Home Dual-phase Cone-beam CT-based Navigation Imaging Significantly Enhances Tumor Detectability and Aids Superselective Transarterial Chemoembolization of Liver Cancer
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Dual-phase Cone-beam CT-based Navigation Imaging Significantly Enhances Tumor Detectability and Aids Superselective Transarterial Chemoembolization of Liver Cancer

Rationale and Objectives

The objective of this study was to investigate the impact of a dual-phase cone-beam computed tomography (DP-CBCT)-based navigation imaging during transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) in a perspective randomized study.

Materials and Methods

Forty-two patients with HCC (39 men, 57 ± 9 years, 13 first-time TACE) underwent TACE using three-dimensional image guidance with automatic detection of tumor-feeding vessels computed from DP-CBCT (early and delayed arterial phases). Forty-nine other patients with HCC (44 men, 55 ± 12 years, 14 first-time TACE) were treated conventionally using digital subtraction angiography (DSA). Tumor detectability in DP-CBCT was compared to DSA and preoperative CT or magnetic resonance (MR) imaging. Tumor-feeding vessel visibility was rated (good, fair, and poor) intraoperatively by the operators. The superselective embolization success rate, the number of DSA acquisitions, fluoroscopy time, and patient radiation dose were collected and compared using paired t test and the Mann-Whitney U test.

Results

Tumor detection of DP-CBCT was superior to DSA (100% vs 83%, P = .001) and comparable to CT-MR (96%, P = .456). Tumor and feeder visibilities were significantly enhanced by DP-CBCT ( P < .001). Compared to using DSA, more superselective embolization was achieved (60% vs 49%) with less DSA acquisitions ( n = 2.6 ± 0.8 vs n = 3.4 ± 0.7, P < .001) and shorter fluoroscopy time (4.1 ± 2.6 vs 7.1 ± 4.2 minutes, P < .001) with a slight increase in patient radiation exposure, that is, air kerma (median: 0.33, first to third quartiles: 0.24–0.48 vs 0.30, 0.24–0.44 Gy; P = .519) and dose-area product (134, 92–181 vs 97, 75–140 Gy⋅cm 2 , P = .048).

Conclusions

DP-CBCT and navigation imaging improve tumor detectability and superselective embolization in TACE.

Introduction

With its high prevalence and poor prognosis due to hepatic impairment and high recurrence rates, liver cancer is the second most common cause of cancer death in the world. Transarterial chemoembolization (TACE), an effective interventional radiological therapy against tumor growth, is provided to patients with unresectable liver cancer and has been reported with potential benefit in patient survival .

One of the keys to successful TACE lies in seeing and reaching tumor lesions after accurate and comprehensive assessment of all feeding arteries. Conventionally, operators rely on fluoroscopy and digital subtraction angiography (DSA). However, the intrinsic two-dimensional nature of DSA and its low-contrast resolution limit tumor detection, resulting in a recent adoption of intraprocedural cone-beam computed tomography (CBCT) for its axial and three-dimensional (3D) volumetric visualization, as well as superior soft tissue sensitivity . Clinical findings have reported that CBCT is superior to DSA and can achieve a degree of intraprocedural liver cancer detection comparable to preprocedural diagnostic CT or magnetic resonance (MR) imaging . The subsequent development of dual-phase cone-beam computed tomography (DP-CBCT) with single-contrast injection has further improved tumor detection from single-phase CBCT . Furthermore, the automated feeding artery identification of the DP-CBCT navigation software has been reported with a tumor-feeder detectability rate of 85%–93%, which is a significant improvement over DSA and CBCT .

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Materials and Methods

Study Design

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Patients

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TABLE 1

Patient Baseline Characteristics

DP-CBCT-guided TACE DSA-guided TACE Total patients 43 (40 male) 56 (48 male) Age (y, mean ± SD) 57 ± 9 55 ± 12 Patients with hepatocellular carcinoma 42 49 Patients with hepatic metastases 1 7 Barcelona Clinical Liver Cancer Staging A 0 0 B 17 22 C 25 27 D 0 0 Child-Pugh score A 38 51 B 5 5 C 0 0 First-time TACE treatment 13 (30%) 18 (32%)

DP-CBCT, dual-phase cone-beam computed tomography; DSA, digital subtraction angiography; SD, standard deviation; TACE, transarterial chemoembolization.

