Comparison of Image Quality and Diagnostic Performance of Cone-Beam CT during Drug-Eluting Embolic Transarterial Chemoembolization and Multidetector CT in the Detection of Hepatocellular Carcinoma

Purpose

To compare image quality and diagnostic performance of cone-beam computed tomography (CT) and multidetector CT in the detection of hypervascular hepatocellular carcinoma (HCC) in patients with cirrhosis undergoing transarterial chemoembolization with drug-eluting embolic agents.

The Role of Cone-Beam CT in Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Systematic Review and Meta-analysis

Purpose

To review available evidence for use of cone-beam CT during transcatheter arterial chemoembolization in hepatocellular carcinoma (HCC) for detection of tumor and feeding arteries.

Sensitivity and Reproducibility of Automated Feeding Artery Detection Software during Transarterial Chemoembolization of Hepatocellular Carcinoma

Purpose

To evaluate the performance of automated feeder detection (AFD) software (EmboGuide; Philips Healthcare, Best, The Netherlands) on hepatocellular carcinoma (HCC) tumors during transarterial chemoembolization.

The Efficacy of Cone-Beam CT–Based Liver Perfusion Mapping to Predict Initial Response of Hepatocellular Carcinoma to Transarterial Chemoembolization

Purpose

To evaluate efficacy of cone-beam CT–based liver perfusion mapping obtained immediately following conventional transarterial chemoembolization of hepatocellular carcinoma (HCC) for assessing tumor vascularity, technical success of chemoembolization, and treatment response.

Noise-Optimized Virtual Monoenergetic Dual-Energy CT Improves Diagnostic Accuracy for the Detection of Active Arterial Bleeding of the Abdomen

Purpose

To evaluate diagnostic accuracy of a noise-optimized virtual monoenergetic imaging (VMI+) reconstruction technique for detection of active arterial abdominal bleeding on dual-energy (DE) CT angiography compared with standard image reconstruction.

Safety and Efficacy of Combined Transarterial Embolization and Percutaneous Radiofrequency Ablation for Liver Tumors Using Cone-Beam CT and Needle Navigation Software in a Single Session

Purpose

To assess the safety and efficacy of single-session transarterial embolization and radiofrequency (RF) ablation for hepatic tumors with the use of needle navigation software.

Outcomes of Patients with Hepatocellular Carcinoma Treated with Conventional Transarterial Chemoembolization Using Guidance Software

Purpose

To evaluate the outcomes of conventional transarterial chemoembolization using guidance software for hepatocellular carcinoma (HCC) patients.

The Role of Dual-Phase Cone-Beam CT in Predicting Short-Term Response after Transarterial Chemoembolization for Hepatocellular Carcinoma

Purpose

To identify computational and qualitative features derived from dual-phase cone-beam CT that predict short-term response in patients undergoing transarterial chemoembolization for hepatocellular carcinoma (HCC).

Quantitative Automated Segmentation of Lipiodol Deposits on Cone-Beam CT Imaging Acquired during Transarterial Chemoembolization for Liver Tumors: A Deep Learning Approach

PurposeTo show that a deep learning (DL)–based, automated model for Lipiodol (Guerbet Pharmaceuticals, Paris, France) segmentation on cone-beam computed tomography (CT) after conventional transarterial chemoembolization performs closer to the “ground truth segmentation” than a conventional thresholding-based model.Materials and MethodsThis post hoc analysis included 36 patients with a diagnosis of hepatocellular carcinoma or other solid liver tumors who underwent conventional transarterial chemoembolization with an intraprocedural cone-beam CT. Semiautomatic segmentation of Lipiodol was obtained. Subsequently, a convolutional U-net model was used to output a binary mask that predicted Lipiodol deposition. A threshold value of signal intensity on cone-beam CT was used to obtain a Lipiodol mask for comparison. The dice similarity coefficient (DSC), mean squared error (MSE), center of mass (CM), and fractional volume ratios for both masks were obtained by comparing them to the ground truth (radiologist-segmented Lipiodol deposits) to obtain accuracy metrics for the 2 masks. These results were used to compare the model versus the threshold technique.ResultsFor all metrics, the U-net outperformed the threshold technique: DSC (0.65 ± 0.17 vs 0.45 ± 0.22, P < .001) and MSE (125.53 ± 107.36 vs 185.98 ± 93.82, P = .005). The difference between the CM predicted and the actual CM was 15.31 mm ± 14.63 versus 31.34 mm ± 30.24 (P < .001), with lesser distance indicating higher accuracy. The fraction of volume present ([predicted Lipiodol volume]/[ground truth Lipiodol volume]) was 1.22 ± 0.84 versus 2.58 ± 3.52 (P = .048) for the current model’s prediction and threshold technique, respectively.ConclusionsThis study showed that a DL framework could detect Lipiodol in cone-beam CT imaging and was capable of outperforming the conventionally used thresholding technique over several metrics. Further optimization will allow for more accurate, quantitative predictions of Lipiodol depositions intraprocedurally.     

