Dual-phase Cone-beam CT-based Navigation Imaging Significantly Enhances Tumor Detectability and Aids Superselective Transarterial Chemoembolization of Liver Cancer

Should Hypervascular Incidentalomas Detected on Per-Interventional Cone Beam Computed Tomography during Intra-Arterial Therapies for Hepatocellular Carcinoma Impact the Treatment Plan in Patients Waiting for Liver Transplantation?

BACKGROUND

Current guidelines do not indicate any comprehensive management of hepatic hypervascular incidentalomas (HVIs) discovered in hepatocellular carcinoma (HCC) patients during intra-arterial therapies (IATs). This study aims to evaluate the prognostic value of HVIs detected on per-interventional cone beam computed tomography (CBCT) during IAT for HCC in patients waiting for liver transplantation (LT).

MATERIAL AND METHODS

In this retrospective single-institutional study, all liver-transplanted HCC patients between January 2014 and December 2018 who received transarterial chemoembolization (TACE) or radioembolization (TARE) before LT were included. The number of ≥10 mm HCCs diagnosed on contrast-enhanced pre-interventional imaging (PII) was compared with that detected on per-interventional CBCT with a nonparametric Wilcoxon test. The correlation between the presence of an HVI and histopathological criteria associated with poor prognosis (HPP) on liver explants was investigated using the chi-square test. Tumor recurrence (TR) and TR-related mortality were investigated using the chi-square test. Recurrence-free survival (RFS), TR-related survival (TRRS), and overall survival (OS) were assessed according to the presence of HVI using Kaplan-Meier analysis.

RESULTS

Among 63 included patients (average age: 59 ± 7 years, H/F = 50/13), 36 presented HVIs on per-interventional CBCT. The overall nodule detection rate of per-interventional CBCT was superior to that of PII (median at 3 [Q1:2, Q3:5] vs. 2 [Q1:1, Q3:3], respectively, p < 0.001). No significant correlation was shown between the presence of HVI and HPP (p = 0.34), TR (p = 0.095), and TR-related mortality (0.22). Kaplan-Meier analysis did not show a significant impact of the presence of HVI on RFS (p = 0.07), TRRS (0.48), or OS (p = 0.14).

CONCLUSIONS

These results may indicate that the treatment plan during IAT should not be impacted or modified in response to HVI detection.

Radiation dose during transarterial chemoembolization and associated factors

PURPOSE

To provide detailed reports on radiation doses during transarterial chemoembolization (TACE) in the cone-beam computed tomography (CBCT) era and to identify the associated factors.

METHODS

This retrospective study included 385 consecutive patients who underwent initial conventional TACE for hepatocellular carcinoma (HCC) between January 2016 and December 2017. In most cases, CBCT was performed at the common hepatic artery or celiac axis to confirm the location of the tumor and the three-dimensional hepatic artery anatomy. Superselective TACE was performed for all technically feasible cases. Information on total dose area product (DAP), total cumulative air kerma (CAK), fluoroscopy time, and DAP and CAK of each digital subtraction angiography (DSA) and CBCT scan was recorded. Multiple linear regression analysis was performed to identify the factors associated with increased DAP during TACE.

RESULTS

The mean values of total DAP and CAK were 165.2 ± 81.2 (Gy·cm²) and 837.1 ± 571.0 (mGy), respectively. The mean fluoroscopy time was 19.1 ± 10.3 min. The mean DAP caused by fluoroscopy, DSA, and CBCT was 51.8 ± 43.9, 28.0 ± 24.1, and 83.9 ± 42.1 Gy·cm², respectively. Male sex, a high body mass index, largest tumor size > 3 cm, presence of aberrant right and left hepatic arteries, and superselective TACE were identified as independent predictors of increased total DAP during TACE.

CONCLUSION

We were able to provide detailed reports on radiation doses during TACE and associated factors.

Cone Beam Computed Tomography for the Interventional Oncologist: A Practical Approach

Transarterial treatment of liver tumors is becoming increasingly common and is considered first- or second-line therapy for many tumor types and stages. Such therapies are heavily dependent on imaging during the procedures; while angiography remains the mainstay of intraprocedural therapies, cone beam computed tomography (CBCT) is becoming increasingly commonly used to guide therapy. This article describes the role of CBCT during transarterial therapies and offers guidance as to how CBCT can be optimally used for these procedures.

Exploring software navigation tools for liver tumour angiography: a scoping review

INTRODUCTION

Liver cancer presents a growing global health concern, necessitating advanced approaches for intervention. This review investigates the use and effectiveness of software navigation in interventional radiology for liver tumour procedures.

