Role of Subtraction MRI in assessment of HFLs post TACE Medical Presentation

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Slide 1-

Role of Subtraction MRI in assessment of HFLs post TACE By Eslam Mohamed Hamdy Under supervision of Dr. Mohsen Gomaa Hassan
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Introduction Liver anatomy Pathology of HCC TACE Subtraction MRI Methodology in brief Cases and figures Results Conclusion References Contents:
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HCC is now the third leading cause of cancer deaths worldwide, with over 500,000 people affected (Llovet et al., 2018). Introduction
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Patients who have advanced disease may benefit from palliative care interventions rather than be subjected to often ineffective therapies (Ferri et al., 2017).
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The most commonly offered therapy is transcatheter arterial chemoembolization (TACE). (Liu et al., 2018).
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Dynamic contrast-enhanced MRI (DCE MRI) can play a significant role as an imaging biomarker, especially in the detection of viable tumor foci, the differentiation between necrosis and viable tumor, and early prediction of response (Kierans et al., 2010).
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Subtraction imaging is a technique where a non-enhanced T1-weighted sequence is digitally subtracted from the T1-weighted image achieved after gadolinium administration. (Amit et al., 2007).
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Thus the subtraction imaging is helpful for the assessment of the therapeutic efficacy for post TACE HCCs, which makes the detection of tumor enhancement difficult on post-contrast T1-weighted images.(Amit et al., 2007).
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Segmental liver anatomy: The traditional morphological anatomy is based on the external appearance of the liver and does not show the internal features of vessels and biliary ducts branching, which are of obvious importance in hepatic surgery. Liver anatomy
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Couinaud (1957) divided the liver into eight functionally independent segments; each segment has its own vascular inflow, outflow and biliary drainage. (Gellada, 2016).
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Middle hepatic vein divides the liver into right and left lobes (or right and left hemi-liver). Right hepatic vein divides the right lobe into anterior and posterior segments. Left hepatic vein divides the left lobe into a medial and lateral part. Portal vein divides the liver into upper and lower segments. The left and right portal veins branch superiorly and inferiorly to project into the center of each segment (Mourya et al., 2018).
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The numbering of the segments is in a clockwise manner. Segment 1 (caudate lobe) is located posteriorly. The left portal vein divides the left lobe of the liver into the superior segments (2 and 4A) and the inferior segments (3 and 4B). The right portal vein divides the right lobe of the liver into superior segments (7 and 8) and the inferior segments (5 and 6).
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The arterial blood is supplied to the liver by the common hepatic artery. This is most commonly a branch of the coeliac axis. It divides into right and left branches just below the porta hepatis. The left hepatic artery divides into medial and lateral segmental branches. The right hepatic artery divides into anterior and posterior segmental branches(Sharma et al., 2017). Arterial supply of the liver
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Possible Mechanisms for Development of HCC: There are two possible mechanisms of development of HCC: De-novo in non cirrhotic liver. Stepwise carcinogenesis in cirrhotic liver: from regenerative nodules to dysplastic nodules to well differentiated hepatocellular carcinoma (Elsayes et al., 2017). Pathology of HCC
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Nodules Classification in liver cirrhosis: There are four classes of lesions that characteristically are found in the cirrhotic liver: Regenerative nodules, Dysplastic foci Dysplastic nodules and Hepatocellular carcinomas. These lesions are referred to collectively as cirrhosis associated hepatocellular nodules (Ali et al., 2018).
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Transcatheter arterial chemoembolization (TACE) is the current standard of care for patients with large or multinodular HCC and relatively preserved liver function, absence of cancer-related symptoms, and no evidence of vascular invasion or extrahepatic spread (i.e., those classified as intermediate stage according to the Barcelona Clinic Liver Cancer (BCLC) staging system) (Bruix et al., 2016). TACE
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The best candidates for TACE are patients with asymptomatic multinodular tumors without vascular invasion or extrahepatic spread. TACE is also offered to patients with early-stage HCC when surgical options or percutaneous ablation are precluded (Sberna et al., 2018) Indications and Contraindications:
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Liver functional reserve is a critical component for careful patient selection. Patients should present with relatively well-preserved liver function (mostly Child-Pugh A or B without ascites); those with liver decompensation or more advanced liver failure should be excluded because the ischemic insult can lead to severe adverse events (Sberna et al., 2018).
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Child Turcotte Pugh classification.
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Subtraction MRI is a technique whereby corresponding contrast- enhanced and unenhanced T1-weighted sequences are digitally subtracted image-by-image using post-processing MRI software. The objective of this process is to remove pre-existing T1-weighted high signal from the post- processed images so that the remaining high signal is solely due to enhancement (Karaosmanoğlu et al., 2018). Subtraction MRI
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1.Characterization of T1 Hyperintense Lesions: Advantages of subtraction MRI
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2.Detection of hypervascular lesions unidentified on contrast-enhanced images
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3.Differentiation between portal vein malignant and bland thrombi
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Our study was a retrospective study conducted on patients with HCC who underwent TACE from January 2017 till December at Maadi Military Hospital. Equipment used: For the MRI examination, a 3 tesla GE MRI machine Methodology in brief:
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Patients underwent dynamic MRI with DWI and Subtraction sequences within 90 days after one or more sessions of TACE. MR images were analyzed for the following: The morphological features of each lesion were recorded including size and signal characteristics at T1, T2 and FAT SATURATED signal characteristics. Pattern of enhancement in the dynamic imaging and subtraction sequences. Signal restriction in DWI.
