Ultrasound in radioembolization induced liver disease (REILD)

Abstract

Background: REILD (radioembolization-induced liver disease) is a rare complication after SIRT (selective internal radiotherapy) of the liver. The diagnosis is based on a combination of clinical signs and symptoms, laboratory values, and MRT findings. Data about sonographic signs associated with REILD are lacking. In this report, we describe sonographic changes in two female patients with REILD.

Case reports: Patient 1: a 34-year-old woman with colorectal carcinoma liver metastasis. Two weeks after SIRT, the patient developed histology-proven REILD. Abdominal ultrasound revealed pronounced hepatomegaly, with inhomogeneous, slightly hyperechoic parenchyma without attenuation. The well-known metastasis could not be delineated easily. Liver veins were compressed, with ill defined borders, and flattened biphasic blood flow in duplex sonography. Signs of portal hypertension with ascites, and splenomegaly were present. A therapy with diuretics, heparin, steroids, and ursodesoxycholic acid was introduced, and the patient recovered. After seven weeks, the ascites had resolved, and the liver parenchyma returned to normal echogenicity. Furthermore, the metastases in both lobes were clearly visible again. The liver veins were well delineated, normal sized, with regular triphasic blood flow in duplex sonography, but splenomegaly persisted. Patient 2: a 58-year-old women with recurrent multifocal peripheral cholangiocarcioma. Abdominal ultrasound 5 weeks after SIRT revealed a slightly increased echogenicity of the liver. Liver veins showed slightly irregular borders with biphasic flow pattern. In contrast to patient no. 1, liver metastases could still be delineated easily. Ascites or splenomegaly were not present. Laboratory parameters and MRT findings were consistent with a diagnosis of mild REILD. Liver biopsy was not performed. No specific therapy was introduced. Five weeks later, the liver parenchyma became more homogeneous again, and the liver veins normalized with smooth vessel borders, but still flattened biphasic flow pattern.

Conclusion: Transient hepatomegaly, with inhomogeneous hyperechoic parenchyma without attenuation, and compressed, ill delineated liver veins, with monophasic or flattened biphasic blood flow, are typical sonographic findings in REILD. In addition, common signs of portal hypertension can be present. Liver alterations and ascites resolve parallel with clinical improvement. Splenomegaly can persist.

Zusammenfassung

Hintergrund: Radioembolization induced liver disease (REILD) ist eine seltene Nebenwirkung nach interner Radiotherapie der Leber (SIRT). Die Diagnose erfolgt anhand klinischer, laborchemischer und bildgebender (MRT) Befunde. Beschreibungen des sonografischen Befunds liegen bis dato nicht vor.

Fallberichte: Patient 1: Eine 34-jährige Patientin mit hepatisch metastasiertem Kolonkarzinom entwickelte 2 Wochen nach bilobärer SIRT eine histologisch gesicherte REILD. Sonografisch fand sich eine vergrößerte, abgerundete Leber mit inhomogenem, gering echoreichem Parenchym ohne dorsale Schallabschwächung. Die vorbekannten Lebermetastasen ließen sich nur mehr schlecht abgrenzen. Desweiteren komprimierte, unscharf berandete Lebervenen mit abgeflachtem biphasischem Fluss in der Duplexsonografie. Daneben Zeichen der portalen Hypertension mit Aszites, verdickter Gallenblasenwand und Splenomegalie. Unter einer Behandlung mit Steroid, Diuretika, Heparin und Ursodesoxycholsäure bildete sich der Aszites komplett zurück, die Echogenität des Leberparenchyms normalisierte sich, die Lebermetastasen waren wieder scharf abgrenzbar, genauso wie Wandkontur und Durchmesser der Lebervenen, die jetzt auch wieder ein triphasisches Flussmuster aufwiesen. Die Splenomegalie persistierte. Patient 2: Eine 58-jährige Patientin mit multifokal rezidiviertem intrahepatischem Cholangiokarzinom entwickelte 5 Wochen nach SIRT ein mildes REILD. Sonografisch fanden sich ein inhomogenes, gering echoreiches Leberparenchym sowie unscharf berandete Lebervenen mit abgeflachtem biphasischem Flussprofil. Keine Splenomegalie, kein Aszites. Nach 5 Wochen weitgehende Normalisierung des Leberparenchyms mit normalkalibrigen scharf berandeten Lebervenen, aber weiterhin abgeflachtem biphasischem Flussprofil.

