Downloaded from www.ajronline.org by Fudan University School of Pharmacy Library on 05/13/15 from IP address 61.129.42.15. Copyright ARRS. For personal use only; all rights reserved
49
The Diagnosis of Small Hepatocellular Carcinomas: Efficacy of Various Imaging Procedures in 100 Patients
.
Kenichi Takayasu1 Noriyuki Moriyama1 Yukio Muramatsu1 Masatoshi Makuuchi2 Hiroshi Hase’’awa2 .3 Nobuo Okazaki Setsuo Hlrohashl
.
The efficacy
of various
imaging
procedures
used
for the diagnosis
of small
hepato-
cellular carcinomas (HCCs) (lesions no larger than 3 cm in diameter) was evaluated in a retrospective study of 100 patients. Seven patients with hepatic adenomatous hyperplastic nodules containing HCC foci were also assessed. In 89 patients, the lesion was initially detected during follow-up of chronic liver disease. diagnosed on the basis of elevated serum alpha-fetoprotein; diagnosed incidentally with imaging procedures. The overall
(84%), CT (84%), and angiography
(81%) were compared
In 21 patients, it was first in the remaining 79 it was sensitivities of sonography with those
of arterial
angie-
graphic CT (82%), portal angiographic CT (91%), lipiodol CT (93%), and intraoperative sonography (96%). The differences in sensitivity between angiography and lipiodol CT (p < .05) and between intraoperative sonography and the other studies (p < .01) were statistically significant. In 22 lesions smaller than I cm, the sensitivities of lipiodol CT and intraoperative sonography were high (83% and 86%, respectively). Adenomatous hyperplasias containing HCC foci were frequently detected by arterial angiographic CT and intraoperative sonography. These results show that sonography or CT and alpha-fetoprotein are useful in detecting small HCCs in screening programs of patients with chronic liver disease. Lipiodol CT and intraoperative sonography are necessary in patients who are candidates for surgery. 155:49-54,
AJR
July 1990
Patients with small hepatocellular carcinomas (HCCs) (lesions 3 cm in diameter) frequently are referred to the National Cancer Center Hospital in Tokyo. The number of such patients who undergo partial hepatectomies is increasing every year [1 ]. This trend is mainly due to the screening program, which includes measurement of alpha-fetoprotein (AFP) and sonography for small HCCs in patients with chronic liver disease, that was instituted recently in Japan [2, 3]. In order to Received December 5, 1989; accepted after revision January This work tryofHeafthand
22, 1990. was supported Research .
in part by the Grant-
(625-1) from the Minis.
.
.
Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 , Tsukiji, Chuo-ku, Tokyo 104, Japan. Address reprint requests to K. Takayasu. 2 Department of Surgery, National Cancer Cen-
determine decrease
the operability postoperative
arterial angiographic
of the lesion and the appropriate recurrence [4], other preoperative
CT [5, 6], portal angiographic
of CT and angiography), surgery. In this study,
and lipiodol we determined
Materials
CT [7] (both are combinations
-
.
for the detection
to as
CT [8-1 0] were carried out in candidates for and compared the efficacy of these various
-
procedures
surgical procedure examinations such
of small HCCs In 100 patients.
and Methods
ter Hospital, Tokyo 1 04, Japan. 3 Department of Intemal cer Center Hospital, Tokyo 4
Medicine, National 104, Japan.
Can-
Pathology Division, National Cancer Center Re-
1 982 to in Tokyo.
From Hospital
maximum
diameter
search Institute, Tokyo, Japan.
30-79
0361-803X/90/1551-0049
liver was suspected
© American
Roentgen
Ray Society
to our
1987, 247 patients Of these,
were selected
years old (average, hospital.
had surgery
100 patients
for HCC at the National
with
135 small
for this study.
The group
57 years old). In approximately
or diagnosed
at other
clinics
HCCs
measuring
comprised
Cancer
82 men and 1 8 women
90% of these patients,
or hospitals,
Center
3 cm or less in
and the patients
HCC in the
were referred
TAKAYASU
50
Downloaded from www.ajronline.org by Fudan University School of Pharmacy Library on 05/13/15 from IP address 61.129.42.15. Copyright ARRS. For personal use only; all rights reserved
TABLE
1: Initial Detection
of Small
Totala
Carcinomas
With and Without
AFP
Sonography
CT
0
2
1
1
1
8 13
23 31
10 9
2 0
34 41
21 (20)
56 (48)
20 (1 8)
3 (3)
76
Note.-AFP = alpha-fetoprotein. a Numbers in parentheses represent patients in whom small hepatocellular the follow-up study for chronic liver disease.
