DOI: 10.1148/rg.25si055507
Staging and Current Treatment of Hepatocellular Carcinoma1
Hollins P. Clark, MD,
W. Forrest Carson, MD,
Peter V. Kavanagh, MD,
Coty P. H. Ho, MD,
Perry Shen, MD and
Ronald J. Zagoria, MD
1 From the Departments of Radiology (H.P.C., W.F.C., P.V.K., R.J.Z.), Internal Medicine (C.P.H.H.), and Surgery (P.S.), Wake Forest University School of Medicine, Meads Hall, 2nd Floor, Medical Center Blvd, Winston-Salem, NC 27157-1088. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received February 8, 2005; revision requested March 29 and received May 24; accepted May 31. The article discusses an investigational or unlabeled use of a commercial device or pharmaceutical that has not been approved for such purpose by the FDA. TheraSphere® (MDS Nordion, Ottawa, Ontario, Canada) has received humanitarian device exemption approval from the U.S. FDA for treatment of unresectable hepatocellular carcinoma and can be used only in an investigational capacity. SIR-Spheres® (Sirtex Medical, Lake Forest, Ill) has received premarket approval from the FDA for use in combination with hepatic arterial fluorouracil therapy to treat colorectal metastasis to the liver; its use for treatment of primary hepatic neoplastic disease is an off-label application. Likewise, intraarterial administration of cisplatin, doxorubicin, and mitomycin C for treatment of hepatocellular carcinoma constitutes off-label use of these pharmacologic products. All authors have no financial relationships to disclose.
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Figure 1. Flowchart shows the algorithm used for selecting the appropriate treatment for HCC when the principal alternatives are surgical resection (the preferred treatment method), transplantation, RF ablation, TACE, selective internal radiation therapy (SIRT), systemic therapy, and supportive care. Treatment for unresectable HCC is selected on the basis of clinical and imaging findings.
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Figure 2a. Unresectable HCC in a 48-year-old man. (a) Contrast-enhanced portal phase CT image shows HCC that involves liver segment V (black arrow) and the gallbladder (white arrow). (b) Contrast-enhanced portal phase CT image obtained at a lower level than a shows enlarged portal lymph nodes (arrowhead), which proved to be metastatic disease at histopathologic analysis after fine-needle aspiration performed with endoscopic US guidance. (c) Coronal contrast-enhanced arterial phase CT image depicts both the hepatic mass (arrow) and adenopathy (arrowhead). The patient was not considered a candidate for surgery or local-regional therapy and was referred for systemic therapy.
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Figure 2b. Unresectable HCC in a 48-year-old man. (a) Contrast-enhanced portal phase CT image shows HCC that involves liver segment V (black arrow) and the gallbladder (white arrow). (b) Contrast-enhanced portal phase CT image obtained at a lower level than a shows enlarged portal lymph nodes (arrowhead), which proved to be metastatic disease at histopathologic analysis after fine-needle aspiration performed with endoscopic US guidance. (c) Coronal contrast-enhanced arterial phase CT image depicts both the hepatic mass (arrow) and adenopathy (arrowhead). The patient was not considered a candidate for surgery or local-regional therapy and was referred for systemic therapy.
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Figure 2c. Unresectable HCC in a 48-year-old man. (a) Contrast-enhanced portal phase CT image shows HCC that involves liver segment V (black arrow) and the gallbladder (white arrow). (b) Contrast-enhanced portal phase CT image obtained at a lower level than a shows enlarged portal lymph nodes (arrowhead), which proved to be metastatic disease at histopathologic analysis after fine-needle aspiration performed with endoscopic US guidance. (c) Coronal contrast-enhanced arterial phase CT image depicts both the hepatic mass (arrow) and adenopathy (arrowhead). The patient was not considered a candidate for surgery or local-regional therapy and was referred for systemic therapy.
