Gd-EOB-DTPA Enhanced MRI-guided Interventional Diagnosis And Treatment Of Liver Tumors With Atypical Manifestations

IntroductionIn 2020,liver cancer ranked fifth and third in the number of new cancer cases and cancer deaths in China.Most of the patients with liver cancer in China have a history of liver cirrhosis and have experienced multistep evolution of liver cancer.Early detection and diagnosis of liver cancer is an effective way to improve the survival rate of patients with liver cancer.Most liver cancer can be diagnosed by imaging,but there are still some liver cancers cannot be diagnosed by imaging,so it is difficult to make clinical diagnosis.For this part of the patients,the pathological diagnosis through puncture biopsy is particularly important.With the development of imaging technology and the advent of the era of precision medicine,image-guided biopsy of small specimens has been accepted by clinicians.Although hepatectomy is still the gold standard treatment for liver cancer,with the gradual minimally invasive treatment,image-guided percutaneous local treatment of liver lesions has become a research hotspot in recent years.With the development of radiofrequency ablation,microwave ablation and cryoablation,the effect of image-guided ablation for early liver cancer has been proved to be consistent with that of surgical resection.The common image-guided methods for the diagnosis and treatment of liver diseases include Ultrasound,Computed Tomography(CT),and Magnetic Resonance Imaging(MRI).The premise of image-guided interventional procedure is that the intraoperative lesions can be clearly and continuously displayed.Ultrasound has poor display effect on deep liver,top of diaphragm and other lesions.CT has ionizing radiation and enhanced contrast agent is transient,so it is difficult to clearly display the lesion boundary.Although MRI has the characteristics of excellent soft tissue resolution and multi-parameter and multi-orientation imaging ability,there are still some liver cancer lesions that are not typical in conventional MRI sequence.For liver lesions with ultrasound,CT,and conventional MRI sequences unable to show clear or difficult boundaries,it is key to improve the degree of lesion visualization to meet the needs of image guided.As a highly liver-specific contrast agent,Gd-EOB-DTPA(Gadoxetate disodium)can not only provide blood perfusion information of diseased tissues,but also provide cellular function information through the uptake of organic anion transport peptides on the liver cell membrane.With the increase of the malignant degree of cirrhotic nodules,the expression of OATP-8 on the hepatocyte surface decreased and the ability of Gd-EOB-DTPA uptake decreased.In the hepatobiliary phase,the signal intensity of the nodules decreased gradually.The increased natural contrast of lesions in hepatobiliary phase provides convenience for interventional diagnosis and treatment under the guidance of MRI.It can not only capture the features of the third stage of the lesions by routine scanning,but also provide continuous contrast during the operation.GdEOB-DTPA has been widely used in the imaging diagnosis of hepatic malignances,but there are few reports on the use of Gd-EOB-DTPA-enhanced MRI-guided biopsy and microwave ablation of hepatic lesions.In this study,the feasibility,safety and effectiveness of biopsy and microwave ablation of hepatic lesions were analyzed and evaluated by 1.0T open MRI combined with Gd-EOB-DTPA hepatobiliary phase.Chapter 1 The clinical application of Gd-EOB-DTPA enhanced MRI-guided biopsy of liver lesionObjective:To analyze the feasibility,safety,and effectiveness of Gd-EOB-DTPA enhanced MRI-guided biopsy for liver lesions with highly suspected of clinical malignancy but atypical on routine radiological images.Materials and Methods:From October 2020 to July 2021,17 patients with suspected malignant liver lesions were hospitalized in our hospital.This study was reviewed and approved by the hospital ethics Committee.Inclusion criteria:(1)Single or multiple focal lesions in the liver,highly suspected of malignancy by clinicians and radiologists(patients with a history of chronic liver disease,cirrhosis or family history of liver cancer with or without AFP>400ng/mL:1.Liver lesions ≤2cm,no or only one positive imaging examination;2.Liver lesions>2cm,no imaging positive),requiring pathological diagnosis;(2)lesions with poor visibility on Ultrasound,CT,and conventional MR images,which was difficult to meet the requirements of interventional guidance;(3)history of malignant tumor;(4)Patients and their families signed informed consent before surgery.Exclusion criteria:(1)Poor general condition,or B liver function,Eastern Cooperative Oncology Group Performance Status>2 points,or serious dysfunction of important organs such as heart,brain,and kidney;(2)Child-Pugh-Turcotte class C liver function;(3)Severe coagulation disorder(international standardized ratio>1.5 or partial prothrombin activation time>2 times of normal value),platelet abnormality(<50×109/L);(4)Unable to cooperate with surgery;(5)Contraindications of MR examination;(6)There is a history of asthma or a history of contrast agent allergy and other Primovist use contraindications.Gd-EOB-DTPA enhanced MRI-guided percutaneous biopsy was performed in 17 patients with liver lesions.Total surgical time(The patient enters the operating room as the starting point,and immediately after procedure T2-SPIR sequence scan ends as the end point)and surgical success rate(the successful procedure was made by specimens to meet pathological,genetic,and other testing requirements)were calculated.The intraoperative and postoperative complications were recorded.The surgical pathological results or clinical follow-up results as the final diagnostic criteria,to assess the diagnostic efficacy of MRI-guided biopsy.Results:Under the guidance