The Use of the Woodchuck as an Animal Model for Evaluation of Transarterial Embolization

There are many shortcomings of current animal models as surrogates of hepatocellular carcinoma that handicap preclinical testing of embolization agents. The present study explores the feasibility of using the woodchuck (Marmota monax) as an animal model for the testing of novel embolization agents. Four woodchucks underwent magnetic resonance imaging, angiography, and left lobar hepatic artery particle embolization. Percutaneous access, arteriography, and lobar embolization were successful in all animals, with angiographic stasis obtained in the target vessel with minimal reflux of embolic material. These results support the feasibility of the woodchuck as an animal model for preclinical testing of embolization agents.     

A SEER Database Analysis of the Survival Advantage of Transarterial Chemoembolization for Hepatocellular Carcinoma: An Underutilized Therapy

Purpose

To measure transarterial chemoembolization utilization and survival benefit among patients with hepatocellular carcinoma (HCC) in the Surveillance, Epidemiology, and End Results (SEER) patient population.

Three-Dimensional Quantitative Color-Coding Analysis of Hepatic Arterial Flow Change during Chemoembolization of Hepatocellular Carcinoma

Purpose

To evaluate feasibility of using three-dimensional (3D) quantitative color-coding analysis (QCA) to quantify substasis endpoints after transcatheter arterial chemoembolization of hepatocellular carcinoma (HCC).

Cone-Beam CT Hepatic Arteriography in Chemoembolization for Hepatocellular Carcinoma: Angiographic Image Quality and Its Determining Factors

PurposeTo analyze image quality and the factors that determine it for cone-beam computed tomography (CT) hepatic arteriography in chemoembolization for hepatocellular carcinoma (HCC).Materials and MethodsFrom September 2009–December 2010, 399 consecutive patients referred for chemoembolization of HCC were scheduled for cone-beam CT scan. There were 12 patients (3%) excluded because of difficulty with breath-hold. Of the 387 patients who underwent cone-beam CT hepatic arteriography, 100 patients were ultimately included in the study according to inclusion criteria. Maximum intensity projection images were scored for image quality of each segmental hepatic artery. Potential determining factors for image quality were diaphragmatic motion, portal vein enhancement, and hepatic artery-to-parenchyma enhancement ratio. The flow rate of contrast media, x-ray delay, and location of the catheter tip were also evaluated.ResultsIt was possible to trace at least subsegmental hepatic arteries in 625 of 700 segments (89.3%) on cone-beam CT hepatic arteriography. Diaphragmatic motion, prominent portal vein enhancement, and low hepatic artery-to-parenchyma enhancement ratio worsened image quality (P < .001, P = .022, and P = .017). Owing to cardiac motion artifacts, image quality of the left lateral segments (S2 and S3) was poorer compared with the remaining hepatic segments (S4–S8).ConclusionsIn most cases, the quality of cone-beam CT hepatic arteriography images was good enough to trace subsegmental hepatic arteries at a minimum. Respiratory and cardiac motion, portal vein enhancement, and hepatic artery-to-parenchyma enhancement ratio significantly affected the image quality of cone-beam CT hepatic arteriography.     

Combined Therapy with Transarterial Chemoembolization and Radiofrequency Ablation for Hepatocellular Carcinoma: Does the Degree of Ethiodized Oil Accumulation within the Tumor Affect the Therapeutic Efficacy?