Real-time sonography (Aloka SSD 250, 256, 258 and/or 280, Tokyo; or Hitachi EUB 40, Tokyo) was performed by using a linear or convex scanner (3.5 MHz) in all but two patients. Unenhanced CT (Toshiba 60A and/or 9005, Tokyo) scans of the whole liver were obtained in 97 patients. Subsequently, dynamic CT at a single-slice level followed injection was
by incremental sequential performed in approximately
after the lesion had ing two-thirds,
detected
been
in whom
a mass
by unenhanced
unenhanced
CT, rapid incremental dynamic
Both
CT without one-third
lesion
initially.
active contrast of 97 patients,
CT. In the remainrecognized on CT was performed
had not been
sequential
CT at a single-slice
level and rapid incremental
CT with bolus injection of 100 ml of 65% methyiglucamine (Angiografin, Schering, Bergkamen, West 3 mI/sec were begun 25-30 sec (Toshiba
scans of three slices repeat series for rapid or 35-40 sec (Toshiba for single-slice dynamic incremental CT with injection
of contrast
diatrizoate at a speed of 2-
Germany) 60A: contiguous
Hepatic
angiograms
99 patients (common hepatic in nine; proper hepatic One or two additional studies were performed conventional
angiography
vascular anomaly
in 60 patients
were
obtained
in
in the remainder).
immediately
chosen
at random.
after If a
right and/or left hepatic artery was shown on the angiogram, portal angiographic CT was carried out to survey the whole liver. In 11 patients, arterial angiographic CT was performed with the use of 75-80 ml of 60% Angiografin (Toshiba 60A) or 60 ml of 20% Angiografin (Toshiba 9005) injected in the common hepatic artery at a speed of 1-2 mI/sec. In these patients, CT scans were obtained beginning 2 sec after the injection of contrast medium [6]. In 17 patients, portal angiographic CT was performed; the catheter with
injection
such as a replaced
tip was placed deep in the superior mesenteric artery of 1 00 ml of 20% Angiografin at a speed of 3 mI/sec
and CT was begun 23 sec later. With both arterial and portal angioCT, incremental CT was used to study the whole liver.
graphic
Lipiodol CT was performed lipiodol (Ethiodol, Andre-Gelbet
and without Dublin, hepatic
days
20 mg of doxorubicin
with the use of 5 ml of Cedex, France) with
(Adriamycin,
Adria,
OH), which was injected in the proper and/or right arteries. Follow-up unenhanced CT was performed
or left 0-75
(average,
patients,
in 43 patients Laboratories,
injection
14 days) ofgelatin
after sponge
hydrochloride
injection particles
of lipiodol
[8-10].
was followed
In 23
by injection
of emulsion of lipiodol and doxorubicin. Portal angiographic CT folowed by lipiodol CT (nine patients) and arterial angiographic CT followed by lipiodol CT (two patients) were performed on the same day. These studies were done within approximately 1 month in more than 90% of cases; the interval between these studies and surgery ranged from 1.0 to 4.5 months (average, 3.2 months). The lesions were measured in the cut surface of the resected specimen.
carcinoma lesions were diagnosed during
Results In 89 of 100 patients, small HCCs were detected during the follow-up study for chronic liver disease (Table 1). In the remaining 1 1 patients, the diagnosis was made incidentally at a medical checkup or during survey for other diseases. In 21 patients, HCC was strongly suspected during the follow-up of chronic liver disease because of a gradual increase in AFP above 400 ng/ml; 56 patients were diagnosed with sonography as the first imaging procedure, 20 with CT, and only three with
angiography.
All four
patients
than 1 cm were diagnosed normal.
1 5.5-sec
for single-slice dynamic CT and four or five incremental CT with 10-sec interscan delay) 9005: contiguous 1 6-sec scans of six slices CT and two or three repeat series for rapid 10-sec interscan delay) after beginning the
medium.
