Lipiodol enhanced CT scanning in assessment of hepatocellular carcinoma

Evaluation of the relationship between hepatocellular carcinoma location and transarterial chemoembolization efficacy

AIM

To evaluate the relationship between the location of hepatocellular carcinoma (HCC) and the efficacy of transarterial chemoembolization (TACE).

METHODS

We evaluated 115 patients (127 nodules), excluding recurrent nodules, treated with TACE between January 2011 and June 2014. TACE efficacy was evaluated according to mRECIST. The HCC location coefficient was calculated as the distance from the central portal portion to the HCC center (mm)/liver diameter (mm) on multiplanar reconstruction images rendered (MPR) to visualize bifurcation of the right and left branches of the portal vein and HCC center. The HCC location coefficient was compared between complete response (CR) and non-CR groups in Child-Pugh grade A and B patients.

RESULTS

The median location coefficient of HCC among all nodules, the right lobe, and the medial segment was significantly higher in the CR group than in the non-CR group in the Child-Pugh grade A patients (0.82 vs 0.62, P < 0.001; 0.71 vs 0.59, P < 0.01; 0.81 vs 0.49, P < 0.05, respectively). However, there was no significant difference in the median location coefficient of the HCC in the lateral segment between in the CR and in the non-CR groups (0.67 vs 0.65, P > 0.05). On the other hand, in the Child-Pugh grade B patients, the HCC median location coefficient in each lobe and segment was not significantly different between in the CR and in the non-CR groups.

CONCLUSION

Improved TACE efficacy may be obtained for HCC in the peripheral zone of the right lobe and the medial segment in Child-Pugh grade A patients.

Evaluation of the blood supply and efficacy of transcatheter arterial chemoembolization for patients with liver metastasis using 18F-fluorodeoxyglucose positron emission tomography/computed tomography

Our study aims to evaluate the efficacy of transcatheter arterial chemoembolization in the treatment of patients with liver metastasis using integrated ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography. A total of 97 liver metastasis patients treated by transcatheter arterial chemoembolization were enrolled in this study. The ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography images of liver metastasis patients were collected before and after transcatheter arterial chemoembolization treatment. The efficacy of transcatheter arterial chemoembolization for the treatment of liver metastasis was evaluated according to the revised Response Evaluation Criteria in Solid Tumors guidelines. The receiver operating characteristic curve analysis was used to determine cut-off values of ¹⁸F-fluorodeoxyglucose positron emission tomography parameters (Tsuvmax, Tsuvmax/Lsuvmax, and Tsuvmax/Lsuvmean) for predicting the efficacy of transcatheter arterial chemoembolization. Progression-free survival and the incidence of postoperative complications were compared. Correlation of Tsuvmax, Tsuvmax/Lsuvmax, and Tsuvmax/Lsuvmean with blood supply and lipiodol deposition in the lesion was analyzed. Among three ¹⁸F-fluorodeoxyglucose positron emission tomography parameters, the receiver operating characteristic analysis showed that Tsuvmax/Lsuvmax with a cut-off value of 3.56 was the best predictor of transcatheter arterial chemoembolization efficacy. According to the cut-off value of Tsuvmax/Lsuvmax, liver metastasis patients were divided into the Tsuvmax/Lsuvmax ≤ 3.56 and Tsuvmax/Lsuvmax > 3.56 groups. Compared with the Tsuvmax/Lsuvmax > 3.56 group, the Tsuvmax/Lsuvmax ≤ 3.56 group showed a longer progression-free survival and a lower incidence of postoperative complications. The Tsuvmax, Tsuvmax/Lsuvmax, and Tsuvmax/Lsuvmean in the lesion with abundant blood supply were significantly lower than those in peripheral liver parenchyma, while the Tsuvmax, Tsuvmax/Lsuvmax, and Tsuvmax/Lsuvmean in the lesion with lack of blood supply were significantly higher than those in peripheral liver parenchyma. Spearman correlation analysis indicated that lipiodol deposition in the lesion was positively correlated with the Tsuvmax, Tsuvmax/Lsuvmax, and Tsuvmax/Lsuvmean. The Tsuvmax/Lsuvmax of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography may be a good tool for predicting the blood supply and efficacy of transcatheter arterial chemoembolization for patients with liver metastasis.

Risk factors and therapeutic results of early local recurrence after transcatheter arterial chemoembolization

AIM: To identify factors affecting early local recurrence after transcatheter arterial chemoembolization (TACE) and investigate treatments and outcomes for local recurrence.

METHODS: Early local recurrence and no early local recurrence groups drawn from 134 patients who were initially diagnosed with hepatocellular carcinoma (HCC) and showed a complete response (CR) to TACE treatment between January 1, 2006, and January 31, 2012, were analyzed by univariate and multivariate analyses. Additionally, the subsequent treatment for patients with recurrence was analyzed, and in cases in which TACE had been performed, the cumulative recurrence rates were calculated using the Kaplan-Meier method and compared with those of the primary lesion.

