Transarterial Chemoembolization of Hepatocellular Carcinoma Using Radiopaque Drug-Eluting Embolics: Impact of Embolic Density and Residual Tumor Perfusion on Tumor Recurrence and Survival

Abstract

Purpose To evaluate the value of dual-phase parenchymal blood volume (PBV) C-arm mounted cone-beam-CT (CBCT) to enable assessment of radiopaque, doxorubicin-loaded drug-eluting embolics (rDEE) based on the visual degree of embolization, embolic density and residual tumor perfusion as early predictors for tumor recurrence after transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC). Material and Methods Thirty patients (50 HCCs) were prospectively enrolled, underwent cross-sectional imaging before and after TACE using 100–300 µm rDEE and had regular follow-up examinations. Directly before and after the TACE procedure, PBV-CBCT was acquired. The response was evaluated and compared to visual degree of embolization (DE) and embolic density (ED) of rDEE deposits, as well as the presence of residual tumor perfusion (RTP) derived from PBV-CBCT. Outcome was assessed by mid-term tumor response applying mRECIST and patient survival after 12 months. Results RTP was detected in 16 HCCs and correlated negatively with DE (p = .03*) and ED (p = .0009*). The absence of RTP significantly improved lesion-based mid-term response rates regarding complete response (CR, 30/34 (88%) vs 2/16 (12.5%), p = .0002*), lesion-based complete response rate was 75% (21/28) for DE ≥ 50% vs. 50% (11/22) for DE < 50% (p = .08) and 82% (27/33) for ED ≥ 2 vs. 29% for ED < 2 (5/17), p = .005*). Thirteen patients were treated with re-TACE within 12 months, 11 of which had shown RTP. 12-month survival rate was 93%. Conclusion Residual tumor perfusions as assessed by PBV-CBCT during rDEE-TACE proved to be the best parameter to predict mid-term response. “Level of Evidence: Level 3”

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

“…However, this study is related to TACE alone procedures, and its clinical application requires dedicated hybrid MR/angio-suite and equipment [ 10 ]. Contrast-enhanced ultrasound can be useful in monitoring post-ablation treatment response [ 31 ]. Yet, contrast-enhanced ultrasound is limited by false negative results secondary to deep located HCCs or by the persistence of hyperemic halos around ablated tissue due to post-ablation inflammatory reactions.…”

Role of gadoxetic acid-enhanced liver magnetic resonance imaging in the evaluation of hepatocellular carcinoma after locoregional treatment

“…In the recent years, perfusion techniques, both with CT and MR, were used to diagnose HCC and determine different treatment responses, especially after medical therapy: in this setting CT perfusion can be considered a reliable tool in the early detection of recurrence, as reported by Choi et al [ 55 ]. More recently the effectiveness of CT perfusion was evaluated by Ruff et al [ 56 ], demonstrating that residual tumor perfusion parameters are linked to HCC recurrence. However, both CT and MR perfusion imaging need an extra time, added costs and are not widely available to be considered convenient tool in daily clinical practice[ 57 ].…”