Optimal injection protocol for CT evaluation during hepatic arterial infusion chemotherapy

Dual-phase CT angiography through the port-catheter system for hepatic arterial infusion chemotherapy using multislice CT: assessment of system dysfunction and impact on predicting clinical problems

BACKGROUND

Hepatic arterial infusion (HAI) chemotherapy is being explored for treatment of malignant liver tumors. Maintenance of HAI systems is important for effective treatment.

PURPOSE

To prospectively evaluate the efficacy of dual-phase CT angiography through the port-catheter system for HAI chemotherapy.

MATERIAL AND METHODS

This study enrolled 47 patients receiving HAI chemotherapy for malignant liver tumors who underwent dual-phase CT angiography through the port-catheter system using multislice CT. Using maximum intensity projection images reconstructed from vascular-phase CT imaging, hepatic arterial patency and catheter location were assessed. Using a combination of vascular- and perfusion-phase CT imaging, system dysfunction and clinical problems were evaluated.

RESULTS

Dual-phase CT angiography was conducted 156 times. Stenosis and obstruction of the hepatic artery and catheter dislodgment were observed seven times in four patients and four times in three patients, respectively. Diagnostic accuracy using vascular-phase CT imaging was 100%. In addition, development of collateral blood supply to the liver and extrahepatic perfusion to the stomach were observed three times in three patients and twice in two patients, respectively. Overall, system dysfunction occurred 16 times in 12 patients, and system correction and treatment modification were required 11 times in 10 patients. In assessing system dysfunction and predicting clinical problems, the accuracy of dual-phase CT imaging was 100%.

CONCLUSION

Dual-phase CT angiography through the port-catheter system is helpful for assessing catheter system dysfunction and predicting clinical problems in HAI chemotherapy.

Superselective intra-arterial chemotherapy for advanced maxillary sinus cancer: an evaluation of arterial perfusion with computed tomographic arteriography and of tumor response

OBJECTIVE

The purpose of our study was to elucidate the relationship between arterial perfusion in advanced maxillary sinus cancer which was opacified by superselective intra-arterial computed tomographic arteriography (IA-CTA) and the tumor response to intra-arterial chemotherapy.

METHODS

Superselective IA-CTA was performed to identify the feeding arteries and their perfusion in advanced maxillary sinus cancer in 10 patients. Cisplatin was selectively infused into these feeding arteries, except for the internal carotid artery.

RESULTS

The results were assessed in 9 of the 10 patients, and a complete response was achieved in 5 patients in whom either the entire tumor, or most of the tumor, was perfused by the branches of the external carotid artery. In 4 patients with a partial response, the residual tumors were seen in the territory of the perfusion defect or in the perfusion territory of the internal carotid artery.

CONCLUSION

Superselective IA-CTA is a useful technique to correctly identify the intratumoral perfusion and to predict tumor response to the intra-arterial chemotherapy of advanced maxillary sinus cancer.

Comparison of intrahepatic and pancreatic perfusion on fusion images using a combined SPECT/CT system and assessment of efficacy of combined continuous arterial infusion and systemic chemotherapy in advanced pancreatic carcinoma

PURPOSE

The purpose of this study was to compare intrahepatic and pancreatic perfusion on fusion images using a combined single-photon emission computed tomography (SPECT)/CT system and to evaluate the efficacy of combined continuous transcatheter arterial infusion (CTAI) and systemic chemotherapy in the treatment of advanced pancreatic carcinoma.

MATERIALS AND METHODS

CTAI was performed in 33 patients (22 men, 11 women; age range, 35-77 years; mean age, 60 years) with stage IV pancreatic cancer with liver metastasis. The reservoir was transcutaneously implanted with the help of angiography. The systemic administration of gemcitabine was combined with the infusion of 5-fluorouracil via the reservoir. In all patients we obtained fusion images using a combined SPECT/CT system. Pancreatic perfusion on fusion images was classified as perfusion presence or as perfusion absent in the pancreatic cancer. Using WHO criteria we recorded the tumor response after 3 months on multislice helical CT scans. Treatment effects were evaluated based on the pancreatic cancer, liver metastasis, and factors such as intrahepatic and pancreatic perfusion on fusion images. For statistical analysis we used the chi-square test; survival was evaluated by the Kaplan Meier method (log-rank test).

