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Aim: To determine the optimal catheter position during superselective conventional transarterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC) using virtual parenchymal perfusion software. Methods: Patients who had newly developed HCC nodules ≤6 cm and five or fewer lesions were eligible. The virtual catheter tip was placed on a tumor‐feeder identified by TACE guidance software using cone‐beam computed tomography during hepatic arteriography to minimize the virtual embolized area (VEA), including the tumor with a safety margin. Conventional transarterial chemoembolization was then carried out at the same position. The VEA and real embolized area where iodized oil was retained on cone‐beam computed tomography after cTACE were compared using the dice similarity coefficient, linear regression analysis, and mean surface distance. Technical success of cTACE and therapeutic effects by the modified Response Evaluation Criteria in Solid Tumors were also evaluated. Results: Ninety‐one tumors in 56 patients were embolized. The mean dice similarity coefficient values in 80 VEAs and real embolized areas were 0.78 ± 0.01. Both volumes were well correlated (r = 0.957, p < 0.001) with a mean surface distance of 2.78 ± 2.11 mm. Eighty‐four (92.3%) tumors were embolized with a safety margin. Regarding the early response of 82 tumors, complete response was achieved in 72 (87.8%), partial response in six (7.3%), and stable disease in four (4.9%). Regarding responses of 81 tumors during the follow‐up (mean, 20 ± 4.9 months), complete response was maintained in 62 (76.5%), whereas 19 (23.5%), including six that were incompletely embolized, locally progressed. Conclusion: Virtual parenchymal perfusion software can determine the optimal catheter position in superselective cTACE. [ABSTRACT FROM AUTHOR]

Purpose: To retrospectively evaluate blood supply to the caudate lobe of the liver from the right inferior phrenic artery (RIPA) using cone-beam computed tomography during arteriography (CBCTA-RIPA). Methods: CBCTA-RIPA examinations during transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) were collected from 2448 procedures in 787 patients. The exclusion criteria were (1) major artifacts, (2) TACE of hepatic arterial branches before performing CBCTA-RIPA, and (3) repeated CBCTA-RIPA studies in the same patient. Blood supply to three subsegments, the Spiegel lobe (SP), paracaval, and caudate process, was evaluated on CBCTA-RIPA images. The origins and routes of branches supplying the caudate lobe were also evaluated by three-dimensional vessel-tracking software. Results: Forty-seven CBCTA-RIPA examinations in 47 patients (38 with a history of TACE [repeated TACE group] and nine without it [initial TACE group]) were eligible, including five who had previously undergone hepatectomy. Seven had caudate lobe HCCs. Blood supply to the caudate lobe was demonstrated in 21 (44.7%) patients: in 50% (19/38) and 22.2% (2/9) of the repeated and initial TACE groups, respectively. The caudate arteries had previously been embolized in eight patients, the RIPA branch in three, and both in one. Forty-one proximal branches mainly supplied the dorsal part of the SP. All branches but five reached there through the inferior vena cava (IVC) ligament. The RIPA supplied eight of nine caudate lobe HCCs, totally (n = 7) or partially (n = 1). Conclusion: The proximal RIPA branches mainly supply the dorsal SP through the IVC ligament, especially in the repeated TACE group. [ABSTRACT FROM AUTHOR]

Aim: To retrospectively evaluate the outcomes of conventional transarterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC) ≥10 cm. Methods: Twenty‐five patients with naïve HCC ≥10 cm (mean maximum tumor diameter, 130 ± 27.6 mm; single [n = 12], 2–9 [n = 6], and ≥10 [n = 7]) without extrahepatic spread treated with cTACE were eligible. Five (20%) had vascular invasion. Two to three stepwise cTACE sessions using iodized oil ≤10 mL in one cTACE session were scheduled. When the tumor recurred, additional cTACE was repeated on demand, if possible. Overall survival (OS) rates were calculated using the Kaplan–Meier method. The prognostic factors were evaluated using uni‐ and multivariate analyses. Results: Stepwise cTACE sessions were completed for 20 (80%) patients, but could not be completed for four (16%). In the remaining (4%) patient, the whole tumor was embolized in one session. Additional treatment, mainly cTACE, was undertaken for 19 (76%) patients. The OS rates at 1, 3, and 5 years were 68, 34.7, and 23.1%, respectively. A tumor number of three was a significant prognostic factor (P = 0.020) and the 1‐, 3‐, and 4‐year OS rates in patients with ≤3 and ≥4 tumors were 81.3 and 33.3, 55.6 and 11.1, and 38.9% and 0%, respectively. Whole tumor embolization and the serum level of protein induced by vitamin K absence or antagonist‐II were also significant prognostic factors (P < 0.001 and P = 0.042, respectively). Bile duct complications requiring additional interventions developed in two (8%) patients. Conclusion: Conventional TACE is safe and effective for huge HCCs, but has limited effects in cases with four or more tumors. [ABSTRACT FROM AUTHOR]

