Search Results (32)

Background/Objectives: The frequency of image-guided biopsies has increased substantially in recent decades; however, high technical success rates are offset by potential complications. Methods: This retrospective study compared the safety profile of ultrasound- and CT-guided percutaneous biopsies in 250 patients involving the liver, thoracic organs, retroperitoneum, peripheral lymph nodes, and bone. The parameters analyzed included procedure duration, technical success, as well as type, frequency, severity, timing, and treatment of complications. Statistical comparisons comprised Mann–Whitney-U and Chi-square tests. Results: The overall technical success rate was 97.6%, with no significant difference between CT and ultrasound (p = 0.491). Ultrasound-guided biopsies were performed more often in women; CT-guided procedures were performed more often in men (p = 0.031). Ultrasound-guided interventions were significantly faster with a median duration of 19:00 min vs. 25:30 min in CT (p < 0.001). Median radiation dose for CT-guided procedures was 445 mGy·cm (interquartile range 307.8–634.0). Including minor events, complications occurred in 19.6% of cases. Complication rates were significantly higher for CT- (30.3%) compared to ultrasound-guided biopsies (7.6%; p < 0.001). Bleeding and pneumothorax were significantly more frequent in CT-guided interventions (p = 0.004). Most complications were mild (85.7%) with no life-threatening events. The majority of complications occurred within four hours post-biopsy (93.9%). The severity of complications did not differ significantly between modalities (p = 0.399). Conclusions: CT-guided biopsies were associated with higher complication rates, likely reflecting procedural complexity and better detection of minor complications. Post-interventional complications such as pneumothorax and bleeding were mostly mild, while severe complications occurrence was extremely rare. Full article

Background and Objectives: Early diagnosis and monitoring of liver fibrosis in chronic hepatitis B are crucial for effective disease management and prognosis. Traditionally, percutaneous liver biopsy has been regarded as the gold standard for assessing the degree of fibrosis histopathologically. However, this method has several drawbacks. Consequently, non-invasive serum scoring systems are becoming increasingly preferred. These serum scoring systems have emerged as valuable non-invasive tools for predicting liver fibrosis in patients with chronic hepatitis B. Multiple serum-based scoring systems have been developed and validated for this purpose. The aim of this study is to determine the role of serum scoring systems in chronic hepatitis B, evaluate their performance, and analyze their correlation with liver biopsy results. Materials and Methods: Patients diagnosed with Chronic Hepatitis B who underwent liver biopsy and were found to have liver fibrosis associated with chronic hepatitis B between August 2018 and July 2024 were included in this retrospective comparative case-control study and liver function tests, INR, alpha-fetoprotein levels, hemogram parameters, kidney function tests, and cholesterol levels at the time of biopsy were recorded. Results: The present study included a total of 249 patients, comprising 138 men (55.5%; mean age 42.1 years) and 111 women (44.5%; mean age 45.8 ± 13.5 years). The results of sixteen commonly used scoring systems in the current literature were evaluated for predicting fibrosis. According to ROC analysis, the most notable score identified was the KING score (0.775). The subsequent scores, in order, were AGAP (0.768), GUCI (0.748), FIB-4 (0.735), APRI (0.729), and S-INDEX (0.701). Conclusions: Non-invasive methods offer potential advantages over liver biopsy. While these scoring systems demonstrate good accuracy in identifying advanced fibrosis and cirrhosis, their performance in detecting mild to moderate fibrosis is generally less reliable. They can function as preliminary screening tests to identify patients who may require further evaluation or to prioritize individuals for more advanced imaging studies or liver biopsy. Full article

Background and Clinical Significance: Combined hepatocellular–cholangiocarcinoma (cHCC-CC) is a rare primary liver malignancy exhibiting both hepatocellular and cholangiocellular features. Due to overlapping clinical, imaging, and pathological characteristics with hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCC), diagnosis remains challenging. Early and accurate differentiation is critical for optimal treatment planning. Case Presentation: We report three histologically confirmed cases of cHCC-CC with different imaging features, biomarker profiles, treatment strategies, and clinical outcomes. Patient 1, a 69-year-old female, presented with a large centrally located liver mass exhibiting iCC-like imaging features and mildly elevated AFP and CA 19-9 levels. Biopsy confirmed poorly differentiated cHCC-CC. Treatment involved palliative chemotherapy, with a survival of 16 months following diagnosis. Patient 2, an 80-year-old female with a small lesion in a cirrhotic liver, demonstrated an HCC-like enhancement pattern but normal AFP levels. Surgical resection was performed, and histology confirmed cHCC-CC with a dual phenotype. Despite initial remission, intrahepatic recurrence developed, treated with TACE and systemic therapy. The patient later transitioned to palliative care due to progression and survived 36 months. Patient 3, a 67-year-old male with chronic hepatitis C, presented with an HCC-like lesion and elevated AFP. Due to comorbidities, surgical resection was not feasible, and the patient was treated with percutaneous microwave ablation as a safer alternative. Biopsy during ablation confirmed cHCC-CC; follow-up was ongoing at submission. Conclusions: These cases highlight the diagnostic complexity and clinical variability of cHCC-CC. Imaging may be misleading, and tumor markers do not reliably predict subtype or prognosis. Histological confirmation is essential, particularly in patients with atypical imaging or discordant biomarker profiles. Individualized management, informed by tumor biology and patient condition, remains critical. Further research is needed to refine diagnostic criteria and develop tailored therapeutic strategies for this challenging tumor entity. Full article

