Final Pr. ID: Poster #: EDU-017
To summarize our experience using Computed Tomography Angiography (CTA) of the liver as an imaging tool for pre-living donor liver transplantation (LDLT) evaluation in biliary atresia (BA) patients. This pictorial review will illustrate and discuss several aspects of imaging techniques and the important findings that clinician need to know before LDLT.
Key imaging findings for vascular anatomy/collateral vessels will be made, emphasizing what clinicians need to know. Correlation with intraoperative findings will also be provided.
Authors: Supakul Nucharin
Final Pr. ID: Paper #: 071
Fontan–associated liver disease (FALD) is associated with increased risk of liver cirrhosis and hepatocellular carcinoma. Liver biopsy is the current gold standard investigation for diagnosing liver fibrosis. Magnetic Resonance Elastography (MRE) is a non-invasive procedure assessing liver stiffness. To date, only limited published studies are available describing the correlation of MRE and biopsy in Fontan-associated pediatric patients. Further, longitudinal changes in MRE require an increase in hepatic stiffness of >22% to indicate true change in stiffness (95% CI). The purpose of this study is to determine the clinical implication of MRE in FALD.
Authors: Tsitsiou Yvonne , Rychik Jack , Biko David , Cahill Anne Marie , Serai Suraj , Durand Rachelle , Golberg David , Glatz Andrew , Rand Elizabeth , Wilkins Benjamin , Witschey Walter , Dodds Kathryn , Russo Pierre
Final Pr. ID: Poster #: CR-004
Calcifying nested stromal epithelial tumor (CNSET) is a very rare primary liver tumor in children. To our knowledge, about 30 cases have been reported in literature. We describe the imaging appearance and histopathologic features of this tumor detected in a 2 year old girl who presented with an incidentally detected calcified liver lesion on a chest x-ray which was obtained for cough.
Computed tomography (CT) demonstrated a 5.5 centimeter sized heterogeneous mass with large coarse calcifications. MRI better demonstrated the margins of the lesion, which was predominantly hyper-intense on T2-weighted images. Large areas of signal void were seen in the superior aspect of the lesion, corresponding to the calcifications seen on CT. The lesion demonstrated restricted diffusion. Post-contrast, the lesion demonstrated enhancement in the portal venous phase with washout on the delayed phase. Initial diagnosis based on imaging findings and patient’s age was hepatoblastoma. However, serum alpha- fetoprotein (AFP) was normal, which is unusual with hepatoblastoma. Patient underwent subsequent wedge biopsy, which was proven to represent calcifying nested stromal epithelial tumor of the liver. PET/CT, obtained to evaluate for metastatic disease, demonstrated increased FDG activity within the primary hepatic lesion, with SUV Max of 3.5, with no evidence of FDG avid metastatic disease. She then underwent right hepatectomy and cholecystectomy.
No sign of tumor recurrence has been noted to date on the follow up abdominal ultrasound examination in the past 2.5 years.
