Single injection dual phase CBCT technique ameliorates results of trans-arterial chemoembolization for hepatocellular cancer

Abstract

Cone-beam CT (CBCT) application to the field of trans-arterial chemoembolization has been recently the focus of several researches. This imaging modality is performed with a rotation of the C-arm around the patient, without needs of patient repositioning. Datasets are immediately processed, obtaining volumetric CT-like images with the possibility of post-processing and reconstruction of images. Dual phase CBCT recently introduced in clinical practice consists in a first arterial acquisition followed by a delayed acquisition corresponding to a venous phase. The introduction of this feature has overcome the limit of single-phase acquisitions, allowing lesions characterization. Moreover these recent advantages have several intra-procedural implications. Detailed technical and acquisition parameters will be widely exposed in this review with particular attention to: catheter positioning, acquisition delay, injection parameters, patient positioning and contrast dilution. Comparison with standard of practice second line imaging [multidetector computer tomography (MDCT) and MDCT/arteriography] demonstrate the capability of detecting occult nodules providing some clinical implications thus potentially identifying a sub set of patients with aggressive disease behaviour. Other intra-procedural advantages of dual phase CBCT usage consist in a better tumor feeder visualization, reduction of proper DSA and fluoroscopic time, suggestion the presence of an extrahepatic parasitic feeder thus resulting in a more accurate treatment. Finally, the volumetrical intraprocedural evaluation of accumulation of embolic agent has proved to be correlate with treatment response if compared with MRI.

Intra-procedural dual phase cone beam computed tomography has a better diagnostic accuracy over pre-procedural MRI and MDCT in detection and characterization of HCC in cirrhotic patients undergoing TACE procedure

“…More recently, CBCT has gained a role in assisting TACE procedures [12,14], but all the existing reports in literature were focused on CBCT sensitivity (pooled sensitivity 90%[95%CI 82%-95%]); in case of diameter < 10 mm, sensitivity 94.5%) [30,31]. Moreover, some Authors reported the ability of CBCT, generally in arterial phase only, to detect occult hepatic lesions (ranging: 11.5-28.7%) [15,16].…”

“…Furthermore, CBCT can be performed before TACE procedure and using contrast media injection as multiphasic imaging. In particular, CBCT has gained attention as a helper tool for tumor detection, intraprocedural guidance and treatment assessment during TACE [10][11][12].…”

Balloon Occluded TACE (B-TACE) vs DEM-TACE for HCC. A Single Center Retrospective Case Control Study.

“…Despite this, literature evidence on oncological response of b-TACE over standard non occluded TACE is controversial [3][4][5][6] In order to evaluate the adjunctive value of b-TACE we retrospectively evaluated the results of patients treated in our institution with b-TACE and compared them with an historical cohort treated with non-occluded DEM-TACE. b-TACE and DEM-TACE were performed by the same team under dual phase CBCT guidance i.e..: better tumor/feeders visualization) 15 , with rigorous standardization of the embolization procedure (sequential embolization with 100 and 200 microns particles 12 ), being the only technical variable the balloon micro-catheter employment. B-TACE had a trend for higher TTR after an initial complete response vs DEM-TACE at 1-year, con rmed also by the Coxregression analyses weighted for the presence of micro-balloon catheter and tumors' diameter.…”

Arms Down Cone Beam CT Hepatic Angiography: Are We Focusing on the Wrong Target?

“…This ability is not just for show, but yield to some major clinical implications: the visualization of an occult nodule identifies a subset of population experiencing fast tumour growth, having consequences on the number of adjunctive treatments controlling tumour growth (adjunctive RFA, or TACE procedures) and prioritization for transplantation [4]. Moreover, bi-phasic CBCT, with its unique ability to intra-procedural permit nodule characterization, could help in patients' reclassification and real-time TACE strategy modification [5].…”