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Figure 3. Unresectable HCC in a 44-year-old man with hepatitis C. Contrast-enhanced portal phase CT image shows a large and heterogeneously enhancing HCC that involves the entire left hepatic lobe and extends into the right lobe. Parenchymal replacement of more than 50% and preexisting hepatic disease greatly increased the risk of hepatic failure with surgical resection. The patient therefore was referred for selective internal radiation therapy instead of surgery.
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Figure 4a. Small resectable HCC in a 47-year-old woman. (a, b) Contrast-enhanced arterial phase CT images in the axial (a) and coronal (b) planes show an exophytic HCC (arrow) that involves the lateral segment of the left hepatic lobe. (c) Photograph shows the HCC-containing liver specimen that was excised by using a laparoscopic hand-assisted left lateral wedge resection.
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Figure 4b. Small resectable HCC in a 47-year-old woman. (a, b) Contrast-enhanced arterial phase CT images in the axial (a) and coronal (b) planes show an exophytic HCC (arrow) that involves the lateral segment of the left hepatic lobe. (c) Photograph shows the HCC-containing liver specimen that was excised by using a laparoscopic hand-assisted left lateral wedge resection.
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Figure 4c. Small resectable HCC in a 47-year-old woman. (a, b) Contrast-enhanced arterial phase CT images in the axial (a) and coronal (b) planes show an exophytic HCC (arrow) that involves the lateral segment of the left hepatic lobe. (c) Photograph shows the HCC-containing liver specimen that was excised by using a laparoscopic hand-assisted left lateral wedge resection.
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Figure 5a. Large resectable HCC in a 67-year-old man. (a, b) Axial contrast-enhanced portal phase CT image (a) and axial T1-weighted MR image obtained with gadolinium-based contrast material and fat saturation (b) show, in the right hepatic lobe, a large HCC that has invaded the right portal vein (arrow). (c, d) Photographs show the liver specimen excised for removal of the tumor thrombus (arrow in d) en bloc at right hepatic lobectomy. (e) Follow-up axial contrast-enhanced CT image shows the liver margin after partial hepatectomy.
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Figure 5b. Large resectable HCC in a 67-year-old man. (a, b) Axial contrast-enhanced portal phase CT image (a) and axial T1-weighted MR image obtained with gadolinium-based contrast material and fat saturation (b) show, in the right hepatic lobe, a large HCC that has invaded the right portal vein (arrow). (c, d) Photographs show the liver specimen excised for removal of the tumor thrombus (arrow in d) en bloc at right hepatic lobectomy. (e) Follow-up axial contrast-enhanced CT image shows the liver margin after partial hepatectomy.
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Figure 5c. Large resectable HCC in a 67-year-old man. (a, b) Axial contrast-enhanced portal phase CT image (a) and axial T1-weighted MR image obtained with gadolinium-based contrast material and fat saturation (b) show, in the right hepatic lobe, a large HCC that has invaded the right portal vein (arrow). (c, d) Photographs show the liver specimen excised for removal of the tumor thrombus (arrow in d) en bloc at right hepatic lobectomy. (e) Follow-up axial contrast-enhanced CT image shows the liver margin after partial hepatectomy.
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Figure 5d. Large resectable HCC in a 67-year-old man. (a, b) Axial contrast-enhanced portal phase CT image (a) and axial T1-weighted MR image obtained with gadolinium-based contrast material and fat saturation (b) show, in the right hepatic lobe, a large HCC that has invaded the right portal vein (arrow). (c, d) Photographs show the liver specimen excised for removal of the tumor thrombus (arrow in d) en bloc at right hepatic lobectomy. (e) Follow-up axial contrast-enhanced CT image shows the liver margin after partial hepatectomy.
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Figure 5e. Large resectable HCC in a 67-year-old man. (a, b) Axial contrast-enhanced portal phase CT image (a) and axial T1-weighted MR image obtained with gadolinium-based contrast material and fat saturation (b) show, in the right hepatic lobe, a large HCC that has invaded the right portal vein (arrow). (c, d) Photographs show the liver specimen excised for removal of the tumor thrombus (arrow in d) en bloc at right hepatic lobectomy. (e) Follow-up axial contrast-enhanced CT image shows the liver margin after partial hepatectomy.
