AJR 2002; 179:102-104
© American Roentgen Ray Society
Saline Injection into the Pleural Cavity to Detect Tumors of the Hepatic Dome with Sonography: A New Approach for Treatment of Hepatocellular Carcinoma
Kazuhiro Katayama1,
Yuko Ooka,
Akio Uemura,
Shinichiro Shinzaki,
Satoshi Egawa,
Masafumi Naito,
Kazunobu Ishibashi and
Ryuichi Kamoi
1 All authors: Department of Internal Medicine, Osaka Koseinenkin Hospital,
4-2-78, Fukushima, Fukushima-ku, Osaka 553-0003, Japan.
Received July 30, 2001;
accepted after revision December 7, 2001.
Address correspondence to K. Katayama.
Introduction
Recently, much effort has been made toward earlier detection and safer
treatment of hepatocellular carcinoma, resulting in remarkable advances in the
prognosis of patients with the disease
[1,2,3].
Percutaneous ethanol injection has been shown to be highly effective in
patients with small hepatocellular carcinomas
[1,
2]. The reported survival rate
of patients given this treatment is comparable with that of patients treated
with surgical resection [3]. In
most cases, percutaneous ethanol injection is performed under sonographic
guidance. However, hepatic nodules of the subphrenic hepatic dome often cannot
be detected on sonography because of obstruction by the lung; thus, in these
cases, sonographic guidance cannot be used.
Several studies have indicated that the size
[4], state of differentiation
[5], and tumor vascularity
[6] of hepatocellular carcinoma
nodules are important prognostic factors in treatment with surgery or
percutaneous ethanol injection. Small well-differentiated hypovascular
hepatocellular carcinoma nodules of the subphrenic hepatic dome are difficult
to treat: Transcatheter arterial embolization is not effective because of poor
arterial blood supply [7], and
percutaneous ethanol injection is also difficult because the lung obstructs
the sonographic visualization of nodules. Surgical resection for patients with
these nodules is often contraindicated because of an impaired liver function.
To facilitate detection and treatment of hepatocellular carcinoma nodules of
the hepatic dome, we developed a new method of performing sonographically
guided percutaneous ethanol injection by injecting saline into the pleural
cavity.
Subjects and Methods
Patients
Twenty patients ranging in age from 41 to 74 years (mean age, 63.3 years)
who had type B; type C; or non-B, non-C chronic liver disease and who were
believed to have hepatocellular carcinoma nodules in the subphrenic hepatic
dome were selected for this study. Surgical resection was contraindicated for
all of the patients because of an impaired liver function or the presence of
multinodular hepatocellular carcinoma. In these patients, hepatocellular
carcinoma nodules in the subphrenic dome that were detectable on CT or MR
imaging were either poorly depicted or not visualized at all on sonography.
Patients with a right-sided pleural thickening or a tendency to bleed
excessively were excluded. Our study was approved by the local ethical
committee of our hospital. Written informed consent was obtained from all
patients.
Methods
To inject saline into the right pleural cavity without injuring the lung,
we first allow a local anesthesia to thoroughly infiltrate the skin,
inter-costal muscle, and parietal pleura, and then we use a needle (Veress;
Olympus Optical, Tokyo, Japan) consisting of a blunt-tipped, spring-loaded
inner stylet and a sharply tailored outer needle
(Fig. 1B) to enter the pleural
cavity. The needle mechanism is designed so that when the outer needle passes
through the chest wall, the blunt-tipped stylet is retracted, allowing the
needle to penetrate the tissue. Once the needle enters the pleural cavity, no
tissue resistance is encountered, permitting the blunt stylet to protrude
beyond the sharp tip of the needle. The needle is then inserted into the
intercostal space where the liver cannot be viewed with sonography. As soon as
the needle reaches the pleural cavity, the blunt-tipped inner stylet extends
to push the lung away to prevent injury. After injecting 0.3-1.0 L of saline
into the pleural cavity by a drop infusion system, we perform sonography. This
procedure is contraindicated in patients with bleeding diathesis or with
right-sided pleural thickening detectable on CT.
View larger version (66K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —Drawing illustrates artificial pleural effusion procedure.
