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

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Abstract

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.

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... In addition, the information from computed tomography (CT) images during arterial portography (CTAP) or hepatic arteriography (CTHA) is sometimes helpful to confirm the diagnosis of hepatic nodules that do not show typical imaging features of HCC. 1,2 In such a case, the use of hepatic angiography is necessary to obtain images. ...
... In addition, the information from CTAP or CTHA is often helpful to confirm the diagnosis of hepatic nodules that do not show typical imaging features of HCC. 1,2 The time from sheath placement to CT aortography was significantly longer in patients with radial access than those with femoral access. This is partly because with radial access, the pigtail catheter used in aortography passes through the bifurcation of the cerebral artery (left internal carotid artery and left vertebral artery) when it is inserted into the descending aorta, and the insertion should be performed slowly and very carefully. ...
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... The USG appearance was of large hyperechoic mass with poor margins and irregular shaped calcify deposits The CT appearance of hepatoblastoma and hepatocellular carcinoma are similar. Metastasis-Metastases occur 20 times more often than other malignancies in the non-cirrhotic liver [14] In this study metastatic disease comprised of 29 cases as compared to 10 of cases of primary malignancy, which was consistent with other studies in literature. Most of the primaries were from GIT (80%) in our study similar to incidence mentioned in literature according to which the most common source of hepatic metastases is gastro-intestinal tumours (65%) [15]. ...
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... This technique has been included in a number of other research studies either as an independent tool to detect targeted tumor(s) or in association with other CBCT techniques to add complementary diagnostic information about HCC imaging features and maximize intraprocedural tumor detection accuracy. CBCT-AP provides high detection sensitivity of small HCCs (,30 mm) when compared with CT during arterial portography (65,74,75). CT during arterial portography was described as the most sensitive modality to detect HCC in 1983 before the advent of diagnostic multiphasic multidetector CT and contrast-enhanced MR imaging. ...
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Cone-beam computed tomography (CBCT) is an imaging technique that provides computed tomographic (CT) images from a rotational scan acquired with a C-arm equipped with a flat panel detector. Utilizing CBCT images during interventional procedures bridges the gap between the world of diagnostic imaging (typically three-dimensional imaging but performed separately from the procedure) and that of interventional radiology (typically two dimensional imaging). CBCT is capable of providing more information than standard two-dimensional angiography in localizing and/or visualizing liver tumors (“seeing” the tumor) and targeting tumors though precise microcatheter placement in close proximity to the tumors (“reaching” the tumor). It can also be useful in evaluating treatment success at the time of procedure (“assessing” treatment success). CBCT technology is rapidly evolving along with the development of various contrast material injection protocols and multiphasic CBCT techniques. The purpose of this article is to provide a review of the principles of CBCT imaging, including purpose and clinical evidence of the different techniques, and to introduce a decision-making algorithm as a guide for the routine utilization of CBCT during transarterial chemoembolization of liver cancer.
... The clinical, radiologic, and pathologic features of HCC have been well-documented previously [10][11][12][13][14]. Recently, many investigators have described CT findings of HCC [15][16][17][18][19][20][21][22][23]. Only 1 publication describing a case of FLHC has appeared in the radiologic literature [9]. ...
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Three new cases of an unusual subtype of hepatocellular carcinoma (HCC) referred to as fibrolamellar hepatocarcinoma (FLHC) recently seen at our institution are described. This report focuses on the clinical, radiologic, and pathologic features of this rare subset of HCC. All three patients were under 30 years of age with no previous history of hepatitis or cirrhosis. Each had had subacute symptoms for 5 months to 1 year before medical attention was sought and/or diagnosis of FLHC was established. There was no reliable correlation with oral contraceptive use in the 2 female patients. Serum alpha-1-fetoprotein levels were normal with only mild elevation of liver enzymes. The CT features, although not specific, were suggestive of an aggressive tumor with amorphous calcification in 2 of the 3 cases. Angiographically all tumors were hypervascular without any evidence of arterioportal shunting or venous invasion of major vessels. The clinical and radiologic recognition of these tumors is important since the surgical resectibility rate and 2- and 5-year survival rates are higher than those applicable to conventional HCC.
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Hepatocellular carcinoma (HCC) is the fifth most prevalent malignancy worldwide. Despite advances in imaging techniques, early diagnosis and management remain very poor. The early diagnosis of HCC requires diagnostic and imaging technologies with high sensitivity and precise quantification ability and with no tissue penetration limit. Nanotechnology-based cancer imaging is a rapidly emerging research area with significant applications in the diagnosis and treatment of cancer, which we review here with application to HCC. Furthermore, we discuss the combination of functional nanotheranostics and magnetic resonance imaging (MRI) for targeted delivery of phytochemical therapeutics, chemotherapeutic drugs, RNAi-based therapeutics, and vaccinations. Finally, this review presents the importance of MRI biomarkers for monitoring HCC treatment response. The use of advanced nanotheranostics as MRI contrast agents for imaging, diagnosis and drug delivery may enhance HCC management and provide a new area of research in tumor imaging technology.
