European Radiology

, Volume 27, Issue 11, pp 4837–4845 | Cite as

Prognostic value of incidental hypervascular micronodules detected on cone-beam computed tomography angiography of patients with liver metastasis

  • Bruno C. OdisioEmail author
  • Veronica L. Cox
  • Silvana C. Faria
  • Suguru Yamashita
  • Xiao Shi
  • Joe Ensor
  • Aaron K. Jones
  • Armeen Mahvash
  • Sanjay Gupta
  • Alda L. Tam
  • Jean-Nicolas Vauthey
  • Ravi Murthy



To determine the clinical relevance of incidentally-found hypervascular micronodules (IHM) on cone-beam computed tomography angiography (CBCTA) in patients with liver metastasis undergoing transarterial (chemo)embolization (TACE/TAE).

Material and methods

This was a HIPAA-compliant institutional review board-approved single-institution retrospective review of 95 non-cirrhotic patients (52 men; mean age, 60 years) who underwent CBCTA prior to (chemo)embolic delivery. IHM were defined by the presence of innumerable subcentimetre hepatic parenchymal hypevascular foci not detected on pre-TACE/TAE contrast-enhanced cross-sectional imaging. Multivariate analysis was performed to compare time to tumour progression (TTP) between patients with and without IHM.


IHM were present in 21 (22%) patients. Patients with IHM had a significantly shorter intrahepatic TTP determined by a higher frequency of developing new liver metastasis (hazard ratio [HR]: 1.99; 95% confidence interval [CI] 1.08–3.67, P= 0.02). Patients with IHM trended towards a shorter TTP of the tumour(s) treated with TACE/TAE (HR: 1.72; 95% CI: 0.98–3.01, P= 0.056). Extrahepatic TTP was not significantly different between the two cohorts (P= 0.27).


Patients with IHM on CBCTA have worse prognosis due to a significantly higher risk of developing new hepatic tumours. Further work is needed to elucidate its underlying mechanisms of pathogenesis.

Key Points

21% of liver metastasis patients undergoing TACE/TAE have IHM on CBTA.

IHM are associated with a high risk of developing new hepatic tumours.

IHA are also associated with a trend toward poorer response to TACE/TAE.


Liver metastasis Cone-beam computed tomography Incidental findings Disease progression Embolization 



Cone-beam computed tomography angiography


Incidentally-found hypervascular micronodules


Modified Response Evaluation Criteria in Solid Tumours


Response Evaluation Criteria in Solid Tumours


Transarterial (chemo)embolization


Compliance with ethical standards


The scientific guarantor of this publication is Bruno C. Odisio.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.


The authors state that this work has not received any funding.

Statistics and biometry

Joe Ensor kindly provided statistical advice for this manuscript.

Ethical approval

Institutional Review Board approval was obtained.

Informed consent

Written informed consent was waived by the Institutional Review Board.