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The 35 HCC patients were classified according to reactivity rate after analysis by 2 experienced readers blinded to each other into 2 independent groups: Reactive group Non reactive group Basic clinical data: Comparative study between the 2 groups revealed non-significant difference as regards age, sex and residence of the patients (p > 0.05). Laboratory data: Comparative study between the 2 groups revealed; highly significant increase in AFP level in reactive group; compared to non-reactive group; with highly significant statistical difference (p = 0.0015). Results
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Dynamic-MRI vs. Dynamic Subtraction-MRI data: Comparative study between D-MRI and DS-MRI assessments revealed; highly significant increase in reactivity rate in DS-MRI in HCC patients during 1st and 2nd readings; with highly significant difference (p = 0.0078 respectively). Radiological data:
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Comparative study between D-MRI and DS-MRI assessments revealed; highly significant increase in disease detection rate, sensitivity, and NPV in favor of DS-MRI in HCC patients; with highly significant difference (p < 0.01 respectively).
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ROC curve analysis to detect reactivity (disease detection): By using ROC-curve analysis, D-MRI assessment discriminated patients with reactivity from patients without, with good accuracy, sensitivity= 73% and specificity= 100% (p < 0.0001). By using ROC-curve analysis, DS-MRI assessment discriminated patients with reactivity from patients without, with perfect accuracy, sensitivity= 100% and specificity= 100% (p < 0.0001).
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ROC curve analysis to detect reactivity (disease detection):
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Roc-curve of D-MRI and DS-MRI to predict patients with reactivity (30) from patients without (5).
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Comparison between D-MRI and DS-MRI as regards diagnostic accuracy assessments.
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Case 1 54 years old male patient with liver cirrhosis and HCV+ve underwent TACE of right hepatic lobe segment VIII focal lesion. Dynamic MRI with subtraction study was done 2 months after embolization. Illustrative cases
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A) is dynamic arterial phase showing early enhancement of the lesion B) is delayed phase of dynamic study showing washout. C) is subtraction image from arterial phase showing typical clearer enhancement and D) is subtraction image from delayed phase showing definite washout denoting residual tumoral activity.
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Case 2 57 years old female patient with liver cirrhosis and HCV+ve underwent TACE of left hepatic lobe segment III focal lesion. Dynamic MRI with subtraction study was done 2 months after embolization.
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A) is Axial T1- weighted pre-contrast image shows heterogeneous but mostly hyper-intense left lobe hepatic focal lesion (red arrow). B) is Axial T1- weighted post-contrast images at arterial phase show: area of high signal intensity (red arrow) that could be compatible with either necrosis or residual tumoral activity and areas of iso intense signal. C) is Axial T1 subtraction image shows no enhancement in the targeted lesion confirming complete treatment necrosis and well embolization (red arrow).
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Case 3 65 years old male patient with liver cirrhosis and HCV+ve underwent TACE of left hepatic lobe segment III focal lesion. Dynamic MRI with subtraction study was done 2 months after embolization.
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A) is Axial T1- weighted pre-contrast image shows heterogeneous but mostly hyper-intense left lobe hepatic focal lesion. B) is Axial T1- weighted post-contrast images at arterial phase show: area of high signal intensity that could be compatible with either necrosis or residual tumoral activity and areas of iso intense signal. C) is Axial T1 subtraction image shows no enhancement in the targeted lesion and D) is axial subtracted image from delayed phase showing no washout confirming complete treatment necrosis and well embolization.
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Case4 65 years old male patient with liver cirrhosis and HCV+ve underwent TACE of right hepatic lobe segment VIII focal lesion. Dynamic MRI with subtraction study was done 2 months after embolization.
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A) is axial T1 pre-contrast image, B) is axial arterial phase image. The embolized zone (Red arrows) appears high signal in both T1 pre contrast and in the dynamic MR arterial phase which could be due to underlying residual disease or due to high signal of post TACE hyperemic changes. C) Subtraction image where the lesion appears hypo intense with no evidence of enhancing viable nodules confirming that the high signal in the arterial phase is not due to viable disease. The Yellow arrow in B) is due to post embolization perfusion abnormality.
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Case5 51 years old female patient with liver cirrhosis and HCV+ve underwent TACE of right hepatic lobe 2 lesions segments VII and VIII focal lesions. Dynamic MRI with subtraction study was done 2 months after embolization.
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A) Axial pre-contrast phase image, B) Axial arterial phase image and C) Axial delayed phase image the TACED zone appears of high signal in the arterial phase and low signal in the delayed phase, however this is not due to arterial enhancement and delayed wash out, but this is due to drop of the signal of the non enhancing embolization zone relative to the progressively enhancing liver parenchyma. This is proved by the subtracted images (D and E) where the two lesions appear well TACED.
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Conclusion: MRI is a powerful tool in detection of tumor viability and complications after TACE of hepatocellular carcinoma. Dynamic MRI is valuable in detecting recurrent lesions however, this value is augmented by the addition of subtraction technique especially in lesions having high signal before administration of contrast medium. We recommend adding the subtraction technique in the protocol of MRI in the follow up after TACE as it increases the diagnostic confidence and this may help to facilitate the appropriate clinical management of patients including the need for re-treatment sessions.