Calcifying nested stromal epithelial tumor should be considered in the differential when a large heterogeneous liver tumor with coarse/ chunky calcifications is identified at imaging in the absence of elevated serum AFP in a child. Currently the standard treatment in complete surgical excision and liver transplantation if excision is not possible. Read More
Final Pr. ID: Poster #: SCI-009
MRI can accurately quantify liver iron concentration (LIC) by using T2* sequences. Vendor based, commercially available 3D multi-echo Dixon sequences provide maps of liver T2*/R2* and allow automated, inline post-processing, avoiding conventional manual post-processing. The purpose of our study was to compare R2*/LIC estimates generated by automated 3D multi-echo Dixon sequence to values generated by GRE-based R2* relaxometry as the reference standard. Read More
Final Pr. ID: Poster #: EDU-016
Congenital portosystemic shunts represent a rare congenital malformation which diverts portal blood to the systemic circulatory system. These malformations can either be intrahepatic or extrahepatic. The intrahepatic portosystemic shunts have been classified into four types. Intrahepatic congenital portosystemic shunts demonstrates a persistent communication between the portal and hepatic venous structures, which were derived from the embryonic vitelline veins or between the vitelline and subcardinal veins. A ductus venosus, a normal structure in neonates, represents an intrahepatic congenital portosystemic shunt between the left portal vein and left hepatic vein. It typically closes between 2-17 days of postnatal life. In our institution, since April 2020, there have been five separate cases of intrahepatic congenital portosystemic shunts in newborns. We will review the imaging for each of these cases, as well as review the current literature and classification of portosystemic shunts. Read More
Final Pr. ID: Poster #: SCI-001 (S)
El hígado es el principal sitio de almacenamiento de hierro en humanos, y la concentración de hierro en el hígado se correlaciona estrechamente con las reservas de hierro en todo el cuerpo. La técnica de resonancia magnética (MR) es capaz de separar las señales de agua y grasa para cuantificar la infiltración de hierro y grasa en el hígado. Esto permite obtener una mejor cuantificación del hierro y observar la relación que existe con el índice de masa corporal (IMC). En este trabajo se propone una medición de acuerdo a lo propuesto por la divisón anatomica por Couinaud. Read More
Final Pr. ID: Poster #: SCI-008
Doppler ultrasound (DUS) is routinely used to assess graft status after liver transplantation (LT). Although early post-surgical assessment is encouraged, the exact prognostic value of DUS parameters is unknown.
The purpose of this study was to determine the prognostic value of DUS parameters obtained in the immediate postoperative period. Read More
Final Pr. ID: Poster #: EDU-021
The purpose of this review is to provide an overview of applications of Eovist in the pediatric population, as well as pitfalls. We will begin with an introduction on the origins of Eovist and how it and other hepatocyte specific contrast agents (HSCAs) differ from conventional gadolinium based contrast agents (GBCAs). We will then provide a sample of imaging protocols when Eovist is used for hepatic mass evaluation and for biliary indications. We will review benefits of Eovist in characterizing a variety of pediatric hepatic neoplasms, including hepatoblastoma, hepatocellular carcinoma, focal nodular hyperplasia, hepatic adenomas, and regenerative nodules, with mention of pathologies that do not follow traditional patterns (i.e., inflammatory adenomas). After this, we will cover biliary applications, including choledochal cysts, biliary obstruction, and postoperative bile leak. Finally, we will review some limitations of Eovist; notably, we will mention several scenarios where the hepatobiliary phase could not be achieved, and recommendations for how to approach these cases. Read More
Final Pr. ID: Poster #: SCI-033
To describe ultrasound (US) and magnetic resonance imaging (MRI) findings of giant hepatic regenerative nodules (GHRN) in pediatric patients with Alagille Syndrome (AS). Read More
Final Pr. ID: Poster #: EDU-004 (T)
Contrast enhanced ultrasound is a radiation free, highly sensitive imaging modality for detection of focal liver lesions in children. CEUS uses ultrasound (US) technology and an US contrast agent (UCA) that is administered intravenously. This educational exhibit provides step-by-step instructions of our institutional protocol for performing CEUS exams. Read More
