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Radiofrequency Ablation of Needle Tract Seeding in Hepatocellular Carcinoma
Radiofrequency Ablation of Needle Tract Seeding in Hepatocellular Carcinoma Sophie Espinoza, MD, Patricio Briggs, MD, Jean-Sébastien Duret, MD, Matthieu Lapeyre, MD, and Thierry de Baère, MD A tumor needle tract seeding, 20 mm in diameter, was detected with magnetic resonance (MR) imaging in a 72-year-old man, 10 months after radiofrequency ablation of a 55-mm subcapsular hepatocellular carcinoma. This seeding was successfully treated with ultrasound-guided percutaneous radiofrequency ablation. No recurrence was found after a 2-year follow-up either on contrast-enhanced computed tomography or MR imaging. Needle tract seeding treatment is not well established. Percutaneous radiofrequency ablation of such seeding is one elegant potential treatment option. Efficacy seems promising but has to be confirmed in larger series. Further evaluation is needed. J Vasc Interv Radiol 2005; 16:743–746 Abbreviations: HCC ⫽ hepatocellular carcinoma, RFA ⫽ radiofrequency ablation
PERCUTANEOUS radiofrequency (RF) ablation (RFA) is considered a relatively low-risk method for the treatment of non-surgical primary or metastatic liver tumors. One of the potential severe complications of this technique is neoplastic needle tract seeding, although its incidence is still controversial (1,2). To our knowledge there is no well-established treatment of such seeding. We present here a case of neoplastic seeding after RFA, treated by percutaneous RFA. It is convenient to note that our institution does not require institutional review board approval for such a retrospective report.
CASE REPORT Screening abdominal ultrasound (US) of a 72-year-old man with a prostate adenocarcinoma revealed a single
From the Institut Gustave Roussy, Department of Interventional Radiology, Service du Pr Roche, 39 avenue Camille Desmoulins, 94800 Villejuif, France. Received August 8, 2004; revision requested October 3; final revision received November 27; accepted December 1. Address correspondence to S.E.; Email: [email protected] None of the authors has identified a potential conflict of interest. © SIR, 2005 DOI: 10.1097/01.RVI.0000153109.56827.70
55-mm hepatic nodule in segment IV. Image-guided biopsy was performed via sub-xyphoid approach with an 18gauge cutting needle, because of absence of specific tumoral serum markers. Pathologic examination demonstrated a well-differentiated hepatocellular carcinoma (HCC) developed in a cirrhotic liver. RFA was planned despite the relative large volume of the tumor because the poor liver reserve of this patient contraindicated liver resection or trans-arterial chemoembolization. The subcapsular location of the tumor was not, at that time, well identified as a risk factor of tumor seeding. With general anesthesia, a triple cluster cooled tip needle with an active tip of 2.5-cm (Radionics, Burlington, MA) was US-guided to reach the tumor through a percutaneous sub-xyphoid access. Then two RF deliveries of 15 minutes each were performed in the automatic mode in two different locations of the tumor with a CC1 generator (Radionics). Four months later, follow-up enhanced-CT revealed a 4-mm hypervascular tumor focus at the posterior part of the RFA zone. Consequently, a second RF session was performed to target this residual tumor focus. This second RF session was CT-guided because it was impossible to distinguish between RFA scar and the active enhancing tumor with US imaging. It
consisted in two RF deliveries in two different locations of the tumor, with a right intercostal approach and an expandable 3.5-cm needle electrode (Leveen needle; Boston Scientific, Natick, MA). Overall treatment of RF deliveries lasted 29 minutes with, respectively, 16 and 13 minutes to achieve treatment in each location. Follow-up CT and MR imaging performed 2 months after the second RFA did not reveal any enhancement of the treated tumor or any other abnormality. A 20-mm sub-xyphoid tumor seeding located in the anterior abdominal wall was discovered at MR imaging 10 months after the first RFA treatment, 5 months after the second one. This seeding was hyperintense on T2weighted images and hypointense on T1-weighted images (Fig 1a). It was highly enhanced on the arterial phase on T1 images after injection of gadolinium (Fig 1b). A retrospective analysis of MR images obtained 7 months after the first RFA treatment revealed the same nodule measuring 6 mm in its largest diameter, but enhancement was difficult to evidence at that time. This seeding was located in the subxyphoid area, hence on the tract of the biopsy or the first RF but not on the tract of the second. After a multidisciplinary discussion it was decided to treat the seeding
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Figure 1. (a) TI-weighted axial MR imaging shows a hyperintense zone of RFA in the left lobe of the liver (arrow) and a hypointense nodule in the subcutaneous fat and muscle corresponding to tumor seeding (arrowhead). (b) MR image obtained 20 seconds after injection of gadolinium revealed no enhancement of the ablated zone and an intense enhancement of the tumor seeding.
