspected. The aim of our work was to assess the possible role of MR cholangiography in late biliary complications of liver transplanted patients. MATERIAL AND METHODS: Twenty-three liver transplant recipients (11 men and 12 women, mean age: 51.1 years) were submitted to MR cholanglography using non-breath-hold, fat-suppressed three-dimensional turbo spin echo sequences, (TR = 3000 ms, TE = 700 ms, ETL = 128). Our patients presented with clinical, laboratory and US patterns doubtful for biliary obstruction. The diagnostic confirmation was obtained at percutaneous transhepatic cholangiography (four cases), endoscopic retrograde cholangiography (eight cases), T-tube cholangiography (one case) or clinical follow-up (ten cases). RESULTS: No biliary tract abnormalities were detected at MR cholangiography in 11 cases. Twelve strictures were diagnosed in eleven patients (9 anastomotic, two nonanastomotic/intrahepatic and one nonanastomotic/extrahepatic, with associated anastomotic and nonanastomotic strictures in two cases). MR cholangiography correctly defined the stricture site and the dilation of the bile ducts above in all cases, with optimal correlation with contrast cholangiographic findings. The common bile duct below the stricture was visible in 9 of 10 patients with extrahepatic strictures on MR cholangiography and in 8 of 10 patients on contrast cholangiograms. The distal common bile duct was missed on both MR cholangiography and diagnostic percutaneous transhepatic cholangiography in a patient only. The strictures were correctly graded in 8 of 10 patients, with two cases of overestimation. Other findings were a 1-cm stone proximal to the obstructed common bile duct, multiple intrahepatic stones in another case and common bile duct kinking at the anastomosis. CONCLUSIONS: MR cholangiography is a useful imaging method in the follow-up of liver transplant recipients which can assess the biliary obstruction and therefore permit to limit the use of invasive procedure only for interventional purposes.
[Morpho-functional study of the kidney in patients with kidney disease and liver disease with magnetic resonance]
Shariat Razavi I. Stacul F. Cova M. Artero M. Carraro M. Malalan F. Pozzi Mucelli R. Dalla Palma L.
Istituto di Radiologia, Universita di Trieste.
INTRODUCTION: We studied renal function and perfusion after the i.v. injection of Gd-DTPA-BMA, a nonionic paramagnetic contrast agent, to assess renal morphology and function in normal subjects, in renal insufficiency patients and in patients with hepatic failure and normal renal function. The latter were chosen because some patients with advanced hepatic failure may suffer from the hepatorenal syndrome, characterized by severe vasoconstriction in the renal cortical vessels. We investigated if dynamic MRI can detect early renal perfusion abnormalities in the patients who will eventually develop this syndrome. MATERIAL AND METHODS: Thirty MR examinations were carried out on 30 subjects after the i.v. injection of Gd-DTPA-BMA. Our series consisted of: 10 normal subjects; 10 renal insufficiency patients; 10 patients with hepatic failure and normal renal function. MR examinations were performed on a Philips ACS II scanner operating at 1.5 T. Two sequences were carried out in all cases: T1-weighted SE and T1-weighted TGE sequences after the bolus injection of .1 mmol/kg contrast agent. Renal longitudinal diameter and parenchymal thickness were measured in all cases and signal intensity time curves were always made. The signal intensity of the cortex, corticomedullary junction, medulla and pyelocaliceal system of each kidney was measured using a region of interest (ROI). The signal intensity curves were made considering quantitative parameters, including the area below the curve (ASC), the peak (P) and the time to peak (T-P). RESULTS: Longitudinal diameter and parenchymal thickness values were significantly lower in renal insufficiency patients than in normal subjects. Four phases were demonstrated after i.v. contrast agent injection in normal subjects, namely A) the cortical phase, B) the corticomedullary junction phase, C) the medullary phase, D) the pyelocaliceal phase. No signal intensity decrease in the medullary and pyelocaliceal curves was observed in renal insufficiency patients. Signal intensity curves values were lower in hepatic failure patients than in those with normal renal function. Hepatic failure patients could be divided into two groups: 5 patients had low P and ASC values and 4 had normal P and ASC values. The patients with lower P and ASC values developed the hepatorenal syndrome within a few months of the MR examination. DISCUSSION: Signal intensity decreased in the pyelocaliceal system phase in normal subjects because of the high paramagnetic contrast agent concentration. The lack of signal intensity decrease in renal insufficiency patients was caused by the reduced capability of concentrating Gd-DTPA-BMA. Lower signal intensity values in hepatic failure patients may be considered an early sign of the hepatorenal syndrome.
[Adjuvant radio-chemotherapy in cancer of the rectum treated with radical surgery and with high risk of recurrence. Preliminary results of a prospective study]
Lupattelli M. Maranzano E. Trancanelli V. Belsanti V. Pinaglia D. Beneventi S. Latini P.
UO di Radioterapia Oncologica, Policlinico di Perugia.
INTRODUCTION MATERIAL AND METHODS: From January, 1990, to December, 1995, 138 consecutive patients with radically resected stage II and III rectal and rectosigmoid cancers were treated with adjuvant radiochemotherapy. Eighty-one patients with 24 months' follow-up were assessable. Low anterior resection (LAR) was performed in 64 (79%) patients and abdominoperineal resection (APR) in 17 (21%). Twentynine (36%) stage II and 52 (64%) stage III patients entered the study. Within 45-60 days from surgery all patients received 5-Fluorouracil chemotherapy at the dose of 500 mg/m2/iv/d 1-5, every 4 weeks, for six cycles. Chemotherapy cycles 3 and 4 were administered at the same daily dose on radiotherapy days 1-3 and 29-31. Radiotherapy total dose consisted of 45 Gy/1.8 Gy/day administered in 5 weeks with 18 MV photon beam to the pelvis with the four field "box" technique. Perineal scar was encompassed only after APR. A boost dose of 5.4 Gy to the tumor bed was given in 3 fractions of 1.8 Gy. Median follow-up was 37 months (range: 24-74 months). RESULTS AND DISCUSSION: Overall recurrent disease was reported in 28 of 81 patients (34%): local, systemic and both local and systemic relapses in 9 (11%), 14 (17%) and 5 (6%) cases, respectively. According to local extension, recurrence rates were 10% and 48% in stages II and III, respectively. Five-year overall and disease-free actuarial survivals were 64% and 61%, respectively. Median time to relapse was 15 months (range: 7-43 months). Significant prognostic factors for better tumor control were: stage (II vs III), disease site (proximal vs distal rectum), the surgical procedure (LAR vs APR), the number of involved nodes (< or = 4 vs > 4) and no extracapsular node invasion. The recommended dose of combined radiochemotherapy regimen used in this trial was generally well tolerated. The incidence of any grade > or = 3 acute toxicity (according to WHO grading) was 20% diarrhea, 6% tenesmus and 4% myelosuppression. Five (6%) patients had cronic diarrhea and other 3 (4%) radiotherapy-related severe late toxicity which required surgery. CONCLUSIONS: This study seems to provide similar survival and recurrence notes to other radio-chemotherapy regimens published in the literature. However, a more aggressive approach is warranted in stage III patients considering the low 5-year survival recorded.