Aim To evaluate the incidence and condition of necrotic tumor excretion into the biliary system in patients with hepatocellular carcinoma (HCC) >5 cm treated with conventional transcatheter arterial chemoembolization (TACE). Methods Eighty-three patients who underwent TACE for newly developed HCC >5 cm without an intraductal tumor thrombus and were followed-up by computed tomography for longer than 6 months were eligible. According to the location, the maximum tumors were divided into central (in contact with the left or right hepatic duct, n = 39) or peripheral (not in contact with them, n = 44). When high-density material in the biliary system that was not seen on pretreatment computed tomography was identified, it was determined as excreted necrotic tumor tissue containing iodized oil. The incidence, interval between TACE and occurrence of the necrotic tumor excretion, and clinical course were evaluated. Results Tumor excretion into the biliary system was identified in nine (10.8%) patients with a central tumor (mean diameter, 85.0 ± 29.6 mm) 28-433 days (mean, 219.3 ± 128.2) after the initial TACE. In one patient, the necrotic tumor cast caused cholangitis 1203 days after the initial TACE, and was endoscopically removed. Infection of the embolized tumor developed in two cases and percutaneous drainage was carried out 105 and 158 days later, respectively. Conclusions Excretion of necrotic tumors into the biliary system after TACE was not rare in patients with centrally located HCC >5 cm. The detached tumor rarely caused symptoms and the communication between the tumor and bile duct caused the infection of tumors. [ABSTRACT FROM AUTHOR]

Aim To evaluate the performance of novel virtual parenchymal perfusion (VPP) software in conventional transcatheter arterial chemoembolization (cTACE) for hepatocellular carcinoma. Methods VPP was retrospectively applied to 43 hepatocellular carcinomas treated with cTACE. The virtual embolized area (VEA) was estimated after positioning a virtual injection point on images of non-selective cone-beam computed tomography during hepatic arteriography, at the same position in superselective cTACE. The real embolized area (REA) was defined as the area where iodized oil was retained on 1-week computed tomography after cTACE. Three dimensions across the tumor (maximum [a] and minimum [b] in the axial and craniocaudal [c]) directions, and the volume of the VEA and REA were compared using linear regression analysis. It was also evaluated whether an adequate safety margin ≥5 mm could be predicted by VPP. Results The mean lengths of a, b, and c of the VEA and REA were 54.6 ± 15.9 mm (range 24.9-91.0 mm) and 55.0 ± 15.7 mm (range 23.9-92.8 mm; r = 0.9448, P < 0.001), 35.4 ± 11.7 mm (range 16.1-66.0 mm) and 35.4 ± 13.2 mm (range 12.2-69.2 mm; r = 0.9369, P < 0.001), and 42.1 ± 11.6 mm (range 25.0-75.7 mm) and 42.9 ± 11.7 mm (range 25.7-78.7 mm; r = 0.9092, P < 0.001), respectively. The mean volume of the VEA and REA was 71.8 ± 44.8 mL and 75.5 ± 46.9 mL, respectively ( r = 0.9913, P < 0.0001). VPP showed no safety margins in seven tumors, including all three actually embolized without safety margins. Conclusion The VEA estimated using VPP showed a good correlation with the REA of cTACE. [ABSTRACT FROM AUTHOR]

Aim To retrospectively evaluate the detectability of tumor recurrence with computed tomography (CT) and magnetic resonance imaging (MRI) after superselective conventional transcatheter arterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC). Methods The detectability of tumor recurrence with CT and gadoxetate disodium-enhanced MRI obtained within 30 days (mean, 16.9 ± 10.1) were compared in 38 patients with recurrent HCC after superselective cTACE. Tumor recurrence was divided into local and distant recurrence. Local recurrence was also divided into intratumoral and peritumoral recurrence. Results Tumor recurrence (maximum diameter, 19.7 ± 10.1 mm) was demonstrated by images 12.4 ± 11.7 months after cTACE. CT could depict 16 (76.2%) of 21 intratumoral recurrences in 12 patients and 14 (53.8%) of 26 peritumoral recurrences in 11, as well as 39 (55.7%) of 70 distant recurrences in 15 (75%) of 20 patients. Arterial phase MRI could depict 20 (95.2%) of 21 intratumoral recurrences in 14 patients and all 26 (100%) peritumoral recurrences in 21, as well as 60 (85.7%) distant recurrences in all 20 (100%) patients. The detectability of tumor recurrence with MRI was significantly higher than that with CT ( P = 0.00549). On MRI, pseudolesions were observed in five (13.2%) patients and artifacts in the arterial phase in five (13.2%). Regarding the diagnostic performance, CT was superior to MRI in two (5.3%) patients and MRI was superior to CT in 19 (50%). They were almost equal in 17 (44.7%). Conclusion The detectability of tumor recurrence after superselective cTACE with gadoxetate disodium-enhanced MRI was superior to that of CT. [ABSTRACT FROM AUTHOR]

