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Hepatocellular Carcinoma: Radio-frequency Ablation of Medium and Large Lesions¹

¹ From the Department of Radiology, Ospedale Civile, Via Cereda, 23, 20059 Vimercate, Italy (T.L., F.M.); the Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (S.N.G.); the Department of Internal Medicine, Ospedale San Biagio, Clusone, Italy (S.L.); the Department of Radiology, Ospedale Generale, Busto Arsizio, Italy (T.I., L.S.); and the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (G.S.G.). From the 1998 RSNA scientific assembly. Received March 10, 1999; revision requested April 27; revision received June 17; accepted July 21. Supported in part by Radionics. Address reprint requests to T.L. (e-mail: lalivra@tin.it).

View larger version (145K): [in a new window]   Figure 1a. Complete necrosis in a large, noninfiltrating HCC treated with one session of RF therapy in a 74-year-old woman. (a) Portal phase CT scan obtained prior to RF therapy demonstrates a single, noninfiltrating 6.0-cm HCC (arrows) in the hepatic dome in segment 8. (b) Intercostal US scan obtained 1 month after RF therapy with three insertions of a single electrode shows two hyperechoic lines (arrowheads) traversing the lesion. These correspond to the location of two of the RF electrodes during therapy; the third electrode track was visible on other images (not shown). (c) Portal phase CT scan obtained 5 months after therapy shows complete absence of contrast enhancement within the tumor (arrows), which indicates complete necrosis.

View larger version (181K): [in a new window]   Figure 1b. Complete necrosis in a large, noninfiltrating HCC treated with one session of RF therapy in a 74-year-old woman. (a) Portal phase CT scan obtained prior to RF therapy demonstrates a single, noninfiltrating 6.0-cm HCC (arrows) in the hepatic dome in segment 8. (b) Intercostal US scan obtained 1 month after RF therapy with three insertions of a single electrode shows two hyperechoic lines (arrowheads) traversing the lesion. These correspond to the location of two of the RF electrodes during therapy; the third electrode track was visible on other images (not shown). (c) Portal phase CT scan obtained 5 months after therapy shows complete absence of contrast enhancement within the tumor (arrows), which indicates complete necrosis.

View larger version (146K): [in a new window]   Figure 1c. Complete necrosis in a large, noninfiltrating HCC treated with one session of RF therapy in a 74-year-old woman. (a) Portal phase CT scan obtained prior to RF therapy demonstrates a single, noninfiltrating 6.0-cm HCC (arrows) in the hepatic dome in segment 8. (b) Intercostal US scan obtained 1 month after RF therapy with three insertions of a single electrode shows two hyperechoic lines (arrowheads) traversing the lesion. These correspond to the location of two of the RF electrodes during therapy; the third electrode track was visible on other images (not shown). (c) Portal phase CT scan obtained 5 months after therapy shows complete absence of contrast enhancement within the tumor (arrows), which indicates complete necrosis.

View larger version (136K): [in a new window]   Figure 2a. Nearly complete necrosis in a large, noninfiltrating HCC located in segment 8 and treated with one session of RF therapy in a 70-year-old man. (a) Arterial phase CT scan obtained prior to therapy demonstrates a large, noninfiltrating 7.1-cm HCC (arrows). Note the area of central necrosis. (b) Arterial phase CT scan obtained 6 months after RF therapy shows nearly complete tumor necrosis. A small hypervascularized area of viable neoplastic tissue (arrow) remains at the posteromedial aspect of the tumor. In this case, hyperechogenicity within the tumor during the procedure may have obscured this portion of the tumor and prevented repositioning of the RF electrode. Because this area could not be seen on follow-up US scans and remained stable in size on subsequent CT scans, additional treatment was postponed.

