Various complications of percutaneous radiofrequency ablation for hepatic tumors: radiologic findings and technical tips

Predictors of Complications in Radiofrequency Ablation for Hepatocellular Carcinoma: A Comprehensive Analysis of 1000 Cases

Background and Objectives: Primary liver cancer is a major cause of mortality, ranking third among the most fatal cancers. In Egypt, liver cancer constitutes 11.75% of gastrointestinal malignancies, with HCC representing 70.5% of cases. The landscape of HCC management was revolutionized by locoregional modalities, which offer a comparable alternative to conventional techniques, with low complications and minimal invasiveness. RFA is a technique that is suitable for early-stage lesions in the liver, with a high overall survival and low complication rates. However, the associated complications cause potential mortality and morbidity. The proper selection of patients may avoid such complications. This study presents a five-year experience of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) in Egypt, analyzing the predictors of complications and the computed tomography (CT) features associated with complications post-ablation. Materials and Methods: The study included 1000 cases (84% males with a mean age of 60), with 90% having HCC. Exclusion criteria included prior chemoembolization and non-HCC primary hepatic tumors. Patients underwent RFA at Cairo University Hospital and two private centers from January 2014 to January 2019. The workup involved clinical assessments, lab tests, and CT scans. Complications were classified as major or minor. Statistical analysis was conducted via SPSS software Version 22.0, with associations evaluated using a chi-square test. A decision tree was employed to determine the predictive values for different variables associated with the complications. Results: Overall, the rate of complications was 4%, and mortality stood low at 0.1%. Subcapsular lesions were associated with complications, as well as the lesion size, site, Child-Pugh classification, and the number of RFA sessions. Decision tree analysis determined the size of a lesion to be the most predictive factor of major complications, whereas the site of the lesion predicted the occurrence of minor complications. Conclusions: RFA offers low complication rates; however, precise patient selection is critical. The approach and imaging modality choice influence the outcomes. Clinician experience enhances early complication detection, thereby allowing for effective treatments.

Complications of Percutaneous Radiofrequency Ablation for Hepatocellular Carcinoma

Radiofrequency ablation (RFA) is a potentially curative treatment option for early Hepatocellular carcinoma. The RFA is considered safe with a relatively low incidence of complications ranging from 2%-7.9%. Though most of the complications are self-limiting, sometimes they can be life-threatening. The occurrence of the particular complication depends on various factors like tumour location and morphology, underlying disease and ablation technique. A detailed understanding of potential complications along with the associated risk factors will help to employ strategies to prevent them, identify them early and manage them when they occur. This article demonstrates various radiofrequency ablation-related complications and discusses the risk factors and technical strategies to minimise them and achieve complete ablation of the tumour.

Complication Rates and Risk of Recurrence After Percutaneous Radiofrequency Ablation and Microwave Ablation for the Treatment of Liver Tumors: a Meta-analysis

RATIONALE AND OBJECTIVES

The rate of complications and risk of local recurrence following percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) for liver tumors varies significantly between investigations. This meta-analysis aimed to assess complication rates and risk of local recurrence after percutaneous RFA and MWA.

MATERIALS AND METHODS

PubMed, Medline, Web of Science, the Cochrane Library, Embase, Google Scholar, and CINAHL were systematically searched from database inception until August 2022 to retrieve articles reporting the complication rates and risk of recurrence after percutaneous RFA and MWA for the treatment of liver tumors. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated and displayed by forest plots. To measure heterogeneity, Cochran Q and I2 statistics were also applied. Egger's test and funnel plots were also performed to assess any potential publication bias. Additionally, subgroup analysis was done to investigate the source of heterogeneity.

RESULTS

26 studies including 2026 and 1974 patients for RFA and MWA, respectively, were included. The rate of minor complications was significantly higher after MWA compared to RFA, yielding an overall OR of 0.688 (95% CI: 0.549-0.862, P = 0.001). Similarly, the rate of major complications was significantly higher after MWA than RFA (P = 0.012), yielding an overall OR of 0.639 (95% CI: 0.450-0.907). No significant difference was found between RFA and MWA in terms of local recurrence after ablation (P > 0.05). In addition, there was no statistical evidence of publication bias.

CONCLUSION

When most factors are considered equally, percutaneous RFA and MWA can be considered safe modalities for the treatment of liver tumors, with RFA superior in terms of the incidence of minor and major complications.

