Das hepatozelluläre Karzinom. Rolle der Bildgebung zur Detektion, Therapieplanung und Therapiekontrolle

Zusammenfassung

Zielsetzung: Vorstellung der Methodik und klinischen Wertigkeit der bildgebenden Diagnostik zu Screening, Detektion, Interventionsplanung und Therapiekontrolle des hepatozellulären Karzinoms (HCC). Diagnostische Untersuchungstechniken werden diskutiert wie farbkodierte Duplexsonographie, Computertomographie (CT, MSCT) und kontrastmittelverstärkte Magnetresonanzverfahren (MRT, MRA und MRCP). Die Therapiekontrolle mittels Bildgebung erfolgt im Rahmen des Einsatzes chirurgischer Therapieverfahren wie Resektion und Lebertransplantation sowie der transarteriellen Chemoembolisation (TACE), Radiofrequenzablation und der laserinduzierten Thermotherapie (LITT). Die farbkodierte Duplexsonographie zeigt beim Screening des HCC bei vorliegender Leberzirrhose Sensitivitäten von 45 - 92 % bei einer Spezifität von 78 - 90 %. Die Ergebnisse der CT konnten durch Etablierung der mehrphasischen Mehrschicht-Spiral-CT verbessert werden. Die höchste diagnostische Treffsicherheit erzielt derzeit die kontrastverstärkte MRT mit einer Sensitivität von 82 - 96 %. Die TACE stellt derzeit ein palliatives Therapiekonzept dar, die MR-gesteuerte LITT und die Radiofrequenzablation werden als thermoablative Verfahren zur Lokaltherapie eingesetzt, und die Therapiekontrolle basiert auf obigen bildgebenden Verfahren. Zusammenfassend ist im Rahmen der Diagnostik und Therapiekontrolle des HCC ein individuell adaptierter Einsatz der bildgebenden Diagnostik erforderlich.

Abstract

Purpose: Demonstration of techniques and clinical value of imaging diagnostics for screening, detection, interventional follow-up and therapy control of hepatocellular carcinoma (HCC). Diagnostic techniques for screening, detection and differential diagnosis of HCC are presented using color-coded duplex sonography (US), computer tomography (CT) and contrast-enhanced magnetic resonance techniques like MRI, MR angiography and MR cholangiopancreaticography (MRCP). Therapy control with imaging was performed for surgical methods like resection and liver transplantation as for well as transarterial chemoembolization (TACE), radiofrequency ablation (RF) and laser-induced thermotherapy (LITT). In screening, HCC color-coded duplex sonography reveals a sensitivity from 45 to 92 % and a specificity from 78 to 90 % when liver cirrhosis is present. The diagnostic results of CT were further improved with the newly developed techniques of multislice CT. The highest diagnostic accuracy can currently be achieved using contrast-enhanced MRI with a sensitivity from 82 to 96 %. TACE presents a palliative therapy concept; MR-guided LITT and radiofrequency ablation are used as thermoablative methods for local therapy and the therapy control is based on the above imaging techniques. Contrast-enhanced MRI proves to be the superior imaging technique for the early diagnosis, differential diagnosis and follow-up of hepatocellular carcinoma.

Schlüsselwörter

Hepatozelluläres Karzinom (HCC) - radiologische Intervention - Transarterielle Chemoembolisation - TACE - laserinduzierte Thermotherapie - Radiofrequenzablation - Sonographie - CT - MRT

Key words

Hepatocellular carzinoma (HCC) - radiological intervention - transarterial chemoembolization - TACE - laser-induced thermotherapy - radiofrequency ablation - sonography - CT - MRI