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Objective: The objective of our study was to assess the value of CT texture analysis for prediction of therapeutic response of hepatocellular carcinoma (HCC) to transcatheter arterial chemoembolization (TACE) with pretherapeutic dynamic CT. Materials and methods: We retrospectively analyzed 132 HCCs in 96 patients treated with TACE who underwent dynamic CT before initial TACE. Imaging findings and arterial enhancement ratios were analyzed. All HCCs were manually segmented, and their texture features were quantitatively extracted using in-house software. CT texture was quantified with 2D and 3D analysis. HCCs were classified as with and without complete response (CR) according to modified Response Evaluation Criteria in Solid Tumors. Predictive factors for CR were assessed with multivariate analysis. Radiologic responses were correlated with time to progression (TTP). Results: Of the 132 HCCs, CR was achieved in 75 (56.8%). Tumor size, subjective arterial tumor attenuation, and arterial enhancement ratios were significantly associated with CR. On 2D and 3D analysis, tumors with CR showed significantly lower homogeneity and higher mean attenuation, gray-level co-occurrence matrix (GLCM) moments, and CT number percentiles (p < 0.05). On multivariate analysis, higher subjective tumor attenuation (adjusted odds ratio [OR] = 23.35), arterial enhancement ratio (OR = 14.07), GLCM moments (OR = 6.57), smaller tumor size (OR = 17.26), and lower homogeneity (OR = 0.69) were significant predictors of CR compared with incomplete response (p < 0.05). Median survival value for TTP was significantly longer in tumors with CR (p < 0.001). Conclusion: Pretherapeutic dynamic CT texture analysis can be valuable to predict CR of HCC to TACE. Higher arterial enhancement and GLCM moments, lower homogeneity, and smaller tumor size are significant predictors of CR after TACE.
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Chapter
Computed tomography (CT) has always played a major role in liver imaging. Recent advances in magnetic resonance imaging (MRI) and ultrasound, such as three-dimensional high-resolution sequences, parallel imaging techniques, and new contrast agents, have also increased the popularity and utilization of these imaging methods (Bryant et al. 2004; Lee et al. 2000). Nevertheless, development of multidetector-row CT technology has helped CT continue to excel in its already established indications, i.e., detection and characterization of hepatic lesions, and to add new clinical indications, i.e., CT angiography for pre-procedural mapping and liver perfusion (Sahani et al., AJR 179(1):53–59, 2002; Sahani et al., Comput Assist Tomogr 28(4):478–484, 2004; Guiney et al., Radiology 229(2):401–407, 2003; Schroeder et al., Radiology 224(2):586–591, 2002). The rapid pace of development of this technology has challenged radiologists in terms of the cost of replacement of scanners, optimization of CT protocols for existing indications, and development of protocols for the new applications made possible by multidetector-row CT technology. This paper discusses the advantages of multidetector-row CT for liver imaging, suggests guidelines to improve image quality through optimization of scanning protocols and strategies for administration of contrast, and reviews the potential clinical applications.
Chapter
The image obtained by X-ray computed tomography (CT) is a computer-assisted reconstruction of averaged X-ray attenuation in the individual pixel of the matrix. Therefore, CT reflects essentially the same information as the conventional X-ray photograph. The advantage and characteristics of CT are seen in better contrast resolution in a true tomogram. With the conventional film-screen system, a normal organ and its neoplasm show a similar X-ray attenu-ation and cannot be distinguished without the aid of contrast material. CT is capable of distin-guishing a 0.5% difference in contrast expressed in Hounsfield units or numbers (which are set at 0 for water and —1000 for air), whereas the conventional film-screen system can barely distinguish ascites from the liver (about 6% contrast).
Chapter
Die Leber ist mit 1500–2000 g Gewicht die größte Drüse des menschlichen Körpers. Sie ist auf Grund ihrer weichen Konsistenz beim gesunden Menschen formbar. Daher wird die Gestalt der Leber durch die Konfiguration des Brustkorbs, der Wirbelsäule und der unmittelbaren Nachbarorgane mitbestimmt. So treten im Bereich der Facies visceralis gewisse oberflächliche Impressionen auf, die durch benachbarte Gebilde wie Kolon, Duodenum, Niere, Gallenblase, Magen bedingt sein können. Eine Organverformung kann aber durch bestimmte Lebensgewohnheiten (Kleidung — Schnürfurche) auftreten. Eine kräftige, bindegewebige Kapsel umschließt das Organ. Durch starke Druckeinwirkungen (z.B. Traumata) können Kapselzerreißungen hervorgerufen werden, die mit schweren, lebensbedrohlichen Blutungen einhergehen. Die Leber gleicht einer dreiseitigen Pyramide, deren Basis der Pars costalis des rechten Zwerchfells direkt anliegt und deren kraniale Fläche von der rechten Zwerchfellkuppel begrenzt wird. Der größte Teil der Leberoberfläche liegt ventral im Schutz des rechten Rippenbogens (Abb. 1).
Chapter
Computed tomography (CT) produces remarkably accurate cross-sectional images of the human body, which are based on small differences in the X-ray attenuation among the various body tissues. The anatomic location, shape and size, homogeneity, and attenuation characteristics of structures in the body are used by the radiologist to determine their identity in the CT images. Based on this information, the radiologist attempts to determine whether a sequence of CT images represents normal anatomy or whether a pathologic lesion is present. Contrast media are routinely given to the patient prior to and during CT scanning to increase the attenuation coefficients of at least some of the tissues and organs or of their lumens. This is done to render some pathologic lesions and some normal anatomic structures more readily detectable so as to help in their differential diagnosis. This chapter will review the nature of contrast enhancement (CE) and the various applications of both conventional and experimental contrast media (CM) to computed tomography.
