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Power Doppler Sonography

Evaluation of Hepatocellular Carcinoma After Treatment with Transarterial Embolization or Percutaneous Ethanol Injection Therapy

¹ Department of Radiology, Sapporo Medical University, S-1, W-16, Chuo-ku, Sapporo, 060-8543, Japan.
² First Department of Surgery, Hokkaido University School of Medicine, N-15, W-7, Kita-ku, Sapporo, 060, Japan.
³ Department of First Surgery, Sapporo Medical University, Sapporo, 060-8543, Japan.
⁴ Department of Public Health, Sapporo Medical University, Sapporo, 060-8543, Japan.

Received November 12, 1998; accepted after revision July 15, 1999.

 
Address correspondence to K. Koito.

Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
OBJECTIVE. The aim of this study was to compare tumor detectability by assessing the vascularity on power and color Doppler sonography and CT after transarterial embolization or percutaneous ethanol injection therapy or both in hepatocellular carcinoma.

SUBJECTS AND METHODS. Forty-seven nodules of hepatocellular carcinoma (size, 28 ± 7 mm [mean ± standard deviation]; range, 20-40 mm) in 38 patients were treated with transarterial embolization (n = 6), percutaneous ethanol injection therapy (n = 23), and transarterial embolization plus percutaneous ethanol injection therapy (n = 9). Power Doppler sonography, color Doppler sonography, and CT were performed before and 2 weeks, 3 months, and 6 months after the treatments. The existence of hepatocellular carcinoma was confirmed by positive findings for color signals on both Doppler sonography techniques and for tumor stains on CT. All the tumors were determined to be malignant by microscopic examination of biopsy specimens.

RESULTS. Before the treatments, power Doppler sonography (100%) and CT (100%) were significantly more effective than color Doppler sonography (61.7%) (p < 0.001, for both). Six months after the treatments, the sensitivity of power Doppler sonography (87.5%) was significantly better than that of color Doppler sonography (12.5%) but was not significant in comparison with CT (66.6%). However, power Doppler sonography detected color signals in two of three tumors in which iodized oil was accumulated and no tumor stain appeared on CT, and the two lesions detected with power Doppler sonography were carcinomas.

CONCLUSION. Power Doppler sonography can be considered the most sensitive technique in assessing the viability of hepatocellular carcinoma treated with transarterial embolization or percutaneous ethanol injection therapy or both.

Introduction

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Hepatocellular carcinoma is commonly recognized as a type of primary malignant tumor of the liver [1]. Although resection of the tumor yields a better prognostic outcome than other nonsurgical treatments, surgery is not an option for some patients because of the poor reserve of hepatic function [2]. On the basis of the essential pathophysiology of the tumor lesion, transarterial embolization [3] or percutaneous ethanol injection therapy [4] or both [5] are applied in these cases; namely, because the tumor is hypervascular, the arterial embolization brings about the interruption of supplying blood flow [3] and because the tumor is small, fibrotic, and soft, injected ethanol permeates the tumor, leading to necrotic change of the cancer lesion [4].

The efficacy of these treatments should be evaluated exactly and concisely, and the assessment has been judged from the presence or absence of the vascularity of the treated lesion: CT and MR imaging are often used for that purpose [6, 7, 8]. Moreover, color Doppler sonography, which is less invasive and easier to perform than CT and MR imaging, is used for the evaluation of hepatocellular carcinoma [9, 10], but color Doppler sonography has some drawbacks including poor detectability of low flow velocity and angle dependence [11].

In contrast to color Doppler sonography, power Doppler sonography displays the integrated power of the Doppler signals instead of the mean Doppler frequency shift and can detect many lower velocity signals [11, 12]; we speculate that power Doppler sonography may be more effective than color Doppler sonography in detecting certain remaining or recurrent tumors (or both) and that this technique can be compatible with CT and MR imaging. In this study, we compared power Doppler sonography, color Doppler sonography, and CT for revealing the vascularity of treated hepatocellular carcinoma.

