Transcript Question 6: Which is/are true regarding artificial ascites? - IO

Adjunct Maneuvers for
Percutaneous Liver Ablation
Jeffrey Forris Beecham Chick, MD, MPH
Gregory J. Nadolski, MD
Department of Radiology
Division of Interventional Radiology
Hospital of the University of Pennsylvania
Pearlman School of Medicine
Penn IR
Disclosures
Jeffrey F. B. Chick
• None
Gregory J. Nadolski
• Consultant: Arrow/Teleflex
• Research grant recipient: Arrow Medical; Guerbet,
LLC
Penn IR
History of Present Illness
65-year-old male status post orthotopic liver
transplantation for hepatitis c cirrhosis with recurrent
hepatocellular carcinoma
MRI: 3.4 cm diameter hepatocellular carcinoma in
extreme inferior aspect of segment 6
Labs: Total Bilirubin: 0.3; Creatinine: 1.6; INR: 1.1
Penn IR
Initial Imaging
A
B
C
Axial (A) and coronal (B) delayed T1-weighted post-contrast MR images and axial diffusion-weighted image (C)
demonstrating a 3.4 cm exophytic mass with contrast washout and pseudocapsule (A and B, arrows) and
restricted diffusion (C, arrows), consistent with hepatocellular carcinoma. Arterial hyper-enhancement not shown.
Penn IR
Question 1: The segment 6
hepatocellular carcinoma is most
amenable to which treatment?
A.
B.
C.
D.
E.
F.
Penn IR
Systemic chemotherapy
Transarterial chemoembolization
Transarterial radioembolization
Percutaneous ablation
Stereotactic body radiation therapy
None of the above
Question 1: The segment 6
hepatocellular carcinoma is most
amenable to which treatment?
A.
B.
C.
D.
E.
F.
Penn IR
Systemic chemotherapy
Transarterial chemoembolization
Transarterial radioembolization
Percutaneous ablation
Stereotactic body radiation therapy
None of the above
Kouri BE, et al. Am Coll Radiol. 2016;13(3):265-73.
Ryan MJ, et al. World J Hepatol. 2016;8(3):191-9.
Question 2: Microwave ablation
was chosen. Which is/are true
regarding this technique?
A.
B.
C.
D.
E.
F.
Penn IR
Cellular death occurs at 20°C (68°F)
Causes realignment of non-polar molecules, heating, and tissue necrosis
Heating independent of tissue impedance
Sensitive to heat sinks
Requires grounding pads
None of the above
Question 2: Microwave ablation
was chosen. Which is/are true
regarding this technique?
A.
B.
C.
D.
E.
F.
Penn IR
Cellular death occurs at 20°C (68°F)
Causes realignment of non-polar molecules, heating, and tissue necrosis
Heating independent of tissue impedance
Sensitive to heat sinks
Requires grounding pads
None of the above
Simon CJ, et al. Radiographics. 2005;25 Suppl 1:S69-83.
Poggi G, et al. World J Hepatol. 2015;7(25):2578-89.
Question 3: In contrast to
microwave ablation, which is/are
true regarding cryoablation?
A.
B.
C.
D.
E.
F.
Penn IR
Governed by the Joule-Thomson theory
Lethal cellular isotherm is 0°C (32°F)
Slow freezing produces extracellular ice crystals
Fast freezing induces cellular dehydration and death
Associated with more intra-procedural pain than microwave ablation
None of the above
Question 3: In contrast to
microwave ablation, which is/are
true regarding cryoablation?
A.
B.
C.
D.
E.
F.
Penn IR
Governed by the Joule-Thomson theory
Lethal cellular isotherm is 0°C (32°F)
Slow freezing produces extracellular ice crystals
Fast freezing induces cellular dehydration and death
Associated with more intra-procedural pain than microwave ablation
None of the above
Ramanathan R, et al. Ther Adv Urol. 2010;(2):51-68.
Niu LZ, et al. J Clin Transl Hepatol. 2014;2(3):182-8.