Article
Objectives: We investigated the frequencies and factors associated with the presence of extra-hepatic feeding arteries (EHFAs) of hepatocellular carcinoma (HCC) using intra-arterial CT aortography images. Methods: A total of 173 patients with HCC who underwent transarterial chemoembolization (TACE) in our institution between January 2013 and March 2015 were enrolled. The types of EHFAs were evaluated by CT aortography images using an apparatus that combines multidetector-row computed tomography and angiography system. In addition, factors associated with the presence of EHFAs were determined. Results: EHFAs were present in 22 (12.7%) patients with HCC. EHFAs most frequently branched from the right inferior phrenic artery (n=19), while others branched from the right adrenal artery (n=2), right renal artery (n=2), right internal thoracic artery (n=2), branches of the superior mesenteric artery (n=1), and an unknown artery from the aorta (n=1). Factors significantly associated with the presence of EHFAs in multivariate analysis were tumor size≥30mm (odds ratio (OR), 5.233 [95% confidence interval (CI), 1.507-17.413]; p=0.009) and number of prior TACE treatments≥3 (OR, 6.847 [95% CI, 1.928-24.311]; p=0.003). Conclusions: EHFAs of HCC were assessed with CT aortography images. Repeat TACE treatments and large tumor size were risk factors for the presence of EHFAs.
Chapter
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Chapter
During the past five years there have been rapid advances in technology and in the development of contrast agents and other techniques used to enhance hepatic imaging capabilities. This chapter briefly summarizes some of these new techniques, including sonography, computed tomography, and magnetic resonance imaging. An overview of the strengths and the limitations of these various techniques, together with their specific applications, is presented.
Chapter
The performance of percutaneous biopsies of circumscribed lesions guided by imaging represents a fundamental technique. This adds diagnostic specificity to the high sensitivity of lesion detection attributable to cross-sectional imaging. The anatomical precision of CT lends itself readily to the guidance of percutaneous biopsies. The modern scanners offer the necessary conditions for a reliable and rapid technique. The large aperture and flaring of the gantry allow easy access to the patient. The laser marker systems on the inside and outside of the gantry determine the site of needle entry on the skin surface and the millimetric control of the table top movements helps to find the desired plane of section. The rapid review of the images and volumetric acquisitions reduces the time of the procedure. The availability of a television screen inside the examination room allows the operator to remain close to the patient all the time [18]. Clinical colleagues must give the radiologist the freedom to decide whether a percutaneous biopsy is indicated. This decision is made with a full knowledge of the patient’s history. The biopsy is usually performed during the course of the diagnostic examination. This approach minimizes the delay in reaching a definitive diagnosis and reduces health costs.
Chapter
Except for the occasional patient with calcified hepatic metastases, there is relatively little difference in x-ray attenuation between metastases and normal liver parenchyma in most patients. Improvement in the computed tomographic (CT) detection of these metastases is dependent on the use of contrast agents to increase the difference in x-ray attenuation and improve visual contrast between the lesion and surrounding normal liver. These agents may selectively increase the attenuation of the normal liver or the metastasis, but ideally should not affect both. Should the x-ray attenuation of both increase, there will be no gain in visual contrast. Contrast agent research has been guided by this principle, and recent work has concentrated in two areas — improvement in the use of existing contrast agents and the development of new agents, such as EOE-13.
Chapter
For the early detection of hepatocellular carcinoma (HCC), the effectiveness of ultrasonography (US) has been widely accepted in Japan. However, US examination of the entire liver is occasionally impossible because of intervening bones, air in the gut or lung, or dense fatty tissue, especially in patients with a small cirrhotic liver. In such patients, computed tomography (CT) has begun to play an increasingly important role in detecting HCC as a complementary imaging method for US. CT is also very useful in differentiating various space-occupying lesions of the liver [1,2], evaluating the location and extension of these lesions, and determining the viability of neoplasms treated by transcatheter arterial embolization (TAE), percutaneous ethanol injection therapy, or chemotherapy. Another advantage of CT is its objectiveness in visualizing the relation between the lesions and the surrounding tissues. For these reasons and because of widespread availability of CT machines in Japan, CT is now performed in almost all patients with HCC and is making a major contribution to the treatment of HCC.
Chapter
With the advent of various sectional imaging modalities such as ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI), the role of hepatic angiography, or hepatic arteriography, has changed. Previously, it was merely a way to diagnose liver tumors and to obtain a vascular map for surgery, but it has since become a more precise method of diagnosis which is often combined with CT and other modalities to manage hepatic malignancies [1–4].
Chapter
The frequency of hepatocellular carcinoma (HCC) is increasing in Japan where it is now the third leading cause of death among males. HCC is relatively uncommon in the West but it is more common in Africa, Southeast Asia and Japan; and it is also known to have a high incidence in areas where the HBs antigen is prevalent.
Chapter
Primary liver cancer is one of the most common causes of cancer death in Japan, and approximately 23,000 patients died of this cancer in 1989 [1]. Moreover, the number of deaths due to primary liver cancer is increasing markedly every year. Hepatocellular carcinoma (HCC) accounts for 90% of primary liver cancer in Japan, and 80 to 90% of HCC is associated with liver cirrhosis [2, 3]. Poor hepatic functional reserve due to underlying cirrhosis is the major factor which limits extended surgical resection in many cases. Obviously it is important to detect HCC at an early stage for curative treatment.