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Figure 6a. Large resectable HCC in a 47-year-old woman. (a) Axial T1-weighted contrast-enhanced MR image obtained with fat saturation depicts a 13-cm-diameter HCC confined to the right hepatic lobe. (b, c) Photographs obtained during laparotomy and right hepatic lobectomy show HCC at the margin of the liver (b) and the free edge of the left hepatic lobe (c) after argon beam coagulation. (d) Photograph shows the gross specimen after right hepatic lobectomy. (e) Postoperative axial contrast-enhanced CT image shows the surgical margin.
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Figure 6b. Large resectable HCC in a 47-year-old woman. (a) Axial T1-weighted contrast-enhanced MR image obtained with fat saturation depicts a 13-cm-diameter HCC confined to the right hepatic lobe. (b, c) Photographs obtained during laparotomy and right hepatic lobectomy show HCC at the margin of the liver (b) and the free edge of the left hepatic lobe (c) after argon beam coagulation. (d) Photograph shows the gross specimen after right hepatic lobectomy. (e) Postoperative axial contrast-enhanced CT image shows the surgical margin.
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Figure 6c. Large resectable HCC in a 47-year-old woman. (a) Axial T1-weighted contrast-enhanced MR image obtained with fat saturation depicts a 13-cm-diameter HCC confined to the right hepatic lobe. (b, c) Photographs obtained during laparotomy and right hepatic lobectomy show HCC at the margin of the liver (b) and the free edge of the left hepatic lobe (c) after argon beam coagulation. (d) Photograph shows the gross specimen after right hepatic lobectomy. (e) Postoperative axial contrast-enhanced CT image shows the surgical margin.
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Figure 6d. Large resectable HCC in a 47-year-old woman. (a) Axial T1-weighted contrast-enhanced MR image obtained with fat saturation depicts a 13-cm-diameter HCC confined to the right hepatic lobe. (b, c) Photographs obtained during laparotomy and right hepatic lobectomy show HCC at the margin of the liver (b) and the free edge of the left hepatic lobe (c) after argon beam coagulation. (d) Photograph shows the gross specimen after right hepatic lobectomy. (e) Postoperative axial contrast-enhanced CT image shows the surgical margin.
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Figure 6e. Large resectable HCC in a 47-year-old woman. (a) Axial T1-weighted contrast-enhanced MR image obtained with fat saturation depicts a 13-cm-diameter HCC confined to the right hepatic lobe. (b, c) Photographs obtained during laparotomy and right hepatic lobectomy show HCC at the margin of the liver (b) and the free edge of the left hepatic lobe (c) after argon beam coagulation. (d) Photograph shows the gross specimen after right hepatic lobectomy. (e) Postoperative axial contrast-enhanced CT image shows the surgical margin.
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Figure 7a. Large resectable HCC in a 73-year-old patient with Child-Pugh class A cirrhosis. (a) Axial contrast-enhanced T1-weighted MR image obtained with fat saturation shows a 9-cm-diameter HCC (arrow) in liver segment VII. The diminutive size of the left hepatic lobe increases the risk of postoperative hepatic failure. (b) Digital subtraction angiogram shows embolization achieved with percutaneous transhepatic access and insertion of coils in branch vessels of the right portal vein to promote left lobe hypertrophy prior to right hepatic lobectomy. (c) Postprocedural contrast-enhanced CT image depicts coils in the right hepatic lobe.
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Figure 7b. Large resectable HCC in a 73-year-old patient with Child-Pugh class A cirrhosis. (a) Axial contrast-enhanced T1-weighted MR image obtained with fat saturation shows a 9-cm-diameter HCC (arrow) in liver segment VII. The diminutive size of the left hepatic lobe increases the risk of postoperative hepatic failure. (b) Digital subtraction angiogram shows embolization achieved with percutaneous transhepatic access and insertion of coils in branch vessels of the right portal vein to promote left lobe hypertrophy prior to right hepatic lobectomy. (c) Postprocedural contrast-enhanced CT image depicts coils in the right hepatic lobe.