of Gd-EOB-DTPA enhanced MRI,a total of 17 liver lesions were biopsied,with a maximum diameter of 0.4～2.8 cm and an average of(1.6±0.7)cm;MRI showed that 15 lesions showed significantly hypointense in the hepatobiliary phase,2 lesions had slightly hypointense in the hepatobiliary phase,but the image quality met the surgical requirements.The total surgical time was 33.0 to 54.0min,with an average of 39.7± 6.4 min.A small amount of bleeding was occurred in 5 patients during procedure,after pushing gelatin sponge’s strips along the needle path,the amount of bleeding was<5 ml;the remaining 12 patients had no complications during or after procedure.Pathological diagnosis of MR-guided biopsy:11 hepatocellular carcinoma,2 colon cancer liver metastasis,3 liver dysplastic nodules with mild cirrhosis,1 liver adenoma.Eleven patients underwent surgery,and all the postoperative pathological diagnosis were hepatocellular carcinoma,6 patients were followed up by postoperative clinical imaging and serology,3 were malignant liver lesions and 3 were benign liver lesions.1 patient biopsy pathological results for the liver HGDN accompanied by mild cirrhosis,postoperative pathology diagnosed as early hepatocellular carcinoma.The diagnostic sensitivity,specificity and accuracy of Gd-EOB-DTPA enhanced MRI-guided liver biopsy were 92.9%、100.0%and 94.1%,respectively.Conclusion:1.Gd-EOB-DTPA enhanced MRI-guided liver lesion biopsy is safe,feasible and accurate.2.For lesions that are clinically highly suspected of malignancies but cannot be clearly shown by ultrasound,CT,and conventional MRI,Gd-EOB-DTPA enhanced MRI guided liver biopsy is an alternative method.Chapter 2 The clinical application of Gd-EOB-DTPA enhanced MRI-guided liver microwave ablation of early-stage hepatocellular carcinomaObjective:To evaluate the feasibility,safety,and effectiveness of Gd-EOB-DTPA enhanced MRI-guided microwave ablation of hepatocellular carcinoma with low degree of lesion visualization in conventional radiological images.Materials and Methods:This study prospectively analyzed 28 HCC patients admitted to our hospital from November 2019 to November 2020.A total of 31 lesions underwent percutaneous microwave ablation for liver cancer under Gd-EOB-DTPA enhanced 1.0T open MRI.Among them,26 patients had single liver cancer.Two patients had multiple intrahepatic lesions.In this study,the inclusion criteria were(1)hepatocellular carcinoma(solitary HCC≤5.0 cm in diameter,or 2-3 HCC tumors,each≤3.0 cm in diameter);(2)lesions with poor visibility at Ultrasound,CT,or conventional MRI;(3)Imaging evidence showed no portal vein or hepatic vein tumor embolus and no extrahepatic metastasis;(4)Child-Pugh-Turcotte class≤B,ECOG score of 2 or less;(5)unresectable tumor or patient was reluctant to undergo surgery therapy.Exclusion criteria were as follows(1)severe decompensated cirrhosis with massive ascites,severe coagulation disorders(international normalized ratio 1.5,or activated partial thromboplastin time over twice the normal value),platelet count<60×109/L;(2)Severe heart,lung,kidney dysfunction;(3)Unable to cooperate with procedure;(4)Contraindications to MRI such as installation of cardiac pacemaker status;(5)Unable to accept Gd-EOB-DTPA contrast enhancement(history of allergy,bronchial asthma,etc.).All patients were treated with Gd-EOB-DTPA-enhanced 1.0T open MR guided and monitored percutaneous microwave ablation therapy for HCC.All patients were followed up for at least 12 months after procedure;if the tumor progresses locally during the follow-up period,MRI-guided microwave ablation of liver cancer is supplemented without other treatments.Procedure success is defined as the postoperative magnetic resonance scan showing that the ablation range exceeds the tumor boundary by more than 0.5cm;technically effective is defined as reexamination within 3 months after surgery,and no clear CT/MRI imaging indicators confirm the presence of new irregular enhancement lesions around the ablation area;local tumor progression is defined as a CT/MRI enhanced scan after 3 months of ablation treatment to confirm that there are new irregular enhancement lesions around the tumor ablation area.Analyze and compare the operation status,operation success rate,technical efficiency,local tumor progression rate,and operation-related complications of the 28 patients.Results:All 31 cases of microwave ablation of hepatocellular carcinoma under MRI guidance were successful,and the success rate was 100%(31/31).The technical effective rate was 96.8%(30/31),One case of lesion in the right posterior lobe of the liver showed abnormal enhancement of the foot and ventral foci around the ablation area on enhanced MRI 2 months after microwave ablation,which was considered as a tumor and received the second microwave ablation treatment.No local tumor progression occurred during the second postoperative follow-up.The follow-up time ranged from 11 to 26 months,with a median follow-up time of 18 months and a mean follow-up time of 18.5±3.4 months.The local progression rate 1 year after procedure was 9.7%(3/31)during the follow-up period.Local progression occurred in 3 lesions at the 7th,8th,and 11th months,and received secondary microwave ablation,respectively.The total operation duration was 51.4±10.1 minutes(37-86 minutes),the preoperative preparation time was 16.6±13.9 minutes(10-24 minutes),and the ablation procedure time was.None of the 28 patients had serious complications.Conclusions:1.Gd-EOB-DTPA enhanced MRI guided and monitored early stage hepatocellular carcinoma microwave ablation is safety,and effective.2.Gd-EOB-DTPA enhanced MRI could significantly improve intraoperative lesion visibility and meet the requirements of accurate guidance,for liver lesions which not clear on ultrasound,CT,and conventional MR imaging,Gd-EOB-DTPA enhanced MRI-guided microwave ablation is an alternative option.