Hepatic Infarction after Radiofrequency Ablation of Hepatocellular Carcinoma with an Internally Cooled Electrode

Complications of Percutaneous Radiofrequency Ablation for Hepatocellular Carcinoma

Radiofrequency ablation (RFA) is a potentially curative treatment option for early Hepatocellular carcinoma. The RFA is considered safe with a relatively low incidence of complications ranging from 2%-7.9%. Though most of the complications are self-limiting, sometimes they can be life-threatening. The occurrence of the particular complication depends on various factors like tumour location and morphology, underlying disease and ablation technique. A detailed understanding of potential complications along with the associated risk factors will help to employ strategies to prevent them, identify them early and manage them when they occur. This article demonstrates various radiofrequency ablation-related complications and discusses the risk factors and technical strategies to minimise them and achieve complete ablation of the tumour.

Combined Trans-Arterial Embolization and Ablation for the Treatment of Large (>3 cm) Liver Metastases: Review of the Literature

(1) Background: The aim of this review was to determine the state of clinical practice in the role of the combined approach of embolization and ablation in patients with secondary liver lesions greater than 3 cm who are not candidates for surgery, and to study its safety and efficacy. (2) Methods: Two reviewers conducted the literature search independently. Eight articles on the combined approach of embolization and ablation in secondary liver lesions were selected. (3) Results: The studies were published between 2009 and 2020. Two studies were prospective in design. The sample size was < 100 patients for all studies. All studies demonstrated the safety of the combined approach based on the low complication rate. Some studies lamented non-uniform systemic chemotherapy regimens and the variability in the sequence of embolization and ablation. (4) Conclusions: This review presents the combined approach of ablation and embolization in liver lesions greater than 3 cm as a safe therapeutic procedure with positive effects on patient survival. Prospective and multicentric studies are needed to further evaluate its efficacy.

Role of Contrast-Enhanced Ultrasound in the Detection of Complications After Ultrasound-Guided Liver Interventional Procedures

The role of contrast-enhanced ultrasound (CEUS) in interventional ultrasound-guided procedures in the liver has been increasingly recognized. However, little is known about the capability of CEUS for diagnosing complications after liver biopsy and ablation with special regard to postprocedural hemorrhage. The aim of this Pictorial Essay is to present the CEUS features of a wide spectrum of vascular complications (with or without bleeding) and injuries of the surrounding abdominal and chest wall occurring after liver interventional procedures.

Contrast-enhanced ultrasound-guided feeding artery ablation as add-on to percutaneous radiofrequency ablation for hypervascular hepatocellular carcinoma with a modified ablative technique and tumor perfusion evaluation

OBJECTIVES

To establish a modified strategy of the feeding artery ablation (FAA) procedure as an add-on to percutaneous radiofrequency ablation (RFA) for patients with hypervascular hepatocellular carcinoma (HCC), and to evaluate the outcomes.

MATERIALS AND METHODS

For this prospective, single-arm study, from June 2014 to August 2016, twenty-five patients with hypervascular HCC, 2-5 cm in diameter were treated by contrast-enhanced ultrasound (CEUS)-guided FAA before conventional RFA. Technical success of FAA and subsequent perfusion change of the tumor were evaluated by CEUS. Technical efficacy and ablation sizes were evaluated by CT/MRI at 1 month. Therapeutic outcomes, including local tumor progression (LTP), overall survival (OS), and recurrence-free survival (RFS) were evaluated using the Kaplan-Meier method.

RESULTS

One or two target feeding arteries were visible on CEUS for 52.6% (61/116) of the hypervascular HCCs 2-5 cm in diameter. The technical success rate of the FAA was 100%; 13/25 (52.0%) target tumors were evaluated as complete perfusion response, while 12/25 (48.0%) were evaluated as partial perfusion response. The ablation volume was 41.9 ± 17.5 cm3 (14.9-78.2 cm3) and the ablative safety margin was 8.2 ± 1.9 mm (4-12 mm) at the 1-month evaluation. These parameters did not differ significantly between the complete and partial subgroups. The cumulative rates of LTP at 1-, 2-, and 3-year follow-ups were 0.0%, 4.2% and 4.2%, respectively. The 3-year OS and RFS were 70.3% vs. 59.8%, respectively. There were no treatment-related deaths. Major complications occurred in one patient (4.0%).