Subjects and Methods

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Patient Population
From April 1995 to August 1998, we treated 38 patients with unresected hepatocellular carcinoma with cirrhosis of the liver (21 men and 17 women; mean age, 61 years; age range, 32-78 years) at our institutes. Child's classifications were 5 in class A, 16 in class B, and 17 in class C. The cause of cirrhosis was hepatitis B virus (n = 12), hepatitis C virus (n = 23), and unknown cause (n = 3). Surgical resection was not performed because of poor hepatic function (i.e., indocyanine green test results, >35%; total bilirubin >3.0 mg/dl) (n = 32), or the presence of more than five tumors (n = 6). The 38 patients suffered from a total of 47 hepatocellular carcinomas, which were measured on sonography to range from 20 to 40 mm (mean ± standard deviation, 28 mm ± 7 mm).

Patients underwent transarterial embolization only (n = 6), percutaneous ethanol injection therapy only (n = 23), or transarterial embolization and percutaneous ethanol injection therapy (n = 9).

Percutaneous ethanol injection therapy was performed only when fewer than three tumors smaller than 3 cm were present. The 15 patients other than the ethanol injection therapy group were treated with transarterial embolization as the first treatment. Percutaneous ethanol injection therapy was finally added (n = 9) when tumors were suspected to be viable or recurrent on color Doppler sonography, power Doppler sonography, or CT during the follow-up period after transarterial embolization. Of the 15 patients receiving transarterial embolization as the first treatment, six were free from tumor recurrence during the follow-up period, but three had recurrence and underwent ethanol injection therapy 3 months later; these three patients and three others had a recurrence and received ethanol injection therapy 6 months later. Of the 23 patients receiving ethanol injection therapy, 10 had recurrence 3 months later, and three of the 10 patients underwent ethanol injection 6 months later.

Procedures for Nonsurgical Treatment
Transarterial embolization was performed with an emulsion made from doxorubicin hydrochloride or epirubicin hydrochloride and iodized oil (Lipiodol Ultra-Fluide; Mitsui, Tokyo, Japan), and sliced particles of gelatin sponge (Spongel; Yamanouchi, Tokyo, Japan). A 4-French catheter (Glidecath II; Terumo Medical, Tokyo, Japan) or 2.5-French coaxial catheter (Renegade; Boston Scientific, Boston, MA) was inserted into the feeding artery or its nearest portion to prevent hepatic failure or gastric ulcer. The injection volume of the emulsion was 3-10 ml (mean, 5 ml) according to the diameter and number of tumors. Sliced particles of gelatin sponge were injected up to disappearance of the feeding arteries. Percutaneous ethanol injection therapy was performed under sonographic guidance with a 21-gauge needle and a scanner (SSA-340A; Toshiba, Tokyo, Japan) with a microconvex electric probe (frequency, 3.75 MHz) (Toshiba). Three to eight milliliters (mean, 5 ml) of sterile pure ethanol was administered to each tumor until the ethanol was distributed throughout or until leakage of ethanol from the tumor was observed. The injection therapy was performed once or twice a week for 6-12 weeks (mean, 8 weeks).

Assessment of Hepatocellular Carcinoma Treatment
To evaluate the response to these treatments, we performed color Doppler sonography, power Doppler sonography, and CT before, 2 weeks, 3 months, and 6 months after every treatment. Color Doppler sonography and power Doppler sonography studies were conducted with a scanner (SSA-340A or SSA-380A; Toshiba) and a 3.75- or 5.0-MHz electronic convex probe (Toshiba). A low-pulse repetition frequency (500-600 Hz) and higher pulse repetition frequency were used to detect tiny color signals in the small tumors. An analysis of the Doppler spectrum using fast Fourier transform analysis was used to evaluate flow characteristics. CT studies were performed with a helical CT scanner (Advantage RP, General Electric Medical Systems, Milwaukee, WI, or Somatomplus S, Siemens, Erlangen, Germany). Helical scanning was performed 25 sec after the start of injection of 100 ml of iopamidol 300 (Iopamiron 300; Shering Japan, Osaka, Japan) during 40 sec via the peripheral veins in the forearm using 120 kVp and 270 mA. The following scanning parameters were used: collimation, 5 mm; table speed, 5 mm/sec; reconstruction thickness, 2.5 mm; and scan time, 30 sec.

The presence of color signals and of pulsatile (i.e., arterial flow) or continuous (i.e., portal flow) waves was studied with color and power Doppler sonography, and tumor stains were evaluated with CT. When color signal was detected on either color Doppler or power Doppler sonography or when tumor stains were detected on CT, we clinically diagnosed the existence of viable hepatocellular carcinoma and injected ethanol into the lesion.