Background and Objectives: Accurate noninvasive differentiation between hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) remains a clinical challenge. This study aimed to assess the dignostic performance of apparent diffusion coefficient (ADC) values from diffusion-weighted MRI in distinguishing between HCC and ICC, with histological confirmation as the gold standard. Materials and Methods: A retrospective analysis was performed on 61 patients (41 HCC, 20 ICC) who underwent liver MRI and percutaneous biopsy between 2019 and 2024. ADC values were measured from diffusion-weighted sequences (b-values of 0, 500, and 1000 s/mm²), and regions of interest were placed over solid tumor areas. Statistical analyses included t-tests, one-way ANOVA, and ROC curve analysis. Results: Mean ADC values did not differ significantly between HCC (1.09 ± 0.19 × 10⁻³ mm²/s) and ICC (1.08 ± 0.11 × 10⁻³ mm²/s). ROC analysis showed poor discriminative ability (AUC = 0.520; p = 0.806). In HCC, ADC values decreased with lower differentiation grades (p = 0.008, η² = 0.224). No significant trend was observed in ICC (p = 0.410, η² = 0.100). Immunohistochemical markers such as CK-7, Glypican 3, and TTF-1 showed significant diagnostic value between tumor subtypes. Conclusions: ADC values have limited utility for distinguishing HCC from ICC but may aid in HCC grading. Immunohistochemistry remains essential for accurate diagnosis, especially in poorly differentiated tumors. Further studies with larger cohorts are recommended to improve noninvasive diagnostic protocols. Full article

Portal hypertension (PH) is a complication of advanced liver diseases, including cirrhosis and hepatocellular carcinoma, often leading to unfavorable outcomes. Endo-hepatology, particularly endoscopic ultrasound (EUS) has revolutionized the assessment of PH. Notably, EUS-guided portal pressure gradient (EUS-PPG) enables measurement of portal and hepatic venous pressures, offering diagnostic precision for both cirrhotic and non-cirrhotic forms of PH, including porto-sinusoidal vascular disorder (PSVD). EUS-based assessment of PH in advanced liver disease can refine diagnostic workup and prognostication, supporting therapeutic decisions. Additionally, EUS-guided liver biopsy (EUS-LB) achieves high-quality histological samples with fewer complications compared to percutaneous techniques, enabling thorough evaluation of chronic liver diseases and vascular abnormalities. EUS-shear wave elastography (EUS-SWE) further refines stiffness measurements where standard imaging fails. Moreover, EUS plays a major role in controlling variceal hemorrhage, a severe PH complication. EUS-guided coil and cyanoacrylate injection for gastric varices demonstrate a great efficacy, often surpassing conventional endoscopy. Similarly, EUS-based identification and treatment of perforator vessels feeding esophageal varices reduce rebleeding risks, particularly in challenging patients. The combination of these state-of-the-art interventions supports a “one-stop strategy”, integrating variceal screening, biopsy, and portal pressure measurement within a single procedure. Despite these advancements, refinements in sedation protocols, patient selection, and cost-effectiveness data are necessary. While noninvasive tools remain central in guidelines, EUS-based methods continue to expand their role, especially in complex cases. This review summarizes the applications and impact of EUS in evaluating PH, emphasizing its importance in contemporary hepatology and its potential as a pivotal diagnostic modality in cirrhosis complicated by PH. Full article