RESULTS: The 1-, 2-, and 3-year survival rates were 92.3%, 60.2%, and 39.8%, respectively, in the early local recurrence group, which were significantly lower than those in both the late local and no local recurrence groups (P < 0.001). On multivariate analyses, non-compact lipiodol uptake, large tumor size, and an alpha-fetoprotein > 20 ng/mL after achieving a CR were significant predictors. When TACE was performed for early and late locally recurrent lesions, a CR was observed in 15 patients (41.7%) and 11 patients (78.6%), and the cumulative recurrence rates at 6, 12, and 24 mo were 17.9%, 43.3%, and 71.2%, respectively, which did not differ significantly from those after the first CR of 20.5%, 44.0%, and 58.6%, respectively (P = 0.639).

CONCLUSION: Closer monitoring and active treatments must be provided to patients with risk factors for early local recurrence of HCC.

Value of lipiodol computed tomography and digital subtraction angiography in the era of helical biphasic computed tomography as preoperative assessment of hepatocellular carcinoma

OBJECTIVE

To compare the diagnostic accuracies of Lipiodol computed tomography (CT) and helical biphasic CT as preoperative imaging modalities for hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

Lipiodol CT after digital subtraction angiography has long been used as a highly sensitive imaging modality for HCC. The recent advent of helical CT has allowed scanning the entire liver during both the arterial and portal venous phase of contrast enhancement.

METHODS

The authors analyzed data from 164 patients who underwent hepatic resection for HCC to calculate the sensitivity and specificity of these modalities. Findings of intraoperative ultrasonography followed by histologic confirmation were set as the gold standard.

RESULTS

Although sensitivity decreased with both modalities as tumors became small and well differentiated, helical CT showed a higher sensitivity than Lipiodol CT in detecting well-differentiated HCC nodules smaller than 2 cm. In contrast, Lipiodol CT was superior to helical CT for the detection of small but moderately to poorly differentiated nodules. The overall sensitivity of helical CT was higher than that of Lipiodol CT. These findings suggest that helical CT is superior in delineating early HCC, whereas Lipiodol CT is specific to the detection of intrahepatic metastases. In terms of specificity, helical CT was superior to Lipiodol CT.

CONCLUSIONS

Helical CT and Lipiodol CT are complementary modalities. At present, helical biphasic CT does not obviate the need for invasive techniques such as angiography and Lipiodol CT as preoperative examinations for HCC.

Diagnostic value and tolerance of Lipiodol-computed tomography for the detection of small hepatocellular carcinoma: correlation with pathologic examination of explanted livers

BACKGROUND/AIMS

This study aimed to assess the tolerance and the real sensitivity of Lipiodol-computed tomography in the detection of small hepatocellular carcinoma by comparison with pathological examination of the explanted livers.

METHODS

Seventy-two patients with cirrhosis (Child A=8, B=36, C=28) awaiting orthotopic liver transplantation underwent Lipiodol-computed tomography to determine the presence, number and location of possible hepatocellular carcinoma nodules. Before liver transplantation six patients had a presumed single hepatocellular carcinoma diagnosed by biopsy. Liver transplantation was performed a mean of 6 months after Lipiodol-computed tomography. Explanted livers were sectioned at 0.8- to 1-cm intervals. Lipiodol-computed tomography staging and pathologic findings were compared.

RESULTS

Pathologic studies showed 24 hepatocellular carcinoma nodules (diameter, 2-42 mm) not diagnosed before liver transplantation in 14 of the 72 livers. Lipiodol-computed tomography detected 6 of these 24 nodules, but none of the daughter lesions (n=9) in the six patients with a presumed single hepatocellular carcinoma. Lesion-by-lesion analysis revealed a sensitivity of 37%. Lipiodol-computed tomography falsely detected three additional nodules not confirmed by pathologic examination (1 haemangioma, 2 nondysplastic regenerating nodules). One Child C patient developed variceal bleeding within 2 days after injection of Lipiodol.

CONCLUSIONS

Tolerance of this procedure was satisfactory, even in Child C patients. Lipiodol-computed tomography has a low sensitivity in the detection of small hapatocellular carcinoma. These results must be considered when liver resection or liver transplantation is proposed for the treatment of hepatocellular carcinoma.

Treatment of inoperable hepatocellular carcinoma by transcatheter arterial chemoembolization using an emulsion of cisplatin in iodized oil and gelfoam

Eighty patients with inoperable hepatocellular carcinoma (HCC) were treated by transcatheter arterial chemoembolization using an emulsion of Lipiodol and Cisplatin. In 59 patients, gelfoam embolization was also given. The tumour size ranged from 0.5 cm to 33 cm in maximum diameter with the median diameter being 8 cm. The chemoembolization sessions were repeated every 1 1/2 to 3 months. The number of sessions the patients underwent varied from 1 to 11, with the mean number of sessions being 3.7. The HCC either disappeared completely or decreased in size in 44 patients (55%). In patients having an HCC of 12 cm or less in size, 31 out of 41 (75.6%) who had the addition of gelfoam demonstrated decrease in tumour size, while seven out of 11 (63.6%) without the addition of gelfoam demonstrated decrease in tumour size. In patients having an HCC of more than 12 cm in size, only six out of 18 (33.3%) who had the addition of gelfoam demonstrated reduction in tumour size and none of the 10 patients without the addition of gelfoam responded. Thus, HCCs of 12 cm or less in size responded better than larger ones to chemoembolization (P < 0.0001) while the addition of gelfoam enhanced the response (P = 0.039). The 1 year survival rate for the 80 patients was 53% and the 2 years survival rate was 38%. The median survival was 13 months. For patients having an HCC of 12 cm or less in size, the 1 year and 2 year survival rates were 69% and 47% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic iodised oil embolisation of liver tumours--the Hammersmith experience