with RFA. This procedure was carried out with US guidance. A cooled-tip single needle with an active tip of 3 cm (Radionics) was used to perform two overlapping RF deliveries of 15 minutes each with cooling with the generator automatic mode. The first delivery was performed at the deepest part of the seeding and the second one was performed after retrieving the needle by 1 cm and a half. The puncture tract was ablated up to the skin with RF without cooling with a target temperature of 80°C until a small burn of 4-mm diameter was seen at the skin surface. Despite a mild pain one day after the treatment, the patient could leave the hospital. Early imaging follow-up after RFA of the seeding shows a peritumoral fat stranding outside of the tumor margin probably delineating the external margins of RFA, in a manner akin to what it was reported in the kidney (3,4) (Fig 2, 3). This stranding organized and thickened on successive imaging follow-up. An imaging follow-up of 2 years demonstrated neither local nor distant recurrence in the liver or at the seeding location at MR imaging and contrast-enhanced CT (Fig 4).
Figure 2. Contrast-enhanced axial CT 2 months after seeding RFA. There is a parietal scar of RF seeding ablation, without enhancement. Notice the peri-ablation fat stranding (arrow).
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Figure 3. Gadolinium-enhanced T1-weighted axial MR image 1 month after treatment shows neither enhancement of the liver ablated zone nor of the RF ablated tumor seeding. There is some fat stranding distant from the tumor seeding probably delineating the external limits of the ablation.
DISCUSSION Percutaneous RFA is an accepted treatment for non-surgical HCC. According to recent multicenter studies (5– 8), major complications occur in about 2.3% to 5% of procedures. They are peritoneal hemorrhage (0.46% to 0.5%), hepatic abscess (0.3% to 2%), biloma (0% to 0.2%), skin burn (0.2% to 1.4%), pneumothorax (0.2% to 0.8%), intestinal perforation (0.2% to 0.3%), and needle tract seeding (0.3% to 2.8%). Only one team, reporting a small number of RF procedures, most often combined with biopsy or alcohol injection, reported more elevated ratio of major complications such as 12.5% of subcapsular hematoma, 3% of peritoneal hemorrhage, and especially 12.5% of needle tract seeding (2). These high rates of needle tract seeding after RFA are still causing debate (1,5). However, it seems that the main risk factors for seeding are the subcapsular location of the tumor, high ␣-fe-
toprotein level, poorly differentiated grade of HCC (9,10) and previously associated percutaneous biopsy (11). In our case, we had at least two of these risk factors, because the tumor was located in a subcapsular position and a previous biopsy had been performed. Indeed a cutting needle biopsy was performed 1 month before the first RF with the same sub-xyphoid approach than the first hepatic RF; therefore, we cannot determine which of both procedures between biopsy and RF can be considered responsible for the seeding. On the other hand, we can exclude the responsibility of the second RFA session because we used a right intercostal approach during this procedure. These data suggest that seeding appeared between 7 and 8 months after these procedures were performed via the sub-xyphoid route, but it was detected after 10 months. Diagnosis of seeding was delayed because it was our first experience with
•
745
such a complication, which was not well described in the literature at that time. Furthermore the 6-mm nodule retrospectively seen on the 7-month MR imaging could have been interpreted as a wall hematoma, as reported elsewhere after percutaneous treatment (12). Tumor growth and enhancement at the arterial phase on MR permitted the correct diagnosis at 10 months. We did not perform a tract ablation after the first RF because at the end of the procedure, post-RF lesion volume developed so close to the liver capsule that we did not consider necessary to perform it. Furthermore, at that time it had not yet been reported that tumor subcapsular location was a risk