No. with Cirrhosis
Angiography
4
1 00 (89)
1990
Liver Cirrhosis
43 53
49
The Diagnosis of Small Hepatocellular Carcinomas: Efficacy of Various Imaging Procedures in 100 Patients
.
Kenichi Takayasu1 Noriyuki Moriyama1 Yukio Muramatsu1 Masatoshi Makuuchi2 Hiroshi Hase’’awa2 .3 Nobuo Okazaki Setsuo Hlrohashl
.
The efficacy
of various
imaging
procedures
used
for the diagnosis
of small
hepato-
cellular carcinomas (HCCs) (lesions no larger than 3 cm in diameter) was evaluated in a retrospective study of 100 patients. Seven patients with hepatic adenomatous hyperplastic nodules containing HCC foci were also assessed. In 89 patients, the lesion was initially detected during follow-up of chronic liver disease. diagnosed on the basis of elevated serum alpha-fetoprotein; diagnosed incidentally with imaging procedures. The overall
(84%), CT (84%), and angiography
(81%) were compared
In 21 patients, it was first in the remaining 79 it was sensitivities of sonography with those
of arterial
angie-
graphic CT (82%), portal angiographic CT (91%), lipiodol CT (93%), and intraoperative sonography (96%). The differences in sensitivity between angiography and lipiodol CT (p < .05) and between intraoperative sonography and the other studies (p < .01) were statistically significant. In 22 lesions smaller than I cm, the sensitivities of lipiodol CT and intraoperative sonography were high (83% and 86%, respectively). Adenomatous hyperplasias containing HCC foci were frequently detected by arterial angiographic CT and intraoperative sonography. These results show that sonography or CT and alpha-fetoprotein are useful in detecting small HCCs in screening programs of patients with chronic liver disease. Lipiodol CT and intraoperative sonography are necessary in patients who are candidates for surgery. 155:49-54,
AJR
July 1990
Patients with small hepatocellular carcinomas (HCCs) (lesions 3 cm in diameter) frequently are referred to the National Cancer Center Hospital in Tokyo. The number of such patients who undergo partial hepatectomies is increasing every year [1 ]. This trend is mainly due to the screening program, which includes measurement of alpha-fetoprotein (AFP) and sonography for small HCCs in patients with chronic liver disease, that was instituted recently in Japan [2, 3]. In order to Received December 5, 1989; accepted after revision January This work tryofHeafthand
22, 1990. was supported Research .
in part by the Grant-
(625-1) from the Minis.
.
.
Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 , Tsukiji, Chuo-ku, Tokyo 104, Japan. Address reprint requests to K. Takayasu. 2 Department of Surgery, National Cancer Cen-
determine decrease
the operability postoperative
arterial angiographic
of the lesion and the appropriate recurrence [4], other preoperative
CT [5, 6], portal angiographic
of CT and angiography), surgery. In this study,
and lipiodol we determined
Materials
CT [7] (both are combinations
-
.
for the detection
to as
CT [8-1 0] were carried out in candidates for and compared the efficacy of these various
-
procedures
surgical procedure examinations such
of small HCCs In 100 patients.
and Methods
ter Hospital, Tokyo 1 04, Japan. 3 Department of Intemal cer Center Hospital, Tokyo 4
Medicine, National 104, Japan.
Can-
Pathology Division, National Cancer Center Re-
1 982 to in Tokyo.
From Hospital
maximum
diameter
search Institute, Tokyo, Japan.
30-79
0361-803X/90/1551-0049
liver was suspected
© American
Roentgen
Ray Society
to our
1987, 247 patients Of these,
were selected
years old (average, hospital.
had surgery
100 patients
for HCC at the National
with
135 small
for this study.
The group
57 years old). In approximately
or diagnosed
at other
clinics
HCCs
measuring
comprised
Cancer
82 men and 1 8 women
90% of these patients,
or hospitals,
Center
3 cm or less in
and the patients
HCC in the
were referred
TAKAYASU
50
Downloaded from www.ajronline.org by Fudan University School of Pharmacy Library on 05/13/15 from IP address 61.129.42.15. Copyright ARRS. For personal use only; all rights reserved
TABLE
1: Initial Detection
of Small
Totala
Carcinomas
With and Without
AFP
Sonography
CT
0
2
1
1
1
8 13
23 31
10 9
2 0
34 41
21 (20)
56 (48)
20 (1 8)
3 (3)
76
Note.-AFP = alpha-fetoprotein. a Numbers in parentheses represent patients in whom small hepatocellular the follow-up study for chronic liver disease.