Oily embolisation of the liver as a diagnostic technique in the management of liver tumours has not proved reliable in our hands. In our study of 20 patients we found: (1) The technique was not risk-free, with complications in four patients, one of whom required emergency surgery. (2) The Bruneton classification is far too simplistic to be relied upon. (3) Residual Lipiodol, particularly in the left lobe of the liver is problematic, making it difficult to distinguish normal from diseased liver. (4) The technique did not contribute to decisions about surgical management in any one of our 20 cases though we accept it might occasionally do so. Our experience was disappointing and in marked contradistinction to enthusiastic reports by some other authors.

Case report: persistence of lipiodol for 13 months in metastatic deposits in the liver on computed tomography

The computed tomography (CT) findings in a 17-year-old male student with liver metastases from a primary adenocarcinoma of the rectum are presented. Lipiodol-enhanced CT 4 days after lipiodol infusion demonstrated several metastases not visible on conventional CT. A repeat CT 13 months later showed lipiodol to have been retained within the original lesions and also demonstrated new metastatic deposits free of lipiodol. Although persistence of lipiodol for up to a year has been reported by workers in Japan imaging hepatocellular carcinoma (Yumoto et al., 1985) this experience has not been confirmed in the UK (Raby et al., 1989). There are relatively few reports investigating metastatic adenocarcinoma (Nakakuma et al., 1985), none of which refers to persistence of lipiodol over 1 year. This case report demonstrates the ability of lipiodol-enhanced CT to detect occult metastases and also to facilitate their follow-up and differentiation from newer lesions.

Advances in neoplastic disease of the liver and biliary tract

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Hepatocellular carcinoma in the Amsterdam area. A retrospective analysis in 61 patients

In a retrospective study clinical features of hepatocellular carcinoma (HCC) in the Amsterdam area (1984-89) were assessed in 61 cases. The data obtained were used to discuss some of the current concepts on aetiology, diagnosis, and treatment of HCC. Presenting symptoms and findings usually reflected advanced (incurable) disease. Of the patients 25% had a normal alpha-1-foetoprotein (AFP), 55% had elevated levels, and in 20% data were absent. Platelet counts greater than 500 x 10(9)/l were found in 8% and hypercalcaemia in 10% of the patients. Treatment modalities were none (70%), surgery (16%), chemotherapy (8%), radiotherapy (3%), and endoprosthesis (2%). Sixty to 70% had died after 3 months and more than 90% after 1 year. Long survivors included 2 patients with the fibrolamellar type of HCC. The low incidence of HCC in The Netherlands probably precludes cost-effective screening programs to identify resectable small HCC. Unidentified masses are malignant until proven otherwise and should be resected if no firm diagnosis of benign disease can be made. Awareness of HCC and its risk factors may lead to earlier diagnosis and more selective use of diagnostic tests.

Lipiodol computerized tomography: how sensitive and specific is the technique in the diagnosis of hepatocellular carcinoma?

Computerized tomography (CT) following the intra-arterial injection of Lipiodol (Lipiodol-CT) was performed on 60 patients suspected of having a hepatocellular carcinoma (HCC). Four main patterns of uptake of the Lipiodol within the liver were seen on CT. Of the 14 well circumscribed lesions with dense homogeneous uptake of Lipiodol, 13 were confirmed to be HCCs. Of the 25 lesions with dense patchy uptake of Lipiodol at the periphery and/or in the centre, 19 were confirmed to be HCCs. In 18 patients, in whom only ill defined faint patchy uptake of Lipiodol was present in the liver, or in whom no hepatic uptake was present at all, only one patient was found later to have an HCC. Of the three hypodense lesions in the liver with no Lipiodol uptake, one was found to be necrotic HCC, one a cholangiocarcinoma and one a regenerative nodule. In the diagnosis of HCC, Lipiodol-CT had an overall sensitivity of 97.1%, an accuracy of 88.3% and a specificity of 76.9%. Of the 34 patients with HCC, only 23 were solitary at diagnosis. The size of the HCCs ranged from 0.8 cm to 11 cm in diameter with the median size at 2.2 cm. Eleven of 34 HCCs (32.3%) were resectable. We conclude that, as part of a screening programme for high risk patients. Lipiodol-CT is useful in the early detection of HCCs. The technique also plays an important role in determining whether the tumour should be resected or managed with chemotherapy. By detecting HCCs while still small, the resectability rate can also be improved.