View larger version (110K): [in a new window]   Figure 2b. Nearly complete necrosis in a large, noninfiltrating HCC located in segment 8 and treated with one session of RF therapy in a 70-year-old man. (a) Arterial phase CT scan obtained prior to therapy demonstrates a large, noninfiltrating 7.1-cm HCC (arrows). Note the area of central necrosis. (b) Arterial phase CT scan obtained 6 months after RF therapy shows nearly complete tumor necrosis. A small hypervascularized area of viable neoplastic tissue (arrow) remains at the posteromedial aspect of the tumor. In this case, hyperechogenicity within the tumor during the procedure may have obscured this portion of the tumor and prevented repositioning of the RF electrode. Because this area could not be seen on follow-up US scans and remained stable in size on subsequent CT scans, additional treatment was postponed.

View larger version (156K): [in a new window]   Figure 3a. Complete necrosis in a noninfiltrating HCC located in segment 4 and treated with two sessions of RF therapy in a 72-year-old woman. (a) Arterial phase CT scan obtained prior to RF therapy demonstrates a noninfiltrating 4.8-cm HCC (arrows). (b) Portal phase CT scan obtained 1 day after RF therapy with one insertion of a single electrode shows complete absence of contrast enhancement within the tumor. A thin rim of hyperattenuation (arrowheads) surrounds the lesion. This was not visible on the arterial phase images and disappeared on subsequent follow-up images. It is thought to represent reactive hyperemia. (c) Longitudinal US scan obtained 1 month after RF therapy shows a hyperechoic line (arrowheads) traversing the lesion. This corresponds to the location of the RF electrode during therapy. Note the eccentric location of this line, which indicates that the electrode was not centered exactly within the tumor during treatment. (d) Arterial phase CT scan obtained 1 month after RF therapy shows a focus (arrow) of hyperattenuation at the caudal portion of the tumor. Persistence of vital neoplastic tissue in this area was due to the eccentric location of the RF electrode during therapy. The remainder of the tumor showed complete necrosis. (e) Longitudinal contrast-enhanced, power Doppler US scan obtained at the same time as d shows signs of vascularization (arrowheads) at the caudal portion of the tumor, which confirms the CT findings. Repeat RF therapy was performed guided by means of these findings. (f) Portal phase CT scan obtained 4 months after repeat treatment shows complete tumor necrosis. This was confirmed on subsequent follow-up scans.

View larger version (159K): [in a new window]   Figure 3b. Complete necrosis in a noninfiltrating HCC located in segment 4 and treated with two sessions of RF therapy in a 72-year-old woman. (a) Arterial phase CT scan obtained prior to RF therapy demonstrates a noninfiltrating 4.8-cm HCC (arrows). (b) Portal phase CT scan obtained 1 day after RF therapy with one insertion of a single electrode shows complete absence of contrast enhancement within the tumor. A thin rim of hyperattenuation (arrowheads) surrounds the lesion. This was not visible on the arterial phase images and disappeared on subsequent follow-up images. It is thought to represent reactive hyperemia. (c) Longitudinal US scan obtained 1 month after RF therapy shows a hyperechoic line (arrowheads) traversing the lesion. This corresponds to the location of the RF electrode during therapy. Note the eccentric location of this line, which indicates that the electrode was not centered exactly within the tumor during treatment. (d) Arterial phase CT scan obtained 1 month after RF therapy shows a focus (arrow) of hyperattenuation at the caudal portion of the tumor. Persistence of vital neoplastic tissue in this area was due to the eccentric location of the RF electrode during therapy. The remainder of the tumor showed complete necrosis. (e) Longitudinal contrast-enhanced, power Doppler US scan obtained at the same time as d shows signs of vascularization (arrowheads) at the caudal portion of the tumor, which confirms the CT findings. Repeat RF therapy was performed guided by means of these findings. (f) Portal phase CT scan obtained 4 months after repeat treatment shows complete tumor necrosis. This was confirmed on subsequent follow-up scans.