RESULTS

On fusion images, pancreatic and intrahepatic perfusion was recorded as hot spot and as homogeneous distribution, respectively, in 18 patients (55%) and as cold spot and heterogeneous distribution, respectively, in 15 (45%). Patients with hot spot in the pancreatic tumor and homogeneous distribution in the liver manifested better treatment results (p < 0.05 and p < 0.01, respectively). Patients with hot spot both in the pancreatic cancer and in the liver survived longer than those with cold spot in the pancreatic cancer and heterogeneous distribution in the liver (median +/- SD, 16.0 +/- 3.7 vs. 8.0 +/- 1.4 months; p < 0.05).

CONCLUSIONS

We conclude that in patients with advanced pancreatic cancer, CTAI with systemic chemotherapy appeared to be effective and may prolong their survival. The development of a reservoir port system allowing for the homogeneous distribution of anticancer drugs is necessary to improve the prognosis of patients with advanced pancreatic cancer.

A simple catheter-vessel model for MR assessment of drug distribution in arteries and optimization of catheter design for intraarterial infusion therapy

PURPOSE

To investigate the efficacy of a new catheter-vessel model for MRI to evaluate drug distribution and to optimize catheter design for intraarterial infusion therapy

MATERIALS AND METHODS

The model consisted of a hepatic artery simulant tube through which blood simulant water flowed continuously and a water cistern. Catheters were inserted into the tube and a gadolinium contrast medium was injected at rates suitable for angiographic or computed tomographic evaluation and commensurate with the clinical drug infusion rate. Axial images of the tube were obtained with a 0.2-T scanner and gradient echo technique. Preliminary studies and catheter tests were conducted. The points at which drug and water were completely mixed were defined as the site with uniform enhancement nearest the catheter tip.

RESULTS

Flip angle and gadolinium concentrations were optimized at 90 degrees, and at 62.5 and 500 mM for the high and low infusion rates, respectively. Drug distribution near the catheter tips was clearly visualized. The drug was mixed in shorter distances via the slit side-hole than the end- or side-hole catheters, and the smaller diametrical than the larger at either rate.

CONCLUSION

This model appeared to be effective for evaluation of drug distribution and optimization of catheter design.

Comparison of Fusion Imaging Using a Combined SPECT/CT System and Intra-arterial CT: Assessment of Drug Distribution by an Implantable Port System in Patients Undergoing Hepatic Arterial Infusion Chemotherapy

Hepatic arterial infusion (HAI) chemotherapy is effective for treating primary and metastatic carcinoma of the liver. We compared the perfusion patterns of HAI chemotherapy on intra-arterial port-catheter computed tomography (iapc-CT) and fused images obtained with a combined single-photon emission computed tomography/computed tomography (SPECT/CT) system. We studied 28 patients with primary or metastatic carcinoma of the liver who bore an implantable HAI port system. All underwent abdominal SPECT using Tc-99m-MAA (185 Mbq); the injection rate was 1 mL/min, identical to the chemotherapy infusion rate, and 0.5 mL/sec for iapc-CT. Delivery was through an implantable port. We compared the intrahepatic perfusion (IHP) and extrahepatic perfusion (EHP) patterns of HAI chemotherapy on iapc-CT images and fused images obtained with a combined SPECT/CT system. In 23 of 28 patients (82%), IHP patterns on iapc-CT images and fused images were identical. In 5 of the 28 patients (18%), IHP on fusion images was different from IHP on iapc-CT images. EHP was seen on fused images in 12 of the 28 patients (43%) and on iapc-CT images in 8 patients (29%). In 17 patients (61%), upper gastrointestinal endoscopy revealed gastroduodenal mucosal lesions. EHP was revealed on fused images in 10 of these patients; 9 of them manifested gastroduodenal toxicity at the time of subsequent HAI chemotherapy. Fusion imaging using the combined SPECT/CT system reflects the actual distribution of the infused anticancer agent. This information is valuable not only for monitoring adequate drug distribution but also for avoiding potential extrahepatic complications.

