Imaging aspects and non-surgical interventional treatment in human alveolar echinococcosis

Alveolar echinococcosis (AE) of the liver caused by the metacestode of the fox tapeworm Echinococcus multilocularis is characterized by a multivesicular structure surrounded by an extensive fibro-inflammatory host reaction. The lesions behave like a slow-growing liver cancer, without sharp limits between the parasitic tissue and the liver parenchyma. Invasion of biliary and vascular walls is another hallmark of this severe disease. Moreover, the poor vascularization of the parasitic mass often leads to necrosis in the central part of the lesion. This explains why liver abscess due to superimposed bacterial infection of the necrotic area may occur in this disease. Currently, a range of imaging techniques can be used at the different stages of management of AE. For diagnosis, ultrasonography remains the first line examination. For a more accurate disease evaluation, aiming to guide the surgical strategy, computerized tomography, Magnetic Resonance (MR) imaging, including cholangio-MR imaging are of importance, providing useful complementary information. More recently, Positive-Emission Tomography using [18F] fluoro-deoxyglucose has been developed for the follow-up of inoperable AE patients under long-term benzimidazoles therapy. This approach seems very promising to assess inflammatory activity and thereby to indirectly depict parasitic activity. Non-surgical interventional procedures, mainly percutaneous biliary and/or centro-parasitic abscesses drainages, are currently a major aspect in the care of incurable AE patients and have largely contributed to the improvement of survival in this situation during the past 20 years. They may also be used as a bridge before a curative surgical procedure in symptomatic patients presenting a life-threatening bacterial and/or fungal infection. It is also very useful in inoperable patients to overcome similar infectious episodes.