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¿Qué es el hígado?

El hígado es uno de los órganos más grandes del cuerpo humano. Mide una media de 26 cm y pesa alrededor de 1,5 kilogramos. Es un órgano de gran importancia por su rol en la actividad metabólica del organismo, así como por la síntesis de proteínas plasmáticas y colesterol y el almacenamiento de vitaminas y glucógeno, entre muchas otras funciones.

El hígado es el único órgano del cuerpo capaz de regenerarse y como curiosidad, puede perder hasta tres cuartos de su sustancia antes de dejar de funcionar.

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Hepatocarcinoma

La insuficiencia hepática está definida por el deterioro de la función hepática. Esta puede ser aguda o crónica y puede aparecer debido a múltiples causas (alcohol, distintos virus, síndrome metabólico, etc.). El carcinoma hepatocelular es el tumor primario del hígado más frecuente que se desarrolla generalmente en pacientes con enfermedad hepática crónica y que representa un problema de salud y económico en aumento a nivel mundial.  

Un diagnóstico temprano es crucial para mejorar el pronóstico de los pacientes. Para realizarlo, existen varias pruebas radiológicas disponibles, como la ecografía, el TC con contraste y la RM con contraste extracelular y con ácido gadoxético.

 

Resúmenes de artículos

    Según los datos obtenidos en el estudio Global Burden of Disease Study 2019, publicado en JAMA oncology, entre los años 2010 y 2019 los casos de cáncer a nivel mundial se incrementaron en un 26,3%, llegando hasta los 23,6 millones de casos en 2019. Del mismo modo, el número de muertes provocadas por cáncer se incrementó en un 20,9% durante el mismo periodo de tiempo, llegando hasta aproximadamente los 10 millones de casos. Además de la incidencia y la mortalidad, otro de los parámetros analizados en el estudio fue los Años de Vida Ajustados por Discapacidad (AVAD). Entre el 2010 y el 2019, los AVAD causados por el cáncer se incrementaron hasta los 250 millones aproximadamente.

    Con estos valores, el cáncer se sitúa a nivel mundial como la segunda enfermedad, después de las cardiovasculares, que más muertes y AVAD provoca. Sin embargo, en los países más desarrollados el cáncer se encuentra ya en la primera posición. De todos los AVAD relacionados a neoplasias, las de origen hepático se ubican en el 5 lugar. Entre los años 2010 y 2019 el cáncer hepático pasó de ser el 7º cáncer que más AVAD provoca al 5º. Se estima que en el año 2019 hubo a nivel mundial unos 534.000 casos de esta patología y que provocó 485.000 muertes.

    En un estudio publicado el año 2020 en la revista Radiology, se estudió el impacto de realizar una RM con ácido gadoxético sobre la mortalidad de pacientes con carcinoma hepatocelular (CHC).

    Este estudio de cohorte retrospectivo de pacientes diagnosticados con CHC entre el año 2008 y 2010 y realizado en Corea del Sur analizó más de 30.000 pacientes diagnosticados de CHC que, como parte de su diagnóstico y estadiaje inicial, se realizaron una TC, una TC + RM con contraste extracelular, o a una TC + RM con ácido gadoxético analizando la mortalidad en los distintos subgrupos.

    Los resultados del estudio sugieren que la realización de una RM con contraste para el estadiaje inicial de pacientes con CHC está asociado a un menor riesgo de muerte. Además, los resultados sugieren que la realización de una RM con ácido gadoxético complementaria al TC versus una RM con contraste extracelular complementaria al TC en el estadiaje inicial se asocia a una menor mortalidad.

    No obstante, los autores mencionan que son necesarios nuevos estudios para validar la efectividad y analizar el coste efectividad de la implementación de una RM con ácido gadoxético rutinaria en pacientes con hepatocarcinomas en fases iniciales. [Si quieres más información has clic aquí]

    Fuente: Kang TW, Kong SY, Kang D, et al.  Use of Gadoxetic Acid–enhanced Liver MRI and Mortality in More than 30 000 Patients with Hepatocellular Carcinoma: A Nationwide Analysis. Radiology. 2020; 295:1, 114-124. Publicado 4 de febrero 2020 doi:  10.1148/radiol.2020190639

    Un estudio publicado en la revista European radiology en el año 2021, investigó la relación entre esteatosis hepática histologicamente demostrada, la técnica de resonancia magnética para calcular la Fracción de Grasa de Densidad de Protones (PDEF) y la elastografía por resonancia magnética en pacientes diagnosticados o con factores de riesgo de esteatohepatitis no alcohólica (NASH).

