US-Guided Radiofrequency Ablation of Hepatic Focal Lesions

Transcription

1 US-Guided Radiofrequency Ablation of Hepatic Focal Lesions Poster No.: C-2219 Congress: ECR 2011 Type: Scientific Exhibit Authors: D. Armario Bel, A. PLA, F. TERREL, X. Serres; BARCELONA/ES Keywords: Neoplasia, Metastases, Outcomes analysis, Ablation procedures, CT, Ultrasound,, Interventional non-vascular, Abdomen, Liver DOI: /ecr2011/C-2219 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 49

2 Purpose We report our results of imaging-guided radiofrequency ablation (RFA) of focal hepatic lesions, from September 2003 to January Page 2 of 49

3 Methods and Materials 72 patients aged between 43 and 84 (mean 70) underwent RF thermal ablation of 91 tumours ranging from 1.1 to 4.5cm (mean 2,7cm). 22 of 72 patients had metastatic hepatic nodules and 50 Hepatocellular carcinoma nodules. Fig.: Hepatocellular carcinoma (HCC) and Metastases from colorectal carcinoma are the most common malignant tumors to affect the liver References: - BARCELONA/ES Page 3 of 49

4 Fig.: Our base data. References: - BARCELONA/ES Tumors were treated percutaneously using the Valleylab CoolTip RF Ablation System under ultrasonographic guidance, administrating energy during 12 minutes and accepting a correct treatment if the temperature in the centre of the tumour was #55ºC. Page 4 of 49

5 Fig.: Internally water cooled electrode and the diameter of heat effect References: - BARCELONA/ES Page 5 of 49

6 Fig.: This figure depicts different materials needed to be succesful. It's necessary to work under sterile conditions. References: - BARCELONA/ES Page 6 of 49

7 Fig.: High temperature is attenuated with cool water pump (a,b), Generator indicates the impedance, the powerful and the temperature (c,d) Local anaesthesia is administrated before the procedure along the electrode traject References: - BARCELONA/ES In some cases with difficult location we did hydrodissection injecting 5 ml of glucosade serum between liver and diaphragma to prevent adjacent organs damage. Page 7 of 49

8 Fig.: Hydrodissection to avoid further complications. References: - BARCELONA/ES Page 8 of 49

9 Images for this section: Fig. 0: Our base data. - BARCELONA/ES Page 9 of 49

10 Fig. 0 - BARCELONA/ES Page 10 of 49

11 Fig. 0: Internally water cooled electrode and the diameter of heat effect - BARCELONA/ES Page 11 of 49

12 Fig. 0: This figure depicts different materials needed to be succesful. It's necessary to work under sterile conditions. - BARCELONA/ES Page 12 of 49

13 Fig. 0: High temperature is attenuated with cool water pump (a,b), Generator indicates the impedance, the powerful and the temperature (c,d) Local anaesthesia is administrated before the procedure along the electrode traject - BARCELONA/ES Page 13 of 49

14 Fig. 0: Hydrodissection to avoid further complications. - BARCELONA/ES Page 14 of 49

15 Results Fig.: Post contrast MRI (a,b) and ultrasonography (c,d,e) shows a focal hepatic lesion, with an arterial contrast enhancing and venous washout, the classical findings of hepatocellular carcinoma References: - BARCELONA/ES Page 15 of 49

16 Fig.: The ablation procedure, showing the needle in the middle of the lesion (a), and the progressive formation of gas (b,c,d) to dissipate the heat. References: - BARCELONA/ES Page 16 of 49

17 Fig.: In this case, contrast enhanced ultrasonogrphy depicts a solitary lesion with an early arterial rim enhancing (b), that turned to be a metastase from colon adenocarcinoma. The lesion was treated without complications (d,e,f) 6 months later, CT showed signs of complete ablation(g,h,i) References: - BARCELONA/ES Page 17 of 49

18 Fig.: (a,b,c) The procedure was realized without complications. The follow-up ultrasound (d,e) and CT (e,f) performed 6 months later showed a residual necrotic lesion without contrast enhancing in either arterial or venous phase. References: - BARCELONA/ES Page 18 of 49

19 Fig.: Ultrasound before (a) and after intravascular contrast administration (b,c) showed a focal hepatic lesion in segment II of the liver with a fast arterial contrast enhancing (b) and an early wash out (c). CT images (d,e) correlate with the ultrasonographic findings. This lesion was an hepatocellular carcinoma. References: - BARCELONA/ES Page 19 of 49

20 Fig.: (a,b) Depicts the needle located in the middle of the lesion and the progresive appearence of gas during the ablation procedure. (c,d) The 6 months follow-up contrast enhanced ultrasonography shows the correctly ablated tumor, without contast enhancing in both aretrial and venous phase. (e,f) The 6 months follow-up CT correlates with the ultrasound findings and demonstrates the result of a completely ablation therapy. References: - BARCELONA/ES Page 20 of 49