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Figure 7c. Large resectable HCC in a 73-year-old patient with Child-Pugh class A cirrhosis. (a) Axial contrast-enhanced T1-weighted MR image obtained with fat saturation shows a 9-cm-diameter HCC (arrow) in liver segment VII. The diminutive size of the left hepatic lobe increases the risk of postoperative hepatic failure. (b) Digital subtraction angiogram shows embolization achieved with percutaneous transhepatic access and insertion of coils in branch vessels of the right portal vein to promote left lobe hypertrophy prior to right hepatic lobectomy. (c) Postprocedural contrast-enhanced CT image depicts coils in the right hepatic lobe.
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Figure 8. RF ablation electrodes. Photograph of a gross bovine liver specimen shows single- and triple-pronged RF ablation electrodes surrounded by charred tissue. The size of in vivo ablation lesions appears similar, but size is affected by the conduction properties of the organ and by the extent of adjacent vascularity.
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Figure 9a. RF ablation of subcapsular HCC in an 82-year-old man with Child-Pugh class B cirrhosis. (a) Coronal contrast-enhanced arterial phase CT image depicts a 4.0 x 1.6-cm hypervascular HCC (arrow) in the inferior section of the right hepatic lobe. (b) Axial CT image obtained for guidance during percutaneous RF ablation shows placement of the electrode in the center of the tumor. (c) Coronal contrast-enhanced CT image, obtained 1 month after RF ablation, depicts a good margin of ablated tissue, with no residual tumor (arrow) and no evidence of injury to adjacent structures.
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Figure 9b. RF ablation of subcapsular HCC in an 82-year-old man with Child-Pugh class B cirrhosis. (a) Coronal contrast-enhanced arterial phase CT image depicts a 4.0 x 1.6-cm hypervascular HCC (arrow) in the inferior section of the right hepatic lobe. (b) Axial CT image obtained for guidance during percutaneous RF ablation shows placement of the electrode in the center of the tumor. (c) Coronal contrast-enhanced CT image, obtained 1 month after RF ablation, depicts a good margin of ablated tissue, with no residual tumor (arrow) and no evidence of injury to adjacent structures.
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Figure 9c. RF ablation of subcapsular HCC in an 82-year-old man with Child-Pugh class B cirrhosis. (a) Coronal contrast-enhanced arterial phase CT image depicts a 4.0 x 1.6-cm hypervascular HCC (arrow) in the inferior section of the right hepatic lobe. (b) Axial CT image obtained for guidance during percutaneous RF ablation shows placement of the electrode in the center of the tumor. (c) Coronal contrast-enhanced CT image, obtained 1 month after RF ablation, depicts a good margin of ablated tissue, with no residual tumor (arrow) and no evidence of injury to adjacent structures.
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Figure 10a. Postablation abscess in a 50-year-old man. (a) Axial unenhanced CT image through segments V and VI of the liver depicts an abscess (arrow) associated with a recent RF ablation site. A percutaneous catheter was placed in the abscess to facilitate healing. (b) Digital subtraction angiogram obtained with infusion of iodinated contrast material via the catheter depicts communication of the abscess with the biliary system (arrow). The patient had a preexistent choledochojejunal anastomosis, which greatly increased the risk for formation of a post–RF ablation abscess.
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Figure 10b. Postablation abscess in a 50-year-old man. (a) Axial unenhanced CT image through segments V and VI of the liver depicts an abscess (arrow) associated with a recent RF ablation site. A percutaneous catheter was placed in the abscess to facilitate healing. (b) Digital subtraction angiogram obtained with infusion of iodinated contrast material via the catheter depicts communication of the abscess with the biliary system (arrow). The patient had a preexistent choledochojejunal anastomosis, which greatly increased the risk for formation of a post–RF ablation abscess.