CONCLUSION

As an add-on to conventional percutaneous RFA, tailored CEUS-guided FAA can reduce tumor perfusion and provide good local control of HCC.

Combination therapy of transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for small hepatocellular carcinoma: comparison with TACE or RFA monotherapy

PURPOSE

To compare the safety and efficacy of combined transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC) with those of TACE or RFA monotherapy.

METHODS

This study included 34 combined TACE and RFA (TACE-RFA), 87 TACE, and 136 ultrasound-guided RFA, which were performed to treat HCC (≤ 3 cm, 3 or fewer) between March and August 2009. The safety (Child-Pugh score indicating hepatic functional reserve, patient discomfort requiring medication, duration of hospitalization, and complications) and efficacy (1-month, 6-month, and 1-year tumor responses) profiles of each treatment were evaluated and compared.

RESULTS

TACE-RFA group showed longer hospital stay and more frequent patient discomfort requiring medication than TACE or RFA group (P < 0.001). The frequency of overall complications after TACE-RFA was higher than TACE (P = 0.006) or RFA (P = 0.009). There were no statistical differences in major complication rates between the three groups (P = 0.094). Child-Pugh score at 1-month follow-up showed no significant difference between the three groups (P = 0.162). 1-month, 6-month, and 1-year tumor responses of TACE-RFA were similar to those of RFA and better than those of TACE.

CONCLUSIONS

TACE-RFA appears to result in more frequent patient discomfort requiring medication, longer hospital stay, and more frequent complications than TACE or RFA monotherapy. Tumor response of TACE-RFA seems to be similar to that of RFA and better than TACE monotherapy. Thus, TACE-RFA for treating small HCC may be required for the selected patients, especially patients with small HCC ineligible for RFA monotherapy.

Ischemic complications after percutaneous radiofrequency ablation of liver tumors: Liver volume loss and recovery

AIM

The liver regrows after acute liver injury and liver resection. However, it is not clear whether the liver regenerates in advanced cirrhosis. This study aimed to evaluate the clinical course of, and liver volume change after, ischemic liver complications caused by radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC).

METHODS

We enrolled 35 patients with ischemic complications after RFA. Ischemic complications were defined as rapid elevation of aspartate aminotransferase (AST) to over 500 U/L, with typical radiological findings. Patient characteristics and the ischemic liver volume were investigated. Long-term liver volume changes at 3-8 months after ischemic complications were also assessed in 32 patients. We also assessed the overall survival rate after ischemic complications.

RESULTS

The median value of peak AST was 798 U/L (range, 531-4096 U/L). The median ischemic liver volume relative to the functional liver volume before RFA was 13% (range, 3.1-46.5%). There was a strong correlation between the peak AST value and the ischemic liver volume (r = 0.84, P < 0.001). The liver volume recovered to some extent in 18 of 32 (56%) patients after ischemic complications. The survival rate after ischemic complications was 45.7% at 5 years and correlated with the functional liver volume after ischemic complications (P = 0.02).

CONCLUSIONS

Ischemic complications after RFA can lead to massive liver parenchymal loss. Although the liver volume recovered to some extent in the majority of our patients, ischemic liver complications after RFA should be avoided to improve the overall survival rate.

Percutaneous cryoablation for perivascular hepatocellular carcinoma: Therapeutic efficacy and vascular complications

OBJECTIVES

To evaluate the therapeutic efficacy of and vascular complications associated with percutaneous cryoablation for the treatment of perivascular HCC.

METHODS

Between August 2015 and September 2017, 58 consecutive patients (48 men, 10 women; mean age, 61.1 years; age range, 44-84 years) who underwent percutaneous cryoablation were included. All patients had a single perivascular HCC (mean size, 1.3 cm; Barcelona clinic liver cancer-stage 0 or A) that was in contact with hepatic vessels, ≥ 3 mm or larger in axial diameter. Local tumour progression (LTP) was estimated by the Kaplan-Meier method. In addition, several procedure-related vascular complications were evaluated immediately after treatment and during follow-up CT: peritumoral vessel thrombosis; infarction; aggressive intrasegmental recurrence (AIR) (the simultaneous development of ≥ 3 nodular or infiltrative tumours). The follow-up CT was performed in all patients 1 month after the procedure, and every 3 months thereafter.

