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DOI:10.2214/AJR.04.0931
AJR 2006; 186:S241-S243
© American Roentgen Ray Society

Case Report

Diaphragmatic Hernia After Radiofrequency Ablation Therapy for Hepatocellular Carcinoma

Akitaka Shibuya1, Takahide Nakazawa1, Katsunori Saigenji1, Kazunori Furuta2 and Keiji Matsunaga3

1 Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1, Kitasato, Sagamihara, Kanagawa 228-8555, Japan.
2 Department of Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa 228-8555, Japan.
3 Department of Radiology, Kitasato University School of Medicine, Sagamihara, Kanagawa 228-8555, Japan.

Received June 13, 2004; accepted after revision February 7, 2005.

 
Address correspondence to A. Shibuya (ashibuya{at}kitasato-u.ac.jp).

Keywords: ablation • radiofrequency • cancer • liver • MDCT


Introduction
Top
 Introduction
Case Report
 Discussion
 References
 
Percutaneous radiofrequency ablation is a novel thermal ablation technique for achieving coagulative necrosis of liver tumors with fewer treatment sessions than percutaneous ethanol injection therapy requires [1, 2]. Several recent developments in radiofrequency ablation technology, such as a high-power (150-200 W) radiofrequency generator, a method for conducting radiofrequency ablation during occlusion of hepatic blood flow, and saline-enhanced radiofrequency ablation techniques, have made it possible to necrotize a larger volume of tissue—3 cm or more in diameter—during a single ablation procedure [3]. Most of the complications after radiofrequency ablation have been minor, but some severe and fatal complications have been reported [4, 5].

In a multicenter study in 2,320 patients with 3,554 lesions [4], six patients (0.3%) died after radiofrequency ablation, including two caused by multiorgan failure following intestinal perforation; one case each of septic shock, tumor rupture, liver failure after bile duct stenosis; and sudden death of unknown cause. Fifty cases (2.2%) of additional major complications were also reported, including 12 (0.5%) of peritoneal bleeding, 12 of tumor seeding, six of hepatic abscess, five of gastrointestinal wall perforation, three of hemothorax, two of rapid hepatic decompensation, and one case each of diaphragmatic paresis, common bile duct stenosis, cardiac arrest, pulmonary embolism, pneumothorax, large biloma, multisegmental hepatic infarction, acute cholestasis, and septicemia. Thermal damage has been documented as a specific complication of radiofrequency ablation.

We recently encountered a patient with a diaphragmatic hernia due to thermal damage of the diaphragm. A defect of the diaphragm occurred after radiofrequency ablation for hepatocellular carcinoma (HCC) and remained quiescent for 18 months until bowel herniated through it. To our knowledge, this is the first case in the literature to report diaphragmatic hernia as a complication of radiofrequency ablation. The clinical presentation was acute abdominal pain, whereas MDCT clearly indicated a diaphragmatic defect.


Case Report
Top
 Introduction
 Case Report
Discussion
 References
 
A 72-year-old man with a history of alcoholic cirrhosis and hepatocellular carcinoma (HCC) presented with acute-onset severe right upper abdominal pain and dyspnea. He had been receiving maintenance hemodialysis because of diabetic nephropathy. Thirty-four months before admission, a solitary HCC that was 28 mm in diameter appeared adjacent to the right diaphragm on the border of hepatic segments IV and VIII (Fig. 1A).


Figure 1
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  		Fig. 1A —72-year-old man with hepatocellular carcinoma (HCC). Transverse contrast-enhanced CT scan obtained during arterial phase before radiofrequency ablation shows hyperattenuating HCC on border of hepatic segments IV and VIII that is 28 mm in diameter.

 
Radiofrequency ablation therapy for the HCC, using a RITA 500 PA system (RITA Medical Systems), which has a needle containing four expandable hook-shaped electrodes with a radiofrequency generator, was performed under sonography guidance. During the treatment, the area of tissue ablation was monitored sonographically to determine the zone of increased echogenicity. It was found to measure 35 x 40 mm, which corresponded to the area of tissue ablation. The patient complained of right shoulder pain both during and after the procedure.

Eighteen months before admission, radiofrequency ablation was repeated using the same radiofrequency ablation system for a local recurrence of HCC, 1.5 cm in diameter, adjacent to the primary tumor. The radiofrequency ablation procedure produced a ball-shaped homogeneous isointense area that was 25 mm in diameter with a hyperintense rim on a T2-weighted MR image. This area corresponded to an area of coagulation necrosis and was in contact with the diaphragm (Fig. 1B). Six months before admission, an abdominal radiograph showed interposition, not observed before the second (and last) radiofrequency ablation procedure, of the colon between the atrophic liver and the diaphragm. This finding is consistent with Chilaiditi syndrome, but the patient did not complain of any symptoms commonly associated with that entity.


Figure 2
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  		Fig. 1B —72-year-old man with hepatocellular carcinoma (HCC). Posttreatment T2-weighted respiratory-triggered fast spin-echo image (TR/TE, 6,666/84) shows isointense homogeneous area with hyperintense rim. Liver was atrophic, and surface was depressed in treatment region.

 


Figure 3
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  		Fig. 1C —72-year-old man with hepatocellular carcinoma (HCC). Coronal MDCT image of chest shows portion of small intestine in right lower thorax, indicating accurately and clearly anatomic relationships of diaphragmatic defect (arrows). Imaging parameters were 120 kVp, 350 mA (automatic milliampere setting), 0.6 sec/rotation, 16 slices x 1.25 mm detector configuration, and 1.375 pitch. Reconstruction interval was 1.25 mm.