factor of seeding (1,10). Although tumor seeding is a major complication, we still consider percutaneous RFA as an achievable non-surgical treatment for HCC with low risk of tumor seeding, and we strongly recommend needle tract coagulation at the end of the procedure. In case of subcapsular tumors, it might be recommended to extend this tract coagulation to the subcutaneous tissues. Treatment of tumor seeding has not been clearly reported but surgical resection seems to be used in most instances. External radiation therapy has been reported (13). We proposed a new RFA session because in our case we considered that the seeding was not superficial enough to induce a risk of skin burn. In addition, the diameter of the lesion was within the maximum size amenable to ablation in a single delivery. Excellent tolerance allows a very short hospital stay, with minimal scar. We found that the advantages of the RF treatment are that it was easy to perform compared with surgical treatment or external radiation therapy, and in our limited experience it seems to be well tolerated and efficient. The same technique had been used once by Shirato et al with good efficacy as in our experience (14). Further evaluations are needed to test the efficacy and safety of RFA of needle tract seeding which can result of a biopsy or of a RF procedure. But these evaluations will be difficult to obtain because of the low incidence of seeding which might decrease even more if needle tract coagulation is performed as a routine practice.
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6.
7.
8.
9.
10.
11.
Figure 4. Contrast-enhanced axial CT obtained 2 years after treatment: there is no pathologic enhancement of the primitive tumor scar or of the RF ablated seeding scar.
References 1. Bolondi L, Gaiani S, Celli N, Piscaglia F. Tumor dissemination after radiofrequency ablation of hepatocellular carcinoma. Hepatology 2001; 34:608. 2. Llovet JM, Vilana R, Bru C, et al. Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma. Hepatology 2001; 33:1124 –1129. 3. Gervais DA, McGovern FJ, Arellano RS, McDougal WS, Mueller PR. Renal
cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors. Radiology 2003; 226:417– 424. 4. de Baere T, Kuoch V, Smayra T, et al. Radiofrequency ablation of renal cell carcinoma: preliminary experience. J Urology 2002; 167:1961–1964. 5. Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF, Goldberg SN. Treatment of focal liver tumors with percutaneous radio-frequency abla-
12.
13.
14.
JVIR
tion: complications encountered in a multicenter study. Radiology 2003; 226: 441– 451. Rhim H, Yoon KH, Lee JM, et al. Major complications after radio-frequency thermal ablation of hepatic tumors: spectrum of imaging findings. Radiographics 2003; 23:123–134. de Baere T, Risse O, Kuoch V, et al. Adverse events during radiofrequency treatment of 582 hepatic tumors. AJR Am J Roentgenol 2003; 181:695–700. Mulier S, Mulier P, Ni Y, et al. Complications of radiofrequency coagulation of liver tumours. Br J Surg 2002; 89:1206 –1222. Hori T, Nagata K, Hasuike S, et al. Risk factors for the local recurrence of hepatocellular carcinoma after a single session of percutaneous radiofrequency ablation. J Gastroenterol 2003; 38:977–981. Kato T, Reddy KR. Radiofrequency ablation for hepatocellular carcinoma: help or hazard? Hepatology 2001; 33: 1336 –1337. Takamori R, Wong LL, Dang C, Wong L. Needle-tract implantation from hepatocellular cancer: is needle biopsy of the liver always necessary? Liver Transpl 2000; 6:67–72. Arrive L, Vurgait A, Monnier-Cholley L, et al. Long-term follow-up after neoplastic seeding complicating percutaneous ethanol injection for treatment of hepatocellular carcinoma. Eur Radiol 2002; 12:74 –76. Ishii H, Okada S, Okusaka T, et al. Needle tract implantation of hepatocellular carcinoma after percutaneous ethanol injection. Cancer 1998; 82:1638 –1642. Shirato K, Morimoto M, Tomita N, et al. Hepatocellular carcinoma: a case of extrahepatic seeding after percutaneous radiofrequency ablation using an expandable needle electrode. Hepatogastroenterology 2002; 49:897– 899.