RESULTS

The median follow-up period was 22 months (range, 3-29 months). The technical success rate of cryoablation was 96.6% (56/58). The 1- and 2-year cumulative LTP rates were 3.6% and 14.6%, respectively. Although peritumoral vessel thrombosis occurred in 6.9% of cases (4/58), no cases of hepatic infarction were observed and AIR did not develop during follow-up. Half of the thombi in the peritumoral vessels immediately after cryoablation disappeared on follow-up CT images.

CONCLUSION

Cryoablation could be an effective tool for the treatment of perivascular HCC with a very low risk of vascular complications.

KEY POINTS

• Cryoablation allowed a high technical success rate for perivascular HCC. • Only 6.9% developed peritumoral vessel thrombosis without major vascular complications like infarction. • Two-year cumulative LTP rate was 14.6%, without aggressive tumour recurrence on follow-up.

Thermal Injury-induced Hepatic Parenchymal Hypoperfusion: Risk of Hepatocellular Carcinoma Recurrence after Radiofrequency Ablation

Purpose To retrospectively evaluate whether thermal injury-induced hepatic parenchymal hypoperfusion can be a significant risk factor for tumor recurrence after radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC). Materials and Methods The institutional review board approved this retrospective study, and the requirement to obtain informed consent was waived. The study population comprised 130 patients (87 men, 43 women; mean age, 61.4 years ± 8.95; age range, 39-84 years) with single nodular HCCs smaller than 5 cm who underwent RFA between January 2011 and December 2012. The development of RFA-induced hepatic parenchymal hypoperfusion was assessed with follow-up computed tomography (CT). After a mean follow-up of 36.7 months ± 10.8, the authors analyzed the overall and recurrence-free survival and the cumulative incidence of each type of recurrence (ie, local tumor progression [LTP], intrahepatic distant recurrence [IDR], and extrahepatic metastasis) by evaluating prognostic factors with use of the Kaplan-Meier method and Cox proportional hazard regression model. Results RFA-induced hepatic parenchymal hypoperfusion developed in 41 of the 130 patients (31.5%) but did not have a significant effect on overall survival (P = .634). However, the estimated 3-year recurrence-free survival rate was 43.3% in the 41 patients with RFA-induced hepatic parenchymal hypoxia and 61.9% in the 89 patients without hypoxia, a statistically significant difference (P = .019). The 3-year cumulative incidence of IDR was significantly higher in patients with RFA-induced hepatic parenchymal hypoperfusion than in those without hypoxia (33.3% vs 54.1%, P = .006). Conversely, the 3-year cumulative incidence of LTP and extrahepatic metastases showed no significant differences (P > .05 for both). Conclusion The development of RFA-induced hepatic parenchymal hypoperfusion is a significant predictive factor of recurrence (of IDR in particular) after RFA of a single nodular HCC. ^© RSNA, 2016 Online supplemental material is available for this article.

Various complications of percutaneous radiofrequency ablation for hepatic tumors: radiologic findings and technical tips

Radiofrequency ablation is a safe and effective treatment for primary and secondary liver malignancies and has a low complication rate; however, there are various radiofrequency ablation-related complications which can occur from the thorax to the pelvis. Although most of these complications are usually minor and self-limited, they may become fatal if diagnosis and treatment are delayed. It is important for radiologists performing radiofrequency ablation to have a perspective regarding the possible radiofrequency ablation-related complications and their risk factors as well as the radiologic findings for their timely detection and increase of the treatment efficacy, and thereby encouraging the use of the radiofrequency ablation technique. This article illustrates the various imaging features of common and rare radiofrequency ablation-related complications as well as offers technical tips in order to avoid these complications.

Complications of image-guided thermal ablation of liver and kidney neoplasms

Image-guided thermal ablation is a widely accepted tool in the treatment of a variety of solid organ neoplasms. Among the different techniques of ablation, radiofrequency ablation, cryoablation, and microwave ablation have been most commonly used and investigated in the treatment of liver and kidney neoplasms. This article will review complications following thermal ablation of tumors in the liver and kidney, and discuss the risks and clinical presentation of each complication as well as how to treat and potentially avoid complications.