View larger version (177K): [in a new window]   Figure 3c. Complete necrosis in a noninfiltrating HCC located in segment 4 and treated with two sessions of RF therapy in a 72-year-old woman. (a) Arterial phase CT scan obtained prior to RF therapy demonstrates a noninfiltrating 4.8-cm HCC (arrows). (b) Portal phase CT scan obtained 1 day after RF therapy with one insertion of a single electrode shows complete absence of contrast enhancement within the tumor. A thin rim of hyperattenuation (arrowheads) surrounds the lesion. This was not visible on the arterial phase images and disappeared on subsequent follow-up images. It is thought to represent reactive hyperemia. (c) Longitudinal US scan obtained 1 month after RF therapy shows a hyperechoic line (arrowheads) traversing the lesion. This corresponds to the location of the RF electrode during therapy. Note the eccentric location of this line, which indicates that the electrode was not centered exactly within the tumor during treatment. (d) Arterial phase CT scan obtained 1 month after RF therapy shows a focus (arrow) of hyperattenuation at the caudal portion of the tumor. Persistence of vital neoplastic tissue in this area was due to the eccentric location of the RF electrode during therapy. The remainder of the tumor showed complete necrosis. (e) Longitudinal contrast-enhanced, power Doppler US scan obtained at the same time as d shows signs of vascularization (arrowheads) at the caudal portion of the tumor, which confirms the CT findings. Repeat RF therapy was performed guided by means of these findings. (f) Portal phase CT scan obtained 4 months after repeat treatment shows complete tumor necrosis. This was confirmed on subsequent follow-up scans.

View larger version (155K): [in a new window]   Figure 3d. Complete necrosis in a noninfiltrating HCC located in segment 4 and treated with two sessions of RF therapy in a 72-year-old woman. (a) Arterial phase CT scan obtained prior to RF therapy demonstrates a noninfiltrating 4.8-cm HCC (arrows). (b) Portal phase CT scan obtained 1 day after RF therapy with one insertion of a single electrode shows complete absence of contrast enhancement within the tumor. A thin rim of hyperattenuation (arrowheads) surrounds the lesion. This was not visible on the arterial phase images and disappeared on subsequent follow-up images. It is thought to represent reactive hyperemia. (c) Longitudinal US scan obtained 1 month after RF therapy shows a hyperechoic line (arrowheads) traversing the lesion. This corresponds to the location of the RF electrode during therapy. Note the eccentric location of this line, which indicates that the electrode was not centered exactly within the tumor during treatment. (d) Arterial phase CT scan obtained 1 month after RF therapy shows a focus (arrow) of hyperattenuation at the caudal portion of the tumor. Persistence of vital neoplastic tissue in this area was due to the eccentric location of the RF electrode during therapy. The remainder of the tumor showed complete necrosis. (e) Longitudinal contrast-enhanced, power Doppler US scan obtained at the same time as d shows signs of vascularization (arrowheads) at the caudal portion of the tumor, which confirms the CT findings. Repeat RF therapy was performed guided by means of these findings. (f) Portal phase CT scan obtained 4 months after repeat treatment shows complete tumor necrosis. This was confirmed on subsequent follow-up scans.

View larger version (195K): [in a new window]   Figure 3e. Complete necrosis in a noninfiltrating HCC located in segment 4 and treated with two sessions of RF therapy in a 72-year-old woman. (a) Arterial phase CT scan obtained prior to RF therapy demonstrates a noninfiltrating 4.8-cm HCC (arrows). (b) Portal phase CT scan obtained 1 day after RF therapy with one insertion of a single electrode shows complete absence of contrast enhancement within the tumor. A thin rim of hyperattenuation (arrowheads) surrounds the lesion. This was not visible on the arterial phase images and disappeared on subsequent follow-up images. It is thought to represent reactive hyperemia. (c) Longitudinal US scan obtained 1 month after RF therapy shows a hyperechoic line (arrowheads) traversing the lesion. This corresponds to the location of the RF electrode during therapy. Note the eccentric location of this line, which indicates that the electrode was not centered exactly within the tumor during treatment. (d) Arterial phase CT scan obtained 1 month after RF therapy shows a focus (arrow) of hyperattenuation at the caudal portion of the tumor. Persistence of vital neoplastic tissue in this area was due to the eccentric location of the RF electrode during therapy. The remainder of the tumor showed complete necrosis. (e) Longitudinal contrast-enhanced, power Doppler US scan obtained at the same time as d shows signs of vascularization (arrowheads) at the caudal portion of the tumor, which confirms the CT findings. Repeat RF therapy was performed guided by means of these findings. (f) Portal phase CT scan obtained 4 months after repeat treatment shows complete tumor necrosis. This was confirmed on subsequent follow-up scans.