Purpose

To evaluate the effects of the degree of ethiodized oil accumulation achieved by transarterial chemoembolization followed by radiofrequency (RF) ablation on the treatment efficacy for a single intermediate-sized hepatocellular carcinoma (HCC).

Imaging guidance with C-arm CT: prospective evaluation of its impact on patient radiation exposure during transhepatic arterial chemoembolization

Purpose

To prospectively evaluate the impact of C-arm CT on radiation exposure to hepatocellular carcinoma (HCC) patients treated by chemoembolization.

Materials and Methods

Patients with HCC (N = 87) underwent digital subtraction angiography (DSA; control group) or combined C-arm CT/DSA (test group) for chemoembolization. Dose-area product (DAP) and cumulative dose (CD) were measured for guidance and treatment verification. Contrast agent volume and C-arm CT utility were also measured.

Results

The marginal DAP increase in the test group was offset by a substantial (50%) decrease in CD from DSA. Use of C-arm CT allowed reduction of DAP and CD from DSA imaging (P = .007 and P = .017). Experienced operators were more efficient in substituting C-arm CT for DSA, resulting in a negligible increase (7.5%) in total DAP for guidance, compared with an increase of 34% for all operators (P = .03). For treatment verification, DAP from C-arm CT exceeded that from DSA, approaching that of conventional CT. The test group used less contrast medium (P = .001), and C-arm CT provided critical or supplemental information in 20% and 17% of patients, respectively.

Conclusions

Routine use of C-arm CT can increase stochastic risk (DAP) but decrease deterministic risk (CD) from DSA. However, the increase in DAP is operator-dependent, thus, with experience, it can be reduced to under 10%. C-arm CT provides information not provided by DSA in 33% of patients, while decreasing the use of iodinated contrast medium. As with all radiation-emitting modalities, C-arm CT should be used judiciously.     

Role of C-Arm CT in Identifying Caudate Arteries Supplying Hepatocellular Carcinoma

PurposeTo evaluate the role of C-arm computed tomography (CT) performed at the proper hepatic artery or equivalent in patients with caudate-lobe hepatocellular carcinoma (HCC) for the detection of tumor-feeding arteries during chemoembolization.Materials and MethodsFrom July 2009 to June 2012, 1,785 patients received initial chemoembolization at a single institution. Among them, 52 patients with caudate HCC underwent initial chemoembolization with the use of C-arm CT. C-arm CT images were obtained at the proper hepatic artery or equivalent. Two radiologists reviewed the C-arm CT scans and angiograms in consensus. The cumulative local recurrence rate was calculated by the Kaplan–Meier method.ResultsTumor-feeding arteries were single (n = 31), double (n = 12), triple (n = 6), and quadruple (n = 3). Seventy-nine tumor-feeding arteries and their origins in 48 patients were demonstrated on C-arm CT. In four patients (7.7%), five tumor-feeding arteries were not clearly indicated on C-arm CT because of poor image quality caused by failure of the patients to hold their breath. Selective chemoembolization via tumor-feeding arteries was successful in 45 patients (87%). The cumulative local recurrence rates at 6 months, 1 year, and 3 years were 19.4%, 32.8%, and 35.8%, respectively. Nonselective chemoembolization of tumor-feeding arteries of caudate-lobe HCC was a significantly important factor in higher cumulative local recurrence rates (hazard ratio, 3.916; 95% confidence interval, 1.367–11.216; P = .011).ConclusionC-arm CT obtained at the proper hepatic artery or equivalent level can demonstrate most tumor-feeding arteries supplying HCCs in the caudate lobe.     