Hepatic infarction complicated with acute pancreatitis precisely diagnosed with gadoxetate disodium-enhanced magnetic resonance imaging

Pancreatitis may induce a spectrum of venous and arterial vascular complications. However, hepatic infarction complicated with acute pancreatitis seldom occurs because of the unique vascular configuration of the liver. We herein describe an extremely rare and unique case in which simultaneous portal vein and hepatic vein thrombosis were present. We precisely assessed both hepatic hemodynamics and hepatocellular function using sequential multidetector computed tomography and gadoxetate disodium-enhanced magnetic resonance imaging, which may provide useful information on the pathophysiological state and diagnosis of hepatic infarction.

Complications of radiofrequency ablation of hepatic, pulmonary, and renal neoplasms

Percutaneous thermal ablation has emerged as a viable technique for treatment of numerous solid organ malignancies. As the number of these procedures increases, so do the complications that are seen. Most common complications are generally related to bleeding from the target organ during or after the procedure and from thermal injury to adjacent structures. The nature of these injuries depends on the particular organ being treated, therefore it it best to categorize them this way. We will review the more common complications seen following the ablation of tumors in the liver, kidney, and lung, discuss the clinical presentation associated with each, and suggest precautions to help avoid them in the future. Understanding the potential risks associated with this procedure is critical for treatment planning and fundamental for performing these procedures safely.

Interventional radiological treatment of hepatocellular carcinoma: an update

Hepatocellular carcinoma is the commonest primary liver tumor and its incidence is on an increase.Transplantation and surgical resection are the gold standard curative treatment options but less than 20%patients are surgical candidates because of advanced liver disease and/or co-morbidities.Various interventional radiological procedures have been developed and intensively investigated for treatment of inoperable HCC.This review summarizes the various interventional radiological treatments in HCC including patient selection, procedural considerations and response evaluation. Transarterial chemoembolization, radioembolization and radiofrequency ablation are mainly discussed.

Effect of interval between transcatheter hepatic arterial embolization and radiofrequency ablation on ablated lesion size in a swine model

PURPOSE

The aim of the study was to clarify the effect of the interval between transcatheter hepatic arterial embolization (TAE) with Lipiodol plus gelatin sponge particles and radiofrequency (RF) ablation on the extent of ablation.

MATERIALS AND METHODS

Eight healthy swine were divided into four groups: RF ablation (ablation only), RF ablation immediately after TAE (immediate ablation), RF ablation 3 days after TAE (3-day ablation), and RF ablation 6 days after TAE (6-day ablation). Five ablated lesions were created in each swine (10 per group). A 2-cm expandable LeVeen needle electrode was used for RF ablation. Ablated lesions are composed of an outer reddish zone and an inner whitish zone.

RESULTS

The average longest length of the major, intermediate, and minor axes and the volume in the immediate ablation, 3-day ablation, and 6-day ablation groups were significant longer and greater (1.52 and 1.52, 1.46 and 1.50, and 1.37 and 1.35 times greater in the red zone and the whitish area, respectively) than those in the ablation-only group (P < 0.05/3). Accumulation of Lipiodol was still noted in the hepatic sinusoids in the 3-day and 6-day ablation groups.

CONCLUSION

RF ablation delayed to 6 days following TAE produced larger ablation volumes than did RF ablation alone.

Coagulation necrosis induced by radiofrequency ablation in the liver: histopathologic and radiologic review of usual to extremely rare changes

As the clinical role of radiofrequency ablation (RFA) of the liver grows, the importance of radiologic imaging after liver RFA to depict the diversity of post-RFA manifestations is also increasing. Because RFA induces coagulation necrosis of the hepatic parenchyma, cross-sectional imaging studies, in principle, demonstrate an area with a defect in contrast enhancement. However, for various reasons, such as the occurrence of a complication, the RFA zone may demonstrate different patterns or be accompanied by other abnormalities. In this investigation, a large number of imaging studies performed after more than 4000 procedures of liver RFA during the past 10-year period were reviewed, and various radiologic manifestations of the RFA zone were compiled. Herein, the basic principles of RFA, as well as the histopathologic features of coagulation necrosis of the liver, are catalogued to provide a more complete understanding of such changes. Through this review, the reader will become more familiar with the usual and unusual radiologic findings of coagulation necrosis induced by RFA in the liver. This increased familiarity will not only facilitate the daily practice of radiology but also deepen understanding of the therapeutic modality of RFA.