Fusion imaging using a hybrid SPECT-CT camera improves port perfusion scintigraphy for control of hepatic arterial infusion of chemotherapy in colorectal cancer patients

PURPOSE

Exclusive and homogeneous perfusion of the liver is considered essential for the efficacy of hepatic arterial infusion of chemotherapy (HAI). The aim of this study was to evaluate port perfusion scintigraphy in colorectal cancer patients using a hybrid SPECT-CT system for control of minimally invasive intra-arterial port systems within the scope of a phase II trial.

METHODS

In 24 consecutive patients, the perfusion territories of intra-arterial hepatic port systems were assessed by port scintigraphy with( 99m)Tc-labelled macroaggregated albumin employing planar imaging, SPECT and SPECT-CT (acquired with a hybrid SPECT-CT camera). The results of blinded reading of the scintigraphic modalities concerning the intra- and extrahepatic perfusion pattern were compared with combined image analysis (angiography and contrast-enhanced dedicated CT) and patient history for validation.

RESULTS

Extrahepatic perfusion was correctly seen in three patients, while suspected extrahepatic perfusion could be excluded in one. In 46 liver lobes, perfusion patterns were correctly visualised by SPECT-CT in 100% of cases (planar, 67%; SPECT, 86%). Assessing the perfusion pattern inside the liver on a segmental basis (segments, n=138), SPECT-CT revealed correct segmental assignment of tracer distribution in 100% and was significantly superior to SPECT alone (accuracy, 84%; p<0.001). The scintigraphic findings resulted in changes in therapeutic management in 8/24 patients (33%); in two of these the relevant findings were visualised only by SPECT-CT.

CONCLUSION

In patients receiving HAI, port perfusion scintigraphy by fusion imaging with a hybrid SPECT-CT system provides important information for therapy optimisation and appears to be superior to SPECT alone.

Catheter position for adequate intra-arterial chemotherapy for advanced pancreatic cancer: evaluation with CT during arterial injection of contrast material

PURPOSE

To identify the drug infusion vessel for use in obtaining the best drug distribution in arterial infusion chemotherapy for advanced pancreatic cancer.

MATERIALS AND METHODS

In 16 cases of advanced pancreatic cancer (pancreatic head, n = 12; pancreatic body and/or tail, n = 4), computed tomography during arterial injection of contrast material was performed at the time of angiography. The sites of catheter placement were celiac artery, superior mesenteric artery, and their branches, such as gastroduodenal artery, inferior pancreatico-duodenal artery, or dorsal pancreatic artery.

RESULTS

In the cases of pancreatic head cancer, all except one with hepatomesenteric vascular variation were supplied by the celiac artery and superior mesenteric artery (dual supply). In the cases of pancreatic body and/or tail cancer, two were supplied by celiac artery alone and two showed dual supply. In the cases of pancreatic head cancer, when the areas supplied by the main trunk were compared with those supplied by its branches, three of nine cases on the celiac artery side and four cases on the superior mesenteric artery side showed that the areas were not consistent, with a partial defect observed in the areas supplied by branches of the superior mesenteric artery. In the cases of pancreatic body and/or tail cancer, on both sides, one of two cases was not consistent.

CONCLUSIONS

To achieve optimal drug distribution in arterial infusion chemotherapy for advanced pancreatic cancer, drug infusion via both the celiac artery and superior mesenteric artery is required in the majority of cases. In many cases, optimal drug distribution is not attainable with drug infusion via a branch; therefore, drug infusion should be administered via the main trunk.