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TACE

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DP-CBCT and Navigation Imaging

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Figure 1, Single hepatocellular carcinoma depicted in a dual-phase cone-beam computed tomography scan. (a) Early arterial phase reveals the hypervascular lesion and surrounding arteries, and (b) late arterial phase shows the hyperdense tumor compared to normal parenchyma.

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Figure 2, Three-dimensional tumor and feeder segmentation in dual-phase cone-beam computed tomography. (a) Feeding arteries to two tumor nodules in the liver and the gallbladder are automatically detected and segmented in dual-phase cone-beam computed tomography using EmboGuide; (b–d) the segmentation can be viewed in the coronal, sagittal, and transverse planes. (Color version of figure is available online.)

Figure 3, Microcatheter placement using an EmboGuide road map. (a) Digital subtraction angiography using a standard catheter shows indistinguishable arterial supply to two tumors and the gallbladder; (b) EmboGuide identifies the artery paths based on automatic three-dimensional segmentation and is overlayed on fluoroscopy as a road map; (c) with a microcatheter in place, digital subtraction angiography confirms the tumor feeder identified by EmboGuide while successfully avoiding entry into the arterial supply to the gall bladder.

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Procedural Impact Assessment

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Statistical Analysis

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Results

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Tumor Detectability

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Tumor and Feeder Visibilities

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TABLE 2

Tumor Detectability and Image Quality of Tumor-feeder Visualization

Dual-phase CBCT-guided TACE ( n = 43) DSA-guided TACE ( n = 56)P Value Number of Tumors Detected CT-MR 97 (100%) 139 (100%) .605 DSA 84 (87%) 117 (84%) .593 DP-CBCT (total detection) 101 (104%) — — Arterial phase 95 (98%) — — Delayed phase 100 (103%) — — DP-CBCT vs CT-MR_P_ = .456 — DP-CBCT vs DSA_P_ = .001 —

Image Quality of Tumor Visualization DSA Good: 53%, fair: 33%, poor: 14% Good: 66%, fair: 27%, poor: 7% .152 DP-CBCT Good: 91%, fair: 7%, poor: 2% — — DP-CBCT vs DSA_P_ < .001 —

Image Quality of Feeder Visualization DSA Good: 35%, fair: 42%, poor: 23% Good: 45%, fair: 45%, poor: 10% .086 DP-CBCT Good: 84%, fair: 14%, poor: 2% — — DP-CBCT vs DSA_P_ < .001 —

DSA, digital subtraction angiography; DP-CBCT, dual-phase cone-beam computed tomography; TACE, transarterial chemoembolization; CT-MR, preprocedural computed tomography or magnetic resonance imaging.

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Procedural Impact

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TABLE 3

Procedural Differences Between the Two Groups

Dual-phase CBCT-guided TACE ( n = 43) DSA-guided TACE ( n = 56)P Value Superselective TACE (successful/total cases [%]) 26/43 (60) 26/56 (46) — DSA acquisitions 2.6 ± 0.8 3.4 ± 0.9 <.001 Fluoroscopy time (min) 4.1 ± 2.6 7.1 ± 4.2 <.001 CBCT acquisitions 4.9 ± 1.2 — — Air kerma (Gy) Median (Q1–Q3 range) 0.34 (0.24–0.47) 0.30 (0.24–0.45) .710 Dose area product (Gy⋅cm 2 ) Median (Q1–Q3 range) 128 (92–178) 97 (71–136) .187

CBCT, cone-beam computed tomography; CT-MR, preprocedural computed tomography or magnetic resonance imaging; DSA, digital subtraction angiography; Q1–Q3, first to third quartile range; TACE, transarterial chemoembolization.

Data presented as mean ± standard deviation when not specified.

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Discussion

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Conclusions

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