Real-time sonography (Aloka SSD 250, 256, 258 and/or 280, Tokyo; or Hitachi EUB 40, Tokyo) was performed by using a linear or convex scanner (3.5 MHz) in all but two patients. Unenhanced CT (Toshiba 60A and/or 9005, Tokyo) scans of the whole liver were obtained in 97 patients. Subsequently, dynamic CT at a single-slice level followed injection was
by incremental sequential performed in approximately
after the lesion had ing two-thirds,
detected
been
in whom
a mass
by unenhanced
unenhanced
CT, rapid incremental dynamic
Both
CT without one-third
lesion
initially.
active contrast of 97 patients,
CT. In the remainrecognized on CT was performed
had not been
sequential
CT at a single-slice
level and rapid incremental
CT with bolus injection of 100 ml of 65% methyiglucamine (Angiografin, Schering, Bergkamen, West 3 mI/sec were begun 25-30 sec (Toshiba
scans of three slices repeat series for rapid or 35-40 sec (Toshiba for single-slice dynamic incremental CT with injection
of contrast
diatrizoate at a speed of 2-
Germany) 60A: contiguous
Hepatic
angiograms
99 patients (common hepatic in nine; proper hepatic One or two additional studies were performed conventional
angiography
vascular anomaly
in 60 patients
were
obtained
in
in the remainder).
immediately
chosen
at random.
after If a
right and/or left hepatic artery was shown on the angiogram, portal angiographic CT was carried out to survey the whole liver. In 11 patients, arterial angiographic CT was performed with the use of 75-80 ml of 60% Angiografin (Toshiba 60A) or 60 ml of 20% Angiografin (Toshiba 9005) injected in the common hepatic artery at a speed of 1-2 mI/sec. In these patients, CT scans were obtained beginning 2 sec after the injection of contrast medium [6]. In 17 patients, portal angiographic CT was performed; the catheter with
injection
such as a replaced
tip was placed deep in the superior mesenteric artery of 1 00 ml of 20% Angiografin at a speed of 3 mI/sec
and CT was begun 23 sec later. With both arterial and portal angioCT, incremental CT was used to study the whole liver.
graphic
Lipiodol CT was performed lipiodol (Ethiodol, Andre-Gelbet
and without Dublin, hepatic
days
20 mg of doxorubicin
with the use of 5 ml of Cedex, France) with
(Adriamycin,
Adria,
OH), which was injected in the proper and/or right arteries. Follow-up unenhanced CT was performed
or left 0-75
(average,
patients,
in 43 patients Laboratories,
injection
14 days) ofgelatin
after sponge
hydrochloride
injection particles
of lipiodol
[8-10].
was followed
In 23
by injection
of emulsion of lipiodol and doxorubicin. Portal angiographic CT folowed by lipiodol CT (nine patients) and arterial angiographic CT followed by lipiodol CT (two patients) were performed on the same day. These studies were done within approximately 1 month in more than 90% of cases; the interval between these studies and surgery ranged from 1.0 to 4.5 months (average, 3.2 months). The lesions were measured in the cut surface of the resected specimen.
carcinoma lesions were diagnosed during
Results In 89 of 100 patients, small HCCs were detected during the follow-up study for chronic liver disease (Table 1). In the remaining 1 1 patients, the diagnosis was made incidentally at a medical checkup or during survey for other diseases. In 21 patients, HCC was strongly suspected during the follow-up of chronic liver disease because of a gradual increase in AFP above 400 ng/ml; 56 patients were diagnosed with sonography as the first imaging procedure, 20 with CT, and only three with
angiography.
All four
patients
than 1 cm were diagnosed normal.
1 5.5-sec
for single-slice dynamic CT and four or five incremental CT with 10-sec interscan delay) 9005: contiguous 1 6-sec scans of six slices CT and two or three repeat series for rapid 10-sec interscan delay) after beginning the
medium.
No. with Cirrhosis
Angiography
4
1 00 (89)
1990
Liver Cirrhosis
43 53
