British Journal of Radiology (2007) 80, e85-e87
© 2007 British Institute of Radiology
doi: 10.1259/bjr/16716757
Superselective transcatheter arterial chemoembolisation of an unresectable hepatocellular carcinoma using three-dimensional rotational angiography
H Takao, MD,
I Doi, MD and
T Watanabe, MD
Department of Radiology, Showa General Hospital, 2-450 Tenjincho, Kodaira, Tokyo, 187-0004, Japan
Correspondence: Dr Hidemasa Takao, Department of Radiology, Showa General Hospital, 2-450 Tenjincho, Kodaira, Tokyo, 187-0004, Japan. E-mail: takaoh-tky{at}umin.ac.jp
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Abstract
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Transcatheter arterial chemoembolisation is the mainstay of treatment for patients with unresectable hepatocellular carcinoma. In patients with poor liver function, superselective catheter placement is necessary to prevent treatment-induced liver failure. Herein, the authors describe a case of a hepatocellular carcinoma successfully treated by superselective transcatheter arterial chemoembolisation using three-dimensional rotational angiography.
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Introduction
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Hepatocellular carcinoma is a leading cause of morbidity and mortality, and its incidence is increasing worldwide because of the dissemination of hepatitis B and C virus infections [1]. In the West, curative treatments are applied to 30–40% of patients [1]. Many patients have unresectable disease when first diagnosed. Transcatheter arterial chemoembolisation is the mainstay of treatment for patients with unresectable hepatocellular carcinoma [2]. The goal of chemoembolisation is to cause tumour necrosis and control tumour growth while preserving as much functional liver tissue as possible. In patients with poor liver function, superselective catheter placement is necessary to prevent treatment-induced liver failure [3, 4].
Three-dimensional (3D) rotational angiography has been widely applied in the evaluation of intracranial aneurysms [5, 6]. The usefulness of 3D rotational angiography for the pre-treatment evaluation of intracranial aneurysms has been established. Compared with digital subtraction angiography, competing imaging techniques such as CT angiography and MR angiography have inferior spatial resolution. To our knowledge, the application of 3D rotational angiography to superselective intraarterial treatment of hepatocellular carcinoma has not been previously reported.
We describe a case of a hepatocellular carcinoma successfully treated by superselective transcatheter arterial chemoembolisation using 3D rotational angiography.
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Case report
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An 85-year-old woman with cirrhosis due to hepatitis C infection underwent abdominal CT. CT images revealed a new 2 cm hypervascular tumour in segment III of the liver, for which imaging findings were compatible with a hepatocellular carcinoma. Ascites was absent. Her medical history included transcatheter arterial chemoembolisation for multiple hepatocellular carcinomas (both lobes) 3 years prior, and congestive heart failure. Laboratory values included albumin level of 3.6 g dl–1, bilirubin level of 1.0 mg dl–1, prothrombin time of 14.6 s (International Normalized Ratio of 1.16), and platelets of 78x109 U l–1.
The patient was referred to the Department of Radiology for superselective transcatheter arterial chemoembolisation because of the patient's advanced age and concomitant congestive heart failure. The right femoral artery was accessed with an 18-gauge Seldinger needle and a 5 Fr sheath was placed. The coeliac artery was selectively catheterized using a 5 Fr catheter. A 2.3 Fr microcatheter (RapidTransit; Cordis, Miami, FL) was advanced coaxially through the catheter into the lateral branch of the left hepatic artery. Angiography revealed a hypervascular tumour in segment III of the liver (Figure 1a
). Rotational angiography (Integris Allura 15; Philips Medical Systems, Best, The Netherlands) was performed for evaluation of feeding vessels, and the rotational images were transferred to a workstation (Integris 3D-RA; Philips Medical Systems) for generating 3D images (Figure 1b). It took about 5 min including post-processing time. One branch artery of the segment III artery was closely related to the tumour and was considered the feeding artery of the tumour. The microcatheter was advanced into the feeding artery. Angiography showed the blush of the entire tumour (Figure 1c). Chemoembolisation was performed using 10 mg of doxorubicin hydrochloride (Adriacin; Kyowa Hakko Kogyo, Tokyo, Japan) dissolved in 1 ml of iopamidol (Iopamiron 370; Schering, Osaka, Japan) and emulsified with 2 ml of iodized oil (Lipiodol Ultra-Fluid; Guerbet, Paris, France), and gelatine sponge particles (Spongel; Yamanouchi Pharmaceutical, Tokyo, Japan). Post-embolisation angiography showed no visualization of the tumour (Figure 1d).
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Figure 1. (a) Angiogram of the lateral branch of the left hepatic artery shows a hypervascular tumour in segment III of the liver. It is difficult to determine which of several overlapping branches is actually supplying the tumour. (b) Three-dimensional (3D) rotational angiograms of the lateral branch of the left hepatic artery show a branch artery (arrowheads) closely related to the tumour (arrows), which was considered the feeding artery of the tumour. The feeding artery arises from the segment III artery and runs backward and to the right. The other branch arteries are separate from the tumour. (c) Superselective angiogram of the feeding artery shows the blush of the entire tumour. (d) Post-embolisation angiogram shows no visualization of the tumour. (e) Unenhanced CT scan obtained 1 month later shows dense deposition of iodized oil in the entire tumour.
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After chemoembolisation, the patient's bilirubin level transiently increased to 1.5 mg dl–1, but by day 7 it had returned to the pre-treatment level. Follow-up CT performed one month later showed dense deposition of iodized oil in the entire tumour (Figure 1e
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Discussion
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Transcatheter arterial chemoembolisation is the most widely used treatment for unresectable hepatocellular carcinoma [1]. A recent meta-analysis that included seven randomized trials of arterial embolisation for unresectable hepatocellular carcinoma has demonstrated a significant improvement in 2 year survival with arterial embolisation compared with control (either conservative management or suboptimal therapy), which was evident for chemoembolisation but not embolisation alone [7]. Patient selection for chemoembolisation is a key point. The benefits of the procedure should not be offset by treatment-induced liver failure. During chemoembolisation, selective catheter placement is recommended to preserve as much functional liver tissue as possible [2]. In patients with poor liver function, superselective chemoembolisation should be performed to prevent treatment-induced liver failure [3, 4].
Chemoembolisation of hepatocellular carcinoma using a unified helical CT and angiography system has been reported in the literature [8–10]. These studies demonstrated its usefulness in identifying feeding vessels. However, this system does not provide additional anatomical information about feeding vessels. For superselective chemoembolisation, trial catheterization and contrast material injection into several different branches may be needed to finally determine which branch is the correct target. Three-dimensional rotational angiography is a relatively new technique that has been widely applied in neuroradiological interventions [5, 6]. Three-dimensional rotational angiography provides a high-resolution three-dimensional representation of the vasculature. Compared with digital subtraction angiography, competing imaging techniques, such as CT angiography and MR angiography, have inferior spatial resolution, whereas several studies have recently demonstrated CT angiography to be an acceptable alternative to angiography [11, 12]. In chemoembolisation of hepatocellular carcinoma, CT angiography with multislice CT will also provide additional information about feeding vessels.
In our case, we used three-dimensional rotational angiography to identify feeding vessels. It provided excellent anatomical information about the feeding vessel, and facilitated superselective catheterization into the feeding vessel. Three-dimensional rotational angiography will be useful for superselective transcatheter arterial chemoembolisation of hepatocellular carcinoma in cases where feeding vessels are difficult to identify.
Received for publication April 18, 2005.
Revision received June 4, 2005.
Accepted for publication June 22, 2005.
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References
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Abstract
Introduction