Final Pr. ID: Poster #: CR-053
Cancer is the most common cause of disease-related mortality for adolescent patients, 13-19 years of age. Primary liver neoplasms are relatively uncommon entities in this population accounting for 0.5-2.0% of all neoplasms as per the current literature. The most common primary liver malignancy in adolescent patients is hepatoblastoma, which accounts for approximately two thirds of liver tumors. Benign tumors of the liver in the adolescent population include adenomas, focal nodular hyperplasia, hamartomas, and vascular tumors. Hepatic neoplasms in adolescent patients are typically not detected clinically until they reach a large size. While there are many exceptions, these patients generally have normal liver function as well as normal growth and development. In this case series, we examine the imaging characteristics across multiple modalities of several large primary hepatic neoplasms in the adolescent population encompassing both benign and malignant as well as common and uncommon entities. We will also review how the underlying pathophysiology of these neoplasms relates to their imaging appearances. Cross-sectional imaging with MRI or CT, similar to evaluation in adult patients, is considered the best method of evaluating the character and extent of hepatic masses. However, initial workup usually includes plain film x-ray or ultrasound. Benign and malignant hepatic neoplasms in the adolescent population share many similar radiographic features, and therefore, knowledge of these entities and their imaging appearances is essential in order to develop an appropriate differential diagnosis. Read More
Final Pr. ID: Poster #: SCI-009
Describe imaging features of pediatric focal nodular hyperplasia (pFNH) in a large cohort of children with clinical, radiological and surgical management with a significant follow up period. We aim to provide an algorithm to treat these patients using the evidence base we have created. Read More
Keywords: Liver, Tumor
Final Pr. ID: Poster #: EDU-022
Liver transplantation is a potentially life-saving procedure for children with liver failure. Pediatric liver transplant recipients are at greater risk for complications such as vascular thrombosis than adults. In addition, children more commonly receive reduced size grafts, which alter the normal liver anatomy. While the postoperative assessment of pediatric liver transplants with sonography has been well studied, less exists in the radiology literature regarding intraoperative Doppler sonography of the graft prior to abdominal closure. We illustrate the intra- and post-operative ultrasound findings in pediatric liver transplants, with an emphasis on normal features, common pitfalls, and frequently encountered vascular complications. Read More
Final Pr. ID: Poster #: CR-042
Congenital portosystemic shunt is a rare vascular malformation that leads to severe complications. Two types are described: extrahepatic and intrahepatic. Extrahepatic shunt is represented by a direct communication of the portal trunk, or one of its branches of origin, to the inferior vena cava, or one of its branches.
We present two cases of extrahepatic shunt treated with stent-graft placement.
Case 1: Two y.o. male with cutaneous telangiectasias and liver calcifications on abdominal ultrasound. An extrahepatic portosystemic shunt was detected on color Doppler examination.
MR and catheter angiography revealed a large fistula between the main portal vein and the suprarenal inferior vena cava. The fistula was closed by deploying a balloon expandable stent-graft in the retrohepatic inferior vena cava. Five years later, the liver function was normalized and no complication was observed.
Case 2: Thirteen y.o. male referred for three hepatic lesions and an extrahepatic portosystemic shunt.
MR and angiography revealed a large fistula between the left portal vein and the inferior vena cava. It was closed by deploying a custom self-expandable stent-graft (Zenith, Cook Medical, Bloomington, IN) in the inferior vena cava. At five years follow-up, the patient is asymptomatic with a resolution of the liver lesions. Read More
Final Pr. ID: Poster #: EDU-013
Management of incidentally discovered pediatric liver lesions can be challenging. As compared with adults, no formal guidelines exist on this subject. Our purpose is to suggest an approach to the management of incidental pediatric liver lesions based on review of the literature and our institutional multidisciplinary experience.
