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Imaging and Imaging-Guided Interventions in the Diagnosis and Management of Hepatocellular Carcinoma (HCC)-Review of Evidence.

Ghanaati H, Alavian SM, Jafarian A, Ebrahimi Daryani N, Nassiri-Toosi M, Jalali AH, Shakiba M - Iran J Radiol (2012)

Bottom Line: A variety of imaging modalities, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine are currently used in evaluating patients with HCC.Although the best option for the treatment of these cases is hepatic resection or transplantation, only 20% of HCCs are surgically treatable.In those patients who are not eligible for surgical treatment, interventional therapies such as transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radio-frequency ablation (RFA), percutaneous microwave coagulation therapy (PMC), laser ablation or cryoablation, and acetic acid injection are indicated.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran ; Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran.

ABSTRACT
The imaging of hepatocellular carcinoma (HCC) is challenging and plays a crucial role in the diagnosis and staging of the disease. A variety of imaging modalities, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine are currently used in evaluating patients with HCC. Although the best option for the treatment of these cases is hepatic resection or transplantation, only 20% of HCCs are surgically treatable. In those patients who are not eligible for surgical treatment, interventional therapies such as transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radio-frequency ablation (RFA), percutaneous microwave coagulation therapy (PMC), laser ablation or cryoablation, and acetic acid injection are indicated. In this paper, we aimed to review the evidence regarding imaging modalities and therapeutic interventions of HCC.

No MeSH data available.


Related in: MedlinePlus

A, Neovascularity and hypervascular lesions in segments 7 and 8 of the liver; B, Complete obliteration of vascular structures within the tumor is seen. Lipiodol droplets are also visualized in the texture of the tumor.
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fig755: A, Neovascularity and hypervascular lesions in segments 7 and 8 of the liver; B, Complete obliteration of vascular structures within the tumor is seen. Lipiodol droplets are also visualized in the texture of the tumor.

Mentions: First of all, for selection of the best vessel branches for TACE, a diagnostic angiography of the celiac trunk and superior mesenteric artery with late-phase imaging of the portal venous system will be done. This is performed via insertion of a 4F introducer sheath in the right common femoral artery (72, 74) for determining the arterial supply to the tumor, detecting possible variations in the hepatic arterial system, identifying the arteries that should be avoided during treatment and determining the patency of the portal vein or the presence of hepatopetal flow through collaterals to the liver in case of portal vein tumor thrombosis. Selective or super selective catheterization with the use of a large-hole microcatheter is preferred. Using a 4F hydrophilic cobra catheter with a hydrophilic guide-wire is enough in about half the cases. The catheter should not be less than twice the diameter of the vessel. In small vessels, the only route for access is using microcatheters designed for TACE. Coil-embolization of all distal ends of non-hepatic artery branches distal to the microcatheter tip is recommended. An arteriogram before injecting any chemotherapic agent is recommended. Complete blockage of the tumor-feeding branches is the goal of procedure, thus it is essential to check for extrahepatic collateral arteries feeding the HCC. An exophytic tumor growth or subcapsular location or peripheral iodized oil retention defect within the tumor or a peripherally located portion of viable tumor on a follow-up CT scan are in favor of external collateral artery (ExCA) feeding the tumor (Figure 5).There are some controversies about how selectively the catheter tip should be placed (lobar or segmental) during TACE (76). Some authors believe that the selective TACE is better than non-selective therapy as the selective method maximizes the drug impact on the tumor and concurrently lowers the damage to normal liver tissues. Thus, they recommend advancement of the catheter tip to the tumor as close as possible in the feeding artery (segmental or subsegmental)(77, 78).The chemoembolization agent is prepared as an emulsion that consists of up to 20 mL of lipiodol and 10-50 mg of doxorubicin hydrochloride; the dose is adjusted according to the size, extent and vascularity of the tumor (78).The right and left hepatic arteries should still be patent at the end of injection, while the flow in the second and third-order branches should be reduced and tumor blush should not be seen. After catheter removal, a plain abdominal film or cone beam CT of the hepatic region is performed to assess the focal uptake of lipiodol into the HCC nodules. Two to four TACE sessions are required depending on the arterial anatomy to treat the entire liver (the second procedure should be performed after 3-4 weeks) The response will be evaluated by repeated imaging studies and tumor markers (51, 67). The sequential TACE is safe in many patients and could increase the survival of the patients (79). In addition to routine agents, a new microsphere that can serve as a drug eluting agent has been introduced in the recent years. It is named DC-Beads and it could provide a precisely controlled and sustained release of chemotherapeutic drugs. It seems that the type of embolic agent does not influence the overall survival (72, 73, 80).