21 Fig.: Both CT and ultrasound demonstrate the presence of a focal hepatic lesion, with an arterial periferic enhancing (a,c) and a fast washout in the venous phase (b,d). The final diagnose was an hepatocelular carcinoma. References: - BARCELONA/ES Page 21 of 49

22 Fig.: The ablation procedure, showing the needle in the middle of the lesion (a), and the progressive formation of gas (b,c,d) to dissipate the heat. References: - BARCELONA/ES Page 22 of 49

23 Fig.: CT and ultrasonography performed 1 year after the ablation procedure demonstrates a necrotic lesion without contrast enhancing in both arterial (a,c) and venous phase (b,d) References: - BARCELONA/ES During seven years of follow-up with contrast enhanced ultrasonography and/or contrast enhanced CT we have seen disease progression in 43 patients. New focal lesions appeared in 34 patients (47%). Only 9 patients (9'9%) showed local recurrence due to a partial ablation therapy. 9 patients were retreated with RF and 2 needed a third session of RFA. Page 23 of 49

24 Fig.: This table shows recurrences reported in the follow-up References: - BARCELONA/ES Page 24 of 49

25 Fig.: Focal hepatic lesions treated with RFA (a,b,c). 4 months later after RFA US was performed and showed cystic area with mural solid nodule hypervascular suggestive of recurrence (d,e,f) References: - BARCELONA/ES Page 25 of 49

26 Fig.: RFA procedure of a hepatic lesion suggestive of hepatocarcinoma (a, b, c). Contrast enhanced US performed 4 months later showed mutliple focal lesions that had a rapid wash-out in venous phase, findings compatible with recurrence (d, e, f). References: - BARCELONA/ES Page 26 of 49

27 Fig.: CT obtained after RFA of HCC depicts hypodense residual lesion with no contrast enhancing. However we can see many ohter lesions hypervascular in arterial phase (a, b, c) and with rapid wash-out in venous phase (d, e, f). These lesions were suggestive of HCC recurrence. References: - BARCELONA/ES We have reported 7 patients (10%) with minor complications and 1 exitus (1'4%) due to the procedure (hemobilia). Minor were solved with medical treatment. These included skin burn, arterioportal shunts and subcapsular haematomas. We reported an important hemoperotneum secondary to vascular lesion after RFA that resolved with embolization. Page 27 of 49

28 Fig.: Residual lesion (*) after RFA (a). Immediately after the procedure appeared an hypoechoic image adjacent the residual lesion suggestive of haematoma (arrow) that became bigger in a few seconds (b, c). After intravenous contrast administration we observed an outflow of contrast suggestive of active bleeding (wide arrow) in arterial (f) and venous phase (g). References: - BARCELONA/ES Page 28 of 49

29 Fig.: The same patient as before. CT image obtained with IV contrast material after RF abaltion was performed. We could see signs of active bleeding in a metastatic liver, with extravasation of contrast and hemoperitoneum (*). Arteriography was performed and left portal vein branch and left hepatic artery were embolized. Nowadays the patient is still alive. References: - BARCELONA/ES 15 patients died (21%), 14 because of multiorganic failure due to advanced cancer and only 1 (1'4%) secondary to the procedure (hemobilia). Page 29 of 49

30 Fig.: This patient undrewent RFA and next day had right abdominal pain and immediately became hemodynamically unstable. CT with no contrast (a, b, c) depicted hyperdense material in choledoch (arrow), findings suggestive of haemobilia. CT after intravenous contrast administration (d, e, f) showed an arteriovenous fistula (*) with intra and extrahepatic biliar tree dilation, fibrotic residual lesions secundary to previous RFA and hypodense lesions suggestive of intrahepatic abscesses (white arrow) related to hemobilia. This patient finally died. References: - BARCELONA/ES Page 30 of 49

31 Images for this section: Fig. 0: In this case, contrast enhanced ultrasonogrphy depicts a solitary lesion with an early arterial rim enhancing (b), that turned to be a metastase from colon adenocarcinoma. The lesion was treated without complications (d,e,f) 6 months later, CT showed signs of complete ablation(g,h,i) - BARCELONA/ES Page 31 of 49

32 Fig. 0: Post contrast MRI (a,b) and ultrasonography (c,d,e) shows a focal hepatic lesion, with an arterial contrast enhancing and venous washout, the classical findings of hepatocellular carcinoma - BARCELONA/ES Page 32 of 49

33 Fig. 0: The ablation procedure, showing the needle in the middle of the lesion (a), and the progressive formation of gas (b,c,d) to dissipate the heat. - BARCELONA/ES Page 33 of 49

34 Fig. 0: CT and ultrasonography performed 1 year after the ablation procedure demonstrates a necrotic lesion without contrast enhancing in both arterial (a,c) and venous phase (b,d) - BARCELONA/ES Page 34 of 49

35 Fig. 0: CT and ultrasonography performed 1 year after the ablation procedure demonstrates a necrotic lesion without contrast enhancing in both arterial (a,c) and venous phase (b,d) - BARCELONA/ES Page 35 of 49