Article
OBJECTIVE. We assessed the local recurrence rate after a single targeted transarterial oily chemoembolization for small hepatocellular carcinoma with the unified helical CT and angiography system and analyzed the factors affecting the local recurrence rate and survival rate with Cox proportional hazards model. MATERIALS AND METHODS. For 54 consecutive patients with 71 small hepatocellular carcinomas (≤5 cm) with no more than two associated lesions, targeted oily chemoembolization was performed with an emulsion of doxorubicin hydrochloride mixed with iodized oil or a suspension of zinostatin stimalamer followed by gelatin sponge particles. When local recurrence or a new lesion appeared, follow-up targeted oily chemoembolization was performed. RESULTS. For 52 of 71 lesions, the catheterization to a subsegmental or more distal feeding artery could be performed. Local recurrence was recognized in 33.2% at 1 year and 37.8% at 2 and 3 years. The significant factors that affected local recurrence were tumor size (p = 0.005) and degree of deposition of iodized oil within the lesion (p = 0.049). The survival rates at 1, 2, and 3 years were 93.3%, 77.1%, and 77.1%, respectively. The significant factors affecting survival rate were tumor thrombus in large vessels (p = 0.0001), appearing after the first chemoembolization, and maximum tumor size (p = 0.022). CONCLUSION. Single targeted transarterial oily chemoembolization with the unified helical CT and angiography system had a low local recurrence rate for small hepatocellular carcinoma, and follow-up embolization resulted in a good survival rate. Tumor size along with degree of intratumoral iodized oil deposition and tumor thrombus along with maximum tumor size were significant factors affecting local recurrence and survival rate, respectively.
Article
Transarterial chemoembolization (TACE) is an important treatment modality for hepatocellular carcinoma (HCC). Accurate identification of feeding arteries and catheterization are necessary for achieving treatment efficacy, especially with selective TACE. However, this often requires multiple imaging studies. We evaluated the utility of a newly developed apparatus that combines multidetector-row computed tomography (MDCT) and angiography (angio-MDCT) to facilitate TACE for treatment of HCC. A total of 73 patients who underwent selective TACE with angio-MDCT were compared with 57 patients who had undergone selective TACE with single-row computed tomography assisted by angiography (angio-CT) in terms of the number of imaging studies needed to complete TACE. The mean number of digital subtraction arteriography (DSA) and CT studies required for characterization of feeding arteries before embolization was 3.53 (range 1-8) and 5.16 (range 2-11), respectively, with single-row angio-CT, and 1.67 (range 1-5) and 2.90 (range 1-5), respectively, with angio-MDCT. Fewer studies were needed in patients who underwent TACE with angio-MDCT (p < 0.0001 for both DSA and CT). Whereas single-row angio-CT failed to identify extrahepatic feeders in three patients (37.5 %), all extrahepatic feeders could be identified with angio-MDCT. Angio-MDCT facilitates rapid and accurate identification of feeding arteries in patients undergoing TACE through the three-dimensional image analyses by the reconstruction with the workstation.
Article
OBJECTIVE:We aimed to investigate the relationship between fatty infiltration in the posterior aspect of hepatic segment IV and pancreaticoduodenal venous drainage.METHODS:Pancreaticoduodenal arteriography was performed in 21 patients who had nontumorous portal perfusion defects in the posterior aspect of hepatic segment IV, as demonstrated on CT during arterial portography (CTAP).RESULTS:In 10 patients, pancreaticoduodenal arteriography showed an aberrant nonportal vessel with flow toward the hepatic hilum in the venous phase. Four of the 10 patients with nonportal vessels from the pancreaticoduodenal arterial system had fatty infiltration in segment IV. In three of these four patients, the fatty infiltration was focal and localized to that area. On the other hand, none of the 11 patients without nonportal vessels from the pancreaticoduodenal arterial system had fatty infiltration in the regions corresponding to the nontumorous portal perfusion defects on CTAP. Moreover, three patients with diffuse fatty liver had a focal nonfatty area in segment IV.CONCLUSIONS:Focal fatty infiltration in the posterior aspect of hepatic segment IV seems to be related to pancreaticoduodenal venous drainage.
Article
We performed serial hemodynamics in 15 patients with 21 well-differentiated hepatocellular carcinomas. The total length of the observation period ranged from 129 to 678 days (median, 368). We investigated both arterial and portal blood flow at intervals of at least 4 months. Arterial blood flow was measured with carbon dioxide-enhanced ultrasonography (US), and portal blood flow was measured with computed tomographic arterial portography (CTAP). None of the tumors were hypervascular on the initial study; however, by the final study nine nodules (42.9%) had become homogeneously hypervascular, two (9.5%) had become partially hypervascular, and the others did not change. Of 10 nodules without portal blood supply on any study, 8 became hypervascular by the final study. Of 11 nodules with portal blood supply on the initial study, a follow-up study showed no change in portal flow in 6 and the loss of portal flow in 5. Four of these five became hypervascular, with a documented loss of portal flow before the increase in arterial flow. The doubling time of tumors with a homogeneous increase in arterial blood flow ranged from 89 to 333 days (median, 172), whereas the doubling time of other tumors ranged from 227 to 607 days (median, 392). Thus, growth rate and vascularity in well-differentiated hepatocellular carcinoma are closely correlated. When the well-differentiated hepatocellular carcinoma has portal blood flow and is not hypervascular, it grows slowly. On the other hand, when it loses portal blood flow and becomes hypervascular, it grows rapidly.
