Selective doxorubicin drug eluting beads chemoembolization of hypovascular hepatocellular carcinoma using cone beam computed tomography
A 60-year-old male with child-pugh class A cirrhosis was detected to have elevated α-fetoprotein levels (180 international units/ml) during routine screening. He was a chronic alcoholic with a history of coronary artery disease. He underwent biphasic contrast-enhanced computed tomography and magnetic resonance imaging, which showed a 6 cm × 5.6 cm hypodense exophytic lesion in segments five and eight of the liver, with minimal enhancement in the arterial phase []. There was no significant washout or enhancement in the portal venous phase []. Mild hypertrophy of the left lobe was also observed, with a few collaterals at the porta and splenic hilum. Fine-needle aspiration of the lesion confirmed the lesion to be HCC.\nAs the patient was unfit for surgery, we decided on DEB TACE. He was taken up for DEB TACE in the digital subtraction angiography (DSA) suite. Selective angiograms of the celiac artery and hepatic artery [] were performed, which showed no significant abnormal blush from the branches of the right hepatic artery (RHA). We decided to selectively cannulate the RHA branches. We first cannulated the medial-most branch, which showed mild abnormal blush, although it was not in the anatomical region of the tumor []. Before embolization we carried out XperCT™ (Philips Healthcare, Best, The Netherlands) acquisition, which showed that the vessel was exclusively supplying the normal hepatic parenchyma []. The possibility of embolizing this normal vessel was thus avoided. XperCT™, a kind of cone-beam CT, was performed with a flat-panel detector C-arm angiography system. Scanning was performed with propeller movement, with an acquisition time of 10 s, a detector size of 30 cm × 38 cm, a fixed tube–detector distance of 0.9 m, a total scanning angle of 240°, and 2480 × 1920 pixel matrix with a 154 μm pixel pitch. Fifteen milliliters of contrast was injected at an injection rate of 1 ml/s in the selectively cannulated hepatic artery branch. The XperCT™ scans were acquired approximately 6 s after the start of injection. The raw datasets from the angiographic C-arm system were sent to a dedicated workstation and reconstructions were performed to generate the volume data. The multiplanar reconstruction (MPR) and maximum intensity projection (MIP) images were studied and the vessels to be embolized were selected based on these images.\nNext, we selectively cannulated the middle and the lateral branches of the RHA and these were seen to be supplying the tumor. Vascular supply to the tumor by these vessels was confirmed on XperCT™ [Figure and ] and we selectively embolized these vessels using DEB. Using XperCT™ we could deliver the drug precisely and accurately into the tumor-feeding vessels and prevent unnecessary embolization of normal hepatic parenchyma. No procedure-related complications occurred. Post-procedure follow-up CT showed almost complete tumoral necrosis [].