Objectives: This study aims to assess the potential role of the ultrasound (US) monochromatic Superb Microvascular Index (mSMI) to predict malignancy of solid focal lesions, correlating the vascular index (VI) with bioptic histological results. Methods: In this single-center retrospective analysis, patients undergoing percutaneous US-guided biopsy of solid lesions were considered. Biopsy indication was given by a multidisciplinary team evaluation based on clinical radiological data. Exclusion criteria were: unfeasible SMI evaluations due to poor respiratory compliance, locations not appreciable with the SMI, previous antiangiogenetic chemo/immunotherapies, and inconclusive histological reports. The mSMI examination was conducted in order to visualize extremely low-velocity flows with a high resolution and high frame rate; the VI was semi-automatically calculated. All bioptic procedures were performed under sole US guidance using 16G or 18G needles, immediately after mSMI assessment. Results: Forty-four patients were included (mean age: 64 years; 27 males, 17 females). Liver (15/43), kidneys (9/43), and lymph nodes (6/43) were the most frequent targets. At histopathological analysis, 7 lesions were benign and 37 malignant, metastasis being the most represented. The VI calculated in malignant lesions was statistically higher compared to benign lesions (35.45% and 11% in malignant and benign, respectively; p-value 0.013). A threshold VI value of 15.4% was identified to differentiate malignant lesions. The overall diagnostic accuracy of the VI with the mSMI was 0.878, demonstrating a high level of diagnostic accuracy. Conclusions: In this study, the mSMI analysis of solid focal lesions undergoing percutaneous biopsy significantly correlated with histological findings in terms of malignant/benign predictive value, reflecting histological vascular changes in malignant lesions. Full article

Odontogenic cysts are frequently encountered in clinical practice. However, residual cysts, a specific type of inflammatory odontogenic cyst, are relatively rare. These cysts may slowly expand over time, damaging surrounding soft tissues and bone, typically without posing a threat to life. We report the case of a 67-year-old man with liver failure and a cystic tumor in his right maxilla that had invaded his oral cavity and cheek, causing nasal obstruction and severe bleeding following an incisional biopsy. A computed tomography (CT) scan of the mass was nonspecific, and an initial histopathological analysis of the tissues was inconclusive due to chronic inflammation and hemorrhagic alterations, complicating the diagnostic pathway. The suspicion of a potentially aggressive malignant neoplasm and the need for immediate intervention due to bleeding necessitated a tracheotomy, tumor removal, percutaneous endoscopic gastrostomy, and transfusions of red blood cells. A subsequent histopathological examination revealed features indicative of a residual cyst. The entire lesion was excised through functional endoscopic sinus surgery. The surgical treatment was performed safely and effectively. Follow-up CT confirmed complete removal of the lesion. This case highlights a rare yet possible complication of odontogenic cysts and underscores the necessity of early diagnosis and comprehensive prophylaxis to prevent severe complications. Full article

Androgens have long been recognized as oncogenic agents. They can induce both benign and malignant hepatocellular neoplasms, including hepatocellular adenoma (HCA) and hepatocellular carcinoma, though the underlying mechanisms remain unclear. Androgen-induced liver tumors are most often solitary and clinically silent. Herein, we reported an androgen-induced HCA complicated by spontaneous rupture. The patient was a 24-year-old male presenting with fatigue, diminished libido, radiology-diagnosed hepatocellular adenomatosis for 3 years, and sudden-onset, severe, sharp, constant abdominal pain for one day. He used Aveed (testosterone undecanoate injection) from age 17 and completely stopped one year before his presentation. A physical exam showed touch pain and voluntary guarding in the right upper quadrant of the abdomen. An abdominal CT angiogram demonstrated multiple probable HCAs, with active hemorrhage of the largest one (6.6 × 6.2 × 5.1 cm) accompanied by large-volume hemoperitoneum. After being stabilized by a massive transfusion protocol and interventional embolization, he underwent a percutaneous liver core biopsy. The biopsy specimen displayed atypical hepatocytes forming dense cords and pseudoglands. The lesional cells diffusely stained β-catenin in nuclei and glutamine synthetase in cytoplasm. Compared to normal hepatocytes from control tissue, the tumor cells were positive for nuclear AR (androgen receptor) expression but had no increased EZH2 (Enhancer of Zeste 2 Polycomb Repressive Complex 2 Subunit) protein expression. The case indicated that androgen-induced hepatocellular neoplasms should be included in the differential diagnosis of acute abdomen. Full article