Needle (arrow) (Veress; Olympus Optical, Tokyo, Japan) used in
procedure—blunt-tipped, spring-loaded inner stylet and sharply tailored
outer needle—is pictured at bottom of figure. After allowing thorough
infiltration of area with local anesthesia, we insert needle into intercostal
space where liver cannot be observed on sonography. As soon as needle reaches
pleural cavity, blunt-tipped inner stylet projects outward to push lung away,
preventing injury.
|
|
Results
We performed an artificial pleural effusion procedure 28 times in 20
patients. In 14 of the 20 patients, hepatic tumors in the subphrenic area that
could not be detected or were poorly visualized on sonography became
completely visible on sonography after an effusion was created. All tumors
were treated with sonographically guided percutaneous ethanol injection, and
the treatment effects were confirmed on CT. In the remaining six patients, no
nodules were detected on sonography after the artificial pleural effusion
procedure. In five of the six patients, tumor stains were observed on digital
subtraction angiography. In one patient, no changes were seen on CT or MR
imaging during the 6-month follow-up period, indicating the absence of
malignant nodules in the
liver.
,
View larger version (97K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —Drawing illustrates artificial pleural effusion procedure.
Solution of 0.9% saline (0.9% sodium chloride [NaCl]) is injected into pleural
cavity by drop infusion method. US = sonographic transducer.
|
|
No significant changes were observed in the patients' blood pressure, pulse
rate, and blood oxygen saturation during or after saline injection. One hour
after the artificial pleural effusion procedure, one patient complained of
having a cough, but the symptom disappeared during the next hour. Another
patient experienced dyspnea 1 hr after the procedure, but the symptom
disappeared after removal of the pleural effusion. Immediately after this
procedure, chest radiographic examination showed a right pleural effusion that
disappeared in a week. In patients who weighed less than 50 kg, we removed the
fluid after the procedure. No lung injury was observed in any of the
patients.
MR imaging revealed three nodules in the liver of a 52-year-old man with
non-B, non-C liver cirrhosis (Fig.
2A,2B,2C,2D).
Digital subtraction angiography revealed tumor stains in two nodules, but none
was seen in the nodule of the right anterosuperior region of the organ. It was
also difficult to detect the nodule on sonography, although a part of the
tumor could be seen sonographically when the patient exhaled. A
sonographically guided biopsy revealed that the nodule was a
well-differentiated hepatocellular carcinoma. The nodule was completely
visible on sonography after the artificial pleural effusion procedure, and the
patient underwent percutaneous ethanol injection. After the treatment, MR
imaging showed decreased intensity of the nodule and no enhancement on
administration of the contrast medium.
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2D. —52-year-old man with non-B, non-C liver cirrhosis. Dynamic MR
image shows tumor as avascular area (arrow), indicating that
treatment with percutaneous ethanol injection was effective.
|
|
Discussion
Our artificial pleural effusion procedure allows the detection of many
nodules in the subphrenic hepatic dome that were either poorly visualized or
undetectable on sonography. Thus, the procedure enabled treatment of
hepatocellular carcinoma nodules with sonographically guided percutaneous
ethanol injection in areas such as the subphrenic liver dome that are not well
visualized on sonography because of air interfaces. When a tumor of the
subphrenic dome is a hypovascular well-differentiated hepatocellular
carcinoma, this procedure becomes especially useful for treatment because
transcatheter arterial embolization is not effective for such nodules
[7]. The lung often blocks
depiction of subphrenic nodules on sonography, preventing treatment with
percutaneous ethanol injection unless artificial pleural effusion is
performed. If the patient's liver function is good, surgical resection is an
option. However, most patients with hepatocellular carcinoma have chronic
liver diseases, and the impairment of their liver function prevents surgical
treatment.
During our study, we found that artificial pleural effusion is not always
effective. In six of the 20 patients, nodules in the subphrenic dome could not
be detected on sonography even after artificial pleural effusion. The
non-visualization of these tumors on sonography may be due to the difficulty
in detecting small hepatic nodules with this modality
[8].
No significant adverse effects were observed in any patients during
artificial plural effusion. After the effusion procedure, one patient
complained of a cough and another of dyspnea. The cough subsided in an hour.
and the dyspnea disappeared after removal of the pleural effusion.