Article
OBJECTIVE. The purpose of our study was to evaluate the use of combined helical CT during arterial portography and CT hepatic arteriography in the preoperative assessment of hepatic metastases from colorectal cancer using a unified CT and angiography system. MATERIALS AND METHODS. Fifty-four patients with hepatic metastases from colorectal cancer preoperatively underwent combined CT during arterial portography and CT hepatic arteriography using the unified CT and angiography system. Three radiologists independently and retrospectively reviewed the images of CT during arterial portography alone, CT hepatic arteriography alone, and combined CT during arterial portography and CT hepatic arteriography. Image review was conducted on a segment-by-segment basis; a total of 432 hepatic segments with (n = 103) 118 metastatic tumors ranging in size from 2 to 160 mm (mean, 25.8 mm) and without (n = 329) tumor were reviewed. RESULTS. Relative sensitivity of combined CT during arterial portography and CT hepatic arteriography (87%) was higher than that of CT during arterial portography alone (80%, p < 0.0005) and CT hepatic arteriography alone (83%, p < 0.005). Relative specificity of CT hepatic arteriography alone (95%, p < 0.0005) and combined CT during arterial portography and CT hepatic arteriography (96%, p < 0.0001) was higher than that of CT during arterial portography alone (91%). Diagnostic accuracy, determined by a receiver operating characteristic curve analysis, was greater with combined CT during arterial portography and CT hepatic arteriography than with CT during arterial portography alone (p < 0.05) or CT hepatic arteriography alone (p < 0.01). CONCLUSION. Using a unified CT and angiography system, we found that combined CT during arterial portography and CT hepatic arteriography significantly raised the detectability of hepatic metastases from colorectal cancer.
Article
OBJECTIVE. We compared radiologists' performance on combined unenhanced, gadolinium-enhanced, and ferumoxides-enhanced MR imaging with their performance on helical CT during arterial portography (CTAP) and biphasic CT during hepatic arteriography (CTHA) for the preoperative detection of malignant hepatic tumors. SUBJECTS AND METHODS. MR images and CT scans obtained in 33 patients were retrospectively analyzed. Images of the liver were reviewed on a segment-by-segment basis; a total of 261 segments with 39 hepatocellular carcinomas and 21 metastases were independently reviewed by three radiologists who were invited from outside institutions. Unenhanced and gadolinium-enhanced MR images were reviewed first, then ferumoxides-enhanced MR images were added for combined review. CTAP images and biphasic CTHA images were reviewed together. RESULTS. Sensitivity for the detection of hepatic tumors was analogous for combined unenhanced, gadolinium-enhanced, and ferumoxides-enhanced MR images (86%) and for combined CTAP images and biphasic CTHA images (87%). Specificity was higher with MR images (95%, p < 0.01) than with CT images (91%). Radiologists' performances were improved (Az = 0.962, p = 0.0502) by combining ferumoxides-enhanced MR images with unenhanced and gadolinium-enhanced MR images (Az) = 0.950), and were analogous for combined unenhanced, gadolinium-enhanced, and ferumoxides-enhanced MR images and for combined CTAP images and biphasic CTHA images (Az = 0.959). CONCLUSION. Radiologists' performances on combined unenhanced, gadolinium-enhanced, and ferumoxides-enhanced MR imaging compared with their performances on combined helical CTAP and biphasic CTHA are analogous for the preoperative detection of malignant hepatic tumors. Such a dedicated combination of MR imaging may obviate the need for more invasive angiographically assisted helical CT for the preoperative detection of malignant hepatic tumors.
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Computed tomography (CT) has had a profound effect on the practice of medicine. Both the spectrum of clinical applications and the role that CT has played in enhancing the depth of our understanding of disease have been profound. Although almost 90 000 articles on CT have been published in peer-reviewed journals over the past 40 years, fewer than 5% of these have been published in Radiology. Nevertheless, these almost 4000 articles have provided a basis for many important medical advances. By enabling a deepened understanding of anatomy, physiology, and pathology, CT has facilitated key advances in the detection and management of disease. This article celebrates this breadth of scientific discovery and development by examining the impact that CT has had on the diagnosis, characterization, and management of a sampling of major health challenges, including stroke, vascular diseases, cancer, trauma, acute abdominal pain, and diffuse lung diseases, as related to key technical advances in CT and manifested in Radiology. © RSNA, 2014 Listen to a discussion of the history of radiology.
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AimThis study aimed to determine the role of morphological patterns seen on imaging in predicting hepatocellular carcinoma recurrence following transarterial chemoembolization therapy.Methods Forty-seven patients from a single center who underwent transarterial chemoembolization to treat unresectable hepatocellular carcinomas between January 2011 and June 2012 were included in this study. We investigated whether the two pretreatment findings on computed tomography during hepatic arteriography (pattern 1, the single nodule pattern; pattern 2, at least one nodule showing the contiguous multinodular pattern) and other factors (age, gender, etiology, serum total bilirubin, serum albumin, prothrombin time, platelet count, serum level of protein induced by vitamin-K deficiency-II, serum alpha-fetoprotein, number of previous treatments for hepatocellular carcinoma, tumor number, and maximum tumor size) could predict post-treatment recurrence.ResultsIn a univariate analysis using Cox's proportional hazards model, serum total bilirubin, the serum level of protein induced by vitamin-K deficiency-II (≤100 vs. ≥101 mAU/mL), tumor morphology (pattern 1 vs. 2), and tumor number (≤3 vs. ≥4) showed statistical significance (≤0.05). In a multivariate analysis of these factors, morphology and tumor number showed significance. According to Kaplan–Meier estimation, the cumulative disease-free survival rates were significantly lower in patients with ≥4 lesions than in those with ≤3 lesions and in patients showing pattern 2 than in those showing pattern 1.Conclusions Patients with pattern 2 hepatocellular carcinoma and/or ≥4 lesions may have a relatively high recurrence rate after transarterial chemoembolization.
