Dual-phase Cone-beam Computed Tomography to See, Reach, and Treat Hepatocellular Carcinoma during Drug-eluting Beads Transarterial Chemo-embolization

The overall goal of the following technique is to see, reach, and assess treatment success during trans arterial chemo embolization. For hepatocellular carcinoma, this is achieved by first performing dual phase cone beam computed tomography or CBCT to see, reach, and assess the targeted tumor. Next, once the target tumor is seen and reached, the targeted tumor is treated with drug eluding beads.

Then dual phase CBCT is performed again in order to assess treatment success. Intraprocedurally results are obtained that show successful treatment based on tumor enhancement identified by dual phase CBCT imaging. The main benefits of BE CT imaging is fairly simple.

It allows us to obtain 3D like images like a CT scan, which is much superior to the current 2D DSA imaging techniques that we usually rely on. So it's again, an improvement on what we already have. This method can help to answer the key question in interventional oncology, such as ways the tumor, how do I reach it and did I treat successfully Well?

The use of different combining CT techniques can provide insight into interventional oncology. It can also be applied to other specialties such as neurointerventional radiology and cardiovascular interventional radiology. To begin place the patient in the supine position on an angiography table through intravenous injection, sedate them with midazolam and administer fentanyl as an analgesic.

Then premedicate the patient with intravenous diphenhydramine, dexamethasone, and ondansetron to reduce the systemic effects of the inflammatory response and nausea. Prepare the patient's right groin by shaving it if necessary, and use povidone iodine soap to scrub the area before applying an antiseptic. Then cover the area in a sterile drape using a micro puncture needle and salinger's technique.

Catheterize the common hepatic artery across the right common femoral artery to insert a sheath and attach a saline flush. Next, using angiographic catheters, catheterize the superior mesenteric artery or SMA and then the celiac axis. Then perform an angiogram of the SMA to ensure standard anatomy, a lack of replaced hepatic arterial supply, and to confirm portal vein patency.

Perform a celiac artery angiogram to determine anatomy and hepatic arterial blood supply. Depending on the tumor location, coaxially advance a microcatheter through the catheter into the right or left hepatic artery. Then perform a repeat right or left super selective hepatic arteriogram to confirm the location of the tumor.

Instruct the sedated patient to be at end expiration apnea during each of the CBCT scans with free breathing between the early arterial and delayed venous phase scans. For each CBCT scan, place the area of interest in the system ISO center next to perform a dual phase or DP CBCT scan. Make a single contrast medium injection and after a three second delay, initiate a five second CBCT scan.

At the end of the scan, instruct the patient to breathe one to two times holding their breath at end expiration apnea. As the second scan starts, control the automatic registration and overlay of the two scans, and if necessary, adjust them manually and validate the two CBCT acquisitions so that they match each other in the axial, coronal and sagittal planes. Correlate the targeted tumors defined by CBCT with other pre-procedural imaging.

Select the prototype software to plan access to the targeted lesions and generate a 3D roadmap to guide device navigation from the best visualization, which is often the delayed venous phase scan segment. The targeted tumors verify the vessel path on the CBCT images automatically detected from the early arterial phase CBCT and extracted by the software in sagittal, coronal and axial planes to ensure that the vessel chosen and path mapped do supply the desired tumor overlay and confirm the segmented tumors and the tumor feeding arteries and the 3D roadmap onto fluoroscopy to reach and treat the tumor. Begin by developing roadmaps to be used to target the tumor.

Use the 3D overlaid roadmap, synchronized on live fluoroscopy to the CR and table movement to catheterize the targeted tumors feeding arteries, and identify tumor feeding vessels supported by the automatic feeder detection functionality. Choose the CR and table position angle and magnification that best facilitates catheterization and minimizes vessel overlap and force shortening to easily target the tumor or tumors. With 3D navigation guidance, reach each tumor feeding artery to minimize the delivery of chemo embolizing material to healthy tissue.

Maximizing the selective drug dose to the tumor next to treat the tumor, use drug eluding beads through the microcatheter to embolize the targeted tumor to the contrast stasis into the tumor before detection of any backflow. Then to assess treatment success, perform a post trans arterial embolization or taste dual phase CBCT, assess a defect of contrast enhancement in the target tumors. Finally, at the end of the procedure, remove the microcatheter catheter and sheath and allow the patient to return to homeostasis.

Presented here a result from a case of a 64-year-old man with an 8.9 centimeter unresectable HCC located in segment seven of the liver. Shown here are axial images of two phases of one dual phase CBCT obtained intraprocedurally before the embolization. The arterial phase shows opacification of the arterial tree of the liver and feeding arteries of the single hepatocellular carcinoma and the venous phase shows liver tumor margins.

In this figure registration of the two scans is performed in the coronal, sagittal, and axial planes. The red shade represents the primary volume early phase, and the gray scale image represents the secondary volume delayed phase shown in the axial plane. The portal venous phase is not yet well blended or windowed for ideal tumor visualization.

Shown here is the delayed venous phase CBCT scan in three planes allowing for more precise tumor segmentation. The tumor volume is represented in a blue colored circle in three planes. The segmentation can be done in any of the three axes, coronal, sagittal, and axial.

The arterial tree and tumor feeding arteries are visualized on all planes in this early arterial phase scan. After their automatic detection and verification, feeding arteries may be represented by different colors and shown from all planes. The segmented tumor is automatically overlaid on all images.

The tumor segmentation and extracted color vessels are represented on the first image. The 3D roadmap in this figure is used to reach the tumor before drug delivery. This case shows a target tumor in segment seven, colored in blue.

The catheter is in the common hepatic artery and the microcatheter is in the segment seven hepatic artery. In this case, the variation of tumor enhancements on dual phase CBCT images is evident before and after embolization on the first A and second B scan phase. No lippy ATOL was used While attempting this procedure.

It's important to remember to instruct the patient how to hold their breath during the acquisition to avoid motion artifacts on corium CT imaging. Other method like CVCT during a part cartography CVCT during selective arty or post depth taste, CBCT can be perform, perform in order to detect tumor filling arteries before the treatment or to look for potential extra artery or to control contrast deposition into the tumor after the ization. This is an important technique, this CT imaging, and it has paved the way for researchers in a field of interventional oncology to assist us, the interventional radiologists intraprocedurally to guide intervention right there in the angio suite.

So this is really a step forward.