    Para esto se diseñó un estudio retrospectivo, en el que participaron 256 pacientes con biopsia hepática y valoración mediante elastografía por resonancia magnética. En primer lugar, analizaron el rendimiento diagnóstico de la PDEF para distinguir esteatosis hepática. En un segundo tiempo, las variables que influyen en la medición de la rigidez hepática (LSM) se seleccionaron con un análisis univariante y luego se identificaron con regresión lineal multivariable. Finalmente, la relación potencial entre PDEF y LSM se evaluó con regresión lineal después del ajuste por otros factores influyentes, en pacientes con esteatosis diagnosticada.

    El estudio concluyó que, en pacientes con esteatohepatitis no alcohólica, la severidad de la esteatosis hepática no tiene una influencia significativa sobre la medición de la rigidez hepática mediante elastografía por resonancia magnética.  [Si quieres más información has clic aquí]. 

    Fuente: Chen, J., Allen, A.M., Therneau, T.M. et al. Liver stiffness measurement by magnetic resonance elastography is not affected by hepatic steatosis. Eur Radiol. 2020; 32, 950–958. Publicado 21 de agosto 2021 doi: https://doi.org/10.1007/s00330-021-08225-w

    El estudio publicado en 2021 en la revista Radiology valoró los hallazgos radiológicos del carcinoma hepatocelular (CHC) de tipo proliferativo, acorde a la nueva clasificación integrada propuesta por Calderaro et al, en imágenes de resonancia magnética realizadas con ácido gadoxético, analizando su significancia pronostica post quirúrgica.

    Se estudió una cohorte retrospectiva de pacientes con CHC únicos de menos de 5 cm tratados quirúrgicamente. Se determinaron los factores predictivos para la tasa supervivencia global, para recurrencia intrahepática a distancia y metástasis extrahepáticas.  Del total de 158 pacientes, 48 (26,6%) presentaban CHC de tipo proliferativo. Los CHC de tipo proliferativo se asociaron a una menor tasa de supervivencia global y a tasas más altas de recurrencia intrahepática a distancia. El realce en anillo en fase arterial (APHE) con ácido gadoxético junto a valores de α-fetoproteina en suero (>100 ng/mL) altos fueron factores predictores independientes de CHC proliferativo. Del mismo modo la presencia de APHE en anillo se asoció a una menor tasa de sobrevida y a una mayor tasa de metástasis extrahepáticas.

    Los investigadores concluyen que el subtipo proliferativo de CHC es un factor independiente para una menor tasa de supervivencia global y que presentan una mayor tasa de metástasis intra y extrahepáticas. El realce arterial en anillo (APHE) con ácido gadoxético puede ayudar a identificar los CHC de tipo proliferativo y ayudar a predecir una tasa de supervivencia global menor y una mayor incidencia de metástasis extrahepáticas. [Si quieres más información has clic aquí].

    Fuente: Kang HJ, Kim H, Lee DH, Hur BY, Hwang YJ, Suh KS, Han JK. Gadoxetate-enhanced MRI Features of Proliferative Hepatocellular Carcinoma Are Prognostic after Surgery. Radiology. 2021 Sep;300(3):572-582. doi: 10.1148/radiol.2021204352. Epub 2021 Jul 6. PMID: 34227881

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    Bibliografía recomendada

      Purpose: To determine the usefulness of T1 values measured using a phase-sensitive inversion recovery (PSIR) sequence for the diagnosis of focal liver lesions.

      Method: The study enrolled 87 patients who underwent gadoxetic acid-enhanced magnetic resonance imaging (MRI) for assessment of 38 hepatocellular carcinomas, 33 hepatic hemangiomas, 30 metastatic liver tumors, and 14 hepatic cysts. PSIR was performed before and 15 min after contrast agent administration, and then the respective T1 values were measured and the T1 reduction rate was calculated. Wilcoxon matched-pairs signed-rank test was used to compare T1 values pre- and post-contrast administration in each tumor. The Kruskal-Wallis test and Dunn's post-hoc test were used to compare T1 values among all tumors pre- and post-contrast administration and the T1 reduction rate among all tumors.

