Download Radiologic Evaluation of the Liver Transplant Candidate

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Transcript
Gia Landry, HMS III
Gillian Lieberman, MD
Spring 2004
Radiologic Evaluation of the
Liver Transplant Candidate
Gia M. Landry, Harvard Medical School Year III
Gillian Lieberman, MD
Gia Landry, HMS III
Gillian Lieberman, MD
Welcome!!!
Before starting the presentation keep in mind that:
• Any writing in this color (blue) is narration
• The asterisk (*) at the bottom of a page is supplemental
information to the main text.
Enjoy!!!
2
Gia Landry, HMS III
Gillian Lieberman, MD
Objectives
• Indications for transplant
• Contraindications for transplant
• Role of imaging in transplant candidate
selection
• Imaging modalities/Menu of Tests
• Implication of radiologic findings
3
Gia Landry, HMS III
Gillian Lieberman, MD
To achieve the objectives a patient will serve as a case example
of the steps taken to clear a patient radiologically for
liver transplantation.
Most of the images will be from patient D.C., and any images
that are from another patient will be labeled as companion 1,
companion 2, etc.
4
Gia Landry, HMS III
Gillian Lieberman, MD
Patient D.C.
CC: Abdominal enlargement and lower extremity edema
HPI: 49-year-old male presented
with ascites and lower
extremity edema was found to
have cirrhosis secondary to
hepatitis C.
-Referred for liver
transplantation evaluation
Over the next 1½ years his signs
and symptoms included:
-ascites
-fatigue
-gastric and esophageal varices
-hepatosplenomegaly
-hepatic encephalopathy
- jaundice
-hepatorenal syndrome
5
Gia Landry, HMS III
Gillian Lieberman, MD
Patient D.C.
PMH: Urethral stricture,
Nephrolithiasis
SH:
-Tobacco-15 pack year history
-Alcohol-Minimal
-Illicit drug use-IV drug
use with needle sharing x2
(30 years ago)
-Tattoos-Multiple
-100 sexual partners
ROS: Fatigue, anorexia,
decreased libido, weakness, nausea
Medications:
-Protonix
-Nadolol
-Aldactone
-Lasix
-Lactulose
-Actigall
-Mycelex
-Calcium + Vit. D
-Magnesium oxide
6
Gia Landry, HMS III
Gillian Lieberman, MD
Patient D.C.
PE:
HEENT-scleral icterus
Skin-spider nevi, palmar erythema
Cardiac-RRR, no m/r/g
Pulm-CTAB, gynecomastia
GI-Hepatosplenomegaly, ascites
Ext-2+ LE pitting edema
Labs:
-Cr: 1-5.3
-INR: 1.4-2.3
-TBili: 2.4-20
-CA 19-9: 81
-CEA: 17
AFP: 16
-AST: 121 ALT: 147 ALP: 260
-HIV negative
-Hep. C Ab, Hep. E core Ab,
Hep. A Ab positive
7
Gia Landry, HMS III
Gillian Lieberman, MD
Indications for Liver
Transplantation
• Acute or chronic liver failure
–
–
–
–
–
–
–
Chronic Hepatitis
Alcoholic Liver Disease
Cholestatic Disease
Metabolic Diseases
Cryptogenic Cirrhosis
Acute Fulminant Hepatic Failure
Hepatocellular Carcinoma (HCC)
*Most of the above conditions will result in cirrhosis.
*80% of transplants are done for cirrhosis or cholestatic disease.
*5% of transplants are done for HCC .
8
Gia Landry, HMS III
Gillian Lieberman, MD
Contraindications for Liver
Transplantation
• Absolute
– Extrahepatic
malignancy
– Advanced
cardiopulmonary
disease
– Active alcohol or drug
abuse
– Infection outside the
biliary tract
• Relative
– Hepatoma (>5cm)
– Mesenteric venous
thrombosis
– Advanced age
– Cholangiocarcinoma
*Depending on transplant centers,
relative contraindications can exclude
a patient from transplantation.
