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Cone-Beam Computed Tomography to Assist in DEB-TACE for HCC in the Caudate Lobe
Abstract: Transarterial chemoembolization (TACE) plays an important role in the treatment of hepatocellular carcinoma (HCC). Recognition of the tumor arterial supply is necessary to perform effective TACE. In this sense cone-beam computed tomography (CBCT) may be a helpful tool to assist interventional oncologists performing TACE in specific situations. We report the case of a 65-year-old patient with HCC located in the caudate lobe successfully treated by CBCT-assisted TACE.
Key words: Hepatocellular carcinoma, caudate lobe, transarterial chemoembolization, drug-eluting beads, cone-beam computed tomography
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Transarterial chemoembolization (TACE) is recommended as the standard of care for nonsurgical large or multinodular noninvasive hepatocellular carcinoma (HCC) isolated to the liver, provided there is good liver function.1 In addition, it may be indicated in patients with inoperable small tumors not suitable for local ablation or as a bridge before liver transplantation.1,2
The caudate lobe is a deep liver anatomic structure, surrounded by major vessels and complex arterial supply and venous drainage. Surgical resection, percutaneous ablation and TACE at this location remain challenging.3
The arterial anatomy of the caudate lobe is complex and variable, rendering identification of the angiographic anatomy with conventional angiography occasionally difficult.3,4 Recognition of feeding arteries of a tumor is crucial to perform an effective TACE.3 In this sense, some authors reported that cone-beam computed tomography (CBCT) could provide more information than standard angiography, particularly in detecting the caudate arteries.4-7 We report the case of a 65-year-old patient with HCC located in the caudate lobe successfully treated by TACE with CBCT assistance.
Case Report
A 65-year-old male with a 3cm HCC in the caudate lobe was referred for TACE as a bridge to liver transplantation. The patient had cirrhosis due to hemochromatosis and idiopathic pulmonary fibrosis. Serum alpha-fetoprotein (854 ng/mL) and bilirubin (1.9 mg/dL) levels were elevated, and serum albumin (2.2 g/dL) decreased, with a PT INR of 1.05. The patient had moderate ascites. Liver function was categorized as Child-Pugh C and performance status as ECOG 2. Magnetic resonance imaging (MRI) showed typical imaging findings of cirrhosis and a single HCC at the caudate lobe (Figure 1).
TACE was performed after obtaining informed consent. The intervention was performed in the angiographic suite (Artis Zeego; Siemens) under conscious sedation. The hepatic angiogram could not depict the HCC even after selective catheterization of the lobar hepatic arteries (Figure 2). CBCT acquisitions were obtained sequentially after catheterization of two different branches of the left hepatic artery (LHA) thought to supply the caudate lobe. CBCT clearly showed enhancement of the normal caudate lobe parenchyma after injection of one caudate artery and tumor enhancement after catheterization of another caudate branch (Figure 3). TACE was performed from the latter arterial feeder with 100-300 µ doxorubicin-loaded DC Beads (BTG).
Follow-up was uneventful and the patient was discharged from the hospital the morning after. At 3 months follow-up, AFP levels dropped to 47.3 ng/mL and MRI showed complete response according to mRECIST criteria (Figure 4). Six months later, cirrhosis evolved leading to further progressive liver and renal failure that ultimately caused the death of the patient, who was still on the liver transplantation waiting list. Autopsy was not performed.
Discussion
Knowledge of the hepatic anatomy is essential to achieve selective catheterization of the tumor-feeding branches. The caudate lobe is divided into 3 subsegments according to portal vein ramification: the Spiegel lobe (the protuberant hepatic portion to the left of the intrahepatic vena cava), the paracaval portion (in front of the intrahepatic vena cava and surrounded by the right and middle hepatic veins), and the caudate process (a tongue-like projection between the vena cava and adjacent portal vein).8,9
The arteries that supply the caudate lobe may arise from the right hepatic artery (RHA), left hepatic artery (LHA), or common hepatic artery (CHA) and are frequently variable and/or multiple.8-10 The caudate process and the paracaval segment are both usually supplied by a caudate artery originated in the RHA.8-10 The Spiegel lobe may be supplied from caudate arteries originating from the LHA or the RHA.8,9 In addition, arterial supply to the latter may arise from the communicating arcade between the RHA and LHA at the hepatic hilum.9,11 The arteries of the caudate lobe usually overlap with other hepatic arteries on angiograms, rendering identification of the angiographic anatomy during chemoembolization procedures difficult.4,8,9
In the case report the HCC was localized in the Spiegel lobe, but its feeders were neither depicted at regular hepatic angiography nor after lobar injections. Acquisition of CBCT after selective catheterization of 2 different branches of the LHA allowed proper identification of the feeding caudate artery of the target tumor. Thus selective TACE with drug-eluting beads (DEB-TACE) could be safely and effectively performed. There were no complications and complete response was observed at follow-up MRI.
CBCT is an imaging technique that provides computed tomography images from a rotational scan acquired with a C-arm equipped with a flat panel detector.5,12 It allows CT-like images using angiographic equipment.
Several authors have advocated the utility of CBCT to assist with TACE in difficult cases.5,6,12 Iwasawa et al5 compared the accuracy in the identification of tumor-feeding arteries during TACE in 33 patients with HCC when using CBCT in addition to regular angiography. They reported higher sensitivity, specificity, and accuracy of CBCT (96.9%, 97.0%, and 96.9%, respectively) compared to angiography (77.2%, 73.0%, and 75.4%). They concluded that CBCT could be a useful tool when there are difficulties to identify tumor arterial feeders during TACE, as it happened in our case report.
Some authors suggested that CBCT might also have a role as a predictor of tumor response or even an impact on patient clinical outcome.12-15 Loffroy et al13 reported that CBCT could serve as an early marker of tumor necrosis and showed a linear correlation with MRI imaging at one month follow up after DEB-TACE. Iwazawa et al14 showed in a retrospective multivariate analysis that CBCT assistance was an independent factor associated with longer overall survival (P=.033) and local progression-free survival (P=.003). Miyayama et al15 reported in a retrospective study that the cumulative local recurrence rates of HCC ≤6 cm were significantly smaller in patients where CBCT guidance was used during TACE.
Conclusion
The use of CBCT could be helpful for the operator in difficult cases and has been recommended to achieve superselective TACE in HCC that has not been showed on angiography, or in the case of hypovascular metastases.16 In our case report, CBCT proved to be useful in identifying the caudate artery feeding the HCC that could not be depicted at regular angiography.
Editor’s note: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Garcia-Monaco reports consultancy to BTG and Celonova, as well as speaker’s fees from Siemens. Dr. Kenny reports no related disclosures.
Manuscript received September 4, 2015; manuscript accepted October 19, 2015.
Ricardo Garcia-Monaco, MD, may be reached at ricardo.garciamonaco@hospitalitaliano.org.ar
Suggested citation: Kenny A, Garcia-Monaco R. Cone-beam computed tomography to assist in DEB-TACE for HCC in the caudate lobe. Intervent Oncol 360. 2015;3(10):E112-E117.
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