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Imaging of Hepatocellular Carcinoma After Treatment with Yttrium-90 Microspheres

Ana L. Keppke1, Riad Salem1, Denise Reddy1, Jie Huang2, Jianhua Jin2, Andrew C. Larson1 and Frank H. Miller1

1 Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair, Ste. 800, Chicago, IL 60611.
2 Department of Preventive Medicine, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL 60611.


Figure 1
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  		Fig. 1A —59-year-old man with hepatocellular carcinoma treated with 90Y microspheres. CT angiogram obtained before 90Y treatment shows 3.0 x 2.9 cm hypervascular tumor (arrow) with central area of low attenuation, suggestive of necrosis, in right hepatic lobe.

 

Figure 2
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  		Fig. 1B —59-year-old man with hepatocellular carcinoma treated with 90Y microspheres. Axial arterial phase contrast-enhanced CT image obtained 1 month after 90Y treatment shows complete necrosis of lesion (arrow). Size of lesion has increased to 5.8 x 3.8 cm. This example shows that lesion size may not be reliable criterion for response evaluation.

 

Figure 3
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  		Fig. 1C —59-year-old man with hepatocellular carcinoma treated with 90Y microspheres. Axial arterial phase contrast-enhanced CT image obtained 3 months after B shows persistent lesion necrosis (arrow) and decrease in size to 4.4 x 3.2 cm. Findings show that initial increase in lesion size after treatment was transient and did not indicate progression of disease. Incidental gallstone is evident.

 

Figure 4
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  		Fig. 2A —72-year-old man with hepatocellular carcinoma and portal vein thrombosis. Axial venous phase contrast-enhanced CT image obtained before 90Y treatment shows 7.0 x 6.4 cm hypodense mass (short arrow) in right hepatic lobe with extension (long arrow) into right portal vein.

 

Figure 5
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  		Fig. 2B —72-year-old man with hepatocellular carcinoma and portal vein thrombosis. Axial venous contrast-enhanced CT image obtained 26 months after 90Y treatment shows significant decrease in lesion (arrow) and thrombus. This example shows that patients with thrombosis of portal vein may respond well to 90Y therapy.

 

Figure 6
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  		Fig. 3A —61-year-old man with hepatocellular carcinoma and lack of correlation between {alpha}-fetoprotein levels and imaging response to 90Y microspheres. Axial arterial phase gadolinium-enhanced T1-weighted spoiled gradient-echo MR image with fat suppression obtained before 90Y treatment shows 3.1 x 3.0 cm hyperenhancing and heterogeneous lesion (arrow) in left hepatic lobe. Alpha-fetoprotein level was 232 ng/mL.

 

Figure 7
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  		Fig. 3B —61-year-old man with hepatocellular carcinoma and lack of correlation between {alpha}-fetoprotein levels and imaging response to 90Y microspheres. Axial arterial phase contrast-enhanced CT image obtained 1 month after 90Y treatment shows complete necrosis and increased size (7.5 x 4.6 cm) of lesion (arrow). Alphafetoprotein level increased to 568 ng/mL and then decreased to 271 ng/mL 1 month later. This example shows that increase in lesion size associated with necrosis is not indicative of disease progression. In addition, it shows that transient increase in {alpha}-fetoprotein level may be due to tumor lysis and not worsening disease.

 

Figure 8
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  		Fig. 4 —Kaplan-Meier (KM) survival curves of hepatocellular carcinoma patients from date of first 90Y microsphere treatment for Okuda stage I disease, Okuda stage II disease, and overall.

 

Figure 9
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  		Fig. 5A —72-year-old man with hepatocellular carcinoma. Axial arterial phase contrast-enhanced CT image obtained before 90Y treatment shows hypervascular lesion (long arrow) in left hepatic lobe and high-density material from previous chemoembolization (short arrows) in right lobe.

 

Figure 10
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  		Fig. 5B —72-year-old man with hepatocellular carcinoma. Axial arterial phase contrast-enhanced CT image obtained 1 month after 90Y treatment shows lesion (arrow) in left hepatic lobe is hypodense with thin rim of enhancement compatible with inflammatory reaction from treatment.

 

Figure 11
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  		Fig. 6A —78-year-old man with hepatocellular carcinoma. Axial arterial phase gadolinium-enhanced T1-weighted spoiled gradient-echo MR image with fat suppression obtained before 90Y treatment shows 4.1 x 3.6 cm hypervascular lesion (arrow).

 

Figure 12
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  		Fig. 6B —78-year-old man with hepatocellular carcinoma. Axial arterial phase contrast-enhanced CT image obtained 1 month after 90Y treatment shows significant reduction in lesion size and peripheral focal enhancing nodule (arrow) in anterior aspect of lesion.

 

Figure 13
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  		Fig. 6C —78-year-old man with hepatocellular carcinoma. Axial arterial phase contrast-enhanced CT image obtained 3 months after B shows further decrease in lesion size and no evidence of nodular enhancement (arrow).

 

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