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Figure 11a. RF ablation of HCC performed after fluid instillation in a 74-year-old woman with Child-Pugh class B cirrhosis. (a) Coronal contrast-enhanced CT image shows a 5 x 4.5-cm HCC (arrow) in liver segment V, directly adjacent to the hepatic flexure of the large bowel. (b) Axial unenhanced CT image obtained to guide ablation shows a 22-gauge needle placed into the right subhepatic space and 150 mL of sterile water (arrow) instilled to displace the bowel from the ablation site. (c) Axial unenhanced CT image obtained during percutaneous RF ablation shows the electrode positioned in the tumor with a right lateral approach. (d) Axial contrast-enhanced CT image obtained immediately after ablation shows a nonenhancing defect (arrow) in the ablation site, a finding consistent with successful RF ablation. No associated bowel injury was identified.
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Figure 11b. RF ablation of HCC performed after fluid instillation in a 74-year-old woman with Child-Pugh class B cirrhosis. (a) Coronal contrast-enhanced CT image shows a 5 x 4.5-cm HCC (arrow) in liver segment V, directly adjacent to the hepatic flexure of the large bowel. (b) Axial unenhanced CT image obtained to guide ablation shows a 22-gauge needle placed into the right subhepatic space and 150 mL of sterile water (arrow) instilled to displace the bowel from the ablation site. (c) Axial unenhanced CT image obtained during percutaneous RF ablation shows the electrode positioned in the tumor with a right lateral approach. (d) Axial contrast-enhanced CT image obtained immediately after ablation shows a nonenhancing defect (arrow) in the ablation site, a finding consistent with successful RF ablation. No associated bowel injury was identified.
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Figure 11c. RF ablation of HCC performed after fluid instillation in a 74-year-old woman with Child-Pugh class B cirrhosis. (a) Coronal contrast-enhanced CT image shows a 5 x 4.5-cm HCC (arrow) in liver segment V, directly adjacent to the hepatic flexure of the large bowel. (b) Axial unenhanced CT image obtained to guide ablation shows a 22-gauge needle placed into the right subhepatic space and 150 mL of sterile water (arrow) instilled to displace the bowel from the ablation site. (c) Axial unenhanced CT image obtained during percutaneous RF ablation shows the electrode positioned in the tumor with a right lateral approach. (d) Axial contrast-enhanced CT image obtained immediately after ablation shows a nonenhancing defect (arrow) in the ablation site, a finding consistent with successful RF ablation. No associated bowel injury was identified.
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Figure 11d. RF ablation of HCC performed after fluid instillation in a 74-year-old woman with Child-Pugh class B cirrhosis. (a) Coronal contrast-enhanced CT image shows a 5 x 4.5-cm HCC (arrow) in liver segment V, directly adjacent to the hepatic flexure of the large bowel. (b) Axial unenhanced CT image obtained to guide ablation shows a 22-gauge needle placed into the right subhepatic space and 150 mL of sterile water (arrow) instilled to displace the bowel from the ablation site. (c) Axial unenhanced CT image obtained during percutaneous RF ablation shows the electrode positioned in the tumor with a right lateral approach. (d) Axial contrast-enhanced CT image obtained immediately after ablation shows a nonenhancing defect (arrow) in the ablation site, a finding consistent with successful RF ablation. No associated bowel injury was identified.
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Figure 12a. Pretreatment assessment of HCC in a 57-year-old man with Child-Pugh class B cirrhosis. (a, b) Axial contrast-enhanced CT images show a heterogeneously enhancing, infiltrative, multifocal HCC and tumor thrombus in the main portal vein (arrow in b). (c) Late-phase digital subtraction angiogram obtained with hepatic artery access depicts hepatofugal flow in the portal vein (arrow). The large volume of ascites, retrograde portal venous flow, and compromised hepatic function (total bilirubin, >2.0 mg/dL) indicated that the patient was too ill for transarterial therapy. He was referred for systemic therapy.