METHODS

In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, a scoping review was conducted of the literature published between 2013 and 2023 sourcing articles through MEDLINE, Scopus, CINAHL and Embase. Eligible studies focused on liver cancer, utilised cone-beam computed tomography (CBCT), and employed software for intervention. Twenty-one articles were deemed eligible for data extraction and analysis.

RESULTS

Categorised by type, software applications yielded diverse benefits. Feeder detection software significantly enhanced vessel identification, reducing non-target embolisation by up to 43%. Motion correction software demonstrated a 20% enhancement in image quality, effectively mitigating breathing-induced motion artefacts. Liver perfusion software facilitated efficient tumour targeting while simultaneously reducing the occurrence of side effects. Needle guide software enabled precise radiofrequency ablation needle placement. Additionally, these software applications provided detailed anatomical simulations. Overall, software integration resulted in shorter procedures, reduced radiation exposure and decreased contrast media usage.

CONCLUSION

This scoping review highlights the innovative yet relatively underexplored role of software navigation for liver tumour procedures. The integration of software applications not only enhances procedural efficiency but also bolsters operator confidence, and contributes to improved patient outcomes. Despite the current lack of uniformity and standardisation, these software-driven advancements hold significant promise for transforming liver tumour interventions. To realise these benefits, further research is needed to explore the clinical impact and optimal utilisation of software navigation tools in interventional radiology.

Value of Latest-generation Cone-beam Computed Tomography for Post Lipiodol-embolization Imaging in Hepatic Transarterial Chemoembolization in Comparison with Multi-detector Computed Tomography

RATIONALE AND OBJECTIVES

To evaluate image quality, radiation dose (phantom study) and tumor volumetry of intraprocedural cone-beam computed tomography (CBCT) compared to postprocedural multidetector computed tomography (MDCT) in patients undergoing hepatic conventional transarterial chemoembolization (cTACE).

MATERIALS AND METHODS

One hundred fourteen patients (64/50 female/male; mean age, 57 ± 14 years) who had undergone cTACE including intraprocedural-CBCT and postprocedural-MDCT were retrospectively enrolled. Subjective image quality (IQ) and suitability for assessing Lipiodol distribution were compared using 4-point Likert scales; additionally, lesion to liver contrast (LLC) and contrast-to-noise-ratio (CNR) were compared. Tumor volumes were measured semi-automatically and compared to magnetic resonance imaging (MRI). Effective doses were measured using an anthropomorphic phantom.

RESULTS

The suitability of CBCT for assessing Lipiodol distribution during cTACE was comparable to MDCT (mean score, 3.2 ± 0.6) and CBCT (3.4 ± 1.0, p = 0.29). Subjective overall IQ was rated with a mean score of 3.2 ± 0.7 (κ = 0.66) in CBCT and 3.1 ± 0.4 (κ = 0.57, p = 0.15) in MDCT. Evaluation of LLC showed significant differences between CBCT and MDCT (mean scores 3.6 ± 1.2 and 2.6 ± 1.5, respectively). CNR analysis demonstrated comparable mean values for CBCT and MDCT (3.5 ± 1.3 vs. 3.4 ± 1.8, p = 0.31). No significant differences were found regarding tumor volumetry (mean volumes: CBCT, 27.0 ± 17.4 mm³; MDCT: 26.8 ± 16.0 mm³; p = 0.66) in comparison to T2-weighted MRI (25.9 ± 17.6 mm³). Effective doses were 3.2 ± 0.6 mSv (CBCT) and 2.5 ± 0.3 mSv (MDCT) (p < 0.001). No cTACE-related complications (bleeding, non-target embolization) were missed on intraprocedural CBCT in comparison to postprocedural MDCT.

CONCLUSION

Latest-generation intraprocedural CBCT provides suitable assessment of Lipiodol distribution and similar image quality compared to MDCT while allowing for robust volumetric tumor measurements and immediate complication control by visualizing non-target embolization and hematoma. Therefore, it may improve patient safety and outcome as well as clinical workflow compared to postprocedural MDCT in hepatic cTACE in certain cases.

Portal Vein Embolization Using N-Butyl Cyanoacrylate-Glue: What Impact Does a Central Vascular Plug Have?

Purpose

To examine if the addition of a central vascular plug (CVP) to portal vein embolization (PVE) with N-butyl cyanoacrylate-glue (NBCA) increases future liver remnant (FLR) growth.