PERCUTANEOUS radiofrequency (RF) ablation (RFA) is considered a relatively low-risk method for the treatment of non-surgical primary or metastatic liver tumors. One of the potential severe complications of this technique is neoplastic needle tract seeding, although its incidence is still controversial (1,2). To our knowledge there is no well-established treatment of such seeding. We present here a case of neoplastic seeding after RFA, treated by percutaneous RFA. It is convenient to note that our institution does not require institutional review board approval for such a retrospective report.
CASE REPORT Screening abdominal ultrasound (US) of a 72-year-old man with a prostate adenocarcinoma revealed a single
From the Institut Gustave Roussy, Department of Interventional Radiology, Service du Pr Roche, 39 avenue Camille Desmoulins, 94800 Villejuif, France. Received August 8, 2004; revision requested October 3; final revision received November 27; accepted December 1. Address correspondence to S.E.; Email: [email protected] None of the authors has identified a potential conflict of interest. © SIR, 2005 DOI: 10.1097/01.RVI.0000153109.56827.70
55-mm hepatic nodule in segment IV. Image-guided biopsy was performed via sub-xyphoid approach with an 18gauge cutting needle, because of absence of specific tumoral serum markers. Pathologic examination demonstrated a well-differentiated hepatocellular carcinoma (HCC) developed in a cirrhotic liver. RFA was planned despite the relative large volume of the tumor because the poor liver reserve of this patient contraindicated liver resection or trans-arterial chemoembolization. The subcapsular location of the tumor was not, at that time, well identified as a risk factor of tumor seeding. With general anesthesia, a triple cluster cooled tip needle with an active tip of 2.5-cm (Radionics, Burlington, MA) was US-guided to reach the tumor through a percutaneous sub-xyphoid access. Then two RF deliveries of 15 minutes each were performed in the automatic mode in two different locations of the tumor with a CC1 generator (Radionics). Four months later, follow-up enhanced-CT revealed a 4-mm hypervascular tumor focus at the posterior part of the RFA zone. Consequently, a second RF session was performed to target this residual tumor focus. This second RF session was CT-guided because it was impossible to distinguish between RFA scar and the active enhancing tumor with US imaging. It
consisted in two RF deliveries in two different locations of the tumor, with a right intercostal approach and an expandable 3.5-cm needle electrode (Leveen needle; Boston Scientific, Natick, MA). Overall treatment of RF deliveries lasted 29 minutes with, respectively, 16 and 13 minutes to achieve treatment in each location. Follow-up CT and MR imaging performed 2 months after the second RFA did not reveal any enhancement of the treated tumor or any other abnormality. A 20-mm sub-xyphoid tumor seeding located in the anterior abdominal wall was discovered at MR imaging 10 months after the first RFA treatment, 5 months after the second one. This seeding was hyperintense on T2weighted images and hypointense on T1-weighted images (Fig 1a). It was highly enhanced on the arterial phase on T1 images after injection of gadolinium (Fig 1b). A retrospective analysis of MR images obtained 7 months after the first RFA treatment revealed the same nodule measuring 6 mm in its largest diameter, but enhancement was difficult to evidence at that time. This seeding was located in the subxyphoid area, hence on the tract of the biopsy or the first RF but not on the tract of the second. After a multidisciplinary discussion it was decided to treat the seeding
743
744
•
RFA of Needle Tract Seeding in HCC
May 2005
JVIR
Figure 1. (a) TI-weighted axial MR imaging shows a hyperintense zone of RFA in the left lobe of the liver (arrow) and a hypointense nodule in the subcutaneous fat and muscle corresponding to tumor seeding (arrowhead). (b) MR image obtained 20 seconds after injection of gadolinium revealed no enhancement of the ablated zone and an intense enhancement of the tumor seeding.
