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Case Report |
1 All authors: Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
Received August 2, 2001;
accepted after revision October 5, 2001.
Address correspondence to T. Yamagami.
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-fetoprotein level
was 240.3 ng/mL. A dynamic CT image obtained before surgery revealed five
hepatocellular carcinoma lesions ranging from 2.0 to 5.0 cm (mean, 3.0 cm) in
diameter in segments III, IV, V (n = 2), and VIII of the liver.
Celiac arteriography also showed five tumor stains consistent with tumorous
enhanced areas as seen on the dynamic CT image. After written informed consent was obtained from the patient, therapy using more than one interventional technique was attempted.
First, we performed transcatheter hepatic arterial chemoembolization of hepatocellular carcinomas in the right lobe. An emulsion of 10 mL of iodized oil (Lipiodol UltraFluid; Laboratoires Guerbet, Aulnay-sous-Bois, France) and 36 mg of epirubicin hydrochloride (Farmorubicin; Pharmacia, Tokyo, Japan) was injected, followed by dry gelatin particles (Spongel; Yamanouchi, Tokyo, Japan) suspended in 5 mL of iopamidol into the right hepatic artery.
Common hepatic arteriography performed just after transcatheter hepatic arterial chemoembolization showed a tumor stain of the whole hepatocellular carcinoma lesion in segment III and a residual stain of part of the hepatocellular carcinoma lesion in segment V. In the other three lesions, no tumor stains remained. On an unenhanced CT scan 1 week later, retention of iodized oil was no longer seen in the part of the hepatocellular carcinoma where it was previously evident in segment V or in any of the hepatocellular carcinoma in segment III; in the other three tumors, sufficient retention of iodized oil was confirmed. Hence, percutaneous radiofrequency ablation for lesions in segments III and V, performed with the patient under local anesthesia, was added to the patient's treatment plan.
Equipment for radiofrequency ablation included a 17-gauge needle with an exposed tip 3 cm in length (single cool-tip radiofrequency electrode; Radionics, Burlington, MA) and a cool-tip radiofrequency generator (Radionics). Two ground pads used with this device were placed on the patient's thighs. First, ablation for the lesion in segment V was performed under CT fluoroscopic guidance, because radiopaque iodized oil in this lesion was clearly visualized as the marker of the target on CT. The CT unit used in this study was an X Vigor Laudator (Toshiba Medical Systems, Tokyo, Japan).
The CT fluoroscopy—guided ablation procedure was performed by an experienced interventional radiologist. The CT beam width was collimated to 3 mm. The patient was in the lateral position, and the ablation needle was advanced from the right lateral upper abdominal wall. The operator wore a protective lead apron and remained in the CT room during the procedure, using a control panel to regulate CT fluoroscopic exposure, table movement, gantry tilt, and the laser beam and a foot pedal to control fluoroscopic exposure. An assistant adjusted the radiofrequency generator. Intermittent real-time CT fluoroscopic technique [3] was preferred, during which the cool-tip radiofrequency electrode needle was advanced while the center was held by surgical forceps and the distal edge on the operator's side was held in the operator's hand. This technique was performed in a stepwise manner, with quick application of CT fluoroscopy to confirm the path of the needle; meticulous care was taken to minimize direct radiation to the operator's hands. After confirmation that the needle tip was in the area of the hepatocellular carcinoma that showed poor uptake of iodized oil, the generator was switched on (Fig. 1A). Three minutes after the beginning of therapy, a second- to third-degree skin burn approximately 2.0 cm in diameter occurred around the needle-insertion point (Fig. 1B). Immediately, the procedure was stopped and the needle removed. Examination of the needle revealed that the insulating coating surrounding the needle lumen had peeled away from the part of the needle held by surgical forceps (Fig. 1C). This part was in contact with the skin during the ablation procedure, and this was apparently the cause of the rise in skin temperature. After replacing the needle with a new cool-tip needle, radiofrequency ablation was resumed. The patient felt only transient pain during the procedure.
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Sequentially, using the same procedure, ablation for the lesion in segment III was performed under sonographic guidance with the patient in the supine position. CT performed immediately after ablation and 1 week later confirmed complete necrosis of the hepatocellular carcinoma lesions in segments III and V. At 3 months after this radiofrequency ablation procedure, we found no recurrence of hepatocellular carcinoma. The skin burn was treated by application of ointment (Geben cream; Tanabe, Tokyo, Japan) to the lesion; it was healed by 3 weeks after the procedure.
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In performing CT fluoroscopy—guided procedures, the problem of direct radiation to the operator's hands must be considered [3]. To avoid such direct radiation, we used the simple method of holding the needle with surgical forceps. However, this method resulted in skin burn in this patient, because peeling away of the needle's coating occurred through its contact with the surgical forceps. To avoid such a complication, we would not use surgical forceps or, if they are necessary, we would use forceps that have some sort of rubber insulation, such as vascular clamps.
Paralleling the increase in the number of radiofrequency ablation procedures for liver tumors, reports of various complications after radiofrequency ablation [1], including intraperitoneal hemorrhage [4], are increasing, but reports of skin burn are relatively few. Most reported skin burns after percutaneous radiofrequency ablation occur along the edge of the grounding pads [1] or during the tract-ablation portion [2]. To our knowledge, this is the first report of skin burn occuring after the insulating coating surrounding the needle lumen has peeled off.
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