36 Fig. 0: (a,b) Depicts the needle located in the middle of the lesion and the progresive appearence of gas during the ablation procedure. (c,d) The 6 months follow-up contrast enhanced ultrasonography shows the correctly ablated tumor, without contast enhancing in both aretrial and venous phase. (e,f) The 6 months follow-up CT correlates with the ultrasound findings and demonstrates the result of a completely ablation therapy. - BARCELONA/ES Page 36 of 49

37 Fig. 0: Ultrasound before (a) and after intravascular contrast administration (b,c) showed a focal hepatic lesion in segment II of the liver with a fast arterial contrast enhancing (b) and an early wash out (c). CT images (d,e) correlate with the ultrasonographic findings. This lesion was an hepatocellular carcinoma. - BARCELONA/ES Page 37 of 49

38 Fig. 0: (a,b,c) The procedure was realized without complications. The follow-up ultrasound (d,e) and CT (e,f) performed 6 months later showed a residual necrotic lesion without contrast enhancing in either arterial or venous phase. - BARCELONA/ES Page 38 of 49

39 Fig. 0: Both CT and ultrasound demonstrate the presence of a focal hepatic lesion, with an arterial periferic enhancing (a,c) and a fast washout in the venous phase (b,d). The final diagnose was an hepatocelular carcinoma. - BARCELONA/ES Page 39 of 49

40 Fig. 0: Residual lesion (*) after RFA (a). Immediately after the procedure appeared an hypoechoic image adjacent the residual lesion suggestive of haematoma (arrow) that became bigger in a few seconds (b, c). After intravenous contrast administration we observed an outflow of contrast suggestive of active bleeding (wide arrow) in arterial (f) and venous phase (g). - BARCELONA/ES Page 40 of 49

41 Fig. 0: The same patient as before. CT image obtained with IV contrast material after RF abaltion was performed. We could see signs of active bleeding in a metastatic liver, with extravasation of contrast and hemoperitoneum (*). Arteriography was performed and left portal vein branch and left hepatic artery were embolized. Nowadays the patient is still alive. - BARCELONA/ES Page 41 of 49

42 Fig. 0: This patient undrewent RFA and next day had right abdominal pain and immediately became hemodynamically unstable. CT with no contrast (a, b, c) depicted hyperdense material in choledoch (arrow), findings suggestive of haemobilia. CT after intravenous contrast administration (d, e, f) showed an arteriovenous fistula (*) with intra and extrahepatic biliar tree dilation, fibrotic residual lesions secundary to previous RFA and hypodense lesions suggestive of intrahepatic abscesses (white arrow) related to hemobilia. This patient finally died. - BARCELONA/ES Page 42 of 49

43 Fig. 0: This table shows recurrences reported in the follow-up - BARCELONA/ES Page 43 of 49

44 Fig. 0: RFA procedure of a hepatic lesion suggestive of hepatocarcinoma (a, b, c). Contrast enhanced US performed 4 months later showed mutliple focal lesions that had a rapid wash-out in venous phase, findings compatible with recurrence (d, e, f). - BARCELONA/ES Page 44 of 49

45 Fig. 0: CT obtained after RFA of HCC depicts hypodense residual lesion with no contrast enhancing. However we can see many ohter lesions hypervascular in arterial phase (a, b, c) and with rapid wash-out in venous phase (d, e, f). These lesions were suggestive of HCC recurrence. - BARCELONA/ES Page 45 of 49

46 Fig. 0: Focal hepatic lesions treated with RFA (a,b,c). 4 months later after RFA US was performed and showed cystic area with mural solid nodule hypervascular suggestive of recurrence (d,e,f) - BARCELONA/ES Page 46 of 49

47 Conclusion Radiofrequency ablation is an interesting therapeutic option for focal hepatic lesions in no surgical patients. The procedure requires conscious sedation and needs short hospitalization time. We have reported a low rate of local recurrence and significant complications and there has been reported only one death due to the procedure in 7 years of followed up. We have had disease progression in nearly half of patients. Page 47 of 49

48 References Gazelle GS, Goldberg SN, Solbiati L, Livraghi T. Tumor ablation with radio-frequency energy. Radiology 2000; 217: Solbiati L, Livraghi T, Goldberg SN, et al. Percutaneous radio-frequency ablation of hepatic metastases from colorectal cancer: long-term results in 117 patients. Radiology 2001; 221: Livraghi T, Goldberg SN, Lazzaroni S, et al. Hepatocellular carcinoma: radio-frequency ablation of medium and large lesions. Radiology 2000; 214: Choi H, Loyer EM, DuBrow RA, et al. Radio-frequency ablation of liver tumors: assessment of therapeutic response and complications. RadioGraphics 2001;21 [spec no]:s41 -S54. McGahan JP, Dodd GD, 3rd. Radiofrequency ablation of the liver: current status. AJR Am J Roentgenol 2001; 176:3-16. Page 48 of 49

49 Personal Information Page 49 of 49