Hypervascular Hepatocellular Carcinoma Research Articles

Helical CT during arterial portography and hepatic arteriography for detecting hypervascular hepatocellular carcinoma.

We assessed whether helical CT hepatic arteriography (CTHA) improves detection of hypervascular hepatocellular carcinoma (HCC) when used in conjunction with helical CT obtained during arterial portography (CTAP). One hundred two patients with 254 hypervascular HCC nodules underwent both CTHA and CTAP. CTHA and CTAP were separately interpreted for detection of hypervascular HCC nodules by three observers who were unaware of tumor burden in the liver, lodized oil CT performed 1 week and 1 month after transcatheter arterial chemoembolization with iodized oil was the gold standard. Sensitivity and positive predictive value for CTHA alone, CTAP alone, and CTAP and CTHA combined were calculated and compared using the McNemar test. We found no significant difference between the sensitivity of CTAP (85%) and CTHA (87%) for revealing hypervascular HCC nodules. The combination of CTAP and CTHA showed significantly higher sensitivity than either CTAP or CTHA alone for revealing HCC nodules smaller than 20 mm in diameter (p < .01). The combination of CTHA and CTAP is recommended to improve the detection sensitivity of small hypervascular HCC nodules.

Lipiodol-CT for hepatocellular carcinoma

Lencioni et al. have nicely presented a positive predictive value of Lipiodol CT for intrahepatic metastasis of hepatocellular carcinoma (HCC) based on 32 consecutive patients undergoing hepatectomy [1]. Lipiodol-CT has been generally regarded as a highly sensitive examination to detect intrahepatic metastases because these mostly occur in hypervascular HCC (advanced or classic HCC, histopathologically moderately or poorly differentiated) and have a similarly hypervascular character. However, there has been no direct confirmation of high sensitivity and specificity by this method. Theoretically and clinicopathologically, Lipiodol is distributed in loci according to their vascularity. Long-term deposits are noted in the necrotic area of the tumor and liver parenchyma, especially after embolization [2]. Thus, any hypervascular nodular lesion such as small cavernous hemangioma and focal nodular hyperplasia and nontumorous area such as focal inflammation and arterioportal shunt could be false-positive cases of intrahepatic metastasis, although the durations of deposit are different case by case [2]. Such cases have been sporadically reported [3, 4]. Lencioni et al. have defined a positive finding of intrahepatic metastasis at Lipiodol-CT as a small, rounded, well-delineated retention less than 2 em in diameter but have not described any pathologic definition or finding. In general, intrahepatic metastases are present in cases with HCC associated with portal tumor thrombus, multiple in number, small in size, and located adjacent to the main tumor [5]. However, intrahepatic metastasis is not a self-evident lesion, especially in patients at high risk for HCC who often have multicentricoccurring tumors of different or same subtype. Even when using DNA analysis, pathologists cannot necessarily confirm whether or not a particular lesion is an intrahepatic metastasis [5, 6].

Treatment of nodular hepatocellular carcinoma larger than 3 cm with ultrasound-guided percutaneous acetic acid injection

To assess the efficacy of ultrasound-guided percutaneous acetic acid (15%, 20%, 30%, 40%, and 50% in concentration) injection for a large nodular hepatocellular carcinoma (HCC), percutaneous acetic acid injection was performed using 15% to 50% acetic acid in 28 patients who had one single nodular HCC larger than 3 cm or one main tumor with fewer than two HCCs smaller than 3 cm during the past 7.5 years; the main tumor was slightly hypervascular in nine patients and was highly hypervascular, showing viable cancer cells despite transcatheter arterial embolization in 19 patients. During the series of treatment sessions for each patient, the same concentration of acetic acid was used. Eight (89%) of nine slightly hypervascular main tumors, 18 (95%) of 19 highly hypervascular main tumors, and all 14 small tumors were treated successfully. No serious complications occurred as a direct sequela to acetic acid injection. The 1-, 2- and 3-year recurrence rate from the original main tumor was 0%, 20%, and 20%, respectively, in patients treated with percutaneous acetic acid injection alone and 12%, 24%, and 24% in patients treated with percutaneous acetic acid injection after transcatheter arterial embolization (P = NS). The 1-, 2- , 3-, 4-, and 5-year survival rates were 100%, 80%, 80%, 80%, and 0%, respectively, in the former and 90%, 81%, 81%, 61%, and 61% in the latter (P = NS). Percutaneous acetic acid injection (15% to 50%) may be an effective therapy for slightly hypervascular nodular HCCs larger than 3 cm and highly hypervascular nodular HCCs larger than 3 cm that remain partly viable after transcatheter arterial embolization. (Hepatology 1996 Dec;24(6):1379-85)