  • retrospective

  • case-control study

  • performed at one institution


  1. 1.
    Wallace MJ, Kuo MD, Glaiberman C et al (2009) Three-dimensional C-arm cone-beam CT: applications in the interventional suite. J Vasc Interv Radiol 20:S523–537CrossRefGoogle Scholar
  2. 2.
    Orth RC, Wallace MJ, Kuo MD, Technology Assessment Committee of the Society of Interventional R (2008) C-arm cone-beam CT: general principles and technical considerations for use in interventional radiology. J Vasc Interv Radiol 19:814–820CrossRefGoogle Scholar
  3. 3.
    Suk Oh J, Jong Chun H, Gil Choi B, Giu Lee H (2013) Transarterial chemoembolization with drug-eluting beads in hepatocellular carcinoma: usefulness of contrast saturation features on cone-beam computed tomography imaging for predicting short-term tumor response. J Vasc Interv Radiol 24:483–489CrossRefGoogle Scholar
  4. 4.
    Ishikawa T, Abe S, Hoshii A et al (2016) Cone-Beam Computed Tomography Correlates with Conventional Helical Computed Tomography in Evaluation of Lipiodol Accumulation in HCC after Chemoembolization. PLoS One 11, e0145546CrossRefGoogle Scholar
  5. 5.
    Bapst B, Lagadec M, Breguet R, Vilgrain V, Ronot M (2016) Cone Beam Computed Tomography (CBCT) in the Field of Interventional Oncology of the Liver. Cardiovasc Intervent Radiol 39:8–20CrossRefGoogle Scholar
  6. 6.
    Lee IJ, Chung JW, Yin YH et al (2014) Cone-beam CT hepatic arteriography in chemoembolization for hepatocellular carcinoma: angiographic image quality and its determining factors. J Vasc Interv Radiol 25:1369–1379, quiz 1379- e1361CrossRefGoogle Scholar
  7. 7.
    Loffroy R, Lin M, Rao P et al (2012) Comparing the detectability of hepatocellular carcinoma by C-arm dual-phase cone-beam computed tomography during hepatic arteriography with conventional contrast-enhanced magnetic resonance imaging. Cardiovasc Intervent Radiol 35:97–104CrossRefGoogle Scholar
  8. 8.
    Miyayama S, Matsui O, Yamashiro M et al (2009) Detection of hepatocellular carcinoma by CT during arterial portography using a cone-beam CT technology: comparison with conventional CTAP. Abdom Imaging 34:502–506CrossRefGoogle Scholar
  9. 9.
    Schernthaner RE, Lin M, Duran R, Chapiro J, Wang Z, Geschwind JF (2015) Delayed-Phase Cone-Beam CT Improves Detectability of Intrahepatic Cholangiocarcinoma During Conventional Transarterial Chemoembolization. Cardiovasc Intervent Radiol 38:929–936CrossRefGoogle Scholar
  10. 10.
    Vigano L, Rubbia-Brandt L, De Rosa G et al (2015) Nodular Regenerative Hyperplasia in Patients Undergoing Liver Resection for Colorectal Metastases After Chemotherapy: Risk Factors, Preoperative Assessment and Clinical Impact. Ann Surg Oncol 22:4149–4157CrossRefGoogle Scholar
  11. 11.
    Dachman AH, Ros PR, Goodman ZD, Olmsted WW, Ishak KG (1987) Nodular regenerative hyperplasia of the liver: clinical and radiologic observations. AJR Am J Roentgenol 148:717–722CrossRefGoogle Scholar
  12. 12.
    Bouyn CI, Leclere J, Raimondo G et al (2003) Hepatic focal nodular hyperplasia in children previously treated for a solid tumor. Incidence, risk factors, and outcome. Cancer 97:3107–3113CrossRefGoogle Scholar
  13. 13.
    Brisse H, Servois V, Bouche B et al (2000) Hepatic regenerating nodules: a mimic of recurrent cancer in children. Pediatr Radiol 30:386–393CrossRefGoogle Scholar
  14. 14.
    Yoo SY, Kim JH, Eo H, Jeon TY, Sung KW, Kim HS (2013) Dynamic MRI findings and clinical features of benign hypervascular hepatic nodules in childhood-cancer survivors. AJR Am J Roentgenol 201:178–184CrossRefGoogle Scholar
  15. 15.
    Yoshimitsu K, Honda H, Kuroiwa T et al (2001) Unusual hemodynamics and pseudolesions of the noncirrhotic liver at CT. Radiographics 21 Spec No:S81-96Google Scholar
  16. 16.
    International Working P (1995) Terminology of nodular hepatocellular lesions. Hepatology 22:983–993CrossRefGoogle Scholar
  17. 17.
    Hayashi M, Matsui O, Ueda K, Kawamori Y, Gabata T, Kadoya M (2002) Progression to hypervascular hepatocellular carcinoma: correlation with intranodular blood supply evaluated with CT during intraarterial injection of contrast material. Radiology 225:143–149CrossRefGoogle Scholar
  18. 18.
    Eisenhauer EA, Therasse P, Bogaerts J et al (2009) New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 45:228–247CrossRefGoogle Scholar
  19. 19.
    Blyth S, Blakeborough A, Peterson M, Cameron IC, Majeed AW (2008) Sensitivity of magnetic resonance imaging in the detection of colorectal liver metastases. Ann R Coll Surg Engl 90:25–28CrossRefGoogle Scholar
  20. 20.
    Kuszyk BS, Bluemke DA, Urban BA et al (1996) Portal-phase contrast-enhanced helical CT for the detection of malignant hepatic tumors: sensitivity based on comparison with intraoperative and pathologic findings. AJR Am J Roentgenol 166:91–95CrossRefGoogle Scholar
  21. 21.
    Yokoyama N, Shirai Y, Ajioka Y, Nagakura S, Suda T, Hatakeyama K (2002) Immunohistochemically detected hepatic micrometastases predict a high risk of intrahepatic recurrence after resection of colorectal carcinoma liver metastases. Cancer 94:1642–1647CrossRefGoogle Scholar
  22. 22.
    Garayoa J, Castro P (2013) A study on image quality provided by a kilovoltage cone-beam computed tomography. J Appl Clin Med Phys 14:3888CrossRefGoogle Scholar
  23. 23.
    Jones A, Abdelsalam, M, Wallace, M Impact of C-arm Cone Beam CT (CBCT) on Radiation Dose during Hepatic ChemoembolizationRadiological Society of North America 2012 Scientific Assembly and Annual MeetingGoogle Scholar

Copyright information

© European Society of Radiology 2017

Authors and Affiliations

  • Bruno C. Odisio
    • 1
    Email author
  • Veronica L. Cox
    • 2
  • Silvana C. Faria
    • 2
  • Suguru Yamashita
    • 3
  • Xiao Shi
    • 4
  • Joe Ensor
    • 5
  • Aaron K. Jones
    • 6
  • Armeen Mahvash
    • 1
  • Sanjay Gupta
    • 1
  • Alda L. Tam
    • 1
  • Jean-Nicolas Vauthey
    • 3
  • Ravi Murthy
    • 1
  1. 1.Department of Interventional Radiology, Division of Diagnostic ImagingThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Diagnostic RadiologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.Department of Diagnostic RadiologyBaylor College of MedicineHoustonUSA
  5. 5.Biostatistics of the Houston Methodist Cancer CenterHoustonUSA
  6. 6.Imaging PhysicsThe University of Texas MD Anderson Cancer CenterHoustonUSA

Personalised recommendations