Diffusion-weighted MR Imaging for Determination of Hepatocellular Carcinoma Response to Yttrium-90 Radioembolization

doi:10.1097/01.RVI.0000227234.81718.EB

Journal of Vascular and Interventional Radiology

Volume 17, Issue 7, July 2006, Pages 1195-1200

https://doi.org/10.1097/01.RVI.0000227234.81718.EB Get rights and content

Early detection of the response of hepatocellular carcinoma (HCC) to yttrium-90 radioembolization therapy may be important to permit repeat radioembolization or alternative treatment options. Water-mobility measurements with use of diffusion-weighted (DW) magnetic resonance (MR) imaging are useful for noninvasive interrogation of microstructural tissue properties. Findings of DW MR imaging may serve as an early biomarker of HCC response. This study tested the hypothesis that DW MR imaging can detect changes in tumor tissue water diffusion in response to 90Y therapy. In each of six patients with HCC included in the study, tumor water diffusion increased significantly after therapy. DW MR imaging is a promising technique for noninvasive assessment of tumor response to 90Y radioembolization.

Section snippets

Patients and ⁹⁰Y Radioembolization Technique

In this prospective clinical study, which was approved by our institutional review board, superselective 90Y radioembolization (TheraSphere; MDS Nordion, Kanata, ON, Canada) was performed in six patients who had a primary diagnosis of HCC. The diagnosis of HCC was established by fine-needle aspiration or core biopsy and/or noninvasively on the basis of α-fetoprotein levels and previous imaging findings. Patient demographic data including age, cause of lesion, and Child-Pugh classification are

RESULTS

All the patients in this study were able to complete the imaging protocol without complications. A representative contrast agent–enhanced image and corresponding ADC map are shown in Figure 1. In this example, the periphery of the larger tumor (lower portion of the image) showed regions of low water mobility within the viable periphery (dark outer rim on the ADC map), whereas the core of the tumor showed increased water mobility corresponding to a necrotic region. T2-weighted half-Fourier

DISCUSSION

In this preliminary study, we successfully demonstrated that DW MR imaging can detect changes in HCC lesions approximately 42 ± 16 days after 90Y therapy. All six patients completed the study, and MR imaging studies were performed before and after 90Y therapy. Changes in water diffusion as measured with tumor ADC values on DW MR imaging were statistically significant (P < .05), whereas tumor changes established by conventional T1- and T2-weighted MR imaging were not statistically significant.

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Investigation and adaptation of imaging modalities for providing additional sensitivity and expanded applications for cancer treatment response assessment is a significant area of active research. Examples span advancing image instrumentation hardware, development of new digital image acquisition capabilities, use of computer-assisted image diagnosis including artificial intelligence and deep learning, image quantification, and automation to provide robust and reproducible prognostic and diagnostic methodologies. This chapter focuses on functional advances and applications of diffusion-weighted MRI (DWI) [12,13] as it has emerged as a widely applicable approach for diagnosis, treatment planning, and assessment of response/recurrence of solid malignancies. MRI is an attractive imaging modality for tumor assessment as it provides high spatial resolution along with excellent soft-tissue contrast aiding radiographic detection and assessment of tumor. Diffusion-weighted imaging offers a unique contrast mechanism along with the ability to be used as a biomarker for the detection of changes in tumor cellular density during cancer treatment. As loss of cellular membrane integrity and overall cellularity can occur earlier than volumetric shrinkage of a tumor mass, DWI has been actively investigated as an early surrogate of cancer treatment response across solid tumor types in both animal models and human subjects. This chapter provides a succinct overview of DWI in the context of oncological research and clinical trials.
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Citation Excerpt :
The use of diffusion-weighted imaging (DWI) in the evaluation of HCC response to LRT is one of the most recently described techniques. Studies have shown differences in the apparent diffusion coefficient (ADC) values between viable and necrotic portions of HCCs after LRT, as well as measurable differences before and after LRT.14–17 Imaging response criteria face different challenges, including inter-reader reproducibility, accuracy in detecting treatment response, and, most importantly, prediction of a survival benefit.
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Citation Excerpt :
DWI is particularly useful during the early follow-up period when a measurable change in tumour size may not be present. Tumour response has been reported to occur as early as approximately 42 days after SIRT therapy with DWI [42]. A 30% increase in ADC values at 30 days following SIRT therapy is predictive of tumour response and prolonged survival in infiltrative HCC with portal vein thrombosis [43].
Embolotherapies used in the treatment of hepatocellular carcinoma (HCC) include bland embolization, conventional transarterial chemoembolization (cTACE) using ethiodol as a carrier, TACE with drug-eluting beads and super absorbent polymer microspheres (DEB-TACE), and selective internal radiation therapy (SIRT). Successfully treated HCC lesions undergo coagulation necrosis, and appear as nonenhancing hypoattenuating or hypointense lesions in the embolized region on computed tomography (CT) and magnetic resonance. Residual or recurrent tumours demonstrate arterial enhancement with portal venous phase wash-out of contrast, features characteristic of HCC, in and/or around the embolized area. Certain imaging features that result from the procedure itself may limit assessment of response. In conventional TACE, the high-attenuating retained ethiodized oil may obscure arterially-enhancing tumours and limit detection of residual tumours; thus a noncontrast CT on follow-up imaging is important post-cTACE. Hyperenhancement within or around the treated zone can be seen after cTACE, DEB-TACE, or SIRT due to physiologic inflammatory response and may mimic residual tumour. Recognition of these pitfalls is important in the evaluation embolotherapy response.
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The established size-based image biomarkers for tumor burden measurement continue to be applied to solid tumors, as size measurement can easily be used in clinical practice. However, in the setting of novel targeted therapies and liver-directed locoregional treatments for hepatocellular carcinoma (HCC), simple tumor anatomic changes can be less informative and usually appear later than biologic changes. Functional magnetic resonance (MR) imaging has the potential to be a promising technique for assessment of HCC response to therapy. Diffusion-weighted MR imaging is now widely used as a standard imaging modality to evaluate the liver. This review discusses the current clinical value of diffusion-weighted MR imaging in the evaluation of tumor response after nonsurgical locoregional treatment of HCC.

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Diffusion-weighted MR Imaging for Determination of Hepatocellular Carcinoma Response to Yttrium-90 Radioembolization

Section snippets

Patients and 90Y Radioembolization Technique

RESULTS

DISCUSSION

Toxicology

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Neoplasia

J Vasc Interv Radiol

J Vasc Interv Radiol

Drug Resist Updat

Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection

Radiology

Chemoembolization of hepatocellular carcinoma: results of a metaanalysis

Am J Clin Oncol

Patients and ⁹⁰Y Radioembolization Technique