Using slow-infusion MR arteriography and an implantable port system to assess drug distribution at hepatic arterial infusion chemotherapy

OBJECTIVE

The purpose of this study was to assess perfusion patterns seen on slow-infusion MR arteriography using the hepatic arterial infusion system compared with those seen on CT arteriography.

SUBJECTS AND METHODS

In 37 patients with liver metastases who had implantable port systems for hepatic arterial infusion chemotherapy, slow-infusion MR arteriography using an infusion rate of 10 mL/hr through an implantable port and CT arteriography using an injection rate of 0.7 mL/sec were performed. In 15 of 37 patients, we evaluated enhancement patterns of tumors of the liver and visceral organs using slow-infusion MR arteriography. In all 37 patients, we compared slow-infusion MR arteriography with CT arteriography concerning intra- and extrahepatic perfusion patterns.

RESULTS

On slow-infusion MR arteriography performed 10-20 min after initiation of infusion, tumors of the liver revealed significant enhancement with only a slight effect of systemic enhancement. In seven (19%) of 37 patients, intrahepatic distributions on slow-infusion MR arteriography differed from those on CT arteriography. In eight patients, the patterns of extrahepatic perfusion into the duodenum and the pancreas head differed on slow-infusion MR arteriography from those seen on CT arteriography. In addition, strong artifact caused by platinum coils in the gastroduodenal artery interfered with the evaluation of perfusion in the area around the coils on CT arteriography, whereas no imaging artifact was seen on slow-infusion MR arteriography.

CONCLUSION

We believe that slow-infusion MR arteriography reflects the actual distribution of infused drugs more accurately than CT arteriography. When clinical complications occur during treatment, slow-infusion MR arteriography should be used to assess perfusion abnormalities.

A review of contrast media research in 1999-2000

Contrast media research published during the years 1999 and 2000 is reviewed in this article, in terms of relevance to developments within the field of diagnostic radiology. The primary focus is on publications from the journal Investigative Radiology, which publishes much of the clinical and laboratory research performed in this field. The journals Radiology and the American Journal of Roentgenology are dominant in the field of diagnostic radiology and together publish more than 10 times the number of articles as appear each year in Investigative Radiology. However, in 1999 for example, these two journals together published fewer articles than did Investigative Radiology alone that concerned basic (animal) research with contrast media. Thirty-six percent of the articles in Investigative Radiology in 1999 had a primary focus on contrast media and 18% on basic (animal) research with contrast media. To make this review more complete, articles from other major journals are cited and discussed, as needed, to provide supplemental information in the few areas not well covered by articles in Investigative Radiology. The safety of contrast media is always an important topic and research continues to be performed in this area, both to explore fundamental issues regarding iodinated contrast media and also to establish the overall safety profile of new magnetic resonance (MR) and ultrasound agents. In regard to preclinical investigations, most of the work performed in the last 2 years has been with MR and ultrasound. In MR, research efforts continue to be focused on the development of targeted agents. In ultrasound, research efforts are split between studies looking at new imaging methods and early studies of targeted agents. In regard to the clinical application of contrast media, the published literature continues to be dominated by MR. Investigations include the study of disease in clinical trials and in animal models. A large number of studies continue to be published in regard to new techniques and applications within the field of contrast-enhanced magnetic resonance angiography. This field represents the single, largest new clinical application of contrast media in MR to emerge in the last decade. New clinical research continues to be published regarding the use of contrast media in computed tomography (CT), ultrasound, and x-ray angiography. The introduction of spiral CT (together with the multidetector scanners) has led to greater utilization of this modality, as well as intravenous iodinated contrast media. The number of publications regarding clinical applications of intravenously injected ultrasound contrast agents remains low, with the high expectations in regard to growth (in terms of number of exams using contrast) of the last decade yet to be fulfilled.