Usefulness of tumor perfusion on cone-beam CT after hepatic arterial infusion port implantation for evaluating tumor response to hepatic arterial infusion chemotherapy in hepatocellular carcinoma treatment

Abstract

Purpose: To compare tumor perfusion on cone-beam computed tomography (CBCT) after hepatic artery infusion port implantation with the tumor response to hepatic arterial infusion chemotherapy (HAIC) in patients with hepatocellular carcinoma (HCC).

Methods: This retrospective study was conducted in patients with advanced HCC treated with HAIC from 2015 to 2020. We performed CBCT with contrast injection via a port on the day following implantation. We classified tumor perfusion on CBCT into three groups: hyperperfusion, isoperfusion, and hypoperfusion. We also evaluated tumor response to HAIC on follow-up images using RECIST 1.1 and compared it with tumor perfusion on CBCT.

Results: This study included 206 tumors in 193 patients (mean: 60.5 years) with HCC. There were 100 hyperperfusion tumors (48.5%), 92 isoperfusion tumors (44.7%), and 14 hypoperfusion tumors (6.8%). The tumor response to HAIC included 10 tumors with a complete response (CR) (4.9%), 66 tumors with a partial response (32%), 60 tumors with stable disease (29.1%), and 70 tumors with progressive disease (34%). Hyperperfusion tumors had a 65% objective response rate (ORR) and a 92% disease control rate (DCR). Isoperfusion tumors had a 12% ORR and a 46.8% DCR, while hypoperfusion tumors had a 0% ORR and a 7.1% DCR. A CR was shown only in hyperperfusion tumors. The ORR and DCR of the three groups were different, with statistical significance (P < 0.001).

Conclusion: Hyperperfusion tumors on CBCT showed a better tumor response to HAIC, with a 65% ORR in patients with HCC. Tumor perfusion on CBCT after implantation of the hepatic arterial infusion port was associated with the tumor response to HAIC.

Keywords: Cone-beam CT; hepatic arterial infusion chemotherapy; hepatocellular carcinoma; tumor perfusion; tumor response.

Figure 1

Tumor perfusion type on cone-beam computed tomography. (a) Hyperperfusion type: the right hepatic tumor must be more enhanced with contrast media than the remaining hepatic parenchyma. (b) The isoperfusion-type tumor and hepatic parenchyma are heterogeneous, with no difference between the tumor and the normal hepatic parenchyma. (c) A hypoperfusion type observed at the posterior segment without contrast enhancement.

Figure 2

Comparison of tumor response in tumor perfusion types. CR, complete response; PR, partial response; SD, stable disease; PD, progressive disease.

Figure 3

A 55-year-old male with hepatitis B virus, a Child–Pugh score of 5A, and refractory TACE. (a) An infiltrative right hepatic tumor with right portal vein tumor thrombosis. (b) Hepatic angiography via port when treated with hepatic arterial infusion chemotherapy (HAIC). (c) Contrast-enhanced cone-beam computed tomography (CT) on the day after port implantation: a right hyperperfusion tumor. (d) Follow-up contrast CT after five cycles of HAIC showing a complete response. TACE, transarterial chemoembolization.

Figure 4

A 75-year-old male with hepatitis C virus and a Child–Pugh score of 7B. (a) Computed tomography (CT) image with multiple hepatocellular carcinoma nodes focusing mainly on the left hepatic lobe and the right posterior hepatic segment. (b) Hepatic angiography via port when treated with hepatic arterial infusion chemotherapy (HAIC). (c) Cone-beam CT on the day following port implantation: Hypoperfusion of the tumor was observed in the posterior segment and a segment of the left lobe located adjacent to the spleen, with isoperfusion tumors in the remaining liver parenchyma. (d) Follow-up contrast CT after four cycles of HAIC: the hypoperfusion tumor increased in size (progressive disease). A left hepatic tumor of the isoperfusion type, with decreased size and no enhanced-contrast media (partial response).