9
Gia Landry, HMS III
Gillian Lieberman, MD
Role of Imaging
• Candidate Selection
– Search for intrahepatic and extrahepatic malignancy
• Prognostic Implications/Surgical Planning
– HCC Staging
– Assessment of vessel patency
• Vascular invasion
– Quantification of diseased liver volume
– Vascular anatomy
– Identification of cirrhosis and sequella of portal hypertension
• Portocaval shunts
*HCC Staging is important because vascular invasion and bilobar
distribution are associated with poor outcomes, often excluding patients
from transplantation.
*5-year survival 60% without vascular invasion, 6% with macroscopic invasion.
10
*5-year survival 53% if unilobar, 15% if bilobar.
Gia Landry, HMS III
Gillian Lieberman, MD
Chest X-Ray and Chest Computed
Tomography
• Cardiopulmonary abnormalities
• Metastases
– Identification
– Staging
• Chest CT for further evaluation of any
abnormality found
11
Gia Landry, HMS III
Gillian Lieberman, MD
Chest X-Ray
Patient D.C.
PACS,BIDMC
Normal CXR
12
Gia Landry, HMS III
Gillian Lieberman, MD
Ultrasound
• Screening tool
• Identification:
–
–
–
–
Liver masses
Malignant thrombosis
Vessel Patency
Direction of flow
• Hepatopedal vs.
Hepatofugal
– Ascites
• US modalities
– Gray Scale
• Sensitivity 50-90%
• Specificity 98%
– Color Doppler
– Duplex Doppler
*Sensitivity is closer to 50%, because
heterogeneity of the liver complicates the
idenitification of masses.
13
Gia Landry, HMS III
Gillian Lieberman, MD
Ultrasound Color Doppler
Pre-Transplant
Portal Vein
PACS,BIDMC
Post-Transplant
Portal Vein
14
Gia Landry, HMS III
Gillian Lieberman, MD
Ultrasound
Liver Mass
HCC
PACS,BIDMC
*HCC can be hypo-, iso-, or hyperechoic
15
Gia Landry, HMS III
Gillian Lieberman, MD
Ultrasound Duplex and Color
Doppler
Patient D.C.
Companion 1
Pre-Transplant
Post-Transplant
Hepatic Artery
Portal Vein
PACS, BIDMC *Duplex not important pre-transplant, more important post16
Gia Landry, HMS III
Gillian Lieberman, MD
Computed Tomography (CT)
• Further characterization of
liver masses
– Multiphasic contrast CT
•
Sensitivity
– CT alone 67%
– CT + US 75%
• Vessel patency
• Global abdominal survey
for extrahepatic
malignancy
• Assessment of liver
volume
• Identification of shunts
17
Gia Landry, HMS III
Gillian Lieberman, MD
Portal Anatomy
Portal vein
Splenic
Vein
IMV
SMV
Netter, F. Atlas of Human Body 1997: 282
18
Gia Landry, HMS III
Gillian Lieberman, MD
Hepatic Anatomy
Hepatic vein
IVC
Portal vein
Netter, F. Atlas of Human Body 1997:226,273
19
Gia Landry, HMS III
Gillian Lieberman, MD
Multiphasic Contrast-enhanced CT
Patient D.C.
Hepatic Arterial Phase Portal Venous Phase
PACS,BIDMC
Hepatic Venous Phase
*70-80% of liver blood supply is from the portal vein.
*HCC blood supply is arterial, and therefore most masses
will enhance early, during arterial phase.
20
Gia Landry, HMS III
Gillian Lieberman, MD
Multiphasic Contrast-enhanced CT
with
HCC
Companion 3
Non-contrast
Hepatic
Arterial
Portal
Venous
Hepatic
Venous
PACS,BIDMC
21
Gia Landry, HMS III
Gillian Lieberman, MD
CT 3D Reconstruction
Proper Hepatic
Artery
PACS,BIDMC
Common Hepatic
Artery
Celiac Artery
Hepatic Vein
Portal Vein
22
Gia Landry, HMS III
Gillian Lieberman, MD
CT Portal Vein Thrombus
Companion 4
Thrombus
Cavernous
Transformation
PACS,BIDMC
*Thrombus may be benign or malignant.
*If benign it will be bypassed during surgery,
if malignant then patient has a worse prognosis.
23
Gia Landry, HMS III
Gillian Lieberman, MD
CT Liver Volume
Right Anterior
Segment
Left Medial
Segment
Right Posterior
Segment
Left Lateral
Segment
Patient D.C.
