Japanese Guidelines for Treatment of Hepatocellular Carcinoma

Child-Pugh Score Online Calculator: Link

The algorithm is based on three factors

1. Severity of liver damage (by Child-Pugh score)
2. Number of tumors
3. Diameter of tumors

Based on this algorithm:

• Resection is considered if only one tumor of any size or two-to-three tumors of any size
• Ablation is considered if 1) single tumor of less than 2 cm + Child-Pugh class 'B', 2) two-to-three tumors of equal or less than 3 cm.
• Embolization is considered when 1) 4 or more tumors, 2) two-to-three tumors of > 3 cm
• Interventional radiology Rx is considered in patients with class 'A' or 'B', not class 'C'

Reference:

Kokudo N, Makuuchi M. Evidence-based clinical practice guidelines for hepatocellular carcinoma in Japan: the J-HCC guidelines. J Gastroenterol 2009;44[Suppl XIX]:119-121.

Suspected Pulmonary Embolism in Pregnant Patient (2)

Potential algorithm for pulmonary embolism diagnosis in pregnant women (adapted from Pahade JK, et al. Radiographics 2009; 10.1148/rg.293085226)

First-Line Imaging Tests

Why Perform Chest Radiography?

• Search for other causes of symptoms
• Use to triage for further test, ie to perform lung scintigraphy or CT pulmonary angiography as the next test
• Normal chest radiograph does not exclude PE

Why Perform Lower Extremity Ultrasound?

• Positive result can be used to justified anticoagulation without further imaging
• Negative result should warrant further imaging in the setting of clinically suspected PE because PE may occur in the absence of DVT, isolated pelvic DVT may occur without DVT in lower extremities
• DVT is more common in the left lower extremity (more than right)

Reference:

Pahade JK, et al. Imaging pregnant patients with suspected pulmonary embolism: what the radiologist needs to know. Radiographics 2009; 10.1148/rg.293085226 (March 30, 2009)

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Jones Fracture

Jones Fracture

• Fracture at proximal 5th metatarsal at metadiaphyseal junction (within 1.5 cm distal to tuberosity of 5th metatarsal)
• Usually involve 4th-5th intermetatarsal joint
• Sharp fracture margins without intramedullary sclerosis indicate acute fracture.
• May present acutely or in a chronic phase
  
• Acute Jones fracture has sharp margin without intramedullary sclerosis - usually Rx nonoperatively with NON weight baring cast
• Persistent delayed union fracture will show fracture line in both cortices, callus, intramedullary sclerosis - usually Rx surgically
  

Reference:

Nunley JA. Fractures of the base of the fifth metatarsal the Jones fracture. Orthop Clin N Am 2001; 32:171-180.

Complications of Radiofrequency Ablation of Liver Tumors

Complications of RFA

1. Vascular
2. Biliary
3. Extrahepatic

Major complication = those that if left untreated will threaten patient's life, causing substantial morbidity and disability, resulting in hospital admission or lengthen the hospital stay

Frequency of Complications

• 4% per complete treatment or 1.9% per treatment session (Major)
• 1.7% per complete treatment or 0.8% per treatment session (Minor)
• In a series of 1000 patients with hepatocellular carcinoma, tumor seeding was the most common complication (1.5%), followed by liver abscess (0.7%), biloma (0.7%), portal vein thrombosis (0.4%) and bleeding requiring blood transfusion (0.4%).

Image Credit:

http://www.radiologyinfo.org/en/photocat/photos_more_pc.cfm?pg=rfa

Reference:

Akahane M, Koga H, Kato N, et al. Complications of percutaneous radiofrequency ablation for hepatocellular carcinoma: imaging spectrum and management. Radiographics 2005; 25:S57-S68.