Rationale and Objectives
To assess patient radiation dose reduction and the image quality of a new X-ray imaging technology during repetitive transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).
Methods
Fifty HCC patients (36 men; 57 ± 11 years) undergoing repetitive TACE were first randomly assigned to receive a TACE treatment on a reference X-ray system or a low-dose system with advanced real-time image processing. The alternate system was used for a repeated TACE (treatment interval, 0.5–6 months). Fluoroscopy time, number of digital subtraction angiography (DSA), air kerma (AK), and dose area product (DAP) were compared between the two systems and between the two repetitive TACE. Three interventional radiologists independently rated the image quality in blinded offline readings.
Results
Fluoroscopy time (8.7 ± 5.9 minutes vs. 8.7 ± 7.9 minutes, P = .981), numbers of DSA runs (6 ± 4 vs. 6 ± 4, P = .735), and exposure images (173 ± 86 vs. 168 ± 91, P = .916) were equivalent between the two systems. No statistical difference in X-ray usage was found between repeated treatments. Compared to the reference system, the technology significantly reduced AK and DAP by 48.6% (0.17 ± 0.13 Gy vs. 0.41 ± 0.36 Gy, P < .0001) and 50.3% (77.3 ± 55.2 Gy cm 2 vs. 195.0 ± 155.5 Gy cm 2 , P < .0001), respectively. Image quality was rated comparable between the new system and the reference, with average scores of 3.9 ± 0.3 versus 4.4 ± 0.3 in fluoroscopy and 4.5 ± 0.2 versus 4.3 ± 0.3 in DSA.
Conclusions
Patient radiation exposure can be substantially reduced by a factor of approximately two with the novel X-ray imaging technology while maintaining image quality.
Introduction
Patients with unresectable hepatocellular carcinoma (HCC) can receive transarterial chemoembolization (TACE) as a palliative treatment . However, guided by fluoroscopy and digital subtraction angiography (DSA), the interventional radiologic procedure could result in a considerable amount of radiation which may put the patient at risk to radiation-induced skin injuries. Furthermore, because of tumor recurrence, repetitive embolization is often required , increasing the burden of cumulative radiation exposure to the patient and the clinical stuff.
In accordance with the “as low as reasonably achievable” (ALARA) principle, radiation dose should be kept at the lowest possible level when conducting radiologic procedures. However, during TACE therapies, clinically sufficient image quality might be obtained at the expense of radiation dose due to the X-ray attenuation while penetrating the abdomen during image acquisitions. Furthermore, noise and artifacts in the images, caused by breathing for instance, may necessitate additional image acquisition and increase patient irradiation.
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Materials and methods
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Table 1
Patient Baseline Characteristics
Age, y ∗ 57 ± 11 Sex Male 36 Female 14 Body mass index (kg/m 2 ) ∗ 23.0 ± 3.2 Repetitive TACE indication Local lipiodol loss 45 Local lesion recurrence 6 New lesion appearance 3 Treatment interval (d) † 50 (11–224)
Assessment 1 (n = 50) Assessment 2 (n = 50) Child–Pugh Score A 34 31 B 16 19 C 0 0 Barcelona clinical liver cancer staging 0 5 5 A 12 12 B 25 25 C 8 8 D 0 0
TACE, transarterial chemoembolization.
Except where indicated, data represent numbers of patients.
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Imaging Technology
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Image Quality Assessment
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Table 2
Image Quality Scoring Scale Used to Assess Fluoroscopy
Score Hepatic Artery Visibility to Sub-subsegmental Level Branches Intravascular Lipiodol Flow Direction and Speed Visibility Tumor Lipiodol Deposition Visibility 5 Clear Clear Clear 4 Clear Clear Fair 3 Clear Fair Fair 2 Subsegmental level, fair; sub-subsegmental level, poor Poor Poor 1 Subsegmental level, poor; sub-subsegmental level, not visible Poor Not visible 0 Not visible Not visible Not visible
Table 3
Image Quality Scoring Scale Used to Assess Digital Subtraction Angiography
Score Hepatic Artery Visibility to Sub-subsegmental Level Branches Tumor (Size, Border) and Feeding Vessel Visibility Portal Vein Visibility 5 Clear Clear Clear 4 Clear Tumor, clear; feeding vessel, fair Clear 3 Clear Fair Fair 2 Subsegmental level, clear; sub-subsegmental level, fair Poor Fair 1 Subsegmental level, clear; sub-subsegmental level, poor Tumor, poor; feeding vessel, not visible Not visible 0 Not visible Not visible Not visible
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Data Collection and Statistical Analysis
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Results
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Table 4
Procedural X-Ray Usage and Patient Radiation Dose
AlluraClarity (n = 50) Reference (n = 50) Average Reduction (%)P Value Fluoroscopy time (min) 8.7 ± 5.9 8.7 ± 7.9 NS DSA runs 6 ± 4 6 ± 4 NS Exposure images 173 ± 86 168 ± 91 NS Total AK (Gy) 48.6 <.0001 Mean ± SD 0.17 ± 0.13 0.41 ± 0.36 Median (Q1–Q3) 0.13 (0.09–0.20) 0.30 (0.21–0.48) AK–fluoroscopy (Gy) <.0001 Mean ± SD 0.05 ± 0.04 0.12 ± 0.10 Median (Q1–Q3) 0.03 (0.02–0.06) 0.08 (0.07–0.14) AK–DSA (Gy) <.0001 Mean ± SD 0.12 ± 0.09 0.30 ± 0.29 Median (Q1–Q3) 0.09 (0.06–0.15) 0.22 (0.15–0.31) Total DAP (Gy∙cm 2 ) 50.3 <.0001 Mean ± SD 77.3 ± 55.2 195.0 ± 155.5 Median (Q1–Q3) 57.4 (45.5–101.0) 149.5 (100.6–245.8) DAP–fluoroscopy (Gy∙cm 2 ) <.0001 Mean ± SD 21.8 ± 17.7 53.4 ± 43.8 Median (Q1–Q3) 15.7 (11.3–27.2) 38.1 (25.7–58.9) DAP–DSA (Gy∙cm 2 ) <.0001 Mean ± SD 55.5 ± 40.4 141.5 ± 127.2 Median (Q1–Q3) 43.3 (29.3–72.4) 114.1 (72.8–155.7)
AK, air kerma; DAP, dose area product; DSA, digital subtraction angiography; NS, not significant; Q1–Q3, first to third quartile range; SD, standard deviation.
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Discussion
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Conclusion
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Acknowledgment
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