Treatment of Nodular Hepatocellular Carcinoma Larger Than 3 Cm With Ultrasound–Guided Percutaneous Acetic Acid Injection

To assess the efficacy of ultrasound–guided percutaneous acetic acid (15%, 20%, 30%, 40%, and 50% in concentration) injection for a large nodular hepatocellular carcinoma (HCC), percutaneous acetic acid injection was performed using 15% to 50% acetic acid in 28 patients who had one single nodular HCC larger than 3 cm or one main tumor with fewer than two HCCs smaller than 3 cm during the past 7.5 years; the main tumor was slightly hypervascular in nine patients and was highly hypervascular, showing viable cancer cells despite transcatheter arterial embolization in 19 patients. During the series of treatment sessions for each patient, the same concentration of acetic acid was used. Eight (89%) of nine slightly hypervascular main tumors, 18 (95%) of 19 highly hypervascular main tumors, and all 14 small tumors were treated successfully. No serious complications occurred as a direct sequela to acetic acid injection. The 1–, 2– and 3–year recurrence rate from the original main tumor was 0%, 20%, and 20%, respectively, in patients treated with percutaneous acetic acid injection alone and 12%, 24%, and 24% in patients treated with percutaneous acetic acid injection after transcatheter arterial embolization ( P = NS). The 1–, 2–, 3–, 4–, and 5–year survival rates were 100%, 80%, 80%, 80%, and 0%, respectively, in the former and 90%, 81%, 81%, 61%, and 61% in the latter ( P = NS). Percutaneous acetic acid injection (15% to 50%) may be an effective therapy for slightly hypervascular nodular HCCs larger than 3 cm and highly hypervascular nodular HCCs larger than 3 cm that remain partly viable after transcatheter arterial embolization.

Detection of hypervascular hepatocellular carcinoma by dynamic MRI and dynamic spiral CT.

Our goal was to evaluate the detectability of hypervascular hepatocellular carcinomas (HCCs) by multislice dynamic MRI and dynamic spiral CT. Prior to transcatheter arterial chemoembolization (TACE) with iodized oil, the liver was subjected to T1- and T2-weighted SE-MRI, multislice dynamic MRI after intravenous bolus injection of Gd-DTPA, early phase imaging with spiral CT (dynamic spiral CT) after intravenous bolus injection of contrast medium (at a rate of 2 or 3 ml/s), and delayed phase CT in 64 patients with 208 HCC nodules. The detectability of HCCs by MRI and CT was evaluated retrospectively compared with CT after TACE as a gold standard. The detectability of nodules < 1 cm in diameter was superior with dynamic MRI (67%) and dynamic spiral CT (50%) in comparison with SE-MRI (26%) and delayed phase CT (11%) (p < 0.01). The detectability of these tumors with dynamic MRI was significantly superior to that with dynamic spiral CT using an injection rate of 2 ml/s (p < 0.01), but not significantly different from that of dynamic spiral CT using a rate of 3 ml/s. Dynamic MRI and dynamic spiral CT are comparable for detecting hypervascular intrahepatic metastases of HCC.

Detectability of Hypervascular Hepatocellular Carcinoma by Arterial Phase Images of MR and Spiral CT

The ability of arterial phase images of breath-hold MR imaging and spiral CT to detect hypervascular hepatocellular carcinomas (HCCs) was evaluated. Prior to transcatheter arterial chemoembolization (TACE) with iodized oil, MR images and spiral CT during i.v. bolus injection of contrast medium (IV-MR imaging and IV-spiral CT) and spiral CT during intraarterial injection of contrast media through catheter (IA-spiral CT) of the entire liver were obtained in 24 consecutive patients with 93 HCCs. In the detection of HCCs less than 1 cm in diameter, IA-spiral CT (87.3%) was superior to IV-MR imaging (63.5%) and IV-spiral CT (54.0%) (p&lt;0.001). There was no significant difference in detectability in any tumor size between IV-MR imaging and IV-spiral CT. IA-spiral CT was the best for detecting hypervascular HCCs, and there was no significant difference between IV-MR imaging and IV-spiral CT.