PACS,BIDMC
*Donor livers 50% smaller or 20% larger are acceptable,
but keep in mind that disparities in volume make surgery
24
more difficult.
Gia Landry, HMS III
Gillian Lieberman, MD
CT Splenorenal Shunt
Patient D.C.
PACS,BIDMC
*Identification of shunts is not critical pre-transplant, but does give
the surgeons the option of ligating them to maximize flow to the
25
transplanted liver.
Gia Landry, HMS III
Gillian Lieberman, MD
Magnetic Resonance Imaging
(MRI)
• Not commonly used
• Provides similar
information as CT
• Used in some
complicated cases
• Mass characterization
– T1-weighted images
• Anatomic detail
– T2-weighted images
• Non-neoplastic vs.
neoplastic
– Additional sequences if
necessary
26
Gia Landry, HMS III
Gillian Lieberman, MD
MRI
Companion 1
T1-weighted
Subtraction
Hemangioma
PACS,BIDMC
27
Gia Landry, HMS III
Gillian Lieberman, MD
Biopsy
• Indication
– Liver mass
– Portal vein thrombus
• Consideration
– Patient cooperation
– Correction of underlying coagulopathy
• Modalities
– Ultrasound
– CT
– Fluoroscopy
28
Gia Landry, HMS III
Gillian Lieberman, MD
Ultrasound-guided Biopsy
Companion 2
Liver Mass
HCC
PACS,BIDMC
*Ultrasound is a useful modality, because color doppler can
29
identify vessels and real-time imaging is used.
Gia Landry, HMS III
Gillian Lieberman, MD
Celiac Axis Anatomy
Left Hepatic Artery
Celiac Artery
Right Hepatic
Artery
Proper Hepatic
Artery
Common
Hepatic Artery
Netter, F. Atlas of Human Body, 1997: 292
30
Gia Landry, HMS III
Gillian Lieberman, MD
Computed Tomography
Angiography (CTA)
• Identification of
thrombosed veins:
Patient D.C.
Celiac Axis
– Portal
– Mesenteric
– Splenic
• Arterial abnormalities
– Hepatic artery
– Celiac axis
– Splenic artery
PACS,BIDMC
*Bile ducts supplied by hepatic artery, therefore it is important
31
to determine the anatomy and patency of the celiac axis.
Gia Landry, HMS III
Gillian Lieberman, MD
Patient D.C.
Impression:
Patient D.C. has no identifiable masses, the vessels are patent and
there are no vascular anomalies.
Patient D.C. is radiologically cleared to undergo liver transplantation.
Patient D.C. had an orthotopic liver transplant in 02/04!!!
32
Gia Landry, HMS III
Gillian Lieberman, MD
Summary
The Role of Radiology in Evaluating the Liver Transplant Candidate:
Candidate Selection
• Malignancy
–
–
–
–
–
CXR/Chest CT
Ultrasound
Abdominal CT
MRI
Biopsy
Prognostic Implications/
Surgical Planning
• Malignancy
• Vessel Patency/Shunts
–
–
–
–
Ultrasound
Abdominal CT
MRI
CTA
• Anatomy
– CT
– MRI
– CTA
33
Gia Landry, HMS III
Gillian Lieberman, MD
References
• Cotler, S, Jensen, D. Patient selection for liver
transplantation. www.uptodate.com. 2003.
• Ferris, J, Marsh, J. Presurgical evaluation of the
liver transplant candidate. Radiologic Clinics of
North America. Imaging of Organ
Transplantation 1995; 33(3): 497-519.
• Hussain, H, Nghiem, H. Imaging of hepatic
transplantation. Clinics of Liver Disease 2002;
6(1): 247-70.
• Netter, Frank. Atlas of Human Body. Second
Edition 1997; 226,273,282,292.
34
Gia Landry, HMS III
Gillian Lieberman, MD
Acknowledgments
•
•
•
•
•
•
•
•
Jeffrey Gremmels, MD
Gillian Lieberman, MD
Alice Fisher, MD
Pamela Lepkowski
Larry Barbaras
Ola Ayodele
Kelly Epps
Shelley Day
35