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