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Contrast-enhanced us with CO2 can improve us liver sensitivity, detecting daughter nodules of HCC not visible with normal us Examination and CT.
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OBJECTIVES: The combination of computed tomography with hepatic arteriography and arterial portography (CTHA/CTAP) can detect additional hepatocellular carcinoma (HCC) nodules undetected by conventional dynamic CT. METHODS: In this single-center, randomized, open-label, controlled trial, we randomly assigned 280 patients who were diagnosed as having HCC by conventional dynamic CT, and eligible for radiofrequency ablation (RFA), to undergo CTHA/CTAP before treatment, or to the control group. Newly detected HCC nodules by CTHA/CTAP were intended to be ablated completely. The primary end point was recurrence-free survival and the key secondary end point was overall survival. The analysis was conducted on an intention-to-treat basis. Those with nonablated nodules were treated as for recurrence. RESULTS: A total of 75 nodules were newly diagnosed as HCC by CTHA/CTAP in 45 patients. Three patients (one in the CTHA/CTAP group and two in the control group) who refused treatment were excluded from all analyses. The cumulative recurrence-free survival rates at 1, 2, and 3 years were 60.1, 29.0, and 18.9% in the CTHA/CTAP group and 52.2, 29.7, and 23.1% in the control group, respectively (P=0.66 by log-rank test; hazard ratio, 0.94 for CTHA/CTAP vs. control; 95% confidence interval (CI), 0.73–1.22). The cumulative overall survival rates at 3 and 5 years were 79.7 and 56.4% in the CTHA/CTAP group and 86.8 and 60.1% in the control group, respectively (P=0.50; hazard ratio, 1.15, 95% CI, 0.77–1.71). CONCLUSIONS: CTHA/CTAP may detect recurrent lesions earlier. However, CTHA/CTAP before RFA did not improve cumulative recurrence-free survival or overall survival.
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Abstract Early detection and characterization of small hepatocellular carcinoma (HCC) by imaging is possible with high confidence, and is important for the improvement of the prognosis of the patient with liver cirrhosis. In this lecture, screening of HCC and its characterization by imaging, with special reference to imaging features of human multi step hepato carcinogenesis will be discussed.
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The angiogenic process plays an important role in tumour growth and metastasis during hepatocarcinogenesis, but it is still uncertain when the process begins during tumour formation. Forty-two small hepatocellular carcinomas (HCC) that measured either less than or equal to 2 cm in diameter were studied by comparing the histologic findings with the angiographic findings, and with immunohistochemical expression of endothelial marker QB-end/10 (QB), a new monoclonal antibody raised against CD34, in the sinusoidal wall. Twenty (91%) of 22 moderately or poorly differentiated HCC revealed a positive reaction for QB, while only eight (40%) of 20 well differentiated HCC demonstrated a positive reaction (P < 0.01). In the tumours showing a ‘nodule in nodule’ appearance, the less differentiated areas were more reactive for QB. Twenty-three (82%) of 28 QB positive tumours were hypervascular, while only three of 14 (21%) QB negative tumours were hypervascular (P < 0.01) by angiography. All six of the poorly differentiated and 13 (81%) of the 16 moderately differentiated tumours were hypervascular, while only seven (35%) of 20 well differentiated HCC were hypervascular (P < 0.01). These results indicate that as the tumour becomes less differentiated, the QB positive areas become wider and angiography demonstrates hypervascularity. We therefore speculate that the HCC sinusoids acquire the characteristics of capillary and precapillary blood vessels during de-differentiation from well to moderate, and thus the tumour begins to reveal hypervascularity on angiography. The above process may be correlated with the stepwise progression of HCC.
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To elucidate the detectability of small hepatocellular carcinoma by various imaging modalities, we performed digital subtraction angiography, computed tomographic arterioportography and carbon dioxide-enhanced ultrasonography. Of 76 patients with a small hepatocellular carcinoma of 2 cm or less in maximum diameter, 61 underwent digital subtraction angiography, computed tomographic arterioportography and enhanced ultrasonography at the same time. Concerning the 61 patients undergoing all the procedures, the characteristics of hepatocellular carcinoma were found in 57.4% (35 of 61) by digital subtraction angiography, 75.4% (46 of 61) by computed tomographic arterioportography and 72.1% (44 of 61) by enhanced ultrasonography. Among them, four hepatocellular carcinomas were detected only by enhanced ultrasonography, three were diagnosed only by computed tomographic arterioportography and two were diagnosed by both of them. Except for six hemangioma nodules that were easily diagnosed only with angiography, four of 55 benign hepatic nodules (7.3%) showed false-positive findings suggestive of hepatocellular carcinoma with either computed tomographic arterioportography or enhanced ultrasonography. In conclusion, computed tomographic arterioportography and enhanced ultrasonography could complementarily detect a small hepatocellular carcinoma more sensitively than digital subtraction angiography. (Hepatology 1994;20:82–87.)