      Results: The T1 values measured before and after contrast enhancement were 1056 ± 292 ms and 724 ± 199 ms for hepatocellular carcinoma, 1757 ± 723 ms and 1033 ± 406 ms for metastatic liver tumor, 2524 ± 908 ms and 1071 ± 390 ms for hepatic hemangioma, and 3793 ± 207 ms and 3671 ± 241 ms for liver cysts, respectively. The T1 values obtained before and after contrast administration showed significant differences for all tumors except liver cysts (P < 0.0001). T1 reduction rate was not significantly different between hepatocellular carcinoma and metastatic liver tumor, but was significantly different among other tumors (P < 0.05).

      Conclusions: T1 mapping using the PSIR sequence is useful to differentiate focal liver lesions.

      Keywords: AUC, area under the ROC curve; CT, computed tomography; Gadoxetic acid-enhanced MRI; HBP, hepatobiliary phase; HCC, hepatocellular carcinoma; Liver; MRI, magnetic resonance imaging; Magnetic resonance imaging (MRI); PSIR, phase-sensitive inversion recovery; Phase-sensitive inversion recovery (PSIR); ROC, receiver operating characteristic; ROI, region of interest; SI, signal intensity; T1 mapping.

      Link: https://pubmed.ncbi.nlm.nih.gov/33392362/

      Objective: To assess gadoxetic acid (Gd-EOB-DTPA) and diffusion-weighted imaging (DWI) value in classification (benign vs. malignant) and characterization of solid focal liver lesions (SFLLs) and impact on confidence in diagnosis.

      Methods: A total of 195 lesions (46 hepatocellular carcinomas [HCCs], 45 metastases, 32 adenomas, 37 focal nodular hyperplasias [FNHs] and 35 hemangiomas) were retrospectively evaluated in 93 patients. Three imaging datasets were compared: DWI/ apparent diffusion coefficient (ADC) (set A), Gd-EOB-DTPA (set B) and combination of both (set C). Two radiologists (R) independently classified (on a five-point ordinal scale) and characterized each lesion. The accuracy in classification and characterization was compared, and the diagnostic confidence was assessed.

      Results: The classification accuracy on set A, B and C was 86.2%, 91.3% and 91.8% (R1), and 84.6%, 91.8% and 93.3% (R2); and characterization accuracy was 67.2%, 88.2% and 87.7% (R1), and 60.5%, 88.2% and 85.6% (R2). Classification by reader 1 showed no significant difference between set A and B (p=.09). For both readers, there was a significant difference between set A and C in both classification and characterization (all p < .05), but no significant difference between set B and C in neither classification nor characterization. No significant difference between the three datasets in classification and characterization of hemangiomas (all p > .05). The diagnostic confidence of the readers has increased progressively from set A to Set C (all p < .01).

      Conclusions: DWI may suggest benignity or malignancy of solid liver lesions, while Gd-EOB-DTPA-enhanced imaging remains superior in lesions characterization and the combination of both increases the diagnostic confidence. DWI is very helpful in the diagnosis of hepatic hemangiomas.

      Link: https://pubmed.ncbi.nlm.nih.gov/33232614/

      Different histopathological manifestations of focal liver lesions show varying common and uncommon imaging findings and some pathologies may show similar appearance despite of different histopathology. It is necessary to characterise focal liver lesions accurately as not only benign and malignant lesions are managed differently, but also certain benign lesions have differing management. These lesions are increasingly being detected due to rapid growth of use of cross-sectional imaging as well as improvement in image quality and new imaging techniques. Contrast enhanced magnetic resonance imaging (MRI) is considered the gold standard technique in characterising focal liver lesions. Addition of gadoxetic acid has been shown to significantly increase diagnostic accuracy in the detection and characterization of liver abnormalities. Classic imaging characteristics of common liver lesions, including their behaviour on gadoxetic acid enhanced MRI, have been described in literature over recent years. It is important to be familiar with the typical aspects of these lesions as well as know the uncommon and overlapping imaging features to reach an accurate diagnosis. In this article, we will review the well-described characteristic imaging findings of common and rare focal liver lesions and present several challenging cases encountered in the clinical setting, namely hepatocellular adenoma, focal nodular hyperplasia, hepatic angiomyolipoma, hepatocellular carcinoma, intrahepatic cholangiocarcinoma, neuroendocrine tumours as well as a pleomorphic liposarcoma of the live

      Link: https://pubmed.ncbi.nlm.nih.gov/34630876/

      Background: This multicentre international randomized trial compared the impact of gadoxetic acid-enhanced magnetic resonance imaging (MRI), MRI with extracellular contrast medium (ECCM-MRI) and contrast-enhanced computed tomography (CE-CT) as a first-line imaging method in patients with suspected colorectal cancer liver metastases (CRCLM).

