Korean J Radiol.  2018 Dec;19(6):1053-1065. 10.3348/kjr.2018.19.6.1053.

Prediction of Local Tumor Progression after Radiofrequency Ablation (RFA) of Hepatocellular Carcinoma by Assessment of Ablative Margin Using Pre-RFA MRI and Post-RFA CT Registration

• Yoon JH
• Lee JM
• Klotz E
• Woo H
• Yu MH
• Joo I
• Lee ES
• Han JK

• KMID: 2424845
• DOI: http://doi.org/10.3348/kjr.2018.19.6.1053

Abstract

OBJECTIVE
To evaluate the clinical impact of using registration software for ablative margin assessment on pre-radiofrequency ablation (RFA) magnetic resonance imaging (MRI) and post-RFA computed tomography (CT) compared with the conventional side-by-side MR-CT visual comparison.
MATERIALS AND METHODS
In this Institutional Review Board-approved prospective study, 68 patients with 88 hepatocellulcar carcinomas (HCCs) who had undergone pre-RFA MRI were enrolled. Informed consent was obtained from all patients. Pre-RFA MRI and post-RFA CT images were analyzed to evaluate the presence of a sufficient safety margin (≥ 3 mm) in two separate sessions using either side-by-side visual comparison or non-rigid registration software. Patients with an insufficient ablative margin on either one or both methods underwent additional treatment depending on the technical feasibility and patient's condition. Then, ablative margins were re-assessed using both methods. Local tumor progression (LTP) rates were compared between the sufficient and insufficient margin groups in each method.
RESULTS
The two methods showed 14.8% (13/88) discordance in estimating sufficient ablative margins. On registration software-assisted inspection, patients with insufficient ablative margins showed a significantly higher 5-year LTP rate than those with sufficient ablative margins (66.7% vs. 27.0%, p = 0.004). However, classification by visual inspection alone did not reveal a significant difference in 5-year LTP between the two groups (28.6% vs. 30.5%, p = 0.79).
CONCLUSION
Registration software provided better ablative margin assessment than did visual inspection in patients with HCCs who had undergone pre-RFA MRI and post-RFA CT for prediction of LTP after RFA and may provide more precise risk stratification of those who are treated with RFA.

Keyword

Radiofrequency ablation; Fusion; Margin; Local tumor progression; Magnetic resonance imaging

MeSH Terms

Carcinoma, Hepatocellular*
Catheter Ablation*
Classification
Humans
Informed Consent
Magnetic Resonance Imaging*
Methods
Prospective Studies

Figure

• 

  Fig. 1 69-year-old man with HCC and hepatitis C-related cirrhosis showing discrepancy between two inspection methods.A. On hepatobiliary phase, 12-mm HCC was seen in S6 (arrows). B. On portal venous phase of post-RFA CT, 52-mm ablative zone was observed in corresponding area (arrowheads). Ablative margin was considered to be sufficient on visual inspection. C. After non-rigid, deformable registration of pre-RFA MRI (left) and post-RFA CT (right) using software, ROI was drawn around index tumor manually on pre-RFA MRI (left, orange circle), and ROI was simultaneously copied on post-RFA CT (right, inner circle) with 5-mm ablative margin (right, outer circle). In software-assisted inspection, ablative margin was determined to be insufficient. However, second-look RFA did not proceed due to unstable vital signs under conscious sedation. D. On ten-month follow-up MRI, LTP (arrows) was observed along mediosuperior margin of ablative zone (arrowheads), and was considered insufficient on software-assisted inspection. CT = computed tomography, HCC = hepatocellular carcinoma, LTP = local tumor progression, MRI = magnetic resonance imaging, RFA = radiofrequency ablation, ROI = region of interest

• 

  Fig. 2 Flow chart of study.*These seven patients were included in both groups due to presence of sufficient and insufficient ablative margins for multiple tumors, †One patient was excluded due to follow-up loss before one-month follow-up CT scan for confirming technical efficacy, ‡One patient was excluded due to failure of achieving technical efficacy on one-month follow-up CT scan. n = number of patients, TACE = transarterial chemoembolization

• 

  Fig. 3 Cumulative incidence of LTP in all tumors and treatment-naïve tumors with technique efficacy.Cumulative incidence of LTP was estimated as 7.9%, 28.6%, and 32.5% at 1-, 3-, and 5-year follow-up, respectively, in all 66 patients (solid line), and 7.2%, 22.6%, and 27.2% at 1-, 3-, and 5-year follow-up, respectively, in 59 patients with treatment-naïve tumors (dotted line).

• 

  Fig. 4 Cumulative incidence of LTP according to ablative margin assessment results of visual assessment and registration software-assisted assessment.Kaplan-Meier graphs classified according to software-assisted inspection (A) and visual assessment (B) in 66 patients with technique efficacy.

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