Role of Cone-Beam CT in the Intraprocedural Evaluation of Chemoembolization of Hepatocellular Carcinoma

Abstract

Purpose. To assess the ability of Cone-Beam CT (CBCT), performed during the Transcatheter Arterial Chemoembolization (TACE), in predicting the response to treatment of hepatocellular carcinoma (HCC). Materials and Methods. We evaluated fifty patients (M/F = 40/10, mean age: 66.7 years ± 8.22) with hepatocellular carcinoma (HCC), for a total of 82 nodules evaluated (mean diameter: 21.4 ± 11 mm). All patients performed a CT scan one month before and one month after TACE. After TACE is completed, a CBCT was performed to assess the degree of drug retention in the lesions. For each lesion, the major diameter, volume, and density of the vital portion were evaluated. The response to TACE was assessed using the mRECIST criteria on the CT scan carried out one month after the procedure. The receiver operating characteristic (ROC) curves were performed to assess the accuracy of the CBCT in predicting the response to treatment and to identify the cut-off points for each parameter under examination. Results. A complete response (CR) was observed in 24/50 patients (48%), a partial response (PR) in 16/50 (32%), stable disease (SD) in 8/50 (16%), and progressive disease (PD) in 2/50 (4%). Evaluation of the area under the ROC curve showed that the diameter, volume, and density of the lesion, measured with CBTC, had an accuracy of 94%, 96%, and 98%, respectively, in discriminating a complete response from a not complete response. Conclusion. CBCT is effective in predicting short-term response at 1-month follow-up of HCC treated by chemoembolization.

Hug sign in intraprocedural cone-beam-CT to predict short-term response to combined treatment of hepatocellular carcinoma

“…Other authors have endeavored to improve the intraprocedural prediction of ablation efficacy and the assessment of ablative safety margin using a FDG-PET-CT-guided ablation [11,12]. Most recently, it was demonstrated that CBCT could be a useful tool for assessing the efficacy of TACE in the intra-operative setting, being a predictor of CR in conventional and DEB-TACE [13][14][15].…”

“…Radiologia d'Urgenza e Interventistica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy ablation with trans-arterial chemoembolization (TACE) have been effectively and safely used to treat single large HCCs [8,9]. Given the challenges in ensuring complete treatment of these larger tumors in real time, immediate prediction of residual disease after combined locoregional treatment, ideally during the procedure itself, could potentially increase the curative effect of these procedures, decreasing treatment failure rates and improving treatment of residual viable tumor, as already demonstrated for TACE and ablative techniques alone [10][11][12][13][14][15]. Recently, a new radiologic "hug sign" depicted at the intraprocedural unenhanced C-arm cone-beam computed tomography (CBCT) was described and suggested to indicate intraprocedural success [16].…”

The Role of Immediate Post-Procedural Cone-Beam Computed Tomography (CBCT) in Predicting the Early Radiologic Response of Hepatocellular Carcinoma (HCC) Nodules to Drug-Eluting Bead Transarterial Chemoembolization (DEB-TACE)

“…However, the association between the presence and features of the contrast deposit and CR after DEB-TACE has not been evaluated. Regarding DSM-TACE (degradable starch microsphere-TACE), a quantitative evaluation of intraprocedural CBCT was performed with predictive purposes in a study by Orlacchio et al [ 26 ], showing that the diameter, volume, and density of lesions had high accuracy in predicting an early CR. In that study, a higher CR rate was observed in lesions in which the chemoembolization mixture retention had nearly the same diameter or volume value as that of the enhancing portion evaluated via preprocedural CT, and the density value was higher than that measured by the preprocedural CT.…”

“…Moreover, qualitative analysis is currently the only feasible method of assessment, as there are no standardized methods for the quantitative analysis of interventional CBCT, considering the intrinsic inability of CBCT to provide a density value measured in Hounsfield units. Some studies have tried to estimate density values from CBCT images, defining an arbitrary unit correlated to CT Hounsfield units [ 18 , 26 , 28 ]. However, this approach might present some limitations and can hardly be generalized to different angiography/CBCT systems, so further studies in this field are needed.…”

In the Era of Systemic Therapy for Hepatocellular Carcinoma Is Transarterial Chemoembolization Still a Card to Play?

“…In a retrospective evaluation in 2011, Iwazawa et al depicted that C-arm CT is nearly equivalent to biphasic multidetector computed tomography (MDCT) for detecting incomplete iodized oil accumulation after cTACE; more precisely, they determined that it helps to recognize a suboptimal treatment immediately post TACE [99]. Several studies followed, supporting these findings [100,101], among which was a recent retrospective analysis by Orlacchio et al that assessed the ability of CBCT to predict short-term response at the 30-day follow-up CT after TACE [102]. Evaluation of the area under the ROC curve showed that the diameter, volume, and density of the lesion measured with CBTC had an accuracy of 94%, 96%, and 98%, respectively, in discriminating a complete response from a not complete response.…”