Real-Time 3D Virtual Target Fluoroscopic Display for Challenging Hepatocellular Carcinoma Ablations Using Cone Beam CT

Three-dimensional virtual target fluoroscopic display is a new guidance tool that can facilitate challenging percutaneous ablation. The purpose of this study was to assess the feasibility, local efficacy, and safety of liver ablation assisted by three-dimensional virtual target fluoroscopic display. Sixty-seven hepatocellular carcinomas (mean diameter: 31 mm, range: 9-90 mm, 24 ≥ 30 mm, 16 of an infiltrative form) in 53 consecutive patients were ablated using irreversible electroporation (n = 39), multibipolar radiofrequency (n = 25), or microwave (n = 3) under a combination of ultrasound and three-dimensional virtual target fluoroscopic display guidance because the procedures were considered to be unfeasible under ultrasound alone. This guidance technology consisted of real-time fluoroscopic three-dimensional visualization of the tumor previously segmented from cone beam computed tomography images acquired at the start of the procedure. The results were assessed by cross-sectional imaging performed at 1 month and then every 3 months in the event of complete ablation. Factors associated with overall local tumor progression (initial treatment failure and subsequent local tumor progression) were assessed using a logistic regression model. Sixty-one (91%) tumors were completely ablated after 1 (n = 53) or 2 (n = 8) procedures. After a median follow-up of 12.75 months (1-23.2) of the 61 tumors displaying imaging characteristics consistent with complete ablation at 1 month, local tumor progression was observed in 9, so the overall local tumor progression rate was 22.3% (15 of 67). Under multivariate analysis, dome locations and infiltrative forms were associated with local tumor progression. No major complications occurred. Three-dimensional virtual target fluoroscopic display is a feasible and efficient image guidance tool to facilitate challenging ablations that are generally considered as infeasible using ultrasound alone.