Identifying Feeding Arteries During TACE of Hepatic Tumors: Comparison of C-Arm CT and Digital Subtraction Angiography

Department of Radiology, Nissay Hospital, 6-3-8 Itachibori, Nishiku, Osaka 550-0012, Japan.
American Journal of Roentgenology (Impact Factor: 2.73). 05/2009; 192(4):1057-63. DOI: 10.2214/AJR.08.1285
Source: PubMed


This study compares the diagnostic accuracy of C-arm CT with digital subtraction angiography (DSA) in identifying tumor-feeding arteries during superselective transarterial chemoembolization (TACE).
Thirty-three consecutive patients with hepatocellular carcinoma (HCC) underwent superselective TACE using a flat-detector angiographic system. Angiographic operators determined which feeding arteries were potentially supplying the target tumor. When two or more feeding arteries were possible, all were included. Superselective DSA and C-arm CT were sequentially performed for each studied artery. Four independent observers separately viewed the DSA and C-arm CT images and used a 5-point grading scale to determine whether a studied artery supplied the target tumor. Diagnostic performance was compared using receiver operating characteristic (ROC) analysis. Sensitivity, specificity, and accuracy were calculated for arteries rated as definite or probable tumor feeders. Iodized oil accumulation on follow-up CT was the reference standard.
We examined 58 possible feeding arteries in 33 patients. Among the studied arteries, follow-up CT confirmed that 33 were verified tumor-feeding arteries, and the remaining 25 were not. C-arm CT resulted in a significantly larger area under the ROC curve (A(z) = 0.995) compared with DSA (A(z) = 0.841). The sensitivity, specificity, and accuracy of C-arm CT (96.9%, 97.0%, and 96.9%, respectively) were significantly higher than those for DSA (77.2%, 73.0%, and 75.4%).
C-arm CT is superior to DSA for identifying tumor-feeding arteries during superselective TACE for HCC.

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    • "DSA is a micro-invasive procedure that is usually utilized to diagnose and treat HCC. Although a false negative for HCC by DSA is a possibility, DSA can differentiate a hepatic pseudolesion caused by vascular malformation from a malignant lesion [20]. Unfortunately, in the case presented here there was focal nodular hyperplasia and only mild vascular malformation; thus, none of the typical signs of vascular malformation were found by DSA. "
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    ABSTRACT: Hepatic pseudolesions detected by helical computed tomography (CT) are not rare, but it is difficult to make a final diagnosis when the hepatic lesion is complicated by the presence of greatly elevated alpha fetoprotein (AFP). Clinical treatment of non-typical hepatic pseudolesions complicated by greatly elevated AFP should confirm the diagnosis and minimize trauma. Non-invasive procedures including ultrasonography, CT, and micro-invasive digital subtraction angiography could not safely differentiate this lesion from a malignant focus when it was complicated by greatly elevated AFP. Laparoscopic hepatectomy was performed, and pathological analysis showed chronic hepatitis, nodular regenerative hyperplasia, focal nodular hyperplasia of the liver, and mild vascular malformation. The tissue was HbsAg(-) , HbcAg(-), and AFP(+). Heightened awareness of hepatic pseudolesion complicated by primarily elevated AFP will help physicians avoid unnecessary invasive procedures. Hepatic biopsy is inevitable because of greatly elevated AFP. For suspected hepatic pseudolesion with elevated AFP, needle-core biopsy and follow-up surveillance instead of hepatectomy are recommended to find the source of AFP and make a final diagnosis of pseudolesion.
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    • "Similarly, Iwazawa et al. reported that the sensitivity of 3D to determine FVs was significantly higher than that of 2D imaging (96.9% vs. 77.2%, P < 0.01) [8]. In our study, it is noteworthy that this superiority was found by the three IRs who reviewed the cases, but the difference was significant only for the two IRs who had more brief career experience (Table 1). "
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    ABSTRACT: The purpose of this study was to evaluate computed analysis of three-dimensional (3D) cone-beam computed tomography angiography (CTA) of the liver for determination of subsegmental tumor-feeding vessels (FVs). Eighteen consecutive patients underwent transarterial chemoembolization (TACE) from January to October 2008 for 25 liver tumors (15 hepatocellular carcinomas [HCCs] and 10 neuroendocrine metastases). Anteroposterior projection angiogram (two-dimensional [2D]) and 3D cone-beam CTA images were acquired by injection of the common hepatic artery. Retrospectively, FVs were independently identified by three radiology technologists using a software package (S) that automatically determines FVs by analysis of 3D images. Subsequently, three interventional radiologists (IRs) independently identified FVs by reviewing the 2D images followed by examination of the 3D images. Finally, the "ground truth" for the number and location of FVs was obtained by consensus among the IRs, who were allowed to use any imaging-including 2D, 3D, and all oblique or selective angiograms-for such determination. Sensitivities, durations, and degrees of agreement for review of 2D, 3D, and S results were evaluated. Sensitivity of 3D (73%) was higher than 2D (64%) images for identification of FVs (P = 0.036). The sensitivity of S (93%) was higher than 2D (P = 0.02) and 3D (P = 0.005) imaging. The duration for review of 3D imaging was longer than that for 2D imaging (187 vs. 94 s, P = 0.0001) or for S (135 s, P = 0.0001). The degree of agreement between the IRs using 2D and 3D imaging were 54% and 62%, respectively, whereas it was 82% between the three radiology technologists using S. These preliminary data show that computed determination of FVs is both accurate and sensitive.
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