- Main considerations when evaluating incidental liver lesions in children (including age, alpha fetoprotein level, lesion size, imaging characteristics differentiating benign and malignant tumors, role of contrast-enhanced US, role of hepatobiliary contrast MRI)
- Suggested approach to the management of incidental liver lesions detected by US, CT, and MRI
- Examples of common incidental liver lesions (cyst, hemangioma, focal nodular hyperplasia, hepatocellular adenoma, focal fatty infiltration and sparing) Read More
Final Pr. ID: Poster #: SCI-008
The diagnosis of hepatic encephalopathy is mainly detected by neuropsychological tests. These tests, however, do not always apply depending on the status of the child (age, social and cultural environment) and are therfore not reliable for subtle changes. We propose to detect minimal hepatic encephalopathy (minHE) in children with chronic liver disease and/or porto-systemic shunting, using MRI with Diffusion-weighted (ADC) and 1H- spectroscopy in the globus pallidum. Read More
Final Pr. ID: Poster #: EDU-010
Intestinal failure is a rare but devastating condition in pediatric patients that is often caused by short bowel syndrome (SBS) secondary to necrotizing enterocolitis, volvulus, or intestinal atresia. Patients require the use of total parenteral nutrition (TPN) to survive, which can lead to cholestasis and end stage liver disease (ESLD). Treatment of intestinal failure in pediatric patients who have developed subsequent liver failure from TPN with multivisceral (MVTx) transplantation has progressed dramatically in the past two decades as a result of improvements in immunosuppression, surgical technique, and post-transplant care. The number of transplantations has always been relatively low due to a lack of appropriate donors and the rarity of intestinal failure. However, given the high acuity of patients that do ultimately undergo these procedures, recognition of post-operative complications is critical for graft survival and improved outcomes. This educational exhibit will review the indications and relevant anatomy for these types of transplantations. Magnetic resonance (MR) findings related to post-transplantation complications will be presented with imaging correlates from other modalities (CT, PET/CT, US) as needed. Read More
Final Pr. ID: Paper #: 008
MR elastography (MRE) is increasingly being used to non-invasively assess diffuse liver disease in children. However, there are limited normal liver stiffness data for MRE in children. The purpose of this study was to determine normal liver stiffness measured by MRE for children and assess for associations with demographic factors, MRI field strength and MRI vendor. Read More
Final Pr. ID: Poster #: EDU-028
Imaging is crucial in the staging of primary pediatric liver tumors. Hepatoblastoma, pediatric HCC and transitional-type lesions (HCC/hepatoblastoma) should be pre-operatively staged at the time of diagnosis using the PRETEXT system. The PRETEXT (PRE-Treatment EXTent of tumor) criteria were first described in 1992 and updated most recently following an international consensus in 2017, and provide reproducible imaging-based prognostic information for patient survival prior to treatment.
The PRETEXT system consists of two criteria; the group and annotation factors. The PRETEXT stage (I-IV) describes the anatomical extent of tumor within the liver, categorized according to contiguous lesion-free liver sections, whilst the annotation factors describe associated features such as vascular involvement, extrahepatic disease and metastases. These are combined and patients are divided into two risk stratified groups. The standard risk group, mostly including Stage I and II tumors, are more likely to be managed by partial hepatectomy whilst higher risk groups including stage IV tumors are often unresectable and require liver transplantation. Its ultimate goal is to determine the feasibility of surgical resection.
At our institution, our hepatobiliary surgeons use the PRETEXT criteria for prognostication and patient management. International use of these consensus criteria is essential in order to unify management of this rare pediatric tumor subtype.
Our objective is to discuss pearls and pitfalls from our experience of using the PRETEXT criteria. Relevant imaging examples from our large specialist pediatric institute will be provided with discussion of variability of scoring between CT and MRI as well as technical challenges. Selected multi-modality case-based examples will be provided with reference to patient management and operative findings where available. Read More
Final Pr. ID: Paper #: 095
Multiple noninvasive magnetic resonance imaging (MRI) methods have been described to detect liver fibrosis, including diffusion-weighted imaging (DWI). The purpose of our study was to evaluate predictors of liver MRI DWI apparent diffusion coefficient (ADC) measurements in pediatric patients with autoimmune liver disease, including the relationship between ADC measurements and liver stiffness.