As the gold standard in our study, we microscopically assessed tumor viability of biopsy specimens of all nodules, which were obtained under sonographic guidance using an 18-gauge needle (Auto Surecut; Create Medic, Tokyo, Japan). Biopsies were performed before and 6 months after transarterial embolization, percutaneous transhepatic ethanol injection therapy, or transarterial embolization plus percutaneous transhepatic ethanol injection therapy had finished.

Statistical Analysis
The significance of the difference in detectability of color signals on color and power Doppler sonography and of tumor stains on CT was assessed using the chi-square test. The significance of the difference of color Doppler sonography, power Doppler sonography, and CT in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the tumor viability 6 months later was calculated with one-factor analysis of variance and the Scheffé test. A p value of less than 0.05 was defined as significant.

Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Power Doppler sonography and CT successfully revealed color signals or stains in all tumors; however, color Doppler sonography showed signals only in 29 (61.7%) of the 47 nodules (p < 0.001) (Fig. 1A, 1B). Table 1 compares the assessment of the therapeutic effect on color and power Doppler sonography and CT 6 months after the treatments. The sensitivities of the three techniques were significantly different (p < 0.005), with power Doppler sonography having the highest sensitivity (Fig. 2A, 2B). No significant difference in therapeutic evaluation between power Doppler sonography and CT was seen. However, power Doppler sonography revealed color signals in two of three tumors in which iodized oil was accumulated and CT showed no stains 6 months after transarterial embolization and percutaneous ethanol injection therapy (Fig. 3A, 3B, 3C); finally, two tumors were microscopically viable, but the third was not. This tumor did not show color signals on power Doppler sonography.

View larger version (174K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —63-year-old man with hepatocellular carcinoma (25 mm in diameter) in anterior segment of right lobe (before treatment). Color Doppler sonogram fails to reveal color signal in tumor (arrows). Note that color signal adjacent to tumor does not reveal tumor vessels but, instead, portal (red) and hepatic (blue) veins.

View larger version (167K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —63-year-old man with hepatocellular carcinoma (25 mm in diameter) in anterior segment of right lobe (before treatment).Power Doppler sonogram shows color signal in tumor (arrows).

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —58-year-old woman with small hepatocellular carcinoma (20 mm in diameter) in anterior segment of right lobe treated by percutaneous ethanol injection therapy. CT scan obtained 6 months after injection therapy reveals low-density nodule (arrows), showing peripheral stain that indicates viable portion of tumor.

View larger version (181K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —58-year-old woman with small hepatocellular carcinoma (20 mm in diameter) in anterior segment of right lobe treated by percutaneous ethanol injection therapy. Power Doppler sonogram reveals color signal in peripheral portion of tumor (arrow) that was not shown on color Doppler sonography.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —46-year-old man with hepatocellular carcinoma treated with transarterial embolization with iodized oil, epirubicin hydrochloride, and sliced particles of gelatin sponge. CT scan obtained before transarterial embolization shows tumor stain (arrows) in nodule in lateral segment of left lobe.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —46-year-old man with hepatocellular carcinoma treated with transarterial embolization with iodized oil, epirubicin hydrochloride, and sliced particles of gelatin sponge. CT scan obtained 6 months after embolization therapy does not enable evaluation of tumor viability (arrows) because of accumulation of iodized oil in tumor.

View larger version (171K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3. —46-year-old man with hepatocellular carcinoma treated with transarterial embolization with iodized oil, epirubicin hydrochloride, and sliced particles of gelatin sponge. Power Doppler sonogram, however, shows color signal in both center and periphery of tumor (arrows). Additional ethanol was injected into color signal areas under power Doppler guidance.

Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Recent advances in imaging techniques have made possible the detection of hepatocellular carcinomas in patients with hepatitis virus—associated cirrhosis of the liver [13]. Unfortunately, surgical intervention is not always an option because of poor hepatic function, multifocality of tumors [2], and the high rate of tumor recurrence after resection [14]. Patients not receiving surgery require alternative treatments such as transarterial embolization [3] or percutaneous ethanol injection therapy [4], both of which have been proven effective for hepatocellular carcinoma.

