Cone-Beam Computed Tomography-Hepatic Arteriography as a Diagnostic Tool for Small Hypervascular Hepatocellular Carcinomas: Method and Clinical Implications

OBJECTIVE: This study proposes a novel reference standard for hypervascular hepatocellular carcinomas (HCCs), established by cone-beam computed tomography-hepatic arteriography (CBCT-HA) and two-year imaging follow-up, and discusses its clinical implication on tumor staging and understanding the intrahepatic distant recurrence (IDR) in relation to dynamic computed tomography (CT).MATERIALS AND METHODS: In this retrospective study, 99 patients were enrolled, who underwent CBCT-HA during initial chemoembolization for HCC suspected on CT. All patients underwent chemoembolization and regular clinical and imaging follow-up for two years. If IDR appeared on follow-up imaging, initial CBCT-HA images were reviewed to determine if a hypervascular focus pre-existed at the site of recurrence. Pre-existing hypervascular foci on CBCT-HA were regarded as HCCs in initial presentation. Initial HCCs were classified into three groups according to their mode of detection (Group I, detected on CT and CBCT-HA; Group II, additionally detected on CBCT-HA; Group III, confirmed by interval growth). We assessed the influence of CBCT-HA and two-year follow-up on initial tumor stage and calculated the proportion of IDR that pre-existed in initial CBCT-HA.RESULTS: A total of 405 nodules were confirmed as HCCs, and 297 nodules initially pre-existed. Of the initial 297 HCCs, 149 (50.2%) lesions were in Group I, 74 (24.9%) lesions were in Group II, and the remaining 74 (24.9%) lesions were in Group III. After applying CBCT-HA findings, 11 patients upstaged in T stage, and 4 patients had a change in Milan criteria. Our reference standard for HCC indicated that 120 of 148 (81.1%) one-year IDR and 148 of 256 (57.8%) two-year IDR existed on initial CBCT-HA.CONCLUSION: The proposed method enabled the confirmation of many sub-centimeter-sized, faintly vascularized HCC nodules that pre-existed initially but clinically manifested as IDR. Our reference standard for HCC helped in understanding the nature of IDR and the early development of HCC as well as the clinical impact of tumor staging and treatment decision.

Evaluation of cone-beam CT hepatic angiography in detecting the tumor-feeding arteries during the performance of TACE for HCC / 介入放射学杂志

Objective To accurately judge the tumor-feeding artery is the most important basis for a successful treatment of hepatocellular carcinoma (HCC) with super-selective hepatic arterial chemoembo lization therapy. This study aims to assess the clinical value of cone-beam CT hepatic arteriography (CBCT-HA) in detecting tumor-feeding arteries during the performance of conventional transarterial chemoembo lization (TACE), and to compare the diagnostic effects between CBCT-HA and non-selective hepatic DSA. Methods Twenty-three consecutive patients with inoperable HCC were enrolled in this study. TACE was carried out in all patients. During the performance of TACE, the DSA-HA, CBCT-HA, Lipiodol-TACE and Lipiodol-CBCT were performed separately. The imaging materials, including DSA-HA and CBCT-HA, were analyzed by two experienced interventional physicians together to judge the tumor-feeding arteries. Statistic analysis was conducted by using chi square test. Results Tumor stain and lipiodol accumulation were regarded as the “gold standard” of the presence of tumor-feeding artery, based on which the tumor-feeding artery was confirmed in 75 lesions. DSA-HA demonstrated positive tumor-feeding artery in 40 lesions, among which true-positive tumor-feeding artery was seen in 32 and false-positive one in 8. CBCT-HA showed positive tumor-feeding artery in 72 lesions, which included true-positive tumor-feeding artery in 68 and false-positive one in 4. The sensitivity of CBCT-HA in judging tumor-feeding artery was 90.7% (68/75), which was much higher than that of DSA-HA (42.6%, 32/75), the difference was statistically significant(P<0.001). The positive predictive value of CBCT-HA in detecting tumor-feeding artery was also higher than that of DSA-HA (94.4% vs. 80.0%; P=0.040). Conclusion Cone-beam CT hepatic arteriography is obviously superior to DSA hepatic arteriography in identifying tumor-feeding arteries, which is very helpful in guiding super-selective TACE for HCC.