Predicting Infectious Complications after Percutaneous Thermal Ablation of Liver Malignancies: A 12-year Single-Center Experience

Background Infectious complications after percutaneous thermal ablation are seldom discussed, but better understanding of risk factors and early prediction is critical. Purpose To estimate the incidence of infectious complications after percutaneous thermal ablation of liver malignancies and to develop prediction models. Materials and Methods This single-center retrospective study reviewed the data of 3167 patients who underwent 7545 percutaneous US-guided thermal ablation procedures of liver malignancies between January 2010 and January 2022. All procedures with infectious complications were included as the case group. For each case, one treatment date-matched control subject without infection was randomly selected following a nested case-control design. Independent factors of overall and hepatobiliary infection were investigated with multivariable logistic regression. Results A total of 80 patients (median age, 59 years; IQR, 51-68 years; 64 men, 16 women) developed infectious complications after 80 ablation procedures; the incidence was 1.1% (80 of 7545 procedures). Of those with infection, 18% (14 of 80 patients) were severe, and 10% (eight of 80 patients) died as a result. Independent risk factors for overall infectious complication included prior biliary intervention (odds ratio [OR], 18.6; 95% CI: 4, 86; P < .001), prior transarterial chemoembolization (TACE) (OR, 2.4; 95% CI: 1.0, 5.8; P = .045), and the largest tumor size (OR, 1.9; 95% CI: 1.3, 2.8; P = .002); on this basis, subcapsular location was an additional risk factor of hepatobiliary infection. Prediction models for overall and hepatobiliary infection had an area under the receiver operating characteristics curve (AUC) of 0.77 and 0.82, respectively, both of which showed better AUC compared with the models, including prior biliary intervention alone (AUC = 0.63 and 0.65, respectively; P = .01 and P = .005, respectively). Conclusion Infectious complications after percutaneous thermal ablation of liver malignancies were uncommon but potentially fatal. Independent predictors were prior biliary intervention, prior transarterial chemoembolization, and the largest tumor size. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Ben-Arie and Sosna in this issue.

Efficacy and safety of microwave ablation and radiofrequency ablation in the treatment of hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. Surgical resection is often only possible in the early stages of HCC and among those with limited cirrhosis. Radiofrequency ablation and Microwave ablation are 2 main types of percutaneous thermal ablation for the treatment of HCC. The efficacy and safety between these 2 therapy methods are still under a debate.

OBJECTIVE

To compare the efficacy and safety of Radiofrequency ablation and Microwave ablation in treating HCC.

METHODS

PubMed, EMBASE, the Cochrane databases and Web of Science were systematically searched. We included randomized controlled trials and cohort studies comparing the efficacy and safety of Radiofrequency ablation and Microwave ablation in HCC patients. Outcome measures on local tumor progression, complete ablation, disease-free survival, overall survival, or major complications were compared between the 2 groups. The random effect model was used when there was significant heterogeneity between studies, otherwise the fixed effect model was used.

RESULTS

A total of 33 studies, involving a total of 4589 patients were identified, which included studies comprised 7 RCTs, 24 retrospective observational trials, and 2 prospective observational trial. Microwave ablation had a lower local tumor progression than Radiofrequency ablation in cohort studies (OR = 0.78, 95% CI 0.64-0.96, P = .02). Complete ablation rate of Microwave ablation was higher than that of Radiofrequency ablation in cohort studies (OR = 1.54, 95% CI 1.05-2.25, P = .03). There was no significant difference in overall survival and disease-free survival between the 2 groups. Meta-analysis showed that there was no significant difference in the main complications between Microwave ablation and Radiofrequency ablation.

CONCLUSIONS

Microwave ablation has higher complete ablation and lower local tumor progression than Radiofrequency ablation in the ablation treatment of HCC nodules. There was no significant difference in overall survival between the 2 therapy methods.

Complications after Thermal Ablation of Hepatocellular Carcinoma and Liver Metastases: Imaging Findings

Tumour ablation is a strategy of treatment of hepatic tumours in patients with small hepatocellular carcinoma (HCC) (<3 cm) or in patients unfit for surgical resection. Moreover, tumor ablation can be used as an adjuvant therapy or may be used in association with resection in case of patients with poor functional liver disease. These types of treatment usually could be performed percutaneously under image guidance. The most clinically verified and used ablation modalities are Radiofrequency Ablation (RFA) and microwave ablation (MWA). However, despite both of them are considered minimally invasive techniques, they could be related to post-procedural complications. The International Working Group on Image-Guided Tumor and the Society of Interventional Radiology (SIR) identified major and minor post-ablative complications. Major complications, as vascular complications, occur in 2.2% to 3.1% of cases and include all the high risk pathological conditions which could increase the level of care or result in hospital admission or substantially prolonged hospital stay (SIR classifications C−E). Minor complications, as biliary complications, occur in 5% to 8.9% and include self-limiting conditions that are considered to be of low risk for the patient’s outcome. The purpose of this review is to summarise the main pathological ultrasound (US) and Computed Tomography (CT) findings, that may arise after ablative treatment. To simplify the analysis, the pathological pictures are divided according to the site of damage into vascular, biliary and extrahepatic complications.