Material and Methods

This is a single-center retrospective study of 115 consecutive patients with colorectal liver metastases undergoing PVE in 2013–2019. All patients were embolized with NBCA as the main embolic agent. In 2017–2019 NBCA was combined with a CVP in the central part of the right portal vein. Growth of the FLR and standardized FLR (sFLR) including degree of hypertrophy (DH) and kinetic growth rate (KGR) were analyzed, as well as procedure data such as use of cone-beam CT (CBCT), dose area product (DAP), fluoroscopy time and contrast dose.

Results

A total of 40 patients (35%) underwent PVE with a combination of CVP and NBCA. The DH was higher in these patients after 4 weeks, mean 13.6% (SD 7.8) vs. 10.5% (SD 6.4; p = 0.022), verified in multivariate analysis (coefficient 4.1, p = 0.015). A CVP did not significantly increase the resection rate (90% vs 82%, p = 0.4). Cone beam CT was used in 65 patients (57%). Use of CBCT did not affect FLR growth, and fluoroscopy time and contrast doses were not different in patients having a CBCT or not. Slightly lower DAP (median 3375 vs. 4499 cGy*cm²; p = 0.09) was seen in procedures where CBCT was used.

Conclusion

A CVP in addition to NBCA embolization was associated with increased growth of the FLR compared to NBCA alone.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00270-021-03014-w.

Short-term outcomes of radiofrequency ablation for hepatocellular carcinoma using cone-beam computed tomography for planning and image guidance

BACKGROUND

Percutaneous radiofrequency ablation (RFA) is an effective treatment for unresectable hepatocellular carcinoma (HCC) and a minimally invasive alternative to hepatectomy for treating tumour recurrence. RFA is often performed using contrast-enhanced computed tomography (CECT) and/or ultrasonography. In recent years, angiographic systems with flat panel image detectors and advanced image reconstruction algorithms have broadened the clinical applications of cone-beam computed tomography (CBCT), including RFA. Several studies have shown the effectiveness of using CBCT for immediate treatment assessments and follow-ups.

AIM

To assess the treatment response to RFA for HCC using CBCT.

METHODS

Forty-eight patients (44 men; aged 37-89 years) with solitary HCC [median size: 3.2 (1.2-6.6) cm] underwent RFA and were followed for 25.6 (median; 13.5-35.2) mo. Image fusion of CBCT and pre-operative CECT or magnetic resonance imaging (MRI) was used for tumour segmentation and needle path and ablation zone planning. Real-time image guidance was provided by overlaying the three-dimensional image of the tumour and needle path on the fluoroscopy image. Treatment response was categorized as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD). Disease progression, death, time to progression (TTP), and overall survival (OS) were recorded. Kaplan-Meier and Cox regression analyses were performed.

RESULTS

Initial post-RFA CECT/MRI showed 38 cases of CR (79.2%), 10 of PR (20.8%), 0 of SD, and 0 of PD, which strongly correlated with the planning estimation (42 CR, 87.5%; 6 PR, 12.5%; 0 SD; and 0 PD; accuracy: 91.7%, P < 0.01). Ten (20.8%) patients died, and disease progression occurred in 31 (35.4%, median TTP: 12.8 mo) patients, resulting in 12-, 24-, and 35-mo OS rates of 100%, 81.2%, and 72.2%, respectively, and progression-free survival (PFS) rates of 54.2%, 37.1%, and 37.1%, respectively. The median dose-area product of the procedures was 79.05 Gy*cm² (range 40.95-146.24 Gy*cm²), and the median effective dose was 10.27 mSv (range 5.32-19.01 mSv). Tumour size < 2 cm (P = 0.008) was a significant factor for OS, while age (P = 0.001), tumour size < 2 cm (P < 0.001), tumour stage (P = 0.010), and initial treatment response (P = 0.003) were significant factors for PFS.

CONCLUSION

Reliable RFA treatment planning and satisfactory outcomes can be achieved with CBCT.

Effectiveness of intraprocedural dual-phase cone-beam computed tomography in detecting hepatocellular carcinoma and improving treatment outcomes following conventional transarterial chemoembolization