Imaging and Imaging-Guided Interventions in the Diagnosis and Management of Hepatocellular Carcinoma (HCC)-Review of Evidence.

Ghanaati H, Alavian SM, Jafarian A, Ebrahimi Daryani N, Nassiri-Toosi M, Jalali AH, Shakiba M - Iran J Radiol (2012)

A, Neovascularity and hypervascular lesions in segments 7 and 8 of the liver; B, Complete obliteration of vascular structures within the tumor is seen. Lipiodol droplets are also visualized in the texture of the tumor.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3569547&req=5

fig755: A, Neovascularity and hypervascular lesions in segments 7 and 8 of the liver; B, Complete obliteration of vascular structures within the tumor is seen. Lipiodol droplets are also visualized in the texture of the tumor.
Mentions: First of all, for selection of the best vessel branches for TACE, a diagnostic angiography of the celiac trunk and superior mesenteric artery with late-phase imaging of the portal venous system will be done. This is performed via insertion of a 4F introducer sheath in the right common femoral artery (72, 74) for determining the arterial supply to the tumor, detecting possible variations in the hepatic arterial system, identifying the arteries that should be avoided during treatment and determining the patency of the portal vein or the presence of hepatopetal flow through collaterals to the liver in case of portal vein tumor thrombosis. Selective or super selective catheterization with the use of a large-hole microcatheter is preferred. Using a 4F hydrophilic cobra catheter with a hydrophilic guide-wire is enough in about half the cases. The catheter should not be less than twice the diameter of the vessel. In small vessels, the only route for access is using microcatheters designed for TACE. Coil-embolization of all distal ends of non-hepatic artery branches distal to the microcatheter tip is recommended. An arteriogram before injecting any chemotherapic agent is recommended. Complete blockage of the tumor-feeding branches is the goal of procedure, thus it is essential to check for extrahepatic collateral arteries feeding the HCC. An exophytic tumor growth or subcapsular location or peripheral iodized oil retention defect within the tumor or a peripherally located portion of viable tumor on a follow-up CT scan are in favor of external collateral artery (ExCA) feeding the tumor (Figure 5).There are some controversies about how selectively the catheter tip should be placed (lobar or segmental) during TACE (76). Some authors believe that the selective TACE is better than non-selective therapy as the selective method maximizes the drug impact on the tumor and concurrently lowers the damage to normal liver tissues. Thus, they recommend advancement of the catheter tip to the tumor as close as possible in the feeding artery (segmental or subsegmental)(77, 78).The chemoembolization agent is prepared as an emulsion that consists of up to 20 mL of lipiodol and 10-50 mg of doxorubicin hydrochloride; the dose is adjusted according to the size, extent and vascularity of the tumor (78).The right and left hepatic arteries should still be patent at the end of injection, while the flow in the second and third-order branches should be reduced and tumor blush should not be seen. After catheter removal, a plain abdominal film or cone beam CT of the hepatic region is performed to assess the focal uptake of lipiodol into the HCC nodules. Two to four TACE sessions are required depending on the arterial anatomy to treat the entire liver (the second procedure should be performed after 3-4 weeks) The response will be evaluated by repeated imaging studies and tumor markers (51, 67). The sequential TACE is safe in many patients and could increase the survival of the patients (79). In addition to routine agents, a new microsphere that can serve as a drug eluting agent has been introduced in the recent years. It is named DC-Beads and it could provide a precisely controlled and sustained release of chemotherapeutic drugs. It seems that the type of embolic agent does not influence the overall survival (72, 73, 80).

Bottom Line: A variety of imaging modalities, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine are currently used in evaluating patients with HCC.Although the best option for the treatment of these cases is hepatic resection or transplantation, only 20% of HCCs are surgically treatable.In those patients who are not eligible for surgical treatment, interventional therapies such as transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radio-frequency ablation (RFA), percutaneous microwave coagulation therapy (PMC), laser ablation or cryoablation, and acetic acid injection are indicated.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran ; Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran.

ABSTRACT
The imaging of hepatocellular carcinoma (HCC) is challenging and plays a crucial role in the diagnosis and staging of the disease. A variety of imaging modalities, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine are currently used in evaluating patients with HCC. Although the best option for the treatment of these cases is hepatic resection or transplantation, only 20% of HCCs are surgically treatable. In those patients who are not eligible for surgical treatment, interventional therapies such as transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radio-frequency ablation (RFA), percutaneous microwave coagulation therapy (PMC), laser ablation or cryoablation, and acetic acid injection are indicated. In this paper, we aimed to review the evidence regarding imaging modalities and therapeutic interventions of HCC.

No MeSH data available.


Related in: MedlinePlus