JSUJournal of Surgical Ultrasound

Journal of Surgical Ultrasound is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright ⓒ 2015 by The Korean Surgical Ultrasound Society

ISSN 2288-9140

Open-approach Radiofrequency Ablation of Hepatocellular Carcinoma using Intraoperative Ultrasonography

Ho-Joong Choi

, Jae-Kyung Seo

, Seung-Hoon Lee

, Yeon-Soo Lim

, Il-Young Park

Departments of

Surgery and

Radiology Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea

Received April 15, 2015 Revised May 7, 2015 Accepted May 9, 2015

Liver resection remains the ‘gold standard’ for curative treatment of Hepatocellular carcino- ma (HCC). However hepatic resection remains unsatisfactory due to recurrence and several complications in cases of severe liver cirrhosis. Radiofrequency ablation (RFA) is used fre- quently in the small and deep located HCC. Percutaneous RFA has a limitation to approach in some cases of HCC. We tried the open approach RFA in cases where the percutaneous ap- proach was difficult and the open approach RFA was performed successfully.

Keywords: Hepatocellular carcinoma, Radiofrequency ablation, Ultrasonography Correspondence to:

Il-Young Park

Department of Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Sosa-dong, Wonmi-gu, Bucheon 420-717, Korea Tel: ＋82-32-340-7021 Fax: ＋82-32-340-7021 E-mail: [email protected]

INTRODUCTION

Hepatocellular carcinoma (HCC) is the fifth most common solid tumor in the world.(1) In recent years, radiofrequency ablation (RFA) has been used to treat small HCC. The most common approach is percuta- neous RFA. However, this involves the possibility of severe complications in certain cases.(2) Here we re- port two cases of open-approach RFA on patients unsuitable for percutaneous RFA.

CASE REPORTS

1. Case 1

A 78-year-old female patient was admitted for an incidentally discovered liver mass. Patient had un- derlying type II diabetes, and alcoholic liver cirrho- sis. During liver evaluation, magnetic resonance im-

aging (MRI) showed a 1.5cm nodule at segment 8 of the liver (Fig. 1). Preoperative α-fetoprotein (AFP) and protein induced by vitamin K absence/antago- nist-II (PIVKA-II) levels were within normal limits.

Percutaneous RFA was deemed difficult because the nodule was located near the liver dome. We attempted open-approach RFA. A right subcostal incision was made. After right liver mobilization, the nodule was found by intraoperative-ultrasonography (Fig. 2A).

Ultrasound guided RFA was performed on the lo- calized cancer mass (Fig. 2B). An abdominal CT scan was performed the next day to confirm proper abla- tion. It showed complete ablation of the cancer nodule and a small amount of right pleural effusion. There were no complications of the procedure and the pa- tient was discharged on post-operative ninth day.

During a 9 month follow-up period, AFP and PIVKA-II levels remained within normal levels. Follow-up CT

CASE REPORT

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Ho-Joong Choi, et al.: Open-approach Radiofrequency Ablation of Hepatocellular Carcinoma using Intraoperative Ultrasonography

23

Fig. 1. MRI (primovist) showed a 1.5 cm sized HCC at segment 8 (white arrow).

Fig. 2. (A) Intraoperative ultrasound showed a hypoechoic mass (white arrow), (B) RFA probe located and ablated the tumor mass.

images show no recurrence.

2. Case 2

A 57-year-old male patient was admitted for a re- current liver mass. The patient had underlying liver cirrhosis induced by hepatitis B and he had received transarterial chemoembolization (TACE) 6 years ago due to HCC. But, follow-up MRI showed HCC recur- rence. A 1.5 cm nodule was discovered on segment 7 of the liver (Fig. 3). Initially, TACE was attempted to treat this recurrent mass. However TACE failed due to arterial cannulation was impossible. The patient was not suitable for percutaneous RFA because the nodule was close to the diaphragm. Open-approach RFA was attempted instead of percutaneous RFA

(Fig. 4). A right subcostal incision was made and in- traoperative-ultrasound guided RFA was performed.

Though abdominal CT the following day did not show arterial enhancement, the ablation zone did not seem enough. In a follow-up MRI, recurrence was seen along the margin of the ablated nodule 7 months later after RFA. This time, TACE was successfully done to treat the recurred tumor. AFP and PIVKA-II levels decreased to normal at 2 months after TACE.

DISCUSSION

Hepatic resection remains the gold standard for

patients with HCC. However, the majority of primary

liver cancers cannot undergo curative resection at

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Fig. 4. Intraoperative ultrasound is being used by surgeon to localize and ablate the tumor (Black arrow: ultrasound probe, white arrow:

RFA probe).

Fig. 3. MRI (primovist) showed an 1.5 cm sized HCC at segment 7 (white arrow).

the time of diagnosis.(3) RFA is an alternative treat- ment that can be done in cases where resection is not suitable. In small and deep HCC, RFA is a useful al- ternative.(4) Open approach RFA and hepatic re- section had similar survival benefits.(5) In general, the percutaneous approach is preferred than the open method. Benefits of the percutaneous approach are less invasiveness, reduced post-operative pain, shorter hospitalization, and reduced cost.(6) However per- cutaneous RFA is difficult if the cancer is close to the gallbladder, major vessels, bile ducts or the dia- phragm.(7,8) If percutaneous RFA is done in such lo- cations, it is possible to burn vital organs such as the

heart and lungs. Open approach RFA is indicated if patient has history of multiple abdominal operations or tumor is situated at the right posterior sector where a full mobilization of the right lobe is needed.(8) Open approach RFA can also ablate larger tumors by repeatedly placing RFA electrodes at multiple sites.(9) The advantages of open approach RFA are better can- cer staging, reduced adjacent organ injury, greater accessibility and the possibility of performing simul- taneous organ resection.(6) In our cases, open-ap- proach RFA was necessary because the tumors were located close to the diaphragm at segments 7 and 8.

Percutaneous RFA and open approach RFA showed no significant difference in survival.(8) The same prin- ciples of open approach RFA can be applied to laparo- scopic RFA. Laparoscopic RFA is an alternative to open approach RFA, and has the same outcome.(10) In conclusion, open approach RFA is useful in situa- tions where percutaneous RFA is difficult or risky.

Surgeons can ablate tumors effectively without hurt- ing vital organs with open approach RFA.

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