Radiofrequency Ablation versus Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma Awaiting Liver Transplant: An Analysis of the Scientific Registry of Transplant Recipients

PurposeTo evaluate differences in waitlist mortality and dropout in liver transplant candidates with hepatocellular carcinoma (HCC) who undergo radiofrequency (RF) ablation versus transarterial chemoembolization (TACE).Material and MethodsFrom 2004 to 2013, 11,824 patients with HCC in the Scientific Registry of Transplant Recipients who underwent RF ablation or TACE were included and followed until December 31, 2019, or 5 years, whichever came first, and were stratified by the Milan criteria. Competing risk and Cox regression analyses to compare waitlist mortality and dropout were performed using adjusted hazard ratios (asHRs, with RF ablation group as reference). Regression models were adjusted for age, race, sex, calculated Model for End-Stage Liver Disease score, tumor size, and number.ResultsThere was no difference in waitlist mortality and dropout for patients outside the Milan criteria (n = 1,226) who underwent TACE (19.2%) or RF ablation (19.0%) (asHR, 0.91; 95% CI, 0.79–1.03). There was also no difference for patients inside the Milan criteria (n = 10,598) in waitlist mortality/dropout (TACE 13.4% vs RF ablation 12.9%) (asHR, 1.29; 95% CI, 0.79–2.09). A subgroup analysis within the Milan criteria demonstrated no difference between TACE and RF ablation treatments in patients with a single tumor of ≤3 cm (asHR, 0.92; 95% CI, 0.77–1.10), with a single tumor of >3 cm (asHR, 1.03; 95% CI, 0.79–1.34), or with >1 tumor (asHR, 0.89; 95% CI, 0.72–1.09).ConclusionsUsing the national registry data, no difference was found in waitlist mortality and dropout for transplant candidates with HCC who received TACE versus RF ablation.     

Hepatic Blood Volume Imaging with the Use of Flat-Detector CT Perfusion in the Angiography Suite: Comparison with Results of Conventional Multislice CT Perfusion

PurposeTo prospectively determine the feasibility of flat-detector (FD) computed tomography (CT) perfusion to measure hepatic blood volume (BV) in the angiography suite in patients with hepatocellular carcinoma (HCC).Materials and MethodsTwenty patients with HCC were investigated with conventional multislice and FD CT perfusion. CT perfusion was carried out on a multislice CT scanner, and FD CT perfusion was performed on a C-arm angiographic system, before transarterial chemoembolization procedures. BV values of conventional and FD CT perfusion were measured within tumors and liver parenchyma. The arterial perfusion portion of CT perfusion BV was extracted from CT perfusion BV by multiplying it by a hepatic perfusion index. Relative values (RVs) for CT perfusion arterial BV and FD CT perfusion BV (FD BV) were defined by dividing BV of tumor by BV of parenchyma. Relationships between BV and RV values of these two techniques were analyzed.ResultsIn all patients, both perfusion procedures were technically successful, and all 33 HCCs larger than 10 mm were identified with both imaging methods. There were strong correlations between the absolute values of FD BV and CT perfusion arterial BV (tumor, r = 0.903; parenchyma, r = 0.920; both P < .001). Bland–Altman analysis showed a mean difference of −0.15 ± 0.24 between RVs for CT perfusion arterial BV and FD BV.ConclusionsThe feasibility of FD CT perfusion to assess BV values of liver tumor and surrounding parenchyma in the angiographic suite was demonstrated.     

The role of MR diffusion in differentiation of malignant and benign hepatic focal lesions

Aim

To determine if focal liver masses could be differentiated as benign or malignant by DWI and ADC maps.

Methods and materials

Sixty focal liver lesions were scanned using 1.5 T MRI. DWI was performed with b 0, b 500 and b 1000 gradients with ADC measurements. Comparison of mean ADC values between each benign and malignant lesion was done. Reference standard of diagnosis was obtained by correlating DWI with histopathologic findings and imaging follow-up. The accuracies of DWI and ADC values were assessed with the Student’s t test, and cut-off values were determined with receiver operating characteristic curve analysis.

Results

When ADC value of 1.0 × 10⁻³ mm²/s was used as a threshold value for differentiation of malignant tumors from benign lesions, sensitivity was 90.3%, specificity 78.57% and accuracy 86.7%. The best result was obtained with the use of ADC cut off value (at b 500) of 1.5 × 10⁻³ mm²/s and ADC cut off value (at b 1000) of 1.0 × 10⁻³ mm²/s, with 90.3% sensitivity, 92.86% specificity, 91.1% accuracy, 96.6% positive predictive value and 81.3% negative predictive value.

Conclusion

DWI and ADC map is a useful tool in differential diagnosis of malignant from benign liver lesions.