Advances in the interventional therapy of hepatocellular carcinoma originating from the caudate lobe

Hepatocellular carcinoma originating from the caudate lobe, also known as segment I hepatocellular carcinoma, is difficult to treat because of its special location, complex vascular supply, and the proximity of important vessels, bile ducts, and organs. This research is conducted to examine the efficacy and safety of interventional therapy for hepatocellular carcinoma in the caudate lobe.

Conclusion

Superselective chemoembolization and ablation techniques for the treatment of caudate lobe hepatocellular carcinoma still need to be improved. The combination of multiple interventional methods and the application of multiple imaging techniques can improve the effectiveness and safety of interventional therapy for hepatocellular carcinoma in the caudate lobe. Multidisciplinary treatment is also essential to improve the prognosis of patients with caudate lobe hepatocellular carcinoma.

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The anatomical characteristics of the arteries in the caudate lobe hepatocellular carcinoma remains an important factor restricting the success rate of superselective transcatheter arterial chemoembolization.

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The application of multiple imaging techniques may improve the effectiveness and safety of interventional therapy.

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The combination of multiple interventional methods has more advantages than disadvantages.

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Multidisciplinary treatment is increasingly becoming a trend in the treatment of caudate lobe hepatocellular carcinoma.

Transarterial Yttrium-90 Radioembolization of Hepatocellular Carcinoma Perfused by the Cystic Artery: Multi-institutional Feasibility Study

PURPOSE

To assess the safety and efficacy of transarterial yttrium-90 radioembolization via the cystic artery for patients with hepatocellular carcinoma (HCC) adjacent to the gallbladder with cystic artery supply.

MATERIALS AND METHODS

This retrospective study included 17 patients treated at 4 institutions. Patients with HCC perfused by the cystic artery who received ablative-dose radioembolization were included. Median tumor size was 3.8 cm (range, 2.0-8.8 cm). Fourteen patients (82%) had Child-Pugh class A cirrhosis and 3 (18%) had class B cirrhosis. Adverse events, tumor response, and time to progression were analyzed.

RESULTS

Median dose to the tissue perfused by the cystic artery was 340 Gy (range, 200-720 Gy). There were no occurrences of acute cholecystitis warranting invasive intervention. Four patients (24%) experienced transient right upper quadrant pain, with symptom resolution within 3 mo. Six patients (35%) exhibited gallbladder wall edema on follow-up imaging. Two (12%) and 0 grade 3/4 increases in alkaline phosphatase and bilirubin were observed, respectively. Follow-up imaging demonstrated complete response in 13 target tumors (76%) and partial response in 4 (24%). There were no cases of target tumor progression during a median follow-up of 9 mo (range, 3-72 mo).

CONCLUSIONS

Direct infusion of 90Y microspheres via the cystic artery appears to have an acceptable safety profile, without resulting in acute cholecystitis warranting invasive intervention. In selected patients with HCC in whom other treatments may be contraindicated and the tumor is supplied via the cystic artery, treatment with selective ablative radioembolization can be considered.

Bilious pleuritis due to hepatic microwave ablation: Two illustrative cases and literature review

Ultrasound guided percutaneous thermal ablation has been well acknowledged in treating hepatic malignancy. Although thermal ablation is safe for the treatment, it may induce some lethal complications such as diaphragmatic injury, bile-stained pleural fistula, and bilious pleuritis.We presented 2 cancer patients in hepatic diaphragmatic dome showed diaphragmatic injury, bile-stained pleural fistula, and bilious pleuritis after microwave ablation (MVA). The symptoms were attenuated after chest drainage and anti-infection therapy. In the literature review, 17 articles published in the recent 10 years on diaphragmatic injury after MVA for treating hepatic cancer were available. Twenty-three cases were obtained, among which 2 showed bilious pleuritis after radiofrequency treatment. Most of the lesions were adjacent to the diaphragma. Among the articles reporting the localization of lesions, most of the cases showed lesions in S8, 2 in S7, 3 in S4, and 3 in S5, respectively. Surgical recovery was required for the patients with massive diaphragmatic injury. Only 2 cases underwent thorascopic surgery. After chest drainage and anti-infection, their symptoms were attenuated to some extent.Radiofrequency or MVA may induce pleural effusion, and special attention should be paid to the diaphragmatic injury induced by thermal ablation.

