Practical report of use for detection of hepatocellular carcinoma (HCC): One patient with recurrent HCC after radiofrequency ablation (RFA)
Kindai University Hospital
Faculty of Medicine, Kindai University
Dept. of Radiology
Drs. Takamichi Murakami (current affiliation: Kobe University), Masahiro Okada (current affiliation: Nihon University)
Division of Hepato-Biliary-Pancreatic Surgery, Dept. of Surgery: Dr. Takuya Nakai
Dept. of Gastroenterology and Hepatology: Dr. Masatoshi Kudo
DATE : 2021
One patient with recurrent HCC after RFA
Patient’s background and objectives of magnetic resonance imaging (MRI)
Male, 60s.
From 1998, the patient was monitored for progression of hepatitis C at a different hospital. HCC was found below the S7/8 dome of the liver in November 2007, so RFA was performed under laparotomy at the authors’ hospital. The patient was subse-quently monitored at the authors’ hospital, and at an out-patient examination in March 2008, 4 months after HCC was treated with RFA, the α-fetoprotein level had increased somewhat, so the patient was admitted to hospital for thorough examination and treatment. The hepatic function parameters were as follows: total bilirubin: 1.5 mg/dL; total protein: 7.5 g/dL; albumin: 3.6 g/dL; prothrombin time: 89%; and indocyanine green: 35%.
Recurrence was confirmed by dynamic computed tomography (CT), but no clear recurrence foci were identified. However, gradual α-fetoprotein and PIVKA-II increases continued, so the presence or absence of recurrence foci was evaluated by Ga-doxetate disodium(Gd-EOB-DTPA) contrast MRI approximately 1 month later.
Local recurrence after RFA
a) Pre-contrast
b) Arterial phase
c) Equilibrium phase
Multidetector CT
The RFA-treated locus in S7/8 of the liver was not shown in the dynamic MDCT arterial phase (b) or equilibrium phase (c), and there was judged to be no local recurrence.
No nodules clearly showing arterial dark staining were found at other loci either, and it was judged that dynamic MDCT showed no recurrence foci, not only in the local area, but at any intrahepatic loci.
d) Pre-contrast, T1-weighted image
g) T2-weighted image
e) Arterial phase
h) Hepatobiliary phase
f) Late phase
MRI
In the arterial phase (e) of dynamic MRI using Gadoxetate disodium(Gd-EOB-DTPA), two small nodules (red arrows), approximately 5 mm in diameter, were found on the margin of the RFA-treated area in S7/8 of the liver, and showed arterial dark staining. The same loci were shown to be contrast-free in the hepatobiliary phase (h), 20 minutes after contrast, and were diagnosed as local recurrence foci.
Recurrence at other loci after RFA treatment
i) Pre-contrast
j) Arterial phase
k) Equilibrium phase
MDCT
The above photographs show dynamic MDCT images of slice sections that are largely the same as those in the below MRI images.
It was judged that no recurrence foci were present.
l) Pre-contrast, T1-weighted image
o) T2-weighted image
m) Arterial phase
p) Hepatobiliary phase
n) Late phase
MDCT
The photographs on the page to the left show three small nodules (red arrows), 2 to 5 mm in diameter, in a section somewhat to the caudal side of the liver, showing dark staining in the arterial phase (m), and absence of contrast in the hepatobiliary phase (p); and one small nodule (blue arrow), approximately 5 mm in diameter, in the hepatobiliary phase. The diagnosis made for these was recurrence foci at other intrahepatic loci.
These small nodules were not visualized by dynamic MDCT (i to k).
Impact of Gadoxetate disodium(Gd-EOB-DTPA) on diagnosis
In general, spatial and temporal resolution with MRI is lower than with CT, but the MRI contrast resolution in soft tissues is considered to be high. In addition, dynamic MRI using gadolinium contrast agents has been reported to have greater visualization capability in the arterial phase than dynamic MDCT using iodine-based agents. However, in practice, when both imaging methods are optimized, there is no significant difference in visualization capability, and some tumors can only be visualized by one or the other, so CT and MRI can be considered to be complementary.
MRI using Gadoxetate disodium(Gd-EOB-DTPA) generates diagnostic information in the hepatobiliary phase, in addition to that generated in the dynamic study, and is considered to be useful for clear visualization of small lesions, such as the present patient’s local recurrence and intrahepatic recurrence focus at a different locus. It is therefore useful for diagnosis of recurrence.
In the case of the present patient, imaging in the arterial phase was also useful, but, due to the dose of Gadoxetate disodium(Gd-EOB-DTPA) being lower than the doses of other gadolinium contrast agents, there are concerns about visualization capability in the arterial phase, and further investigation of the administration and imaging methods is needed in future.
Impact of Gadoxetate disodium(Gd-EOB-DTPA) on treatment
With the present patient, the high tumor visualization capability of Gadoxetate disodium(Gd-EOB-DTPA) contrast MRI enabled visualization of local recurrence foci 2 to 5 mm in diameter, and an intrahepatic recurrence focus at a different locus, which could not be visualized by dynamic MDCT.
Previously, even when no recurrence was found by MDCT, if recurrence was strongly suspected on the basis of tumor-markers, superparamagnetic iron oxide (SPIO) contrast MRI was requested, and there were sometimes concerns about resulting delays in initiation of treatment. However, as a single session of Gadoxetate disodium(Gd-EOB-DTPA) contrast MRI can provide the information for which both MDCT and SPIO contrast MRI have to be performed, Gadoxetate disodium(Gd-EOB-DTPA) contrast MRI is expected to facilitate unproblematic initiation of treatment, and thus to be useful not only for detailed pre-treatment examination of primary, malignant, hepatic, mass-type lesions, but also for evaluation of post-treatment recurrence.
In addition, the number and sizes of tumors are important for the HCC treatment algorithm, and use of Gadoxetate disodium(Gd-EOB-DTPA) contrast MRI, which can visualize even small lesions, is expected to have a major impact on selection of treatment methods. With the present patient, six tumors were identified by Gadoxetate disodium(Gd-EOB-DTPA) contrast MRI, and for the next treatment a switch will be made from RFA to transarterial chemoembolization.
- *The case introduced is just one clinical case, so the results are not the same as for all cases.
- *Please refer to the Package Insert for the effects and indications, dosage and administration method, and warnings, contraindications, and other precautions with use.