with RFA. This procedure was carried out with US guidance. A cooled-tip single needle with an active tip of 3 cm (Radionics) was used to perform two overlapping RF deliveries of 15 minutes each with cooling with the generator automatic mode. The first delivery was performed at the deepest part of the seeding and the second one was performed after retrieving the needle by 1 cm and a half. The puncture tract was ablated up to the skin with RF without cooling with a target temperature of 80°C until a small burn of 4-mm diameter was seen at the skin surface. Despite a mild pain one day after the treatment, the patient could leave the hospital. Early imaging follow-up after RFA of the seeding shows a peritumoral fat stranding outside of the tumor margin probably delineating the external margins of RFA, in a manner akin to what it was reported in the kidney (3,4) (Fig 2, 3). This stranding organized and thickened on successive imaging follow-up. An imaging follow-up of 2 years demonstrated neither local nor distant recurrence in the liver or at the seeding location at MR imaging and contrast-enhanced CT (Fig 4).
Figure 2. Contrast-enhanced axial CT 2 months after seeding RFA. There is a parietal scar of RF seeding ablation, without enhancement. Notice the peri-ablation fat stranding (arrow).
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Figure 3. Gadolinium-enhanced T1-weighted axial MR image 1 month after treatment shows neither enhancement of the liver ablated zone nor of the RF ablated tumor seeding. There is some fat stranding distant from the tumor seeding probably delineating the external limits of the ablation.
DISCUSSION Percutaneous RFA is an accepted treatment for non-surgical HCC. According to recent multicenter studies (5– 8), major complications occur in about 2.3% to 5% of procedures. They are peritoneal hemorrhage (0.46% to 0.5%), hepatic abscess (0.3% to 2%), biloma (0% to 0.2%), skin burn (0.2% to 1.4%), pneumothorax (0.2% to 0.8%), intestinal perforation (0.2% to 0.3%), and needle tract seeding (0.3% to 2.8%). Only one team, reporting a small number of RF procedures, most often combined with biopsy or alcohol injection, reported more elevated ratio of major complications such as 12.5% of subcapsular hematoma, 3% of peritoneal hemorrhage, and especially 12.5% of needle tract seeding (2). These high rates of needle tract seeding after RFA are still causing debate (1,5). However, it seems that the main risk factors for seeding are the subcapsular location of the tumor, high ␣-fe-
toprotein level, poorly differentiated grade of HCC (9,10) and previously associated percutaneous biopsy (11). In our case, we had at least two of these risk factors, because the tumor was located in a subcapsular position and a previous biopsy had been performed. Indeed a cutting needle biopsy was performed 1 month before the first RF with the same sub-xyphoid approach than the first hepatic RF; therefore, we cannot determine which of both procedures between biopsy and RF can be considered responsible for the seeding. On the other hand, we can exclude the responsibility of the second RFA session because we used a right intercostal approach during this procedure. These data suggest that seeding appeared between 7 and 8 months after these procedures were performed via the sub-xyphoid route, but it was detected after 10 months. Diagnosis of seeding was delayed because it was our first experience with
•
745
such a complication, which was not well described in the literature at that time. Furthermore the 6-mm nodule retrospectively seen on the 7-month MR imaging could have been interpreted as a wall hematoma, as reported elsewhere after percutaneous treatment (12). Tumor growth and enhancement at the arterial phase on MR permitted the correct diagnosis at 10 months. We did not perform a tract ablation after the first RF because at the end of the procedure, post-RF lesion volume developed so close to the liver capsule that we did not consider necessary to perform it. Furthermore, at that time it had not yet been reported that tumor subcapsular location was a risk factor of seeding (1,10). Although tumor seeding is a major complication, we still consider percutaneous RFA as an achievable non-surgical treatment for HCC with low risk of tumor seeding, and we strongly recommend needle tract coagulation at the end of the procedure. In case of subcapsular tumors, it might be recommended to extend this tract coagulation to the subcutaneous tissues. Treatment of tumor seeding has not been clearly reported but surgical resection seems to be used in most instances. External radiation therapy has been reported (13). We proposed a new RFA session because in our case we considered that the seeding was not superficial enough to induce a risk of skin burn. In addition, the diameter of the lesion was within the maximum size amenable to ablation in a single delivery. Excellent tolerance allows a very short hospital stay, with minimal scar. We found that the advantages of the RF treatment are that it was easy to perform compared with surgical treatment or external radiation therapy, and in our limited experience it seems to be well tolerated and efficient. The same technique had been used once by Shirato et al with good efficacy as in our experience (14). Further evaluations are needed to test the efficacy and safety of RFA of needle tract seeding which can result of a biopsy or of a RF procedure. But these evaluations will be difficult to obtain because of the low incidence of seeding which might decrease even more if needle tract coagulation is performed as a routine practice.