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Figure 12b. Pretreatment assessment of HCC in a 57-year-old man with Child-Pugh class B cirrhosis. (a, b) Axial contrast-enhanced CT images show a heterogeneously enhancing, infiltrative, multifocal HCC and tumor thrombus in the main portal vein (arrow in b). (c) Late-phase digital subtraction angiogram obtained with hepatic artery access depicts hepatofugal flow in the portal vein (arrow). The large volume of ascites, retrograde portal venous flow, and compromised hepatic function (total bilirubin, >2.0 mg/dL) indicated that the patient was too ill for transarterial therapy. He was referred for systemic therapy.
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Figure 12c. Pretreatment assessment of HCC in a 57-year-old man with Child-Pugh class B cirrhosis. (a, b) Axial contrast-enhanced CT images show a heterogeneously enhancing, infiltrative, multifocal HCC and tumor thrombus in the main portal vein (arrow in b). (c) Late-phase digital subtraction angiogram obtained with hepatic artery access depicts hepatofugal flow in the portal vein (arrow). The large volume of ascites, retrograde portal venous flow, and compromised hepatic function (total bilirubin, >2.0 mg/dL) indicated that the patient was too ill for transarterial therapy. He was referred for systemic therapy.
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Figure 13a. Chemoembolization of HCC in a 78-year-old man. (a, b) Axial contrast-enhanced T1-weighted MR image obtained with fat saturation (a) and contrast-enhanced arterial phase CT image (b) depict a 13 x 12-cm heterogeneously enhancing HCC that has nearly replaced the right liver lobe. Because of the extensive liver involvement and comorbidities, the patient was a poor candidate for surgery. (c) Digital subtraction angiogram, obtained with right hepatic artery access via a 3-F microcatheter, shows arteries draped around the large tumor. For therapy, a mixture of cisplatin, doxorubicin, and mitomycin C in a 1:1 emulsion of ethiodol was infused via the same microcatheter and was followed immediately by an infusion of 500–700-µm-diameter polyvinyl alcohol particles to achieve arterial embolization. No additional arterial supply to the tumor was identified. (d) Right hepatic arteriogram, obtained after embolization, shows an accumulation of ethiodol in the tumor bed and decreased arterial blood flow to the tumor. (e) Axial unenhanced CT image obtained just before the patient’s discharge shows a fairly uniform accumulation of ethiodol in the tumor and none in the normal liver tissue, findings that provided assurance that chemotherapy was appropriately administered.
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Figure 13b. Chemoembolization of HCC in a 78-year-old man. (a, b) Axial contrast-enhanced T1-weighted MR image obtained with fat saturation (a) and contrast-enhanced arterial phase CT image (b) depict a 13 x 12-cm heterogeneously enhancing HCC that has nearly replaced the right liver lobe. Because of the extensive liver involvement and comorbidities, the patient was a poor candidate for surgery. (c) Digital subtraction angiogram, obtained with right hepatic artery access via a 3-F microcatheter, shows arteries draped around the large tumor. For therapy, a mixture of cisplatin, doxorubicin, and mitomycin C in a 1:1 emulsion of ethiodol was infused via the same microcatheter and was followed immediately by an infusion of 500–700-µm-diameter polyvinyl alcohol particles to achieve arterial embolization. No additional arterial supply to the tumor was identified. (d) Right hepatic arteriogram, obtained after embolization, shows an accumulation of ethiodol in the tumor bed and decreased arterial blood flow to the tumor. (e) Axial unenhanced CT image obtained just before the patient’s discharge shows a fairly uniform accumulation of ethiodol in the tumor and none in the normal liver tissue, findings that provided assurance that chemotherapy was appropriately administered.