Recent advances of radiofrequency ablation for early hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third leading cause of death in the malignant neoplastic diseases in the world. Surgical operation is sometimes not indicated because of complicated liver cirrhosis and extrahepatic disorders. Radiofrequency ablation has been developed as a less invasive treatment for HCC since 1999, and long-term outcome has been shown. There are several complications which should be paid attention, and to improve the prognosis, combination treatment with transarterial chemoembolization should be discussed. Overall survival after between RFA and surgical resection should be compared prospectively. Establishment of staging system for treatment allocation of HCC and prevention of HCC recurrence is important issue to be examined.

Planning and follow-up after ablation of hepatic tumors: imaging evaluation

CTs or MRIs are essential for preablative therapy planning of hepatic tumors to identify accurate size, number, and location of tumors. Tumors larger than 5 cm and located near the major branches of the portal vein and hepatic vein have a higher potential for incomplete ablation. Postablative imaging studies are needed to determine if the entire tumors are included in the treatment zone to minimize the risk of local tumor recurrences. Complications of ablative therapy can be identified on post-treatment imaging studies.

Eleven cases of postoperative hepatic infarction following pancreato-biliary surgery

BACKGROUND

Postoperative hepatic infarction is rare; therefore, clinical characteristics and outcomes of postoperative hepatic infarction after pancreatobiliary surgery have not been obvious.

METHODS

Eleven patients encountered hepatic infarction after pancreato-biliary surgery. Management, clinical course, and outcome of these 11 patients were retrospectively analyzed.

RESULTS

Possible causes of the hepatic infarction were inadvertent injury of the hepatic artery during lymph node dissection in five patients, right hepatic artery ligation in two patients, long-term clamp of the hepatic artery during hepatic arterial reconstruction in two patients, suturing for bleeding from the right hepatic artery in one patient, and celiac axis compression syndrome in one patient. Five of the 17 infarcts extended for one whole section of the liver, and distribution of the other 12 was less than one section. Ten patients discharged from hospital; however, one patient died of sepsis of unknown origin.

CONCLUSIONS

Attention should be paid to inadvertent injury of hepatic artery to prevent hepatic infarction. Hepatic infarctions after pancreato-biliary surgery seldom extend to the entire liver and most of them are able to be treated without intervention.

Imaging after radiofrequency ablation of hepatic tumors

Radiofrequency ablation (RFA) is now increasingly used as a first-line therapeutic modality for small malignant hepatic tumors in many parts of the world. The importance of radiological imaging at follow-up to assess therapeutic effectiveness, presence of complications, and recurrences cannot be overemphasized, as RFA treatment is minimally invasive and locally applied. A broad spectrum of imaging findings obtained by the use of various modalities has been reported by many investigators. In this review, we describe findings, including chronologic changes of the ablation zones, both local and remote recurrences, and complications that occur after RFA of the liver as well as the advantages and disadvantages of the use of each imaging modality for a specific situation.

Massive hepatic infarction after pure ethanol injection and radiofrequency ablation therapy for hepatocellular carcinoma: a case report

Hepatic infarction is a rare complication of radiofrequency ablation (RFA) for hepatocellular carcinoma. Hepatic infarction is thought to be caused by injury to either the hepatic arterial system or to both the hepatic arterial and portal venous supply. The efficacy of RFA is reduced in the presence of nearby vessels larger than 3 mm in diameter due to a heat-sink effect. Such an effect can be diminished by performing percutaneous pure ethanol injection prior to RFA. Although larger vessels are unlikely to be ablated or obliterated by RFA alone, it can happen and cause massive liver damage, particularly if RFA was preceded by other therapies such as percutaneous pure ethanol injection and/or transcatheter arterial embolization. Here, we report a case of massive liver infarction after sequential use of both treatment modalities for hepatocellular carcinoma.

Radiofrequency ablation of hepatic tumors: lessons learned from 3000 procedures

Radiofrequency ablation has been accepted as the most popular local ablative therapy for unresectable malignant hepatic tumors. For 9 years from April 1999, we performed 3000 radiofrequency ablation procedures for hepatic tumors in our institution. Our results on the safety (mortality, 0.15%/patient) and therapeutic efficacy (5-year survival rate, 58%) are similar to those of previous studies reported, supporting the growing evidence of a clear survival benefit, excellent results for local tumor control and improved quality of life. The most important lesson learned from our 3000 procedures is that the best planning, safe ablation and complete ablation are key factors for patient outcome. Furthermore, multimodality treatment is the best strategy for recurrent hepatocellular carcinoma encountered after any kind of first-line treatment.