Final Pr. ID: Poster #: SCI-007 (S)
demonstrate that using the anatomical division of the liver suggested by Couinaud allows a more accurate quantification of the amount of fat. Read More
Final Pr. ID: Paper #: 039
The Fontan operation, used to palliate single ventricle congenital heart disease, increases venous pressure in the liver and is associated with Fontan associated liver disease (FALD), for which liver fibrosis is the final common pathway. Elastography (ultrasound [US] or MRI) can be used to non-invasively measure liver stiffness associated with liver fibrosis. However, these measures are confounded in Fontan patients due to venous congestion. The purpose of this study was to prospectively document the stiffening effect of passive hepatic congestion following the Fontan operation and track changes in liver stiffness over the post-operative period. Read More
Final Pr. ID: Poster #: SCI-033
Biliary stenosis continues to be an important source of morbidity in pediatric liver transplantation. Percutaneous transhepatic cholangiography (PTC) with cholangioplasty and placement of an internal/external biliary drainage catheter has been the standard of care for biliary stenosis at our institution for over twenty years. The purpose of this article is to present the largest and most comprehensive pediatric series to date detailing the percutaneous management of liver transplants complicated by biliary stenosis. Read More
Final Pr. ID: Poster #: EDU-091
Pediatric liver transplant (PLT) is an established treatment for many hepatic conditions in children. In recent years there has been a significant increase in the number of PTL associated with an improved survival. In children however, due to the complex surgical procedures and peculiar hemodynamic physiology there is also an increased risk for vascular and biliary complications. High resolution ultrasonography (US) is the modality of choice to evaluate and monitor the evolution of pediatric liver graft. This exhibit intends to illustrate fellows and residents with the US characteristics of the normal hepatic anatomy, the normal early and late US appearances of the graft, and the US features of complications that may compromise graft’s survival. Read More
Final Pr. ID: Poster #: EDU-023
It is well known that ultrasound is a powerful imaging tool for pediatric patients after liver transplantation. With proper use, ultrasound provides static as well as dynamic information of the transplanted liver. The purpose of this educational exhibit is to demonstrate the way of good ultrasound examination after pediatric liver transplantation. Read More
Authors: Nosaka Shunsuke
Final Pr. ID: Poster #: SCI-032
Ultrasound guided percutaneous liver biopsy is frequently performed in pediatric patients. Published post-biopsy complication rates range between 0.3 - 3.3% according to Society of Interventional Radiology Standards of Practice. Post-biopsy tract embolization has been prophylactically used to theoretically decrease the bleeding risk, but is not the current standard of care at our institution. The goal of this study is to determine if there is a need for prophylactic biopsy tract-embolization after ultrasound guided liver biopsy in the pediatric population.
Final Pr. ID: Poster #: EDU-010
Congenital vascular anomalies of the liver are rare entities that take on different physical forms and clinical presentations, with imaging being highly important in the diagnosis and follow-up of these entities. The purpose of this educational presentation is to provide a multimodality imaging review of several different congenital vascular anomalies of the liver that have been observed at a single pediatric tertiary care center. These include infantile hepatic hemangiomas, congenital portosystemic shunts, and congenital intrahepatic arterioportal shunt. The clinical course and management/treatment for each of these entities, to also include the role of imaging in follow-up, will also be briefly discussed. Read More
Final Pr. ID: Poster #: SCI-018
To apply the Couinaud’ system of segmentation and PRETEXT staging system of the liver to the tumor staging, combined with MSCT for evaluate the effectiveness in pre or post therapy of hepatoblatoma. Read More
Final Pr. ID: Poster #: EDU-028
In a child the abdominal organs are more at risk from blunt injury, the reasons for this include the fact that the organs are relatively more anterior and inferior and lie inferior to the ribs rather than behind them as in an adult. Additionally, paediatric ribs are cartilaginous and so although rib fractures are less likely, compressive injuries secondary to the relative elasticity of the rib cage are far more common. The computed tomography (CT) features of abdominal visceral injury include lacerations, subcapsular or parenchymal haematomas, active haemorrhage, and vascular injuries, all of which the radiologists must be familiar with. Although there is an increasing trend toward non-operative management of abdominal solid organ injury, radiologists must also be aware of the key imaging features that suggest the need for surgical or interventional radiology input.
Based on our experience as one of the largest Level 1 trauma centres in Europe, the aims of this educational exhibit are to:
(i) Provide a pictorial review the spectrum of findings in blunt injury to the liver, kidneys and spleen as demonstrated on CT.
(ii) Discuss the role of Interventional Radiology in cases of associated vascular injury. Read More