Aim We evaluated the performance of automated tumor-feeder detection (AFD) software using cone-beam computed tomography technology in identifying tumor-feeders of extrahepatic collaterals. Methods AFD was prospectively used in superselective transarterial chemoembolization (TACE) or embolization (TAE) of extrahepatic collaterals for 29 hepatocellular carcinomas and one liver metastasis (mean tumor diameter ± standard deviation, 28 ± 15.6 mm) in 25 patients. The detectability of extrahepatic tumor-feeders with non-selective digital subtraction angiography (DSA) and AFD was evaluated and compared using a χ2-test. Tumor response of target lesions in each patient at 2-3 months after treatment was evaluated using the modified Response Evaluation Criteria in Solid Tumors. Complications were also evaluated. Results Of 46 tumor-feeders, non-selective DSA and AFD could identify 26 and 44, respectively ( P < 0.001). Regarding the origin of tumor-feeders, both non-selective DSA and AFD could identify 14 of 15, six of seven and two of two tumor-feeders of the right inferior phrenic, omental and right renal capsular artery, respectively. In the cystic and left gastric or right colic artery, AFD could identify 13 of 13 and nine of nine tumor-feeders but non-selective DSA could identify only three of 13 and one of nine, respectively ( P < 0.001). Complete response was obtained in 15 patients, partial response in six, stable disease in three and progressive disease in one. No severe complications developed except for right pleural effusion after embolization of the right inferior phrenic artery. Conclusion AFD has a sufficient ability to identify extrahepatic tumor-feeders and may improve the safety and local effects of TACE/TAE of extrahepatic collaterals. [ABSTRACT FROM AUTHOR]

Simple Summary: Although transarterial chemoebolization (TACE) is indicated for small hepatocellular carcinoma (HCC) as a second choice, TACE for small HCC is frequently difficult and less effective because of less hypervascularity and the presence of tumor portions receiving a dual blood supply. The aim of this study was to evaluate the efficacy of superselective cTACE under guidance software for patients with HCC within three lesions smaller than 3 cm. By using TACE guidance software, 81.2% of HCC lesions could be completely embolized and the cumulative local tumor progression rates in 303 tumors at 1, 3, 5, and 7 years were 17.8, 27.8, 32.0, and 36.0%, respectively. The 1-, 3-, 5-, and 7-year overall and recurrence-free survival rates in 175 patients were 97.1 and 68.7, 82.8 and 34.9, 64.8 and 20.2, and 45.3 and 17.3%, respectively. Our results indicate the efficacy of superselective cTACE using guidance software for HCC within three lesions smaller than 3 cm. The indication of transarterial chemoembolization (TACE) has advanced to hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage A when surgical resection (SR), thermal ablation, and bridging to transplantation are contraindicated; however, TACE for small HCC is frequently difficult and ineffective because of less hypervascularity and the presence of tumor portions receiving a dual blood supply. Here, we report outcomes of superselective conventional TACE (cTACE) for 259 patients with HCCs within three lesions smaller than 3 cm using guidance software. Automated tumor feeder detection (AFD) functionality was applied to identify tumor feeders on cone-beam computed tomography during hepatic arteriography (CBCTHA) data. When it failed, the feeder was identified by manual feeder detection functionality and/or selective angiography and CBCTHA. Regarding the technical success in 382 tumors (mean diameter, 17.2 ± 5.9 mm), 310 (81.2%) were completely embolized with a safety margin (5 mm wide for HCC ≤25 mm and 10 mm wide for HCC >25 mm). In 61 (16.0%), the entire tumor was embolized but the safety margin was not uniformly obtained. The entire tumor was not embolized in 11 (2.9%). Regarding the tumor response at 2–3 months after cTACE in 303 tumors excluding those treated with combined radiofrequency ablation (RFA) or SR and lost to follow-up, 287 (94.7%) were classified into complete response, seven (2.3%) into partial response, and nine (3.0%) into stable disease. The mean follow-up period was 44.9 ± 27.6 months (range, 1–109) and the cumulative local tumor progression rates at 1, 3, 5, and 7 years were 17.8, 27.8, 32.0, and 36.0%, respectively. The 1-, 3-, 5-, and 7-year overall and recurrence-free survival rates in 175 patients, excluding those with Child–Pugh C class, who died of other malignancies, or who underwent combined RFA or hepatic resection, were 97.1 and 68.7, 82.8 and 34.9, 64.8 and 20.2, and 45.3 and 17.3%, respectively. Our results indicate the efficacy of superselective cTACE using guidance software for HCC within three lesions smaller than 3 cm. [ABSTRACT FROM AUTHOR]