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Figure 13c. Chemoembolization of HCC in a 78-year-old man. (a, b) Axial contrast-enhanced T1-weighted MR image obtained with fat saturation (a) and contrast-enhanced arterial phase CT image (b) depict a 13 x 12-cm heterogeneously enhancing HCC that has nearly replaced the right liver lobe. Because of the extensive liver involvement and comorbidities, the patient was a poor candidate for surgery. (c) Digital subtraction angiogram, obtained with right hepatic artery access via a 3-F microcatheter, shows arteries draped around the large tumor. For therapy, a mixture of cisplatin, doxorubicin, and mitomycin C in a 1:1 emulsion of ethiodol was infused via the same microcatheter and was followed immediately by an infusion of 500–700-µm-diameter polyvinyl alcohol particles to achieve arterial embolization. No additional arterial supply to the tumor was identified. (d) Right hepatic arteriogram, obtained after embolization, shows an accumulation of ethiodol in the tumor bed and decreased arterial blood flow to the tumor. (e) Axial unenhanced CT image obtained just before the patient’s discharge shows a fairly uniform accumulation of ethiodol in the tumor and none in the normal liver tissue, findings that provided assurance that chemotherapy was appropriately administered.
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Figure 13d. Chemoembolization of HCC in a 78-year-old man. (a, b) Axial contrast-enhanced T1-weighted MR image obtained with fat saturation (a) and contrast-enhanced arterial phase CT image (b) depict a 13 x 12-cm heterogeneously enhancing HCC that has nearly replaced the right liver lobe. Because of the extensive liver involvement and comorbidities, the patient was a poor candidate for surgery. (c) Digital subtraction angiogram, obtained with right hepatic artery access via a 3-F microcatheter, shows arteries draped around the large tumor. For therapy, a mixture of cisplatin, doxorubicin, and mitomycin C in a 1:1 emulsion of ethiodol was infused via the same microcatheter and was followed immediately by an infusion of 500–700-µm-diameter polyvinyl alcohol particles to achieve arterial embolization. No additional arterial supply to the tumor was identified. (d) Right hepatic arteriogram, obtained after embolization, shows an accumulation of ethiodol in the tumor bed and decreased arterial blood flow to the tumor. (e) Axial unenhanced CT image obtained just before the patient’s discharge shows a fairly uniform accumulation of ethiodol in the tumor and none in the normal liver tissue, findings that provided assurance that chemotherapy was appropriately administered.
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Figure 13e. Chemoembolization of HCC in a 78-year-old man. (a, b) Axial contrast-enhanced T1-weighted MR image obtained with fat saturation (a) and contrast-enhanced arterial phase CT image (b) depict a 13 x 12-cm heterogeneously enhancing HCC that has nearly replaced the right liver lobe. Because of the extensive liver involvement and comorbidities, the patient was a poor candidate for surgery. (c) Digital subtraction angiogram, obtained with right hepatic artery access via a 3-F microcatheter, shows arteries draped around the large tumor. For therapy, a mixture of cisplatin, doxorubicin, and mitomycin C in a 1:1 emulsion of ethiodol was infused via the same microcatheter and was followed immediately by an infusion of 500–700-µm-diameter polyvinyl alcohol particles to achieve arterial embolization. No additional arterial supply to the tumor was identified. (d) Right hepatic arteriogram, obtained after embolization, shows an accumulation of ethiodol in the tumor bed and decreased arterial blood flow to the tumor. (e) Axial unenhanced CT image obtained just before the patient’s discharge shows a fairly uniform accumulation of ethiodol in the tumor and none in the normal liver tissue, findings that provided assurance that chemotherapy was appropriately administered.
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Figure 14a. Selective internal radiation therapy of HCC in an 82-year-old man. (a) Axial contrast-enhanced arterial phase CT image depicts a 5 x 4.5-cm hypervascular HCC (arrow) that involves liver segments VIII and IVa. The location of the tumor directly adjacent to the inferior vena cava precludes surgical management and RF ablation. (b) Coronal whole-body PET images show avid uptake of the radioisotope by the HCC in the liver dome (arrows). (c) Digital subtraction angiogram of the celiac arterial trunk demonstrates right hepatic arterial supply to the HCC (arrow). (d) Digital subtraction angiogram shows the tumor after superselective catheterization and infusion of 150 Gy of 90Y via a 3-F microcatheter into the arterial blood supply.