Gastrointestinal tract injuries after thermal ablative therapies for hepatocellular carcinoma: A case report and review of the literature

BACKGROUND

Radiofrequency ablation (RFA) and microwave ablation (MWA) represent the standard of care for patients with early hepatocellular carcinoma (HCC) who are unfit for surgery. The incidence of reported adverse events is low, ranging from 2.4% to 13.1% for RFA and from 2.6% to 7.5% for MWA. Gastrointestinal tract (GIT) injury is even more infrequent (0.11%), but usually requires surgery with an unfavourable prognosis. Due to its low incidence and the retrospective nature of the studies, the literature reporting this feared complication is heterogeneous and in many cases lacks information on tumour characteristics, comorbidities and treatment approaches.

CASE SUMMARY

A 77-year-old man who had undergone extended right hepatectomy for HCC was diagnosed with early disease recurrence with a small nodule compatible with HCC in the Sg4b segment of the liver with a subcapsular location. He was treated with percutaneous RFA and a few week later he was urgently admitted to the Surgery ward for abdominal pain and fever. A subcutaneous abscess was diagnosed and treated by percutaneous drainage. A fistulous tract was then documented by the passage of contrast material from the gastric antrum to the abdominal wall. The oesophagogastroduodenoscopy confirmed a circular wall defect at the lesser curvature of gastric antrum, leading directly to the purulent abdominal collection. An over-the-scope clip (OTSC) was used to successfully close the defect

CONCLUSION

This is the first reported case of RFA-related GIT injury to have been successfully treated with an OTSC, which highlights the role of this endoscopic treatment for the management of this complication.

Cardiac tamponade after radiofrequency ablation for hepatocellular carcinoma: Case report and literature review

RATIONALE

Radiofrequency ablation (RFA) is a safe and effective local treatment modality with a low complication rate and is commonly used to treat hepatocellular carcinoma (HCC). The clinical outcome of RFA may be closely related to the location, size, and shape of index tumors, and major complications, including hemorrhage, liver abscess, infarction, visceral organ perforation, hemothorax, pneumothorax, tumoral seeding, and hepatic failure. Cardiac tamponade is a rare and serious life-threatening complication associated with RFA. To date, a review of the medical literature reported 5 cases of cardiac tamponade after RFA for HCC. Herein, we report another case of cardiac tamponade after RFA for HCC in a 56-year-old man.

PATIENT CONCERNS

He had suffered from liver cirrhosis due to alcohol abuse. He had chronic obstructive pulmonary disease. Magnetic resonance imaging showed a 3.0-cm exophytic subcapsular HCC in segment IVa of left hepatic lobe. As the patient was at high risk for surgery because of poor lung function, RFA was selected as the treatment of choice. The index tumor was located in the vicinity of the diaphragm and colon. During RFA procedure, thermal injury to the adjacent diaphragm and colon was minimized by introducing artificial ascites. Bleeding or tumoral seeding was prevented by ablating the electrode track during electrode retraction.

DIAGNOSIS

Two hours after RFA, the patient presented with dyspnea, chest discomfort, and low blood pressure (80/60 mm Hg), suggesting cardiac tamponade. Immediate follow-up contrast-enhanced computed tomography image depicted the slightly high attenuated hemopericardium. Transthoracic echocardiography (TTE) showed a moderate amount of pericardial effusion with tamponade and a large hematoma.

INTERVENTIONS

Under fluoroscopy and portable echocardiography guidance, a cardiologist immediately inserted a 7-French pigtail catheter into the pericardial space and collected more than 200 cc of bloody pericardial fluid.

OUTCOMES

After pericardiocentesis, the patient's symptoms and hemodynamic status were dramatically improved. Follow-up TTE showed scanty amount of pericardial effusion and the drainage catheter was removed. The patient was discharged.

LESSONS

When treating HCC in the left lobe (especially segments II and IVa), attention should be paid to cardiac tamponade. The early diagnosis and immediate treatment of cardiac tamponade may increase the chance of cure.

Gastrointestinal tract complications after hepatic radiofrequency ablation: CT prediction for major complications

PURPOSE

To analyze CT features that predict major gastrointestinal tract (GIT) complication after hepatic radiofrequency ablation (RFA).