Despite the introduction of serological neoplastic biomarkers and typical radiological characteristics in clinical practice, liver biopsy (LB) is often still necessary to establish a histological diagnosis, especially in ambiguous cases. Nowadays, LB via the percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonography (US) guidance, is the route of choice. However, certain focal liver lesions can be challenging to access percutaneously. In such cases, endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) may represent an attractive, minimally invasive alternative. This retrospective observational study aimed to evaluate the efficacy, diagnostic performance, and safety of EUS-FNB conducted on 58 focal liver lesions located in both liver lobes. The adequacy of FNB samples for focal liver lesions located in the left and right lobes was 100% and 81.2%, respectively, and the difference was statistically significant (p = 0.001). Technical success was 100% for both liver lobes. The overall sensitivity and specificity were 95% and 100%, respectively. EUS-FNB is effective in making an accurate diagnosis with an excellent safety profile for focal liver lesions located in both liver lobes. Full article

Background: The efficacy of endoscopic ultrasound-guided liver biopsy (EUS-LB) compared to percutaneous liver biopsy (PC-LB) remains uncertain. Methods: Our data consist of randomized controlled trials (RCTs) comparing EUS-LB to PC-LB, found through a literature search via PubMed/Medline and Embase. The primary outcome was sample adequacy, whereas secondary outcomes were longest and total lengths of tissue specimens, diagnostic accuracy, and number of complete portal tracts (CPTs). Results: Sample adequacy did not significantly differ between EUS-LB and PC-LB (risk ratio [RR] 1.18; 95% confidence interval [CI] 0.58–2.38; p = 0.65), with very low evidence quality and inadequate sample size as per trial sequential analysis (TSA). The two techniques were equivalent with respect to diagnostic accuracy (RR: 1; CI: 0.95–1.05; p = 0.88), mean number of complete portal tracts (mean difference: 2.29, −4.08 to 8.66; p = 0.48), and total specimen length (mean difference: −0.51, −20.92 to 19.9; p = 0.96). The mean maximum specimen length was significantly longer in the PC-LB group (mean difference: −3.11, −5.51 to −0.71; p = 0.01), and TSA showed that the required information size was reached. Conclusion: EUS-LB and PC-LB are comparable in terms of diagnostic performance although PC-LB provides longer non-fragmented specimens. Full article

Percutaneous CT-guided biopsy is a frequently performed procedure for the confirmation and molecular workup of hepatic metastases of pancreatic ductal adenocarcinoma (PDAC). Tumor necrosis of primary PDAC has shown a negative prognostic impact in recent studies. This study aims to examine predictability in CT scans and the prognostic impact of necrosis in hepatic metastases of PDAC. In this tertiary-center retrospective cohort study, we included 36 patients with hepatic metastases of PDAC who underwent CT-guided hepatic biopsies. Normalized attenuation of the biopsied metastasis was determined in venous phase contrast-enhanced planning scans obtained prior to biopsy by automatic, threshold-based 3D segmentation and manual, blinded 2D segmentation. A board-certified pathologist specialized in hepatic pathology histologically quantified the tumor necrosis and cellularity of the biopsy cylinders. We found a significant inverse-linear correlation between normalized attenuation and the fraction of necrosis (Pearson’s r = 0.51, p < 0.001 for automatic 3D segmentation or Pearson’s r = 0.52, p < 0.001 for manual 2D segmentation), whereas no correlation was found with tumor cellularity. Additionally, we discovered that patients with a fraction of necrosis ≥ 20% in metastases had a significantly shorter overall survival (p < 0.035). In summary, tumor necrosis of PDAC metastases can be estimated from contrast-enhanced CT scans, which could help to improve biopsy sample pattern planning. In addition, liver metastatic necrosis may serve as a prognostic biomarker in PDAC. Full article

We present the first documented case of a fistula between the treated zone and the appendix after RFA in a patient with HCC. Contrast-enhanced CT and MRI revealed a subcapsular hepatic nodule with image findings of HCC located adjacent to the ascending colon and cecum. An ultrasound-guided core needle biopsy was subsequently performed to distinguish between hepatic metastasis and HCC. Post-RFA imaging identified a low-attenuating ablated area adjacent to an air-filled appendix. The patient later experienced complications, including increased liver enzymes and an abscess at the ablation site. Imaging revealed a fistulous tract between the RFA zone and the appendix. Over the following months, the patient underwent conservative treatment involving intravenous antibiotics and repeated percutaneous drainage, exhibiting eventual symptom relief and an absence of the fistulous tract upon subsequent imaging. This case highlights the rare complications that can arise during RFA due to peculiar anatomical variations, such as a subhepatic appendix, resulting from midgut malrotation and previous surgery. It is imperative for operators to be cognizant of potential anatomical variations when considering RFA treatment, ensuring comprehensive pre-procedural imaging and post-procedure monitoring. This case also emphasizes the potential viability of nonoperative management in complex scenarios in which surgical interventions pose significant risks. Full article