Schlussfolgerung: Sonografisch finden sich bei REILD eine passagere Hepatomegalie mit erhöhter Echogenität des Leberparenchyms ohne dorsale Schallabschwächung, eine Kompression und Randunschärfe der Lebervenen mit abgeflachtem Flussprofil, sowie unspezifische Zeichen der portalen Hypertension wie Aszites und Splenomegalie.

Schlüsselwörter

SIRT - REILD - Ultraschall - Lebererkrankungen - Duplexsonografie - portale Hypertension

Key words

SIRT - REILD - ultrasound - liver disease - duplex sonography - portal hypertension

• References

• 1 Sangro B, Gil-Azugaray B, Rodriguez J et al. Liver disease induced by radioembolization of liver tumors. Description and possible risk factors. Cancer 2008; 112: 1538-1546
• 2 Gil-Alzugaray R, Chopitea A, Inarrairaegui M et al. Prognostic factors and prevention of radioembolization-induced liver disease. Hepatology 2013; 57: 1078-1087
• 3 Sienz M, Ignee A, Dietrich CF. Reference values in abdominal ultrasound – liver and liver vessels. Z Gastroenterol 2010; 48: 1141-1152
• 4 Dietrich CF, Lee JH, Gottschalk R et al. Hepatic and portal vein flow pattern in correlation with intrahepatic fat deposition and liver histology in patients with chronic hepatitis C. Am J Roentgenol 1998; 171: 437-443
• 5 Guhar C, Kavanagh BD. Hepatic radiation toxicity. Avoidance and amelioration. Seminars Radiol 2011; 21: 256-263
• 6 Lassau N, Leclère J, Auperin A et al. Hepatic veno-occlusive disease after myeloablative treatment and bone marrow transplantation: value of gray-scale and Doppler US in 100 patients. Radiology 1997; 204: 545-552
• 7 Mahgerefteh SY, Sosna J et al. Radiologic imaging and intervention for gastrointestinal and hepatic complications of hematopoietic stem cell transplantation. Radiology 2011; 258: 256-263
• 8 Myers KC, Dandoy C, El-Bietar J et al. Veno-occlusive disease of the liver in the absence of elevation in bilirubin in pediatric patients after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2014; pii: S1083-8791(14)00607-7 DOI: 10.1016/j.bbmt.2014.09.026. [Epub ahead of print]
• 9 Hommeyer SC, Teefey SA, Jacobson AF et al. Venocclusive disease of the liver: prospective study of US evaluation. Radiology 1992; 184: 683-686
• 10 Hashigushi M, Okamura T, Yoshimoto K et al. Demonstration of reversed flow in segmental branches of the portal vein with hand-held color Doppler ultrasonography after hematopoietic stem cell transplantation. Bone Marrow Transplant 2005; 36: 1071-1075
• 11 Nicolau C, Brú C, Carreras E et al. Sonographic diagnosis and hemodynamic correlation in veno-occlusive disease of the liver. J Ultrasound Med 1993; 12: 437-440
• 12 McCarville MB, Hoffer FA, Howard SC et al. Hepatic veno-occlusive disease in children undergoing bone-marrow transplantation: usefulness of sonographic findings. Pediatr Radiol 2001; 31: 102-105
• 13 Sayer HG, Will U, Schilling K et al. Hepatic veno-occlusive disease (VOD) with complete occlusion of liver venules after tandem autologous stem cell transplantation – successful treatment with high-dose methylprednisolone and defibrotide. J Cancer Res Clin Oncol 2002; 128: 148-152
• 14 Teefey SA, Brink JA, Borson RA et al. Diagnosis of venoocclusive disease of the liver after bone marrow transplantation: value of duplex sonography. Am J Roentgenol 1995; 164: 1397-1401
• 15 Herbetko J, Grigg AP, Buckley AR et al. Venoocclusive liver disease after bone marrow transplantation: findings at duplex sonography. Am J Roentgenol 1992; 15: 1001-1005
• 16 Brown PB, Abu-Jousef M, Farner R et al. Doppler sonography: a noninvasive method for evaluation of hepatic venocclusive disease. Am J Roentgenol 1990; 154: 721-724
• 17 Schiavetti A, Matrunola M, Varraso G et al. Ultrasound in the management of hepatic veno-occlusive disease in three children treated with dactinomycin and vincristine. Pediatr Hämatol Oncol 1996; 13: 521-529