To obtain good regional control of the tumors and a good prognosis in patients with hepatocellular carcinoma using transarterial embolization, percutaneous ethanol injection therapy, or both, the most important objective is that tumor viability be evaluated exactly. Until now, CT [6, 7, 8], MR imaging [7, 8], and color Doppler sonography [9, 10] have been described as useful for evaluating the response to these treatments. Color Doppler sonography is an especially effective noninvasive technique for assessing the vascularity and recurrence of hepatocellular carcinoma and can be adopted to point out areas of residual tumor for an additional ethanol injection therapy [10]. However, as previously described, color Doppler sonography has some shortcomings for evaluating tumor vascularity [11]: namely, low-velocity flow or flow that is perpendicular to the ultrasound beam cannot be detected using this technique. Power Doppler sonography overcomes these weak points [11]. Indeed, our previous study showed that power Doppler sonography is more effective than color Doppler sonography for assessing color signals of hepatocellular carcinoma [12].

In this study, our findings proved that power Doppler sonography was significantly more successful than color Doppler sonography in showing color signals in the residual portion of the tumors after treatment but that power Doppler sonography was nearly equal to CT in showing tumor vascularity. The portion including color signals revealed by color or power Doppler sonography corresponded to the enhanced areas seen on CT, which is supported by previous reports [9, 10].

Therefore, power Doppler sonography enables the attending physicians to inject ethanol precisely into the hypervascular (viable) area of the tumors under its guidance, just as color Doppler enables biliary drainage [15]. Moreover, power Doppler sonography can depict signal signs in the iodized oil-accumulated portion where CT could not reveal tumor stains because of high attenuation of iodized oil. Bartolozzi et al. [8] reported that when iodized oil is completely accumulated throughout the whole hepatocellular carcinoma lesion, the lesion is necrotic; however, this is not always true, as we showed in this study that power Doppler sonography detected color signals in iodized oil-accumulated tumors (Fig. 3A, 3B, 3C), and their biopsy specimens were microscopically malignant.

One limitation of our study is that it is not a comparative evaluation of findings on power Doppler sonography and histopathologic findings of resected specimens. Neither CT nor tumor biopsy findings after the treatments ensure complete necrosis of hepatocellular carcinoma. A small volume of viable portions, which revealed no stain or to which the tip of biopsy needles could not be reached, might be present in the tumors. Therefore, our data may contain false-negative nodules. To get more certain results, a longer follow-up study is needed. Another limitation of our study is that we did not evaluate the tumor vascularity on MR images. MR imaging is certainly available for evaluating the posttreatment condition of hepatocellular carcinoma [7, 8]; a high signal intensity on T2-weighted images after injection therapy shows tumor necrosis and sometimes indicates tumor persistence [7]. Enhanced MR imaging using a contrast agent such as meglumine gadopentatate may give us more useful information about tumor viability [8]; however, using a high-resolution MR machine and contrast medium increases the medical cost. Alternatively, power Doppler sonography costs less than MR imaging and, unlike MR imaging, can be performed on patients repeatedly at the bedside under their physiologic conditions and does not require contrast material. At present, we believe that power Doppler sonography and CT are sufficient techniques for assessing tumor viability after transarterial embolization percutaneous ethanol injection therapy, or both.

Power Doppler sonography has several drawbacks. Using this technique requires more time to determine multiple tumors and point out tumors smaller than 2 cm; there is still a false-negative rate of detecting color signals, especially when the tumors are smaller than 1 cm in diameter [12], and there is a false-positive rate due to motion artifact, which needs to be confirmed with analysis of Doppler spectrums. Therefore, CT is necessary for evaluating treatment response when the tumor is smaller than 1 cm or multiple tumors exist in the liver (or both). However, as Lencioni et al. [10] pointed out, such small tumors are usually completely ablated with percutaneous ethanol injection therapy, so this drawback may be of little practical consequence. We believe the main reasons tumor vascularity remains undetected using power Doppler sonography are that small collateral feeding arteries and the lower velocity level of the feeding or draining vessels cannot be detected with this sonographic technique.

Recently, a stabilized galactose-based microbubble contrast material for color and power Doppler sonography has been developed and its usefulness was reported [16, 17]. Indeed, contrast material for color Doppler sonography such as a galactose-based microbubble contrast material should raise the detectability rate of the vascularities in hepatocellular carcinomas. However, our data disclosed that diagnostic indexes of power Doppler sonography after treatments of the disease are high (sensitivity, 87.5%; specificity and positive predictive value, 100%; negative predictive value, 97.5%; accuracy, 97.9%). We think that power Doppler sonography should be performed with a contrast agent only when power Doppler has failed to detect color signals in tumors. Sonography is, essentially, the least invasive technique among the diagnostic imaging techniques; we believe that using a contrast agent would make this technique invasive, require more time, and increase the cost.

