1. Haemodynamic events and localised parenchymal changes following TACE for hepatic malignancy: interpretation of imaging findings The British Journal of Radiology,2010 Chung, J, korea

2. Abstract Following (TACE), the appearances on CT or MR images are largely related to the chemical and ischaemic insults to the portal tract. Understanding the mechanism of TACE- induced changes is essential for radiologists in order to determine the therapeutic effect as well as to distinguish these changes from recurrent tumours.

3. Aim In this article, we review the TACE- induced haemodynamic and parenchymal changes and illustrate their CT and MRI features.

4. Hepatic framework Portal venous perfusion is essential for the function and survival of hepatocytes, whereas the hepatic artery primarily supplies the hepatic framework of the portal tract. Almost all hepatic tumours receive their blood supply from the hepatic artery (Figure 1)

5. Figure 1.

6. Protocols for TACE Routine protocol : 1–20 ml of iodised oil;10–50 mg of doxorubicin(the dose depending on the size, extent and vascularity of the tumour). If possible, the emulsion is injected exclusively into the tumour-feeding segmental or subsegmental arterial branches. This is followed by administration of gelatin sponge fragments

7. Follow-up The first follow-up CT is performed three or four weeks after TACE, and further follow-up CT examina-tions are performed three months and six months after TACE (Fig.2). MRI is needed for artefacts from dense lipiodol accumulation and arterial hypervascular pseudolesions from perfusion variation, and a technical limitation such as unoptimised arterial phase imaging for follow- up CT.

8. Figure 2

9. Factors of Bile duct injuries The incidence of bile duct injury was significantly higher in patients with non- advanced cirrhotic liver, those undergoing highly selective embolisations and those with a history of repeated TACE.

10. Stage of Bile duct injuries Acute-stage: necrosis of the bile ductule followed by rupture may lead to biloma formation, with or without secondary infection, and abscess formation. Chronic-stage: stricture and dilatation of the bile duct. (Figures 3 and 4)

11. Figures 3

14. Figures 4

15. Portal vein obliteration The dilated bile duct proximal to the stricture site will gradually compress the adjacent portal vein branches in the injured portal tract Gross appearance of large intrahepatic bile duct injury (1 month after TACE) tends to be followed by obliteration of the adjacent portal vein(1 to 6 month after TACE). (Figure 5 and 6)

16. Figure 5

17. Figure 6

18. Periportal edema Periportal edema, shown as bilateral linear low attenuating areas alongside the portal vein, is the result of extravasated bile or reactive fluid collection in addition to bile duct dilatation.( Figure 7)

19. Figure 7

20. Acute parenchymal infarct Embolic materials flow into the portal venules through the transplexal route, which leads to obliteration of the portal venules The simultaneously decreased arterial and portal venous perfusion results in parenchymal infarction, which appears as a low-density area on all phases of dynamic CT (Figure 8)

21. Figure 8

22. During the follow-up periods, some arterial inflow can be recovered by arterial recanalisation or collateralisation (Fig.9) Arterial reperfusion of previously infarcted parenchyma can demonstrate inhomogeneous enhancement on arterial phase images.

23. Figure 9

24. Owing to the decreased attenuation of the infarcted area on pre-contrast and equilibrium-phase images, it can be hard to differentiate the reperfused area from a viable tumour that shows subsequent washout of contrast material. SPIO uptake is also decreased in the infarcted parenchyma in the vicinity of the lesion (Figure 10)

25. Figure 10

26. Perilesional parenchymal enhancement Another frequent finding is the presence of perilesional parenchymal enhancement in patients after TACE treatment. We consider this finding probably as benign physiologic hemodynamic response to the other parenchymal changes,including bile duct injury, chemical arteritis, and portal vein branches obliteration. (Figure 11)

27. Figure 11

28. Arterioportal fistulae chemical or ischaemic injury of the portal tract and direct mechanical injury of the arterial wall by the guide wire or catheter itself can induce the formation of a fistulae between small arteries and the portal vein branches. Typically, subcapsular, wedge-shaped or irregular arterial phase enhancement during CT or MRI could be regarded as an arterioportal fistula (APF) (Figure 12)

29. Figure 12

30. Owing to the traumatic or acute inflammatory nature of this injury, most traumatic APFs would disappear on the serial follow-up imaging studies (Fig.13).

31. Figure 13

32. In the advanced cirrhotic liver, differential diagnosis of APF from recurrent HCC is sometimes difficult because of the parenchymal distortion and inhomogeneous attenuation of the background liver on delayed-phase images. MRI using (SPIO) is helpful for excluding a true tumour from an acute APF-induced arterioportal shunt that shows normal SPIO uptake (Figure 14)

33. Figure 14

34. Parenchymal atrophy Parenchymal atrophy occurs because of decreased portal venous perfusion following acute or gradual vascular compromise caused by bile duct injury, arterial vasculitis, portal phlebitis and/or passive compression. Yu reported the mean time between TACE and the appearance of atrophic changes as 20 weeks.

35. Conclusion After TACE, the appearances on CT or MRI are largely related to the chemical and ischemic insults to the portal tract. Serial follow-up is still essential and selective application of liver-specific contrast-enhanced MRI is recommended for accurate assessment of relevant conditions.

36. Conclusion The mechanism and imaging findings of TACE-induced changes should be familiar to radiologists, so that they can determinate the therapeutic effect as well as distinguish such changes from a recurrent tumour.

37. Thank you for your attention !