Other percutaneous ablation treatments—including thermal methods such
as microwave coagulation therapy and radiofrequency ablation—have been
recently developed and shown to be highly successful
[9]. Yamashita et al.
[10] have reported treating
tumors in the subphrenic hepatic dome with microwave coagulation using
thoracoscopic guidance. Unlike the procedure described by those researchers,
our artificial pleural effusion procedure does not require general anesthesia
and thus can be performed more easily. It is likely that artificial pleural
effusion would also be useful in radiofrequency ablation because the ablation
is performed with sonographic guidance. Further study is needed to clarify the
usefulness of the artificial pleural effusion procedure for other percutaneous
ablation treatments.
In conclusion, our artificial pleural effusion procedure permits treatment
of small hypovascular hepatocellular carcinoma nodules in the subphrenic
hepatic dome. The procedure is safe and can be performed repeatedly.
References
-
Shiina S, Tagawa K, Unuma T, et al. Percutaneous ethanol injection
therapy of hepatocellular carcinoma: analysis of 77 patients.
AJR
1990;155:1221
-1226[Abstract/Free Full Text]
-
Tanaka K, Nakamura S, Numata K, et al. Hepatocellular carcinoma:
treatment with percutaneous ethanol injection and transcatheter arterial
embolization. Radiology
1992;185:457
-460[Abstract/Free Full Text]
-
Castells A, Bruix J, Bru C, et al. Treatment of small
hepatocellular carcinoma in cirrhotic patients: a cohort study comparing
surgical resection and percutaneous ethanol injection.
Hepatology
1993;18:1121
-1126[Medline]
-
Hiratake J, Takeda S, Kanai T, Nakano S, Tokui N. Predictable
factors for estimating prognosis of patients after resection of hepatocellular
carcinoma. Cancer
1993;72:1178
-1183[Medline]
-
Takayama T, Makuuchi M, Hirohashi S, et al. Early hepatocellular
carcinoma as an entity with a high rate of surgical cure.
Hepatology
1998;28:1241
-1246[Medline]
-
Toyoda H, Kumuda T, Nakano S, et al. Significance of tumor
vascularity as a predictor of long-term prognosis in patients with small
hepatocellular carcinoma treated by percutaneous ethanol injection therapy.
J Hepatol
1997;26:1055
-1062[Medline]
-
Takayasu K, Wakao F, Moriyama N, et al. Response of early-stage
hepatocellular carcinoma and borderline lesions to therapeutic arterial
embolization. AJR
1993;160:301
-306[Abstract/Free Full Text]
-
Ikeda K, Saitoh S, Koida I, et al. Imaging diagnosis of small
hepatocellular carcinoma. Hepatology
1994;20:82
-87[Medline]
-
Livraghi T, Goldberg SN, Lazzaroni S, Meloni F, Solbiati L, Gazelle
GS. Small hepatocellular carcinoma: treatment with radio-frequency ablation
versus ethanol injection. Radiology
1999;210:655
-661[Abstract/Free Full Text]
-
Yamashita Y, Sakai T, Maekawa T, Watanabe K, Iwasaki A, Shirakusa
T. Thoracoscopic transdiaphragmatic microwave coagulation therapy for a liver
tumor. Surg Endoscopy
1998;12:1254
-1258
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
T. de Baere, C. Dromain, M. Lapeyre, P. Briggs, J. S. Duret, A. Hakime, V. Boige, and M. Ducreux
Artificially Induced Pneumothorax for Percutaneous Transthoracic Radiofrequency Ablation of Tumors in the Hepatic Dome: Initial Experience
Radiology,
August 1, 2005;
236(2):
666 - 670.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Minami, M. Kudo, T. Kawasaki, H. Chung, C. Ogawa, and H. Shiozaki
Percutaneous Radiofrequency Ablation Guided by Contrast-Enhanced Harmonic Sonography with Artificial Pleural Effusion for Hepatocellular Carcinoma in the Hepatic Dome
Am. J. Roentgenol.,
May 1, 2004;
182(5):
1224 - 1226.
[Full Text]
[PDF]
|
|
|
Top
Introduction
Subjects and Methods