To investigate the effectiveness of intraprocedural dual-phase cone-beam computed tomography (CBCT) in detecting hepatocellular carcinoma (HCC) during conventional transcatheter arterial chemoembolization (TACE) and its effect on improving treatment outcomes. Between November 2018 and November 2019, data from 111 patients with unresectable HCCs (N = 263 lesions) were reviewed retrospectively. All patients had undergone baseline magnetic resonance imaging (MRI) scans within one month prior to the procedure. Both arterial-phase (AP) and delayed-phase CBCT images were acquired during all conventional TACEs. Each HCC detection rate when read by AP-CBCT and when read by dual-phase (DP) CBCT including both AP and delayed phase was compared with that of MRI, and the diagnosis of HCC was based on MRI. Additionally, the follow-up results concerning lipiodol uptake status and tumor response of the lesions detected only by AP-/DP-CBCT were analyzed and compared with MRI-only detected lesions. The overall sensitivity of DP-CBCT (94.7%) was significantly higher than that of AP-CBCT (89.0%) (p = 0.003). In particular, the rate of subcentimeter HCC detection by DP-CBCT was pronounced (91.5% vs. 80.3%) (p = 0.01). Lesions found only by DP-CBCT exhibited positive lipiodol uptake (n = 31/31; 100%) and showed complete or partial responses (n = 24/31; 77.4%) on follow-up CT imaging, while MRI-only detected lesions had less lipiodol uptake (n = 6/14, 42.9%) and complete or partial responses (n = 4/14; 28.6%) (p ≤ 0.001). DP-CBCT imaging during TACE enabled better detection of HCCs than when using AP-CBCT alone, and AP- and DP-CBCT is superior to MRI in detecting chemoembolization-sensitive lesions. This resulted in increased detectability of HCCs and the achievement of better treatment outcomes.

"Primum Non Nocere" in Interventional Oncology for Liver Cancer: How to Reduce the Risk for Complications?

Interventional oncology represents a relatively new clinical discipline based upon minimally invasive therapies applicable to almost every human organ and disease. Over the last several decades, rapidly evolving research developments have introduced a newer generation of treatment devices, reagents, and image-guidance systems to expand the armamentarium of interventional oncology across a wide spectrum of disease sites, offering potential cure, control, or palliative care for many types of cancer patients. Due to the widespread use of locoregional procedures, a comprehensive review of the methodologic and technical considerations to optimize patient selection with the aim of performing a safe procedure is mandatory. This article summarizes the expert discussion and report from the Mediterranean Interventional Oncology Live Congress (MIOLive 2020) held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions as a means for providing guidance on prudent ways to reduce complications. The aim of the paper is to provide an updated guiding tool not only to residents and fellows but also to colleagues approaching locoregional treatments.

A systematic review of automated feeder detection software for locoregional treatment of hepatic tumors

PURPOSE

The purpose of this study was to perform a systematic review of current literature describing the efficacy and technical outcomes of transarterial liver therapies using automated feeder detection (AFD) software.

MATERIALS AND METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A structured search was performed in the PubMed, SCOPUS, and Embase databases of patients undergoing locoregional therapy of liver tumors utilizing AFD software. Demographic data, procedure data (including radiometrics) and tumor response rate were recorded. Where available, performance of AFD was compared to conventional digital subtraction angiography (DSA) and cone-beam CT (CBCT) without AFD.

RESULTS

A total of 14 full-text manuscripts met inclusion criteria, comprising 1042 tumors in 604 patients (305 men, 156 women; mean age, 68.6±6.0 [SD] years), including 537 patients with hepatocellular carcinoma, 8 with metastases from neuroendocrine tumors, and 59 patients without reported etiology. Reported sensitivity of AFD ranged between 86% and 98.5%, compared to DSA alone (38% - 64%) or DSA in combination with CBCT (69% - 81%). Three studies reported tumor response by modified response evaluation criteria in solid tumors (mRECIST) guidelines, with complete response in the range of 60% - 69%.

CONCLUSION

AFD is a promising new technology for the identification of intrahepatic and extrahepatic tumor-feeding arteries and should be considered a useful adjunct to conventional DSA and CBCT in the treatment of liver tumors.

Utility of 'dual phase' cone beam computed tomography during radioembolisation in patients with hepatocellular carcinoma: what is really changing in flow dynamics before and after 90Y delivery?

Purpose

The aims of the study were: 1) to compare two phases of dual-phase cone beam computed tomography (DP-CBCT) achieved before and after Yttrium-90 (⁹⁰Y) administration and to evaluate additional benefits during radioembolisation (RE) procedures; and 2) to compare DP-CBCT with pre-procedure contrast enhanced cross-sectional images in terms of tumour detection.

Material and methods

Twenty-three hepatocellular carcinoma patients undergoing RE treatment were scanned with DP-CBCT consisting of early arterial (EA) and late arterial (LA) phases before and after ⁹⁰Y administration. The CT-like datasets were compared according to embolisation effect, enhancement patterns, lesion detectability, image quality, and artifacts by two interventional radiologists blinded to each other. The compatibility of the two radiologists was evaluated with kappa statistical analysis, and the difference between EA and LA phases was evaluated with marginal homogeneity test. Also, DP-CBCT images were compared with preprocedural cross-sectional images (CT/MRI).