Intra-procedural Imaging
A
B
C
Axial (A) and coronal (B) and axial (C) intra-procedural computed tomography images demonstrating the
segment 6 hepatocellular carcinoma (A and B, arrows). A microwave ablation probe has been inserted into the
lesion (C, arrows).
Penn IR
Question 4: Which is/are a concern
based on the intra-procedural
imaging?
A.
B.
C.
D.
E.
F.
Penn IR
Suboptimal tumor conspicuity
Lack of safe percutaneous access
Potential injury to the body wall
Possible damage to the diaphragm
Proximity of the bowel
None of the above
Question 4: Which is/are a concern
based on the intra-procedural
imaging?
A.
B.
C.
D.
E.
F.
Penn IR
Suboptimal tumor conspicuity
Lack of safe percutaneous access
Potential injury to the body wall
Possible damage to the diaphragm
Proximity of the bowel
None of the above
Intra-procedural Imaging
A
B
C
Axial (A) and coronal (B) and axial (C) intra-procedural computed tomography images showing the proximity of
the bowel (A, B, and C, arrows) to the segment 6 hepatocellular carcinoma.
Penn IR
Question 5: Which is/are potential
adjunct maneuvers that may be
helpful in this situation?
A.
B.
C.
D.
E.
F.
Penn IR
Intermittent computed tomography fluoroscopy
Graded abdominal compression with a compression paddle
Creation of artificial ascites
Use of artificial pneumoperitoneum
Creation of an artificial pneumothorax
None of the above
Question 5: Which is/are potential
adjunct maneuvers that may be
helpful in this situation?
A.
B.
C.
D.
E.
F.
Penn IR
Intermittent computed tomography fluoroscopy
Graded abdominal compression with a compression paddle
Creation of artificial ascites
Use of artificial pneumoperitoneum
Creation of an artificial pneumothorax
None of the above
Artificial Ascites
A
B
C
Multiple intra-procedural computed tomography images (A, B, and C) demonstrating the instillation of dilute
contrast material (A, B, and C, arrows) to create artificial ascites and provide a buffer between the segment 6
hepatocellular carcinoma and bowel.
Penn IR
Question 6: Which is/are true
regarding artificial ascites?
A.
B.
C.
D.
E.
F.
Penn IR
Effective when tumor located at bare area of liver
Reduces sonographic window of tumor
D5W preferred for radiofrequency ablation as it is non-ionic
Normal saline preferred in non-diabetic patients
Ascites induction success ranges from 50-76%
None of the above
Question 6: Which is/are true
regarding artificial ascites?
A.
B.
C.
D.
E.
F.
Penn IR
Effective when tumor located at bare area of liver
Reduces sonographic window of tumor
D5W preferred for radiofrequency ablation as it is non-ionic
Normal saline preferred in non-diabetic patients
Ascites induction success ranges from 50-76%
None of the above
Uehara T, et al. J Gastroenterol. 2007;42(4):306-11.
Koda M, et al. AJR Am J Roentgenol. 2004;183(3):583-8.
Tsoumakidou, et al. Tech Vasc Interv Radiol. 2011;14(3):170-6.
Artificial Pneumoperitoneum
A
B
Multiple intra-procedural computed tomography images (A and B) showing the injection of carbon dioxide (A and
B, arrows) to create artificial pneumoperitoneum and provide a buffer between the segment 6 hepatocellular
carcinoma and bowel.
Penn IR
Question 7: Which is/are true
regarding artificial
pneumoperitoneum?
A.
B.
C.
D.
E.
F.
Penn IR
Effective in the presence of adhesions
Increases sonographic window of tumor
Low risk of gas embolism if blood vessel inadvertently injected
Instillation of carbon dioxide may create carbonic acid and induce pain
Increased heat sink effect compared to artificial ascites
None of the above
Question 7: Which is/are true
regarding artificial
pneumoperitoneum?
A.
B.
C.
D.
E.
F.
