J Liver Cancer.  2019 Mar;19(1):19-29. 10.17998/jlc.19.1.19.

Conventional Chemoembolization for Hepatocellular Carcinoma: Role of Cone-Beam Computed Tomography Guidance

  • 1Department of Radiology, National Cancer Center, Goyang, Korea.
  • 2Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea. chungjw@snu.ac.kr


Conventional chemoembolization using Lipiodol-based regimens was introduced in the 1980s, and it is currently recommended as the primary treatment modality for patients with unresectable, intermediate, or locally advanced hepatocellular carcinoma (HCC) by the international guidelines. For better therapeutic efficacy and safety, chemoembolization should be performed as selectively as possible through tumor-feeding arteries, based on the detection of arterial supply to the HCC. With the technical advancement of flat-panel detector, cone-beam computed tomography (CBCT) is mounted on the C-arm of the angiographic machine. CBCT facilitates the detection of small occult HCCs and fine tumor-feeding arteries, recognition of extrahepatic collateral supply, navigation of a microcatheter to the target feeding arteries, prevention of non-target embolization, and intraprocedural assessment of the completeness of treatment with chemoembolization. These functions performed by CBCT ultimately improve the safety and efficacy of chemoembolization and may contribute to improving the prognosis of the patient with HCC.


Hepatocellular carcinoma; Therapeutics; Cone-beam computed tomography

MeSH Terms

Carcinoma, Hepatocellular*
Cone-Beam Computed Tomography*


  • Figure 1. Superselective cTACE for a single small tumor in a 60-year-old man. (A) Liver MRI shows a 1.8 cm nodular tumor (arrows) with arterial enhancement (left side) and delayed washout (right side) in the segment 8 of the liver. (B) Common hepatic arteriography shows a faint enhancing tumor (arrows). (C) The tip (white arrow) of microcatheter is placed at the tumor-feeding artery, and the Lipiodol-based emulsion is infused. The portal veins (arrowheads) and tumor (black arrows) are visualized in the fluoroscopy image. (D) 3-month (left side) and 36-month (right side) follow-up CT shows dense Lipiodol accumulation at the tumor (arrows) without local recurrence. cTACE, conventional transarterial chemoembolization; MRI, magnetic resonance imaging; CT, computed tomography.

  • Figure 2. CBCT-guided cTACE for two nodular tumors in a 45-year-old man. (A) The arterial phase image of liver MRI shows two enhancing tumors (arrows) in segment 8 (left side) and segment 6 (right side). (B) Two enhancing tumors (arrows) are demonstrated in the common hepatic arteriography. (C) Axial image of CBCT shows two enhancing tumors (arrows) that are correlated with the preprocedural MRI. (D) The tumors (arrows) and their tumor-feeding arteries can be analyzed by using maximum intensity projection image (left side) and volume rendered image (right side). (E) Superselective chemoembolization is performed through each tumor-feeding artery. (F) Immediate, unenhanced CT shows dense Lipiodol accumulation in the tumors (arrows). CBCT, conebeam computed tomography; cTACE, conventional transarterial chemoembolization; MRI, magnetic resonance imaging; CT, computed tomography.

  • Figure 3. Depiction of the tumor-feeding arteries of four nodular tumors (arrows) using automated vessel tracking system (Emboguide; Phillips Medical Systems, Eindhoven, the Netherlands) in a 61-year-old woman.

  • Figure 4. Recognition of extrahepatic collateral arterial supply to the tumor using CBCT images in a 62-year-old man. (A) Arterial phase image of CT shows large hypervascular tumor (arrows) in the paracaval portion of the liver. The RIPA is also demonstrated around the tumor (arrowhead). (B) Common hepatic angiography shows the hypervascular tumor (arrow). (C) Non-enhancing part (arrows) of the tumor is demonstrated in the axial image of CBCT but not in the preprocedural CT image (Fig. 4A), which suggests the presence of extrahepatic collateral artery supplying the tumor. (D) Angiography of the RIPA shows tumor staining. Angiography of the RIPA shows tumor staining (arrowhead). (E) Supserselective cTACE is performed through the RIPA, segment 7 hepatic artery, segment 8 hepatic artery, and caudate artery. (F) Immediate, unenhanced CT shows dense Lipiodol accumulation at the tumor (arrows). CBCT, cone-beam computed tomography; CT, computed tomography; RIPA, right inferior phrenic artery; cTACE, conventional transarterial chemoembolization.

  • Figure 5. Recognition of extrahepatic collateral arterial supply to the small tumor using CBCT images in a 55-year-old man. (A) Arterial phase image of MRI shows a small-rim enhancing tumor (arrow) at the paracaval portion of the liver. (B) On distal subtraction angiography of the common hepatic arteriography (left side), it is difficult to know whether or not there is tumor staining. However, the axial image of CBCT (right side) shows no tumor staining and the parenchymal perfusion defect at the paracaval portion (circle), which suggests the presence of an extrahepatic collateral arterial supply. This is the typical location that is supplied by the right inferior phrencic artery. (C) Tumor staining (arrow on left side) is suspected on distal subtraction angiography of the right inferior phrenic arteriography, but it is difficult to be sure. However, the axial image of CBCT clearly shows the small tumor (arrow on right), which is detected with preprocedural MRI. CBCT, cone-beam computed tomography; MRI, magnetic resonance imaging.


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