Detectability of Hypervascular Hepatocellular Carcinoma by Arterial Phase Images of MR and Spiral CT

Detectability of Hypervascular Hepatocellular Carcinoma by Arterial Phase Images of MR and Spiral CT

Detectability of Hypervascular Hepatocellular Carcinoma by Arterial Phase Images of MR and Spiral CT

The ability of arterial phase images of breath-hold MR imaging and spiral CT to detect hypervascular hepatocellular carcinomas (HCCs) was evaluated. Prior to transcatheter arterial chemoembolization (TACE) with iodized oil, MR images and spiral CT during i.v. bolus injection of contrast medium (IV-MR imaging and IV-spiral CT) and spiral CT during intraarterial injection of contrast media through catheter (IA-spiral CT) of the entire liver were obtained in 24 consecutive patients with 93 HCCs. In the detection of HCCs less than 1 cm in diameter, IA-spiral CT (87.3%) was superior to IV-MR imaging (63.5%) and IV-spiral CT (54.0%) (p < 0.001). There was no significant difference in detectability in any tumor size between IV-MR imaging and IV-spiral CT. IA-spiral CT was the best for detecting hypervascular HCCs, and there was no significant difference between IV-MR imaging and IV-spiral CT.

Color Doppler sonography of hepatic tumors with a galactose-based contrast agent: correlation with angiographic findings.

The purpose of this study was to evaluate the clinical usefulness of a galactose-based, IV sonographic contrast agent for assessing tumor vascularity and diagnosing hepatocellular carcinoma. We used color Doppler sonography with the sonographic contrast agent to examine 22 patients with 26 hepatic nodules (18 hepatocellular carcinomas, four hemangiomas, two adenomatous hyperplasias, and two metastatic tumors). In all 26 lesions, intratumoral arterial flow signals were examined before and after IV injection of the sonographic contrast agent at three concentrations (200, 300, and 400 mg/ml), and the findings on color Doppler sonograms of each lesion were correlated with angiographic findings. Conventional color Doppler sonograms showed flow in nine hepatocellular carcinomas (50%) and one hemangioma (25%). When the contrast agent was used, color Doppler sonograms showed intratumoral arterial flow in 11 hepatocellular carcinomas (61%) and one hemangioma (25%) at a concentration of 200 mg/ml, in 14 hepatocellular carcinomas (78%) and 1 hemangioma (25%) at 300 mg/ml, and in 15 hepatocellular carcinomas (83%) and two hemangiomas (50%) at 400 mg/ml. The detectability of intratumoral arterial flow was improved by the contrast agent, especially in hepatocellular carcinomas smaller than 30 mm in diameter. Angiography revealed neovascularization or staining in 15 hepatocellular carcinomas, four hemangiomas, and none of the adenomatous hyperplasias or metastatic tumors. Among 15 angiographically hypervascular hepatocellular carcinomas, the detection rate of intratumoral arterial flow with contrast-enhanced color Doppler sonography was 73% at 200 mg/ml, 93% at 300 mg/ml, and 100% at 400 mg/ml. No intratumoral Doppler signals were depicted with the use of contrast agent in any angiographically undetected tumors. Preliminary findings on contrast-enhanced color Doppler sonograms correlate well with angiographic findings for evaluating tumor vascularity. This noninvasive technique may be useful in diagnosing hypervascular hepatocellular carcinomas.

Comparison between conventional and spiral CT in patients with hypervascular hepatocellular carcinoma

To determine the usefulness of spiral CT in the detection of hypervascular hepatic lesions, we compared conventional contrast enhanced CT (CECT) with whole liver dynamic scanning during the artery-dominant phase by spiral CT (SDCT), using hypervascular hepatocellular carcinoma (HCC) as a model. Twenty-nine patients with 56 hypervascular nodular type HCCs detected by hepatic digital subtraction angiography were examined by both CT techniques. These nodular type HCCs were divided into three groups according to diameter: <10 mm ( n = 7), 10–20 mm ( n = 17), and over 20 mm ( n = 32). None of seven lesions less than 10 mm in diameter was seen by either technique. Of 17 lesions 10–20 mm in diameter, four (24%) were detected by precontrast CT plus CECT, whereas 14 (82%) were detected by precontrast CT plus SDCT. There were no lesions detected by CECT only, whereas 10 lesions were detected by SDCT only ( P < 0.01 by signed test). For 32 lesions over 20 mm in diameter, there was no significant difference in detection rates between the CT techniques. Our results indicate that spiral CT is useful for the detection of relatively small hypervascular hepatic lesions such as hypervascular HCCs.

