Application value of dual-phase cone-beam computed tomography during hepatic arteriography in the detection of ≤2 cm hypervascular hepatocellular carcinoma and its feeding arteries.

BACKGROUND: Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality worldwide. Accurate detection of small hypervascular HCC (≤2 cm) and precise identification of tumor-feeding arteries are pivotal to optimizing transarterial chemoembolization (TACE) efficacy. Conventional imaging modalities have inherent limitations in identifying minute lesions and fine feeding vessels. This study aimed to investigate the diagnostic performance and vascular mapping capability of dual-phase cone-beam computed tomography during hepatic arteriography (CBCT-HA) for ≤2 cm hypervascular HCC and their feeding arteries, in comparison with conventional imaging modalities. METHODS: This retrospective study enrolled 134 HCC patients with 222 target lesions (≤2 cm in diameter) who underwent TACE between February 2021 and April 2023. All patients received preoperative gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI), intraoperative dual-phase CBCT-HA and digital subtraction angiography (DSA), and immediate post-embolization lipiodol cone-beam computed tomography (L-CBCT); 99 patients also completed preoperative contrast-enhanced ultrasound (CEUS). Lesions were stratified into ≤1 cm (n=100) and 1-2 cm (n=122) subgroups. The chi-squared test was applied to compare lesion-level detection rates, patient-level diagnostic rates, and feeding artery identification rates across modalities. RESULTS: At the lesion level, dual-phase CBCT-HA detected 217 lesions (overall sensitivity 97.7%), with significantly higher detection rates than DSA (78.4%) in both size subgroups (all P<0.001). For ≤1 cm lesions, its detection rate (97.0%) was significantly higher than EOB-MRI (86.0%, P<0.001); for 1-2 cm lesions, its performance was comparable to EOB-MRI (98.4% vs. 100.0%, P>0.05). In the CEUS subgroup, it outperformed CEUS in both groups (all P<0.001) and was equivalent to EOB-MRI. At the patient level, its positive diagnostic rate (98.5%) was significantly higher than DSA (87.3%, P<0.001) and comparable to EOB-MRI. For feeding artery detection, dual-phase CBCT-HA achieved an overall rate of 87.4%, markedly higher than DSA (45.0%, all P<0.001). CONCLUSIONS: Dual-phase CBCT-HA delivers significantly higher diagnostic sensitivity than CEUS and DSA for ≤2 cm hypervascular HCC, with superior performance to EOB-MRI for ≤1 cm micro-HCC and comparable efficacy for 1-2 cm lesions. It also greatly improves tumor-feeding artery detection, facilitating precise superselective TACE. EOB-MRI remains the superior non-invasive modality for hypovascular early-stage HCC and high-grade dysplastic nodules (HGDNs) via the hepatobiliary phase (HBP).