 
Two days before admission, the patient experienced sudden right upper abdominal pain with dyspnea that gradually worsened, although no blunt abdominal trauma had occurred. On admission, complete blood count and blood chemistry findings were all within normal limits, but a specimen of arterial blood revealed that the oxygen saturation was 89.8%, the oxygen partial pressure was 53.8 mm Hg, the CO2 partial pressure was 32.5 mm Hg, and the pH was 7.45. A chest radiograph showed multiple loops of intestine above the diaphragm in the right thoracic cavity. A subsequent MDCT of the chest (coronal multiplanar reconstruction) showed a portion of the small intestine in the right lower thorax as a result of a diaphragmatic defect (Fig. 1C). Urgent surgical repair was performed, and thermal damage to the diaphragm was confirmed to be adjacent to the radiofrequency ablation-treated region. The patient recovered from the operation well and was discharged from the hospital 2 weeks after admission.


Discussion
Top
 Introduction
 Case Report
 Discussion
References
 
Studies have indicated the superiority of radiofrequency ablation over percutaneous ethanol injection therapy in local tumor control and the need for fewer treatment sessions [2, 6], but the complication rate of radiofrequency ablation has been reported to be approximately 5-10% [4, 5]. Livraghi et al. [4] reported that complications after performing the radiofrequency ablation technique for HCCs or metastatic liver tumors were encountered in a multicenter study. They classified the complications into four types: thermal damage from heating; and mechanical, septic, and other unexplained causes. The last three probably resulted from imaging-guided needle procedures, but the thermal damage can be attributed directly and specifically to radiofrequency ablation alone.

The most common complication due to thermal damage was perforation of the gastrointestinal wall, which occurred in 0.3% in the multicenter study [4], and only one case of diaphragmatic paresis, in a patient with metastatic liver tumor located in segment VIII, was observed. Other authors have reported thermal burns to the diaphragm with associated hepatic abscesses that were followed by sepsis and multiorgan failure [7]. Hepatic abscesses occurred after radiofrequency ablation more frequently in patients bearing a biliary-enteric anastomosis than in others [5].

It is characteristic of radiofrequency ablation complications that the clinical symptoms of thermal damage, such as gastrointestinal perforation, manifest several days after the procedure, a delay that is probably due to the fact that sloughing of the dead cells within the bowel wall requires several days. In our patient, a small defect in the diaphragm due to a thermal burn expanded progressively and became so large that the intestine slipped through the defect. Interposition of the intestine between the liver and the diaphragm (Chilaiditi syndrome) triggered herniation.

Prompt diagnosis of posttraumatic diaphragmatic hernia is necessary to perform urgent surgical repair. In the present case, the patient complained of sudden and progressive right upper abdominal pain with dyspnea, and the efficacy of MDCT for the diagnosis of diaphragmatic hernia was shown. MDCT permits increased scanning speeds with thinner slice acquisition and increased spatial resolution in the z-axis compared with conventional helical scanners [8]. The rapid scanning capability of MDCT allows optimal phase scanning during a short breath-hold in patients having difficulty suspending respiration. MDCT in our patient more accurately and more clearly depicted anatomic relationships of the diaphragmatic defect and the intestinal herniation of the right thorax.

Recent clinical procedures using radiofrequency ablation technology for treatment of liver tumors adjacent to the diaphragm can result in diaphragmatic thermal burns. Diaphragmatic injuries, although relatively common, usually result in shoulder pain but rarely result in an actual defect in the diaphragm. Clinicians must beware of thermal damage, which can progress latently and appear suddenly after a period of quiescence.


References
Top
 Introduction
 Case Report
 Discussion
 References
 

  1. Rossi S, Di Stasi M, Buscarini E, et al. Percutaneous RF interstitial thermal ablation in the treatment of hepatic cancer. AJR 1996; 167:759 -768[Abstract/Free Full Text]
  2. 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]
  3. Yamasaki T, Kurokawa F, Shirahashi H, Kusano N, Hironaka K, Okita K. Percutaneous radiofrequency ablation therapy for patients with hepatocellular carcinoma during occlusion of hepatic blood flow: comparison with standard percutaneous radiofrequency ablation therapy. Cancer 2002; 95:2353 -2360[CrossRef][Medline]
  4. Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF, Goldberg SN. Treatment of focal liver tumors with percutaneous radio-frequency ablation: complications encountered in a multicenter study. Radiology 2003;226 : 441-451[Abstract/Free Full Text]
  5. de Baere T, Risse O, Kuoch V, et al. Adverse events during radiofrequency treatment of 582 hepatic tumors. AJR2003; 181:695 -700[Abstract/Free Full Text]
  6. Lencioni RA, Allgaier HP, Cioni D, et al. Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection. Radiology 2003;228 : 235-240[Abstract/Free Full Text]
  7. Wood TF, Rose DM, Chung M, Allegra DP, Foshag LJ, Bilchik AJ. Radiofrequency ablation of 231 unresectable hepatic tumors: indications, limitations, and complications. Ann Surg Oncol2000; 7:593 -600[Medline]
  8. Sahani D, Saini S, Pena C, et al. Using multidetector CT for preoperative vascular evaluation of liver neoplasms: technique and results. AJR 2002; 179:53 -59[Abstract/Free Full Text]

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