Hepatocellular Carcinoma: Prediction of Blood Supply from an Internal Mammary Artery with Multi–Detector Row CT

Chemoembolization of Hepatocellular Carcinoma with Extrahepatic Collateral Blood Supply: Anatomic and Technical Considerations

Transarterial chemoembolization (TACE) is considered a standard local-regional treatment for intermediate-stage hepatocellular carcinoma (HCC) and the most common bridging therapy. This treatment is offered to more than 70% of patients who are on the waiting list for liver transplantation in the United States. HCC typically receives its blood supply from the hepatic artery; however, it can recruit a parasitic supply from extrahepatic collateral (EHC) arteries. The development of an EHC arterial blood supply can interfere with the therapeutic efficacy of TACE and result in treatment failure and poor outcome. Cross-sectional imaging-specifically computed tomography and magnetic resonance imaging-has some limitations in depicting the presence or absence of an EHC arterial supply during the pre-TACE evaluation. Catheterization and angiography of every possible EHC artery during a routine TACE procedure would be time consuming and technically challenging and would not always be feasible. Therefore, the prediction of a potential EHC arterial supply on the basis of tumor location before, during, and after TACE is fundamental to achieving optimal therapeutic efficacy. To perform TACE through EHC arteries, special considerations are necessary to avoid potentially serious complications. The authors review the factors influencing the development of an EHC arterial blood supply to HCC and describe a systematic approach to enhance the ability to predict the presence of EHC arteries. They also describe the proper technique for TACE of each EHC artery and how to avoid potential technique-related complications. ^©RSNA, 2017.

Evaluation of extrahepatic collateral arteries in hepatocellular carcinoma in three independent groups in a single center

To improve the efficacy of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC), this study evaluated the prevalence and causes of extrahepatic arteries (EHAs) and identified feeding arteries in HCCs in three independent clinical groups in a single inverventional radiology center. Between November 2011 and September 2012, 942 cases of HCC were included in this retrospective study. The patients were treated in three independent groups of 285, 301 and 356 patients, respectively. Enhanced computed tomography, enhanced magnetic resonance imaging and digital subtraction angiography were reviewed retrospectively and correlations between the presence of tumor-feeding EHAs and tumor number, size and location in the liver, number of repeat TACE procedures and complications were assessed. There were 698 EHAs in the 942 cases of HCC, with 182, 233 and 283 EHAs in the three independent groups, respectively. Tumor size was associated with EHA formation; the percentages of patients with EHAs were 2.7±3.0, 5.5±0.5, 43.2±4.0, 61.8±5.2 and 93.4±1.8% with tumor sizes of 2-3, 3-5, 5-7, 7-9 and >9 cm, respectively. There were 159±19 EHAs in each group feeding tumors in peripheral locations in the liver, but only 48.7±6.8 in the central zone. The most common EHA was the right inferior phrenic artery, with a mean of 101.0±14.1 per group. The number of EHAs increased proportionally with the number of TACE sessions. The number of EHAs was positively associated with tumor size, peripheral location of the tumor and number of TACE sessions.

Chemoembolization via the left internal mammary artery supplying hepatocellular carcinoma

PURPOSE

To present radiologic findings that show favorable tumor response after chemoembolization via the left internal mammary artery (LIMA).

MATERIALS AND METHODS

Between October 2002 and April 2013, 57 patients with hepatocellular carcinoma (HCC) underwent 69 sessions of chemoembolization via the LIMA. Imaging findings including tumor size, location, and visibility of tumor-feeding artery on cross-sectional images were retrospectively reviewed in consensus by two radiologists. Tumor response after chemoembolization via the LIMA was assessed by the modified Response Evaluation Criteria in Solid Tumors on follow-up multidetector computed tomography in consensus.

RESULTS

The mean tumor size supplied by the LIMA was 6.8 cm (range, 1.0-21.0 cm). HCCs supplied by the LIMA tended to be located in the subcapsular area including exophytic features (57 of 57; 100%) and were more likely to be located in the left lobe of the liver (56 of 57; 98%). HCCs supplied by the LIMA were more likely to be multiple or infiltrative (52 of 57; 91%) and marginally recurred (43 of 57; 75%). Feeding arteries of the LIMA were identified in a high percentage of cases (49 of 66; 74%) on cross-sectional images obtained before embolization. Regarding tumor response, tumors that were newly developed or exclusively supplied by the LIMA showed better target tumor response (P = .011 and P < .0001, respectively). On multivariate analysis, tumors exclusively supplied by the LIMA showed significantly better target tumor response with odds ratio of 16.32.

CONCLUSIONS

Chemoembolization via the LIMA has a favorable target tumor response when HCCs are exclusively supplied by the LIMA.

Hepatocellular carcinoma vascularization: from the most common to the lesser known arteries

Hepatocellular carcinoma is the sixth most common cancer throughout the world. It is almost exclusively arterially vascularized, unlike the vascularization of the liver, which has a dual supply with a portal component of 75 to 80% and an arterial component of 20 to 25%. The reference treatment for intermediary stages of the Barcelona (B) classification is hepatic artery chemoembolization. The aim of chemoembolization is to inject the tumor chemotherapy into the artery and then to embolize the artery (or arteries), which supply the tumor. For this, knowledge of the anatomy of the hepatic artery is essential. Approximately 55% of the patients belong to the modal distribution, although numerous anatomical variants exist and must be recognized. In addition, primarily non-hepatic arteries may contribute to the vascularization of some hepatocellular carcinomas. Furthermore, new arterial supplies can be recruited by tumors after surgical or chemoembolization treatments. The aim of this article is to describe the different arteries, which may vascularize hepatocellular carcinomas. These arteries must be looked for, recognized, and reported by the radiologist on cross-section examinations in the pre-treatment assessment.