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Abstract A 65 year old woman with lupoid hepatitis developed hepatocellular carcinoma which was diagnosed at an early stage. She had no history of blood transfusion and serum hepatitis B virus markers were negative. Prednisolone and 6-mercaptopurine were administered for the treatment of lupoid hepatitis. A hepatocellular carcinoma was detected by the elevation of serum α-fetoprotein and imaging studies. A tumour, 1.4 cm in diameter, was located in the lateral segment of the left hepatic lobe. It was resected by hepatic subsegmentectomy. Histological study showed a hepatocellular carcinoma of Edmondson type II against a background of posthepatitic cirrhosis. The patient was in good condition 2.5 years after the operation.
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Recently, perfusion imaging has been of increasing interest in MRI. We applied this method for semiquantitative evaluation of hepatic parenchymal portal blood flow in patients with diffuse liver damage. Twenty patients with diffuse hepatic damage were divided according to the Child's Classification and studied. Gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) was administered into the superior mesenteric artery (SMA), and a dynamic series of T2*-weighted fast low angle shot (FLASH) images was obtained. We evaluated relative regional portal blood volume (rrPBV), mean transit time (MTT), and relative regional portal blood flow (rrPBF). The relationship between the rrPBV, rrPBF, and plasma indocyanine green retention rate test at 15 minutes (ICGR15) was also evaluated in 12 patients. Both rrPBF and rrPBV are significantly decreased in Child B & C patients compared with Child A patients. On the other hand, the MTT is significantly prolonged in Child B & C patients compared with Child A patients. Significant correlations were also noted between rrPBV and ICGR15 and between rrPBF and ICGR15. By means of selective catheterization into the SMA, we were able to estimate rrPBV, rrPBF, and MTT. This method may play a clinical role for assessment of regional portal perfusion in various diseases with diffuse liver damage.
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ABSTRACT— Adenomatous hyperplasia (AH), a hyperplastic parenchymal nodule, is detected most often through radiological and pathological observations in chronic advanced liver disease. AH can be classified into two categories: ordinary type or macroregenerative nodule (MRN) type I, and atypical type or MRN type II. Characteristically, both types contain portal tracts with portal veins and biliary elements. Ordinary AH may represent a large regenerative nodule with limited growth potential. Atypical AH shows slightly cellular and structural atypia, altered phenotypic expression, and increased proliferative activity compared to the surrounding liver. Histologic differentiation of atypical AH from well-differentiated hepatocellular carcinoma (HCC) is controversial, and generally accepted diagnostic criteria are still lacking. Atypical AH occasionally contains overt malignant foci. Histological observations and portography show that nodules of AH are supplied by portal venous blood. While AH nodules appear to be hypoperfused according to arteriographic studies, atypical AH contains small arterial branches which are abundant in contrast to the surrounding liver. The data obtained so far indicate that atypical AH may be a hepatocellular neoplasm which belongs nosologically to a gray area of neoplasm, in which overt HCC is likely to develop. It is clinically recommended that atypical AH is treated as “malignant” because of the occasional inclusion of HCC foci. For its treatment, percutaneous ethanol injection is becoming popular.
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A series of 60 patients with hepatocellular carcinoma (HCC) were evaluated over a 2-year period of ultrasonography (US), computed tomography (CT), and angiography. The angiographic studies carried out with intraarterial digital technology were compared to both US and CT of the liver. In 16 of 60 patients, we observed discordance of the findings obtained with angiography, CT, and US. We therefore compared these three methodologies in those cases where diagnostic discordance was noted. In our experience, US had a sensitivity of 73.4%, 76.7% for CT, and 95% for angiography. In 13 of 60 patients, we performed CT with arterial portography (CTAP) which demonstrated a better resolution than conventional CT. In view of the sensitivity of US — comparable to that of CT — and for the even greater sensitivity of intraarterial digital angiography, we performed an US study of patients at risk of HCC. CT was found to play a diagnostic/staging role after angio graphic study has been performed, especially when enhanced by arterial portography.
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Purpose To develop a computer-aided image analysis (CAIA) algorithm for analyzing US features of focal hepatic lesions and to correlate the feature values of CAIA with radiologists’ grading. Materials and methods Two abdominal radiologists, blinded to the final diagnosis, independently evaluated sonographic images of 51 focal hepatic lesions in 47 patients: hemangiomas (n = 19), hepatic simple cysts or cystic lesions (n = 14), hepatocellular carcinoma (n = 11), metastases (n = 6), and focal fat deposition (n = 1). All images were graded using a 3- to 5-point scale, in terms of border (roundness, sharpness, and the presence of peripheral rim), texture (echogenicity, homogeneity, and internal artifact), posterior enhancement, and lesion conspicuity. Using a CAIA, texture and morphological parameters representing radiologists’ subjective evaluations were extracted. Correlations between the radiologists and the CAIA for assessing parameters in corresponding categories were computed by means of weighted κ statistics and Spearman correlation test. Results A good agreement was achieved between CAIA and radiologists for grading echogenicity (weighted κ = 0.675) and the presence of hyper- or hypoechoic rim (weighted κ = 0.743). Several CAIA-derived features representing homogeneity of the lesions showed good correlations (correlation coefficient (γ) = 0.603∼0.641) with radiologists’ grading (P < 0.05). For internal artifact (γ = 0.469–0.490) and posterior enhancement (γ = −0.516) of the cyst and lesion conspicuity (γ = 0.410), a fair correlation between CAIA and radiologists was obtained (P < 0.05). However, parameters representing lesions’ border such as sharpness (γ = 0.252–0.299) and roundness (γ = −0.134–0.163) showed no significant correlation (P > 0.05). Conclusion As a preliminary step in US computer-aided diagnosis for focal hepatic lesions, a CAIA algorithm was constructed with a good agreement and correlation with human observers in most US features. In addition, these features should be weighted highly when a computer-aided diagnosis for characterizing focal liver lesions on US is designed and developed.