In conclusion, power Doppler sonography appears to be the promising diagnostic technique for judging the therapeutic effect of transarterial embolization and percutaneous ethanol injection therapy on a tumor larger than 20 mm in diameter; moreover, power Doppler sonography provides certain information concerning the indication for an additional treatment during the follow-up period of unresected hepatocellular carcinoma patients under physiologic conditions.

References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

1. Peters RL. Pathology of hepatocellular carcinoma. In: Okuda K, Peters RL, eds. Hepatocellular carcinoma. New York: Wiley, 1976:107-168
2. Okuda K, Ohtsuki T, Obata H, et al. Natural history of hepatocellular carcinoma and prognosis in relation to treatment. Study of 850 patients. Cancer 1986;56:918-928
3. Yamada R, Sato M, Kawabata M, Nakatsuka H, Nakamura K, Takashima S. Hepatic artery embolization in 120 patients with unresectable hepatoma. Radiology 1983;148:397-401[Abstract/Free Full Text]
4. Shiina S, Tagawa K, Unuma T, Terano A. Percutaneous ethanol injection therapy for the treatment of hepatocellular carcinoma. AJR 1990;154:947-951[Free Full Text]
5. Tanaka K, Okazaki H, Nakamura S, et al. Hepatocellular carcinoma: treatment with a combination therapy of transcatheter arterial embolization and percutaneous ethanol injection therapy. Radiology 1991;179:713-717[Abstract/Free Full Text]
6. Murayama S, Tsukamoto Y, Watanabe H, Nakata H. Computed tomography of residual hepatomas following transcatheter arterial embolization. J Comput Assist Tomogr 1986;10:969-972[Medline]
7. Lencioni R, Caramella D, Bartolozzi C. Response of hepatocellular carcinoma to percutaneous ethanol injection: CT and MR evaluation. J Comput Assist Tomogr 1993;17:723-729[Medline]
8. Bartolozzi C, Lencioni R, Caramella D, Falaschi F, Cioni R, Dicoscio G. Hepatocellular carcinoma: CT and MR imaging features after transcatheter arterial embolization and percutaneous ethanol injection. Radiology 1994;191:123-128[Abstract/Free Full Text]
9. Tanaka K, Inoue S, Numata K, et al. Color Doppler sonography of hepatocellular carcinoma before and after treatment by transcatheter arterial embolization. AJR 1992;158:541-546[Abstract/Free Full Text]
10. Lencioni R, Caramella D, Bartolozzi C. Hepatocellular carcinoma: use of color Doppler US to evaluate response to treatment with percutaneous ethanol injection. Radiology 1995;194:113-118[Abstract/Free Full Text]
11. Rubin JM, Bude RO, Carson PL, Bree RL, Adler RS. Power Doppler sonography: a potentially useful alternative to mean frequency-based color Doppler sonography. Radiology 1994;190:853-856[Abstract/Free Full Text]
12. Koito K, Namieno T, Morita K. Differential diagnosis of small hepatocellular carcinoma and adenomatous hyperplasia with power Doppler sonography. AJR 1998;170:157-161[Abstract/Free Full Text]
13. Koito K, Suga T, Murashima Y. Radiological diagnosis and staging of hepatocellular carcinoma. Endoscopy 1993;25:131-137[Medline]
14. Belghiti J, Panis Y, Farges O, Benhamou JP, Fekete F. Intrahepatic recurrence after resection of hepatocellular carcinoma complicating cirrhosis. Ann Surg 1992;214:114-117
15. Koito K, Namieno T, Nagakawa T, Morita K. Percutaneous transhepatic biliary drainage using color Doppler sonography. J Ultrasound Med 1996;16:203-206
16. Kim AY, Choi BI, Kim TK, et al. Hepatocellular carcinoma: power Doppler US with a contrast agentpreliminary results. Radiology 1998;209:135-140[Abstract/Free Full Text]
17. Bartolozzi C, Lencioni R, Ricci P, Paolicchi A, Rossi P, Passariello R. Hepatocellular carcinoma treatment with percutaneous ethanol injection: evaluation with contrast-enhanced color Doppler US. Radiology 1998;209:387-393[Abstract/Free Full Text]

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