Results

For 23 patients 92 data were acquired. Thirteen patients showed a decrease on post-embolisation images both visually and on Hounsfield unit (HU) measurements. No statistical difference was found for tumour detection between EA and LA phases (p = 1.0). Tumour enhancement was visually superior at LA phases whereas EA phases were better for arterial mapping for selective catheterisation. DP-CBCT images were not inferior to preprocedural cross-sectional imaging findings.

Conclusions

DP-CBCT is a promising tool for predicting tumour response to therapy and is not inferior to preprocedural cross-sectional imaging in terms of tumour detection. It allows better assessment during RE procedures because early phases provide good mapping for superselective catheterisation whereas late phases are better for visualisation of tumour enhancement.

Comparison between C-arm cone beam computed tomography and interventional angiography in transarterial chemoembolization of hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy of adults. One of the established treatment procedures performed worldwide for HCC is transcatheter arterial chemoembolization (TACE). By using conventional angiography in TACE, we can detect and identify the vascular anatomy of the liver through obtaining 2D images. Recently C-arm cone beam computed tomography (CBCT) is introduced for obtaining cross-sectional and three-dimensional (3D) images for better visualization of small tumors and their feeding arteries.

Results

The number of detected focal lesions by angiography was 51 compared to 87 focal lesion detected by CBCT; of those, 45 and 77 were active lesions by both procedures respectively. For lesions, less than 1 cm CBCT detected 23 lesions while angiography detected only one lesion. Angiography detected 87 feeding arterial branch while cone beam CT-HA detected 130 branches to the same number of target lesion. Feeder tractability and confidence were better by CBCT.

Conclusion

CBCT is superior to angiography in tumor detectability, detection of lesions less than 1 cm, feeder detection, and feeder traction; however, conventional angiography and DSA are irreplaceable. Thus, combination of CBCT with angiography during TACE produces better results and less complication.

Radiation Exposure During Transarterial Chemoembolization: Angio-CT Versus Cone-Beam CT

INTRODUCTION

Cone-beam computed tomography (CBCT) has been developed to improve reliability of many interventional radiology (IR) procedures performed with Angio system, such as transarterial chemoembolization (TACE). Angio-CT has emerged as a new imaging technology that combines a CT scanner with an Angio system in the same IR suite. The purpose of our study was to compare Angio system with CBCT capability and Angio-CT in terms of patient radiation exposure during TACE procedures.

MATERIALS AND METHODS

Consecutive TACE procedures performed between January 2016 and September 2017 with the two imaging modalities (Artis Zeego defining the CBCT group and Infinix-i 4D-CT defining the Angio-CT group) were reviewed. TACE and patient's characteristics and patient radiation exposure parameters were collected. Dose-area products (DAP) and dose-length products (DLP) were converted into effective doses (ED) using conversion factors. Accuracy of tumor targeting and response was retrospectively assessed.

RESULTS

A total of 114 TACE procedures in 96 patients were included with 57 procedures in each group. The total ED in the Angio-CT group was 2.5 times lower than that in the CBCT group (median 15.4 vs. 39.2 mSv, p < 0.001). Both 2D ED and 3D ED were lower in the Angio-CT group than in the CBCT group (5.1 vs. 20 mSv, p < 0.001, and 7.4 vs. 17.9 mSv, p < 0.001, respectively). There was no significant difference neither in terms of classes of tumor targeting (p = 0.509) nor in terms of classes of tumor response (p = 0.070) between both groups.

CONCLUSION

Angio-CT provides significant decrease in patient effective dose during TACE procedures compared to Angio system with CBCT.

Liver chemoembolization of hepatocellular carcinoma using TANDEM® microspheres

Transarterial chemoembolization (TACE) combines intra-arterial delivery of a chemotherapeutic agent with selective embolization to obtain a synergistic effect. TACE is recognized as the standard treatment of hepatocellular carcinoma patients at an intermediate stage. If conventional TACE, defined as the injection of an emulsion of a drug with ethiodized oil, still has a role to play, the development of drug-eluting beads has allowed many improvements and optimization of the technique. TANDEM^® microspheres are second-generation drug-loadable microspheres. This device raised a special interest due to its tightly calibrated spherical microspheres, with small sizes down to 40 μm available. In this review, we describe the technical characteristics of these microspheres, analyze the scientific literature and hypothesize on the future perspectives.