Literatur

• 1 Bruix J, Sherman M, Llovet J M, Beaugrand M, Lencioni R, Burroughs A K, Christensen E, Pagliaro L, Colombo M, Rodes J. EASL Panel of Experts on HCC. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver.  J Hepatol. 2001;  35 421-430
• 2 Kanematsu M, Hoshi H, Yamada T, Murakami T, Kim T, Kato M, Yokoyama R, Nakamura H. Small hepatic nodules in cirrhosis: ultrasonographic, CT, and MR imaging findings.  Abdom Imaging. 1999;  24 47-55
• 3 Bartolozzi C, Lencioni R, Caramella D, Palla A, Bassi A M, Di Candio G. Small hepatocellular carcinoma. Detection with US, CT, MR imaging, DSA, and Lipiodol-CT.  Acta Radiol. 1996;  37 69-74
• 4 Kubota K, Hisa N, Nishikawa T. et al . Evaluation of hepatocellular carcinoma after treatment with transcatheter arterial chemoembolization: comparison of Lipiodol-CT, power Doppler sonography, and dynamic MRT.  Abdom Imaging. 2001;  26 184-190
• 5 Horigome H, Nomura T, Saso K, Itoh M. Standards for selecting percutaneous ethanol injection therapy or percutaneous microwave coagulation therapy for solitary small hepatocellular carcinoma: consideration of local recurrence.  Am J Gastroenterol. 1999;  94 1914-1917
• 6 Torzilli G, Minagawa M, Takayama T, Inoue K, Hui A M, Kubota K, Ohtomo K, Makuuchi M. Accurate preoperative evaluation of liver mass lesions without fine-needle biopsy.  Hepatology. 1999;  30 889-893
• 7 Oi H, Murakami T, Kim T, Matsushita M, Kishimoto H, Nakamura H. Dynamic MR imaging and early-phase helical CT for detecting small intrahepatic metastases of hepatocellular carcinoma.  Am J Roentgenol. 1996;  166 369-374
• 8 Horigome H, Nomura T, Saso K, Itoh M, Joh T, Ohara H. Limitations of imaging diagnosis for small hepatocellular carcinoma: Comparison with histological findings.  J Gastroenterol Hepatol. 1999;  14 559-565
• 9 Tsai T J, Chau G Y, Lui W Y, Tsay S H, King K L, Loong C C, Hsia C Y, Wu C W. Clinical significance of microscopic tumor venous invasion in patients with resectable hepatocellular carcinoma.  Surgery. 2000;  127 603-608
• 10 Takamori R, Wong L L, Dang C, Wong L. Needle-tract implantation from hepatocellular cancer: is needle biopsy of the liver always necessary?.  Liver Transpl. 2000;  6 67-72
• 11 Llovet J M, Vilana R, Bru C, Bianchi L, Salmeron J M, Boix L, Ganau S, Sala M, Pages M, Ayuso C, Sole M, Rodes J, Bruix J. Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma.  Hepatology. 2001;  33 1124-1129
• 12 Bismuth H, Chiche L, Adam R, Castaing D, Diamond T, Dennison A. Liver resection versus transplantation for hepatocellular carcinoma in cirrhotic patients.  Ann Surg. 1993;  218 145-151
• 13 Vogl T, Schroeder H, Trapp M. Multisequentielle arterielle Chemoembolisation fortgeschrittener hepatozellulärer Karzinome: Computertomographische Verlaufsparameter zur Beurteilung des Ansprechens auf die Therapie.  Fortschr Röntgenstr. 2000;  172 43-50
• 14 Vogl T, Trapp M, Schroeder H. et al . Transarterial chemoembolization for hepatocellular carcinoma: volumetric and morphologic CT criteria for assessment of prognosis and therapeutic success - results from a liver transplantation center.  Radiology. 2000;  214 349-357
• 15 Bartolozzi C, Lencioni R, Caramella D. et al . Treatment of large HCC: transcatheter arterial chemoembolization combined with percutaneous ethanol injection versus repeated transcatheter arterial chemoembolization.  Radiology. 1995;  197 812-818
• 16 Vogl T, Mack M, Straub R, Roggan A, Felix R. Percutaneous MRI-guided laser-induced thermotherapy for hepatic metastases for colorectal cancer.  The Lancet. 1997;  350 29
• 17 Allgaier H P, Deibert P, Zuber I, Olschewski M, Blum H E. Percutaneous radiofrequency interstitial thermal ablation of small hepatocellular carcinoma.  Lancet. 1999;  353 1676-1677
• 18 Curley S A, Izzo F, Ellis L M, Nicolas Vautey J, Vallone P. Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis.  Ann Surg. 2000;  232 381-391
• 19 Pacella C M, Bizzarri G, Cecconi P. et al . Hepatocellular carcinoma: long-term results of combined treatment with laser thermal ablation and transcatheter arterial chemoembolization.  Radiology. 2001;  219 669-678
• 20 Koike Y, Shiratori Y, Sato . et al . Risk factors for recurring hepatocellular carcinoma differ according to infected hepatitis virus - an analysis of 236 consecutive patients with a single lesion.  Hepatology. 2000;  32 1216-1223
• 21 Lopez Hanninen E, Vogl T J, Bechstein W O, Guckelberger O, Neuhaus P, Lobeck H, Felix R. Biphasic spiral computed tomography for detection of hepatocellular carcinoma before resection or orthotopic liver transplantation.  Invest Radiol. 1998;  33 216-221
• 22 Vogl T J, Hammerstingl R, Schwarz W. Imaging techniques for the diagnosis of hepatocellular carcinoma: technique, results, indications.  Der Radiologe. 2001;  41 895-905
• 23 Lim J H, Choi D, Cho S K, Kim S H, Lee W J, Lim H K, Park C K, Paik S W, Kim Y I. Conspicuity of hepatocellular nodular lesions in cirrhotic livers at ferumoxides-enhanced MR imaging: Importance of Kupffer cell numbers.  Radiology. 2001;  220 669-676
• 24 Krinsky G A, Lee V S, Theise N D, Weinreb J C, Rofsky N M, Diflo T, Teperman L W. Hepatocellular carcinoma and dysplastic nodules in patients with cirrhosis: prospective diagnosis with MR imaging and explantation correlation.  Radiology. 2001;  219 445-454
• 25 Ding H, Kudo M, Onda H, Suetomi Y, Maekawa K. Hepatocellular carcinoma: depiction of tumor parenchymal flow with intermittent harmonic power doppler US during the early arterial phase in dual-display mode.  Radiology. 2001;  220 349-356
• 26 Keogan M T, Edelman R R. Technologic advances in abdominal MR imaging.  Radiology. 2001;  220 310-320
• 27 Pauleit D, Textor J, Bachmann R, Conrad R, Flacke S, Layer G, Kreft B, Schild H. Hepatocellular carcinoma: detection with Gadolinium- and Ferumoxides-enhanced MR imaging of the liver.  Radiology. 2002;  222 73-80
• 28 Brancatelli G, Federle M P, Grazioli L, Carr B I. Hepatocellular carcinoma in noncirrhotic liver: CT, clinical, and pathologic findings in 39 U.S. residents.  Radiology. 2002;  222 89-94
• 29 Dill-Macky M J, Burns P N, Khalili K, Wilson S R. Focal hepatic masses: enhancement patterns with SH U 508A and pulse-inversion US.  Radiology. 2002;  222 95-102
• 30 Habermann C R, Weiss F, Hillner M, Staedtler C, Schoder V, Welger J, Bücheler E, Adam G. Stellenwert der dreiphasischen Spiral-CT in der Detektion des hepatozellulären Karzinoms bei Leberzirrhose.  Fortschr Röntgenstr. 2002;  174 96-100