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Three-dimensional Evaluation of Lipiodol Retention in HCC after Chemoembolization

Posted Feb 28, 2014 Updated Apr 10, 2023
By Zhijun Wang MD PhD , MingDe Lin PhD , David Lesage PhD , Rongxin Chen MD PhD , Julius Chapiro MD , Tara Gu BS , Vania Tacher MD , Rafael Duran MD , Jean-François Geschwind MD
10 min read

Rationale and Objectives

To evaluate the capability of cone-beam computed tomography (CBCT) acquired immediately after transcatheter arterial chemoembolization (TACE) in determining lipiodol retention quantitatively and volumetrically when compared to 1-day postprocedure unenhanced multidetector computed tomography (MDCT).

Materials and Methods

From June to December 2012, 15 patients met the inclusion criteria of unresectable hepatocellular carcinoma (HCC) that was treated with conventional TACE (cTACE) and had intraprocedural CBCT and 1-day post-TACE MDCT. Four patients were excluded because the lipiodol was diffuse throughout the entire liver or lipiodol deposition was not clear on both CBCT and MDCT. Eleven patients with a total of 31 target lesions were included in the analysis. A quantitative three-dimensional software was used to assess complete, localized, and diffuse lipiodol deposition. Tumor volume, lipiodol volume in the tumor, percent lipiodol retention, and lipiodol enhancement in Hounsfield units (HU) were calculated and compared between CBCT and MDCT using two-tailed Student’s t test and Bland–Altman plots.

Results

The mean value of tumor volume, lipiodol-deposited regions, calculated average percent lipiodol retention, and HU value of CBCT were not significantly different from those of MDCT (tumor volume: 9.37 ± 11.35 cm 3 vs 9.34 ± 11.44 cm 3 , P = .991; lipiodol volume: 7.84 ± 9.34 cm 3 vs 7.84 ± 9.60 cm 3 , P = .998; lipiodol retention: 89.3% ± 14.7% vs. 90.2% ± 14.9%, P = .811; HU value: 307.7 ± 160.1 HU vs. 257.2 ± 120.0 HU, P = .139). Bland–Altman plots showed only minimal difference and high agreement when comparing CBCT to MDCT.

Conclusions

CBCT has a similar capability, intraprocedurally, to assess lipiodol deposition in three dimensions for patients with HCC treated with cTACE when compared to MDCT.

Hepatocellular carcinoma (HCC) is the sixth most prevalent cancer worldwide and the third most common cancer leading to death. However, only a minority of all patients with HCC are surgical candidates at the time of diagnosis . Transcatheter arterial chemoembolization (TACE) is one of the most commonly used intra-arterial therapies to treat unresectable HCC, and several clinical trials have demonstrated that TACE has the potential to show survival benefits in patients with HCC . Conventional TACE (cTACE) is a frequently used technique and usually includes intra-arterial delivery of emulsions mixed with chemotherapeutic agents and lipiodol, followed by the administration of the embolic agent. It has been demonstrated that the degree of intratumoral lipiodol deposition correlates well with tumor necrosis, tumor recurrence, and survival rate after TACE . Fluoroscopic imaging is widely used to assess the lipiodol accumulation during and immediately after TACE. However, this modality has several limitations for the assessment of lipiodol retention because it cannot provide volumetric information, as does cross-sectional imaging. An alternative method for the evaluation of lipiodol accumulation is unenhanced multidetector computed tomography (MDCT) imaging. MDCT can be more accurate to assess lipiodol accumulation in HCC when compared to fluoroscopy imaging and is routinely used to evaluate the lipiodol deposition within 1 week after TACE.