The field of hepatocellular carcinoma (HCC) has faced significant change on multiple levels in the past few years. The increasing emphasis on the various HCC phenotypes and the emergence of novel, specific therapies have slowly paved the way for a personalized approach to primary liver cancer. In this light, the role of percutaneous liver biopsy of focal lesions has shifted from a purely confirmatory method to a technique capable of providing an in-depth characterization of any nodule. Cancer subtype, gene expression, the mutational profile, and tissue biomarkers might soon become widely available through biopsy. However, indications, expectations, and techniques might suffer changes as the aim of the biopsy evolves from providing minimal proof of the disease to high-quality specimens for extensive analysis. Consequently, a revamped position of tissue biopsy is expected in HCC, following the reign of non-invasive imaging-only diagnosis. Moreover, given the advances in techniques that have recently reached the spotlight, such as liquid biopsy, concomitant use of all the available methods might gather just enough data to improve therapy selection and, ultimately, outcomes. The current review aims to discuss the changing role of liver biopsy and provide an evidence-based rationale for its use in the era of precision medicine in HCC. Full article

Alagille syndrome (ALGS) is a multisystem condition characterized by cholestasis and bile duct paucity on liver biopsy and variable involvement of the heart, skeleton, eyes, kidneys, and face and caused by pathogenic variants in the JAG1 or NOTCH2 gene. The variable expressivity of the clinical phenotype and the lack of genotype–phenotype correlations lead to significant diagnostic difficulties. Here we present an analysis of 18 patients with cholestasis who were diagnosed with ALGS. We used an NGS panel targeting coding exons of 52 genes, including the JAG1 and NOTCH2 genes. Sanger sequencing was used to verify the mutation in the affected individuals and family members. The specific facial phenotype was seen in 16/18 (88.9%). Heart defects were seen in 8/18 (44.4%) patients (pulmonary stenosis in 7/8). Butterfly vertebrae were seen in 5/14 (35.7%) patients. Renal involvement was detected in 2/18 (11.1%) cases—one patient had renal cysts, and one had obstructive hydronephrosis. An ophthalmology examination was performed on 12 children, and only one had posterior embryotoxon (8.3%). A percutaneous liver biopsy was performed in nine cases. Bile duct paucity was detected in six/nine cases (66.7%). Two patients required liver transplantation because of cirrhosis. We identified nine novel variants in the JAG1 gene—eight frameshift variants (c.1619_1622dupGCTA (p.Tyr541X), c.1160delG (p.Gly387fs), c.964dupT (p.C322fs), c.120delG (p.L40fs), c.1984dupG (p.Ala662Glyfs), c.3168_3169delAG (p.R1056Sfs*51), c.2688delG (p.896CysfsTer49), c.164dupG (p.Cys55fs)) and one missense variant, c.2806T > G (p.Cys936Gly). None of the patients presented with NOTCH2 variants. In accordance with the classical criteria, only six patients could meet the diagnostic criteria in our cohort without genetic analysis. Genetic testing is important in the diagnosis of ALGS and can help differentiate it from other types of cholestasis. Full article

Background and Objectives: The development of liver fibrosis as a consequence of continuous inflammation represents a turning point in the evolution of chronic liver diseases. The recent developments of artificial intelligence (AI) applications show a high potential for improving the accuracy of diagnosis, involving large sets of clinical data. For this reason, the aim of this systematic review is to provide a comprehensive overview of current AI applications and analyze the accuracy of these systems to perform an automated diagnosis of liver fibrosis. Materials and Methods: We searched PubMed, Cochrane Library, EMBASE, and WILEY databases using predefined keywords. Articles were screened for relevant publications about AI applications capable of diagnosing liver fibrosis. Exclusion criteria were animal studies, case reports, abstracts, letters to the editor, conference presentations, pediatric studies, studies written in languages other than English, and editorials. Results: Our search identified a total of 24 articles analyzing the automated imagistic diagnosis of liver fibrosis, out of which six studies analyze liver ultrasound images, seven studies analyze computer tomography images, five studies analyze magnetic resonance images, and six studies analyze liver biopsies. The studies included in our systematic review showed that AI-assisted non-invasive techniques performed as accurately as human experts in detecting and staging liver fibrosis. Nevertheless, the findings of these studies need to be confirmed through clinical trials to be implemented into clinical practice. Conclusions: The current systematic review provides a comprehensive analysis of the performance of AI systems in diagnosing liver fibrosis. Automatic diagnosis, staging, and risk stratification for liver fibrosis is currently possible considering the accuracy of the AI systems, which can overcome the limitations of non-invasive diagnosis methods. Full article