Chemoembolization for Hepatocellular Carcinoma via the Inferior Pancreaticoduodenal Artery in Patients with Celiac Artery Stenosis

Twenty-one patients with hepatocellular carcinoma (HCC) accompanied by extensive celiac artery stenosis or obstruction were treated by chemoembolization via the inferior pancreaticoduodenal artery (IPDA). The tip of the catheter was placed in the arteries in front of the confluence with the proper hepatic artery in 12 patients (group A: the proximal portion of the IPDA in 10, and common hepatic artery in 2), and in the proper hepatic artery or branches of it (group B) in 9 using a coaxial catheter system. Transient hyperamylasemia was observed in 10 of the 12 patients in group A and in 3 of the 9 patients in group B after chemoembolization. Splenic infarction developed in 8 patients in group A and in none in group B. Intrapancreatic fluid collection was present in 2 patients in group A following chemoembolization. No fatal complications were encountered. The 1-, 2-, and 3-year survival rates of the 10 patients in group A treated by only chemoembolization were 90, 57, and 23%, respectively (mean survival 780 days). The 1- and 2-year survival rates of 9 patients in group B were 85.8 and 85.8% (mean 879 days), respectively. Considering the severity of complications and the survival rates in groups A and B, chemoembolization by superselective catheterization into the hepatic artery via the IPDA is the treatment of choice. However, chemoembolization from the arteries in front of the confluence with the proper hepatic artery seems to be acceptable in cases of hypervascular HCC which fail to be superselectively catheterized.

Lipiodol-Cisplatin embolisation in hepatocellular carcinoma. Radiological techinique and evaluation

In a 1-year period, 14 patients with inoperable, biopsy-proven hepatocellular cacinoma (HCC) underwent 18 superselective catheterisations of the proper hepatic artery with combined injection of Cisplatin and Liodol. According to Okuda et al. [1], patients were classified into clinical Stages I (2), II (7) and III (5). All 5 Stage III patients died during follow-up. Distal superselective catheterisation of the proper hepatic artery, in order to avoid Lipiodol embolism to the gastroduodenal, gastric or other anastomotic arteries was possible with conventional diagnostic catheters use and inexpensive coaxial (5 cases) or, an easry-to-use an inexpensive coaxial catheterisation system (13 cases). Radiological follow-up was by means of computed tomography (CT) 24 h and 6 weeks after chemoembolisation. Further CT studies were performed depending on the patient's progress. Twelve patients had CT follow-up over at least 6 weeks. Hypervascular hepatocellular carcinomas tend to diminish in volume, especially those which retain Lipiodol after 6 weeks, and survival after intra-arterial chemotheraphy is shorter in patients with hypovascular tumours which do not retain Lipiodol. We have treated only a limited number of patients, but consider chemoembolisation okf inoperable HCC with Lipiodol and Cisplatin as useful treatment for Okuda Stage 1 and II patients, but not for those in Stage III. Hypervascularity and Lipiodol retention on follow-up CT could indicate a favourable prognosis.

Radioiodinated fatty acid esters in the management of hepatocellular carcinoma: preliminary findings

Radioiodinated fatty acid esters, such as lipiodol or ethiodol, are localized in the hypervascular hepatocellular carcinoma (HCC) for a long time following intra-arterial hepatic injection, enabling delivery of high internal radiation to the tumor. The desired radiation can easily be delivered to small HCC, less than 5 cm in diameter, in single or multiple procedures with an 8-week interval. For larger tumors, [131I]lipiodol or [131I]ethiodol in conjunction with chemotherapy emulsion, Ivalon embolization or all three combinations should be considered for maximal clinical results. A strong beta emitter with shorter physical half-life, i.e. 90Y will be more effective in the management of HCC if one can label lipiodol with 90Y.

Work in progress: dynamic sequential computed tomography during arterial portography in the detection of hepatic neoplasms.

Dynamic sequential computed tomography with table incrementation during arterial portography (DSCTI-AP) of the entire liver was performed in an attempt to improve the detection of hepatic neoplasms. In 13 of 17 patients, DSCTI-AP detected more hepatic lesions than were detected by other imaging methods, including radionuclide liver scans, ultrasound, computed tomography, and hepatic angiography. In only one case, an extremely hypervascular hepatocellular carcinoma, hepatic angiography was superior to DSCTI-AP. DSCTI-AP is a simple technique that may be carried out as a part of hepatic angiography. We believe that DSCTI-AP is a sensitive and useful method for the accurate detection of hepatic neoplasms.