      Methods: Between October 2008 and September 2010, patients with suspected CRCLM were randomized to one of the three imaging modalities. The primary endpoint was the proportion of patients for whom further imaging after initial imaging was required for a confident diagnosis. Secondary variables included confidence in the therapeutic decision, intraoperative deviations from the initial imaging-based surgical plan as a result of additional operative findings, and diagnostic efficacy of the imaging modalities versus intraoperative and pathological extent of the disease.

      Results: A total of 360 patients were enrolled. Efficacy was analysed in 342 patients (118, 112 and 112 with gadoxetic acid-enhanced MRI, ECCM-MRI and CE-CT respectively as the initial imaging procedure). Further imaging was required in 0 of 118, 19 (17.0 per cent) of 112 and 44 (39.3 per cent) of 112 patients respectively (P < 0.001). Diagnostic confidence was high or very high in 98.3 per cent of patients for gadoxetic acid-enhanced MRI, 85.7 per cent for ECCM-MRI and 65.2 per cent for CE-CT. Surgical plans were changed during surgery in 28, 32 and 47 per cent of patients in the respective groups.

      Conclusion: The diagnostic performance of gadoxetic acid-enhanced MRI was better than that of CE-CT and ECCM-MRI as the initial imaging modality. No further imaging was needed in the gadoxetic acid-enhanced MRI group and comparison of diagnostic efficacy parameters demonstrated the diagnostic superiority of gadoxetic acid-enhanced MRI.

      Link: https://pubmed.ncbi.nlm.nih.gov/24652690/

      Objectives: To assess the costs of diagnostic workup and surgery of three strategies for patients with colorectal cancer liver-metastases (CRCLM): gadoxetic-acid-enhanced MRI (Gd-EOB-DTPA-MRI), MRI with extracellular contrast-media (ECCM-MRI) or contrast-enhanced MDCT (CE-MDCT).

      Methods: The within-trial cost evaluation was modelled as a decision-tree to calculate the cost of diagnosis and surgery. The model used clinical outcomes and resource utilization data from a prospective randomized multicentre study. Analyses were performed for the 354-patient safety population from eight participating countries.

      Results: The diagnostic workup cost using Gd-EOB-DTPA-MRI upfront resulted in savings compared to ECCM-MRI in all countries except Thailand (difference <2 %). Compared to CE-MDCT, initial imaging with Gd-EOB-DTPA-MRI was less costly in all countries except Korea and Spain (differences 4 and 8 %, respectively). Significantly more patients in the Gd-EOB-DTPA-MRI group were eligible for surgery (39.3 % (48/122) vs. 31.0 % (36/116) and 26.7 % (31/116) for ECCM-MRI and CE-MDCT, respectively), allowing more patients to undergo potentially curative surgery, but resulting in higher treatment costs for the strategy starting with Gd-EOB-DTPA-MRI.

      Conclusions: The benefits of Gd-EOB-DTPA-MRI due to less additional imaging and similar diagnostic workup costs in the three groups suggest that Gd-EOB-DTPA-MRI should be the preferred initial imaging procedure to evaluate hepatic resectability in patients with CRCLM. Key points: • Diagnostic imaging cost to evaluate resectability was similar among the groups • Cost for imaging was rather small compared to the cost of surgery • Significantly more patients in the Gd-EOB-DTPA-MRI arm were eligible for surgery • Gd-EOB-DTPA-MRI is recommended for evaluating hepatic resectability in patients with CRCLM.

      Link: https://pubmed.ncbi.nlm.nih.gov/26905871/

      Background: The impact on survival of gadoxetic acid-enhanced MRI in addition to multiphase contrast material-enhanced CT for initial staging in patients with hepatocellular carcinoma (HCC) is unknown. Purpose To compare all-cause mortality in patients with HCC who underwent CT only, CT plus non-gadoxetic acid-enhanced MRI, or CT plus gadoxetic acid-enhanced MRI as part of their initial diagnostic work-up.