746
•
May 2005
RFA of Needle Tract Seeding in HCC
6.
7.
8.
9.
10.
11.
Figure 4. Contrast-enhanced axial CT obtained 2 years after treatment: there is no pathologic enhancement of the primitive tumor scar or of the RF ablated seeding scar.
References 1. Bolondi L, Gaiani S, Celli N, Piscaglia F. Tumor dissemination after radiofrequency ablation of hepatocellular carcinoma. Hepatology 2001; 34:608. 2. Llovet JM, Vilana R, Bru C, et al. Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma. Hepatology 2001; 33:1124 –1129. 3. Gervais DA, McGovern FJ, Arellano RS, McDougal WS, Mueller PR. Renal
cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors. Radiology 2003; 226:417– 424. 4. de Baere T, Kuoch V, Smayra T, et al. Radiofrequency ablation of renal cell carcinoma: preliminary experience. J Urology 2002; 167:1961–1964. 5. Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF, Goldberg SN. Treatment of focal liver tumors with percutaneous radio-frequency abla-
12.
13.
14.
JVIR
tion: complications encountered in a multicenter study. Radiology 2003; 226: 441– 451. Rhim H, Yoon KH, Lee JM, et al. Major complications after radio-frequency thermal ablation of hepatic tumors: spectrum of imaging findings. Radiographics 2003; 23:123–134. de Baere T, Risse O, Kuoch V, et al. Adverse events during radiofrequency treatment of 582 hepatic tumors. AJR Am J Roentgenol 2003; 181:695–700. Mulier S, Mulier P, Ni Y, et al. Complications of radiofrequency coagulation of liver tumours. Br J Surg 2002; 89:1206 –1222. Hori T, Nagata K, Hasuike S, et al. Risk factors for the local recurrence of hepatocellular carcinoma after a single session of percutaneous radiofrequency ablation. J Gastroenterol 2003; 38:977–981. Kato T, Reddy KR. Radiofrequency ablation for hepatocellular carcinoma: help or hazard? Hepatology 2001; 33: 1336 –1337. Takamori R, Wong LL, Dang C, Wong L. Needle-tract implantation from hepatocellular cancer: is needle biopsy of the liver always necessary? Liver Transpl 2000; 6:67–72. Arrive L, Vurgait A, Monnier-Cholley L, et al. Long-term follow-up after neoplastic seeding complicating percutaneous ethanol injection for treatment of hepatocellular carcinoma. Eur Radiol 2002; 12:74 –76. Ishii H, Okada S, Okusaka T, et al. Needle tract implantation of hepatocellular carcinoma after percutaneous ethanol injection. Cancer 1998; 82:1638 –1642. Shirato K, Morimoto M, Tomita N, et al. Hepatocellular carcinoma: a case of extrahepatic seeding after percutaneous radiofrequency ablation using an expandable needle electrode. Hepatogastroenterology 2002; 49:897– 899.