Korean J Radiol.  2015 Oct;16(5):1068-1078. 10.3348/kjr.2015.16.5.1068.

Does Establishing a Safety Margin Reduce Local Recurrence in Subsegmental Transarterial Chemoembolization for Small Nodular Hepatocellular Carcinomas?

• Kang HJ
• Kim YI
• Kim HC
• Jae HJ
• Hur S
• Chung JW

• KMID: 2160774
• DOI: http://doi.org/10.3348/kjr.2015.16.5.1068

Abstract

OBJECTIVE
To test the hypothesis that a safety margin may affect local tumor recurrence (LTR) in subsegmental chemoembolization.
MATERIALS AND METHODS
In 101 patients with 128 hepatocellular carcinoma (HCC) nodules (1-3 cm in size and < or = 3 in number), cone-beam CT-assisted subsegmental lipiodol chemoembolization was performed. Immediately thereafter, a non-contrast thin-section CT image was obtained to evaluate the presence or absence of intra-tumoral lipiodol uptake defect and safety margin. The effect of lipiodol uptake defect and safety margin on LTR was evaluated. Univariate and multivariate analyses were performed to indentify determinant factors of LTR.
RESULTS
Of the 128 HCC nodules in 101 patients, 49 (38.3%) nodules in 40 patients showed LTR during follow-up period (median, 34.1 months). Cumulative 1- and 2-year LTR rates of nodules with lipiodol uptake defect (n = 27) and those without defect (n = 101) were 58.1% vs. 10.1% and 72.1% vs. 19.5%, respectively (p < 0.001). Among the 101 nodules without a defect, the 1- and 2-year cumulative LTR rates for nodules with complete safety margin (n = 52) and those with incomplete safety margin (n = 49) were 9.8% vs. 12.8% and 18.9% vs. 19.0% (p = 0.912). In multivariate analyses, ascites (p = 0.035), indistinct tumor margin on cone-beam CT (p = 0.039), heterogeneous lipiodol uptake (p = 0.023), and intra-tumoral lipiodol uptake defect (p < 0.001) were determinant factors of higher LTR.
CONCLUSION
In lipiodol chemoembolization, the safety margin in completely lipiodolized nodule without defect will not affect LTR in small nodular HCCs.

Keyword

Safety margin; Local tumor recurrence; Subsegmental transarterial chemoembolization; Hepatocellular carcinoma; Cone-beam CT

MeSH Terms

Adult
Aged
Carcinoma, Hepatocellular/radiography/*therapy
Chemoembolization, Therapeutic
Cone-Beam Computed Tomography
Ethiodized Oil/*administration & dosage
Female
Follow-Up Studies
Humans
Liver Neoplasms/radiography/*therapy
Male
Middle Aged
Multivariate Analysis
Neoplasm Recurrence, Local/radiography
Ethiodized Oil

Figure

• 

  Fig. 1 Sustained complete tumor response after TACE in 60-year-old female with hepatocellular carcinoma. A. Arterial-phase CT scan showing 1.5 cm-sized hypervascular tumor at segment 5 of right hepatic lobe (arrows). B. On cone-beam CT hepatic arteriography, hypervascular tumor nodule showed clear tumor margin (arrows). C. After subsegmental TACE, tumor showed homogenous lipiodol uptake in entire tumor nodule (arrows) on lipiodol CT. D. Three years later, TACE-treated nodule was shrunken in size without evidence of local tumor recurrence (arrowheads). TACE = transarterial chemoembolization

• 

  Fig. 2 Local tumor recurrence after TACE in 80-year-old female with hepatocellular carcinoma. A. Arterial-phase CT scan showing 1.5 cm-sized hypervascular tumor at segment 8 of right hepatic lobe. Posterior aspect of tumor is relatively hypovascular (black arrows). B. On cone-beam CT hepatic arteriography, anterior hypervascular part of tumor showed strong contrast enhancement with clear tumor margin. In contrast, posterior hypovascular part showed subtle contrast enhancement with indistinct tumor margin (black arrows). C. After subsegmental TACE, tumor showed heterogeneous lipiodol uptake (dense lipiodol uptake in hypervascular component and faint lipiodol uptake in hypovascular component) (white arrow) on lipiodol CT. D. Three years later, arterial-phase CT scan showed enhanced recurrent tumor at area of hypovascular component (black arrowheads). Area of hypervascular component was shrunken in size with persistent lipiodol uptake (white arrowhead). TACE = transarterial chemoembolization

• 

  Fig. 3 Methods used to determine lipiodol uptake defect in tumor after TACE. A, B. Non-contrast thin-section CT taken immediately after TACE (B) revealed complete lipiodol retention throughout hypervascular tumor at left hepatic lobe on cone-beam CT hepatic arteriography (A). C, D. Non-contrast thin-section CT after TACE (D) revealed focal lipiodol uptake defect (arrow in D) in hypervascular tumor at segment 4 upon cone-beam CT hepatic arteriography (C). TACE = transarterial chemoembolization

• 

  Fig. 4 Methods used to determine safety margin in liver parenchyma surrounding tumor after TACE. A. On non-contrast thin-section CT taken immediately after TACE, wedge-shaped parenchymal lipiodol deposition completely encased entire surface of tumor, which was interpreted as 'complete safety margin' (black arrows). B. On non-contrast CT thin-section CT taken immediately after TACE, posteromedial aspect of tumor was not completely covered by parenchymal lipiodol deposition (white arrows), which was interpreted as 'incomplete safety margin'. TACE = transarterial chemoembolization

• 

  Fig. 5 Cumulative local tumor recurrence curve showing cumulative local tumor recurrence rate depending on presence or absence of intra-tumoral lipiodol uptake defect and safety margin. In completely lipiodolized nodules (nodules without intra-tumoral lipiodol uptake defect), completeness of safety margin did not affect cumulative local recurrence rate (p = 0.912). SM = safety margin

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