Ectopic blood supply of hepatocellular carcinoma as depicted by angiography with computed tomography: associations with morphological features and therapeutic history

OBJECTIVE

To investigate the associations of ectopic blood supply of hepatocellular carcinoma (HCC) with its morphological features and therapeutic history.

METHODS

Three hundred and six patients with 373 HCC lesions were enrolled in this study, and underwent biphasic contrast-enhanced scans on a 64-section MDCT. The anatomy of ectopic blood supply, morphological characteristics of HCC including the size, location and pseudocapsule, and history of transcatheter arterial chemoembolization (TACE) therapy were quantitively assessed and statistically analyzed.

RESULTS

Ectopic blood supply was found in 30.8% (115/373) lesions. The ectopic arteries were predominantly composed of inferior phrenic artery (86/115) followed by left and right gastric artery (25/115). Tumor size, location, status of pseudocapsule, and history of TACE therapy could impact the origination of ectopic arteries (all p<0.05).

CONCLUSION

The ectopic feeding arteries of HCC predominantly composed of the perihepatic arteries are associated with the morphological features of the tumor and therapeutic history.

Hepatocellular carcinoma: prediction of blood supply from an intercostal artery with multidetector row computed tomography

PURPOSE

To evaluate the ability of multidetector row computed tomography (CT) to detect blood supply from the intercostal artery in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Between January 2003 and December 2007, angiography of the intercostal artery was performed in 93 patients (76 men and 17 women, mean age 58 years) with HCC who had also undergone multidetector row CT. CT scans and digital subtraction angiograms of these patients were retrospectively reviewed by two investigators in consensus to evaluate tumor feeding vessels. Multiple logistic regression analysis was used to identify factors that predict the presence of an HCC blood supply from an intercostal artery.

RESULTS

Tumor staining fed by an intercostal artery was noted in 65 patients (70%; 112 tumor feeding vessels) by intercostal angiography. Readers interpreted that tumor feeding vessels were evident by CT in 35 (54%) of these 65 patients with tumor staining supplied by an intercostal artery by angiography. Multiple logistic regression analysis showed that a visible tumor feeding vessel by CT (P = .003) and hepatic artery attenuation by angiography (P = .014) were significantly related to the presence of a blood supply from an intercostal artery.

CONCLUSIONS

Visualization of a tumor feeding vessel from the intercostal artery by multidetector row CT is an important sign of parasitic supply to an HCC.

Patient radiation management and preprocedure planning and consent

Protection of patients from excessive medical radiation has become a high priority in health care. As clinical physicians, interventional radiologists must remain cognizant of the radiation we use in daily practice. Radiation reduction begins before the procedure itself, as with appropriate preprocedural planning the amount of fluoroscopy and angiography used can then be reduced. Patients should be counseled regarding the potential for use of significant amounts of radiation when procedures associated with such doses are planned, as part of the process of obtaining informed consent. If significant radiation is used, patients should be alerted to have appropriate follow-up. The amount of radiation used can be reduced by careful attention to imaging technique.

Chemoembolization of the left inferior phrenic artery in patients with hepatocellular carcinoma: 9-year single-center experience

OBJECTIVE

The purpose of this study was to evaluate retrospectively the radiologic findings and imaging response of hepatocellular carcinoma supplied by the left inferior phrenic artery.

MATERIALS AND METHODS

From January 2000 through December 2008, chemoembolization of the left inferior phrenic artery was performed on 152 patients (123 men, 29 women; mean age, 55.8 years) with hepatocellular carcinoma. The CT scans and digital subtraction angiograms of these patients were retrospectively reviewed in consensus by two investigators, who evaluated tumor location, tumor-feeding vessels, origin of the left inferior phrenic artery, technical success of chemoembolization, complications, and tumor response. Tumor response was assessed on the basis of the criteria of the European Association for the Study of the Liver.

RESULTS

Tumors supplied by the left inferior phrenic artery were located in Couinaud segment 2/3 (n = 100), segment 4 (n = 45), and other segments (n = 7). The most common tumor-feeding vessel was the anteromedial limb of the left inferior phrenic artery (n = 82) followed by the lateral limb (n = 40) and the anterior limb (n = 30). Selective chemoembolization via the left inferior phrenic artery was achieved in 58 of the patients (38%). Complete or partial response as detected on first follow-up CT images (mean follow-up time, 2.5 months) was achieved by 30 patients. In 33 patients in whom the tumor was supplied exclusively by the left inferior phrenic artery, the tumor response was more favorable in patients who underwent selective than in those who underwent nonselective chemoembolization via the left inferior phrenic artery (p = 0.028).

CONCLUSION

Selective chemoembolization via the left inferior phrenic artery is possible and results in good response of tumors supplied exclusively by the left inferior phrenic artery.

Left inferior phrenic artery feeding hepatocellular carcinoma: angiographic anatomy using C-arm CT

OBJECTIVE

The left inferior phrenic artery (LIPA) is one of the common extrahepatic collateral arteries that supply hepatocellular carcinomas (HCCs). The purpose of this study is to describe the anatomy of the LIPA that supplies HCCs using C-arm CT in 23 patients.

CONCLUSION

The anteromedial limb of the ascending branch was present in 14 patients and accessory gastric branches were noted in 11 patients. The use of angiography and C-arm CT of the LIPA showed 26 tumor feeders in 23 patients. The feeders were seen in the anteromedial limb (n = 12), lateral limb (n = 9), anterior limb (n = 3), and descending branch (n = 2). The anteromedial limb of the ascending branch is a common tumor feeder of the LIPA and can supply HCCs located in the right liver dome. Gastric staining is also frequently depicted on LIPA angiography and should not be confused with tumor staining.