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Figure 14b. Selective internal radiation therapy of HCC in an 82-year-old man. (a) Axial contrast-enhanced arterial phase CT image depicts a 5 x 4.5-cm hypervascular HCC (arrow) that involves liver segments VIII and IVa. The location of the tumor directly adjacent to the inferior vena cava precludes surgical management and RF ablation. (b) Coronal whole-body PET images show avid uptake of the radioisotope by the HCC in the liver dome (arrows). (c) Digital subtraction angiogram of the celiac arterial trunk demonstrates right hepatic arterial supply to the HCC (arrow). (d) Digital subtraction angiogram shows the tumor after superselective catheterization and infusion of 150 Gy of 90Y via a 3-F microcatheter into the arterial blood supply.
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Figure 14c. Selective internal radiation therapy of HCC in an 82-year-old man. (a) Axial contrast-enhanced arterial phase CT image depicts a 5 x 4.5-cm hypervascular HCC (arrow) that involves liver segments VIII and IVa. The location of the tumor directly adjacent to the inferior vena cava precludes surgical management and RF ablation. (b) Coronal whole-body PET images show avid uptake of the radioisotope by the HCC in the liver dome (arrows). (c) Digital subtraction angiogram of the celiac arterial trunk demonstrates right hepatic arterial supply to the HCC (arrow). (d) Digital subtraction angiogram shows the tumor after superselective catheterization and infusion of 150 Gy of 90Y via a 3-F microcatheter into the arterial blood supply.
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Figure 14d. Selective internal radiation therapy of HCC in an 82-year-old man. (a) Axial contrast-enhanced arterial phase CT image depicts a 5 x 4.5-cm hypervascular HCC (arrow) that involves liver segments VIII and IVa. The location of the tumor directly adjacent to the inferior vena cava precludes surgical management and RF ablation. (b) Coronal whole-body PET images show avid uptake of the radioisotope by the HCC in the liver dome (arrows). (c) Digital subtraction angiogram of the celiac arterial trunk demonstrates right hepatic arterial supply to the HCC (arrow). (d) Digital subtraction angiogram shows the tumor after superselective catheterization and infusion of 150 Gy of 90Y via a 3-F microcatheter into the arterial blood supply.
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Figure 15a. Pretreatment scintigraphy in a patient scheduled for selective internal radiation therapy. (a) Anterior and posterior planar projection images obtained with a gamma camera after a hepatic arterial infusion of 2 mCi (74 MBq) of 99mTc macroaggregated albumin via a catheter to quantitate the hepatic artery–to–hepatic vein shunting effect created by the tumor and to demonstrate any reflux toward the gastrointestinal tract, prior to the administration of 90Y for therapy. (b) Regions of interest drawn on anterior and posterior projection images were used to measure and compare the ratio of hepatic activity to pulmonary activity. Excessive shunting requires either dose reduction or treatment cancellation.
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Figure 15b. Pretreatment scintigraphy in a patient scheduled for selective internal radiation therapy. (a) Anterior and posterior planar projection images obtained with a gamma camera after a hepatic arterial infusion of 2 mCi (74 MBq) of 99mTc macroaggregated albumin via a catheter to quantitate the hepatic artery–to–hepatic vein shunting effect created by the tumor and to demonstrate any reflux toward the gastrointestinal tract, prior to the administration of 90Y for therapy. (b) Regions of interest drawn on anterior and posterior projection images were used to measure and compare the ratio of hepatic activity to pulmonary activity. Excessive shunting requires either dose reduction or treatment cancellation.
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Copyright © 2005 by the Radiological Society of North America.