Penn IR
Effective in the presence of adhesions
Increases sonographic window of tumor
Low risk of gas embolism if blood vessel inadvertently injected
Instillation of carbon dioxide may create carbonic acid and induce
pain
Increased heat sink effect compared to artificial ascites
None of the above
Raman SS, et al. Roentgenol. 2004:197-200.
Buy X, et al. Cardiovasc Intervent Radiol. 2009;32(3):529-34.
Blaser A, et al. Surg Endosc. 1999;13(7):713-4.
Balloon Displacement
A
B
C
Multiple intra-procedural computed tomography images (A, B, and C) demonstrating the placement and inflation
of a 14 mm angioplasty balloon (A and B, arrows) to displace the bowel away from the segment 6 hepatocellular
carcinoma prior to microwave ablation. A microwave ablation probe is seen within the lesion (C, arrow).
Penn IR
Treatment and Follow-Up
After creation of artificial ascites and pneumoperitoneum
and balloon displacement, the segment 6 hepatocellular
carcinoma was treated with two microwave ablation
probes at 65 Watts for 8 minutes. Patient was discharged
home.
Patient returned for follow-up imaging and evaluation at
one month.
Penn IR
Follow-Up Imaging
A
B
C
Axial T1-weighted post-contrast (A), axial T1-weighted pre-contrast, and axial T1-weighed post-contrast images
demonstrating the post-treatment ablation zone (A, arrows) without enhancement to suggest residual or
recurrent disease. A 10 cm T1-hyperintense, non-enhancing hematoma is seen medial to the ascending colon (B
and C, arrows).
Penn IR
Question 8: Which is/are true
regarding ablation-associated
complications?
A.
B.
C.
D.
E.
F.
Penn IR
Liver failure is common in patients with Child-Pugh Score A
Cauterization of needle track reduces bleeding, but not seeding
Ablation-associated portal vein thrombosis reduces heat sink
Biloma formation is often transient and does not require catheter drainage
Bowel injury is less likely in patients with previous surgery
None of the above
Question 8: Which is/are true
regarding ablation-associated
complications?
A.
B.
C.
D.
E.
F.
Penn IR
Liver failure is common in patients with Child-Pugh Score A
Cauterization of needle track reduces bleeding, but not seeding
Ablation-associated portal vein thrombosis reduces heat sink
Biloma formation is often transient and does not require catheter drainage
Bowel injury is less likely in patients with previous surgery
None of the above
Ding J, et al. Clin Radiol 2013;68: 608-615.
Bertot LC, et al. Eur Radiol 2011;21: 2584-2596.
Clinical Course
Follow-up imaging showed complete ablation of segment
6 hepatocellular carcinoma.
Patient reported ongoing mild residual abdominal pain
likely due to pericolonic hematoma, but no signs of
infection, difficulty with bowel movements, or decreasing
hemoglobin.
Follow-up imaging and clinical evaluation planned for
three months.
Penn IR
Discussion
Percutaneous ablation may be limited by suboptimal tumor
conspicuity, lack of safe percutaneous access, and potential
thermal injury to adjacent critical structures.
Successful ablation may be limited by concerns regarding injury
to the diaphragm, body wall, or other perihepatic structures such
as bowel.
Penn IR
Lee EJ, et al. AJR Am J Roentgenol. 2008;190(6):1659-6.
Hinshaw JL, et al. AJR Am J Roentgenol. 2006;186(5 Suppl):S306-10.
Discussion
Artificial ascites, pneumoperitoneum, or balloon displacement
provide a buffer that separates the ablation zone from critical
structures, dissipates heat through fluid motion, or insulates from
heat transfer.
Use of artificial ascites, pneumoperitoneum, or balloon
displacement may enable more aggressive ablations that result in
more optimal margins and reduce the incidence of local recurrence
while preventing complications, excessive post-procedure pain,
narcotic use, and lengthy hospital stays.
Penn IR
Kondo Y, et al. Br J Surg. 2006;93(10):1277-82
Nishimura M, et al. Acta Med Okayama. 2012;66(3):279-84.
Thank You
Jeffrey F. B. Chick
• [email protected]
Gregory J. Nadolski
• [email protected]
Penn IR