The advent and development of cone-beam computed tomography (CBCT) technology provide interventional radiologists with an intraprocedural method to volumetrically assess lipiodol retention. CBCT offers soft tissue cross-sectional imaging using a flat-panel detector. It provides volumetric information about tumor location, number, and vascularity and can be used for real-time image guidance as well as to predict tumor response . Compared to MDCT, CBCT has several unique advantages, such as a lower dose of x-ray exposure and convenience for immediately assessing lipiodol accumulation after TACE . Iwazawa et al recently showed CBCT is nearly equivalent to MDCT to detect incomplete lipiodol accumulation using a semiquantitative visual grading score. However, several drawbacks existed in this study. For example, the parameters were semiquantitative, and diffuse lipiodol retention in the tumor was not taken into account. In addition, MDCT was performed 1 week after the procedure. Furthermore, recent work has been done by Chen et al to better quantify the lipiodol retention, but the study was bidimensional (2D) . To address these limitations, we build on both works using a quantitative and volumetric three-dimensional (3D) semiautomatic software. This software can more clearly visualize the degree of lipiodol deposition within the targeted lesion using color-coding and can automatically calculate three-dimensionally, both the volume of the tumor and the volume of the lipiodol deposition, even for diffuse retention in CBCT and MDCT. The purpose of this study is to quantify the capability of CBCT acquired immediately after cTACE to assess lipiodol retention in three dimensions for patients with HCC when compared to unenhanced MDCT.

Materials and methods

Patient Selection

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Transcatheter Arterial Chemoembolization

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CBCT Imaging

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MDCT Imaging

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Semiautomatic Segmentation of Tumor and Lipiodol Retention

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Figure 1, Three-dimensional semiautomatic evaluation of complete lipiodol retention in HCC on a representative case. Segmentation of the tumor ( red circle ) on CBCT at corresponding slice level as MDCT (a, b) . Three-dimensional segmentation volume rendering on the same slice (c, d) . Quantitative lipiodol color map of CBCT and MDCT (e, f) . The box represents the location of the background ROI. The tumor volumes on CBCT and on MDCT were 4.69 cm 3 and 3.97 cm 3 , respectively. The volumes of lipiodol on CBCT and on MDCT were 4.66 cm 3 and 3.97 cm 3 , respectively. CBCT, cone-beam computed tomography; HCC, hepatocellular carcinoma; MDCT, multidetector computed tomography; ROI, region of interest.

Figure 2, Three-dimensional semiautomatic evaluation of diffuse lipiodol retention in HCC on a representative case. Segmentation of the tumor ( red circle ) on CBCT at corresponding slice level as MDCT (a, b) . Three-dimensional segmentation volume rendering on the same slice (c, d) . Quantitative lipiodol color map of CBCT and MDCT (e, f) . The box represents the location of the background ROI. The tumor volumes on CBCT and on MDCT were 50.89 cm 3 and 50.78 cm 3 , respectively. The volumes of lipiodol on CBCT and on MDCT were 42.87 cm 3 and 45.30 cm 3 , respectively. CBCT, cone-beam computed tomography; HCC, hepatocellular carcinoma; MDCT, multidetector computed tomography; ROI, region of interest.

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Automatic Measurement of Complete, Localized, and Diffuse Lipiodol Retention

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Statistics

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Results

Patient Demographics

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Lipiodol Conspicuity in the Tumor

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Tumor and Lipiodol Volume on CBCT and MDCT

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Table 1

Tumor and Lipiodol Volume and Percentage of Lipiodol to Tumor as Measured on Cone-beam Computed Tomography (CBCT) and Multidetector Computed Tomography (MDCT)

CBCT MDCT_P_ Value Tumor volume (cm 3 ) 9.37 ± 11.35 9.34 ± 11.44 .991 Lipiodol volume (cm 3 ) 7.84 ± 9.34 7.84 ± 9.60 .998 Percentage of lipiodol retention 89.3% ± 14.7% 90.2% ± 14.9% .811

Data were expressed as mean ± SD.

Figure 3, Bland–Altman plots comparing tumor volume, lipiodol retention between CBCT and MDCT. These plots graphically show the agreement between the two measurement methods. The heavy line is the mean difference and the dashed line is ±2 standard deviations. As shown by the plots, different modalities show excellent agreement, and the low variability. CBCT, cone-beam computed tomography; MDCT, multidetector computed tomography.

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Discussion

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Conclusion

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Academic Radiology, Volume 21, Issue 3
Journals General Radiology
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