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Aim: Corona enhancement is the visualized drainage area from a hypervascular tumor observed on single-level dynamic computed tomography during hepatic arteriography (CTHA) and is thought to be a high-risk area for micrometastases. However, because it cannot be visualized with ordinary ultrasonography (US), we aimed to visualize corona enhancement on US by means of arterial injection of the contrast material and to measure its thickness. Method: Forty-one hypervascular hepatocellular carcinoma (HCC) cases were prospectively investigated. US during hepatic arteriography (USHA) was executed by means of selective injection of the contrast material perfluorobutane (Sonazoid) from the hepatic artery. Ordinary contrast-enhanced US with venous administration of contrast material and single-level dynamic CTHA were also performed. Results: Corona enhancement was observed in 36 cases (88%) on USHA and in 25 cases (61%) on single-level dynamic CTHA. The thickness of corona enhancement of 36 cases visualized with USHA ranged 3.1-18.4 mm and the mean thickness ± standard deviation was 6.0 ± 3.0 mm. Thickness of corona enhancement was less than 10.0 mm in 34 cases (94%). Conclusion: Corona enhancement could be visualized even on US images, and the average thickness of them was 6 mm.
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Background: Postoperative early recurrence is a crucial issue in the treatment of hepatocellular carcinoma (HCC) patients. Some early recurrences seem to occur from minute tumors which were overlooked during both preoperative and intraoperative investigations. Therefore, it is urgently necessary to increase detectability of minute HCCs during operation. If they could be detected and resected during surgery, the prognosis should be improved. The purpose of this study is to investigate the usefulness of contrast-enhanced intraoperative ultrasound (CEIOUS) for the diagnosis and treatment of HCC. Methods: Institutional ethics committee approval and informed consent were obtained. Fifty-two patients (mean age 65 years; 38 males and 14 females) who underwent liver resection with either preoperative computed tomography during angiography (CTA) or CEIOUS with Sonazoid (perflubutane microbubble contrast agent) were studied. We determined the presence of HCC on the basis of the histopathological findings of resected specimens. Results: The sensitivity of CEIOUS [97.6% (95% CI 91.8-99.4)] was higher than that of CTA [89.4% (95% CI 81.1-94.3)]. The positive predictive values of CEIOUS [91.2% (95% CI 83.6-95.5) and CTA [91.6% (95% CI 83.6-95.9)] were similar. Eight new HCCs from 7 patients, which accounted for 9.4% (8/85) of the total HCCs, were correctly detected and diagnosed by CEIOUS, and we performed an additional partial hepatectomy in 3 of these 7 patients. Conclusions: CEIOUS with Sonazoid provided increased sensitivity of detection of small HCCs compared with preoperative CTA, thereby leading to a more appropriate surgical procedure and contributing to complete tumor removal.
Article
Background and aims This study was part of an on-going randomized controlled trial to investigate the utility of computed tomography (CT) during hepatic arteriography and arterial portography (CTHA/CTAP) as a pre-treatment examination for patients with small hepatocellular carcinoma (HCC). Methods A total of 137 patients with HCC who were diagnosed by dynamic CT showing hyperattenuation in the arterial phase and hypoattenuation in the equilibrium phase, were Child–Pugh class A, and had three or less tumors with diameters ≤ 3.0 cm were randomly assigned to undergo CTHA/CTAP. We compared the diagnostic utilities of CTHA/CTAP and dynamic CT. Univariate and multivariate logistic regression analyses with stepwise variable selection were performed to identify factors related to the detection of additional nodules. Results The total number of HCCs at the time of diagnosis with contrast-enhanced dynamic CT was 197. 75 nodules with a mean diameter of 8.7 mm (range 2–20) in 45 patients (32.8%) were additionally diagnosed as definite HCC on CTHA/CTAP compared with dynamic CT. A retrospective review revealed that 54 nodules could have been identified on arterial or equilibrium phase of the previous dynamic CT, whereas 21 were indiscernible. Multivariate logistic regression analysis revealed that multinodularity on dynamic CT [odds ratio (OR) = 5.35, P = 0.002], recurrent case as opposed to initial case (OR = 2.16, P = 0.06), and seronegativity for hepatitis B surface antigen (OR = 10.0, P = 0.03) were associated with the detection of additional nodules. Conclusion CTHA/CTAP may be useful for detecting additional nodules prior to percutaneous ablation in patients with multinodular HCC on dynamic CT, in recurrent cases, and in hepatitis B surface antigen-negative cases.
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