View larger version (150K): [in a new window]   Figure 3f. Complete necrosis in a noninfiltrating HCC located in segment 4 and treated with two sessions of RF therapy in a 72-year-old woman. (a) Arterial phase CT scan obtained prior to RF therapy demonstrates a noninfiltrating 4.8-cm HCC (arrows). (b) Portal phase CT scan obtained 1 day after RF therapy with one insertion of a single electrode shows complete absence of contrast enhancement within the tumor. A thin rim of hyperattenuation (arrowheads) surrounds the lesion. This was not visible on the arterial phase images and disappeared on subsequent follow-up images. It is thought to represent reactive hyperemia. (c) Longitudinal US scan obtained 1 month after RF therapy shows a hyperechoic line (arrowheads) traversing the lesion. This corresponds to the location of the RF electrode during therapy. Note the eccentric location of this line, which indicates that the electrode was not centered exactly within the tumor during treatment. (d) Arterial phase CT scan obtained 1 month after RF therapy shows a focus (arrow) of hyperattenuation at the caudal portion of the tumor. Persistence of vital neoplastic tissue in this area was due to the eccentric location of the RF electrode during therapy. The remainder of the tumor showed complete necrosis. (e) Longitudinal contrast-enhanced, power Doppler US scan obtained at the same time as d shows signs of vascularization (arrowheads) at the caudal portion of the tumor, which confirms the CT findings. Repeat RF therapy was performed guided by means of these findings. (f) Portal phase CT scan obtained 4 months after repeat treatment shows complete tumor necrosis. This was confirmed on subsequent follow-up scans.

View larger version (182K): [in a new window]   Figure 4a. Treatment failure in an infiltrating HCC located in segment 7 with satellite lesions in a 64-year-old man. (a) Arterial phase CT scan obtained prior to RF therapy demonstrates a large 7.6-cm HCC (large arrows). Another small hypervascular tumor (small arrow) is adjacent to the Glisson capsule. (b) Portal phase CT scan obtained 6 months after RF therapy with one insertion of a cluster electrode shows complete necrosis of the tumor and a small area previously occupied by extranodular tumor growth (short arrow). In this case, the proximity of the vena cava did not limit heating of tumor adjacent to the vessel. Note the persistent contrast enhancement within satellite lesions (lower long arrows), which, because of interposed fibrotic tissue, remained untreated. The small superficial lesion (upper long arrow) received a treatment with PEI during the interval between the RF procedure and the present follow-up after the RF procedure.

View larger version (179K): [in a new window]   Figure 4b. Treatment failure in an infiltrating HCC located in segment 7 with satellite lesions in a 64-year-old man. (a) Arterial phase CT scan obtained prior to RF therapy demonstrates a large 7.6-cm HCC (large arrows). Another small hypervascular tumor (small arrow) is adjacent to the Glisson capsule. (b) Portal phase CT scan obtained 6 months after RF therapy with one insertion of a cluster electrode shows complete necrosis of the tumor and a small area previously occupied by extranodular tumor growth (short arrow). In this case, the proximity of the vena cava did not limit heating of tumor adjacent to the vessel. Note the persistent contrast enhancement within satellite lesions (lower long arrows), which, because of interposed fibrotic tissue, remained untreated. The small superficial lesion (upper long arrow) received a treatment with PEI during the interval between the RF procedure and the present follow-up after the RF procedure.