      Materials and Methods: The authors performed a nationwide retrospective cohort study of patients diagnosed with HCC in South Korea between January 2008 and December 2010. Follow-up extended through December 2014. The primary outcome was all-cause mortality. Cox proportional hazards regression model with adjustment of confounding factors was used to estimate hazard ratios (HRs) for all-cause mortality.

      Results: Among 30 023 patients with HCC (mean age ± standard deviation, 58.5 years ± 10.7, 23 978 men), the proportions of patients in whom HCC was diagnosed using CT only, CT plus non-gadoxetic acid-enhanced MRI, and CT plus gadoxetic acid-enhanced MRI were 56.1%, 12.9%, and 31.0%, respectively. In adjusted analysis using CT only as the reference category, the HR for mortality for CT plus gadoxetic acid-enhanced MRI was 0.64 (95% confidence interval [CI]: 0.62, 0.67; P < .001), and the HR for CT plus non-gadoxetic acid-enhanced MRI was 0.71 (95% CI: 0.68, 0.75; P < .001). Use of CT plus gadoxetic acid-enhanced MRI was associated with lower mortality compared with CT plus non-gadoxetic acid-enhanced MRI (adjusted HR, 0.90; 95% CI: 0.85, 0.95; P < .001), but this survival advantage was restricted to patients with localized disease.

      Conclusion: In patients with hepatocellular carcinoma, additional use of contrast-enhanced MRI was associated with lower mortality. Furthermore, CT plus gadoxetic acid-enhanced MRI was associated with better survival than CT plus non-gadoxetic acid-enhanced MRI but only in patients with localized disease.

      Link: https://pubmed.ncbi.nlm.nih.gov/32013789/

      Background: Hepatocellular carcinomas (HCCs) are heterogeneous neoplasms, and the prognosis varies based on the subtype. Two broad molecular classes of HCC have been proposed: a proliferative and a nonproliferative class. Purpose To evaluate the gadoxetate-enhanced MRI findings of the proliferative class HCC and its prognostic significance after surgery.

      Materials and Methods: This retrospective cohort study evaluated patients with surgically resected treatment-naive single HCC (≤5 cm) who underwent hepatic resection from January 2010 through February 2013 and preoperative gadoxetate-enhanced MRI. A Cox proportional hazards model was used to determine the predictive factors for overall survival (OS), intrahepatic distant recurrence, and extrahepatic metastasis (EM). The mean follow-up period was 75.5 months ± 30.2 (standard deviation). Multivariable logistic regression was performed to determine factors associated with proliferative class HCC.

      Results: A total of 158 patients (mean age, 57 years ± 11; 128 men and 30 women) were evaluated. Forty-two of the 158 HCCs (26.6%) were proliferative class HCCs (17 macrotrabecular-massive HCCs, 14 keratin 19-positive HCCs, 10 scirrhous HCCs, and one sarcomatoid HCC). The proliferative class was associated with worse OS (hazard ratio [HR], 3.1; 95% CI: 1.5, 6.0; P = .01) and higher rates of intrahepatic distant recurrence (HR, 1.83; 95% CI: 1.1, 2.9; P = .01) and EM (HR, 9.97; 95% CI: 3.2, 31.4; P < .001). Rim arterial phase hyperenhancement (APHE) at gadoxetate-enhanced MRI (odds ratio [OR], 6.35; 95% CI: 1.9, 21.7; P = .01) and high serum α-fetoprotein (>100 ng/mL) (OR, 4.18; 95% CI: 1.64, 10.7; P = .01) were independent predictors for proliferative HCC. The presence of rim APHE was associated with poor OS (HR, 2.4; 95% CI: 1.2, 4.9; P = .02) and higher rates of EM (HR, 7.4; 95% CI: 2.5, 21.7; P < .01).

      Conclusion: The proliferative class of hepatocellular carcinoma (HCC) is an independent factor for poor overall survival with increased rates of intrahepatic and extrahepatic metastasis. Rim arterial phase hyperenhancement at gadoxetate-enhanced MRI may help to identify proliferative class HCC and predict poor overall survival and an increased incidence of extrahepatic metastasis.

      Link: https://pubmed.ncbi.nlm.nih.gov/34227881/#:~:text=Prognostic%20after%20Surgery-,Gadoxetate%2Denhanced%20MRI%20Features%20of%20Proliferative%20Hepatocellular%20Carcinoma%20Are%20Prognostic,doi%3A%2010.1148%2Fradiol

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