MATERIALS AND METHODS

Of 3933 patients who underwent RFA for hepatic malignancy from January 2005 to September 2016, 52 patients (1.32%) who had GIT complications were retrospectively enrolled. Electronic medical records and CT results were reviewed for location (left vs. right lobe, subcapsular vs. non-subcapsular) and tumor size, distance from the hepatic capsule, number and length of needles, ablation time, presence of artificial ascites, previous history of percutaneous treatment or operation, injured organs, length and thickness of injured GIT, presence of adjacent infiltration, ascites, mucosal discontinuity, and free air, and eccentricity. Patients were divided into those that recovered with conservative treatment (minor group) and those that required operation (major group). Chi-square test, Fisher's exact test, and Mann-Whitney U test analyzed differences between the two groups; however, the most significant variable was found using binary logistic regression analysis.

RESULTS

Of 52 patients who had GIT complications after hepatic RFA, 2 patients (0.05%) had major GIT complications, while the remaining 50 patients (1.27%) had minor complications. Most (47/52, 90.4%) of the tumors were located at subcapsular portion. 66% of tumors were located at the left hepatic lobe. Stomach was the most frequent injured organ (28/52, 53.8%), followed by colon (17/52, 32.7%) and small bowel (7/52, 13.5%). Patients with major GIT complications had significantly thicker (1.8 vs. 1.1 cm) and concentric (2/2, 100% vs. 1/50, 2.0%) bowel wall thickening with mucosal discontinuity (2/2, 100% vs. 0/50, 0%) than those with minor complications (P < 0.05).

CONCLUSION

GIT complication after hepatic RFA is rare and often requires conservative treatment. However, patients who show >1.65-cm-thick, concentric bowel wall thickening with mucosal disruption on CT after hepatic RFA may have major GIT injury that requires bowel surgery.

Percutaneous radiofrequency ablation of hepatocellular carcinoma in cirrhosis: analysis of complications in a single centre over 20 years

OBJECTIVE

To report on our 20 years' experience on complications after radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) in patients with cirrhosis.

METHODS

From 1994 to 2014, 1787 RFA procedures were performed percutaneously in 1162 patients with cirrhosis (852 Child A and 310 Child B) with HCC nodules (1.2-7 cm), prothrombin time >50%, platelet count of 50.000 mm³ and total bilirubin ranging from 0.80 to 4.5 mg dl^-1. In 67 patients, RFA was performed on both intraparenchymal HCC nodule and tumour thrombus extended in the main portal vein and/or its branches.

RESULTS

Four patients (0.3%) died after RFA. 39 patients (3.2%) changed in Child's class: 26 out of 28 Child A patients with cirrhosis changed to Child B and 2 changed to Child C class; 11 Child B patients changed to Child C class. On multivariate analysis, the total bilirubin pre-RFA was the only independent risk factor for impairment of liver function and death. Complications were hemoperitoneum, abscess and intrahepatic haematoma.

CONCLUSION

RFA of HCC in patients with cirrhosis is safe, even in case of invasion of the portal venous system. Functional liver reserve should be strictly monitored, mainly when pre-RFA total bilirubin value is >2.5 mg dl^-1. The study was approved by our institutional review board. Advances in knowledge: The total bilirubin value >2.5 mg dl^-1 represents the main marker of functional liver reserve that predicts decompensation of liver cirrhosis in patients undergoing RFA for HCC.

Ultrasound-Guided Percutaneous Radiofrequency Ablation of Liver Tumors: How We Do It Safely and Completely

Ultrasound-guided percutaneous radiofrequency (RF) ablation has become one of the most promising local cancer therapies for both resectable and nonresectable hepatic tumors. Although RF ablation is a safe and effective technique for the treatment of liver tumors, the outcome of treatment can be closely related to the location and shape of the tumors. There may be difficulties with RF ablation of tumors that are adjacent to large vessels or extrahepatic heat-vulnerable organs and tumors in the caudate lobe, possibly resulting in major complications or treatment failure. Thus, a number of strategies have been developed to overcome these challenges, which include artificial ascites, needle track ablation, fusion imaging guidance, parallel targeting, bypass targeting, etc. Operators need to use the right strategy in the right situation to avoid the possibility of complications and incomplete thermal tissue destruction; with the right strategy, RF ablation can be performed successfully, even for hepatic tumors in high-risk locations. This article offers technical strategies that can be used to effectively perform RF ablation as well as to minimize possible complications related to the procedure with representative cases and schematic illustrations.