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Vascular and Interventional Radiology |
1 Department of Radiology, Ospedale Civile, Via C. Battisti 23, 20059 Vimercate, Italy (T.L., F.M.)
2 Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (S.N.G., G.S.G.)
3 Department of Internal Medicine, Ospedale San Biagio, Clusone, Italy (S.L.)
4 Department of Radiology, Ospedale Generale, Busto Arsizio, Italy (L.S.).
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Abstract |
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 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: Eighty-six patients with 112 small (
3-cm-diameter) HCCs underwent RF ablation (42 patients with 52 tumors) or percutaneous ethanol injection (44 patients with 60 tumors). Therapeutic efficacy was evaluated with dual-phase spiral computed tomography performed at least 4 months after treatment.
RESULTS: Complete necrosis was achieved in 47 of 52 tumors with RF ablation (90%) and in 48 of 60 tumors with percutaneous ethanol injection (80%). These results were obtained with an average of 1.2 sessions per tumor with RF ablation and 4.8 sessions per tumor with percutaneous ethanol injection. One major complication (hemothorax that required drainage) and four minor complications (intraperitoneal bleeding, hemobilia, pleural effusion, cholecystitis) occurred in patients treated with RF ablation; no complications occurred in patients treated with percutaneous ethanol injection.
CONCLUSION: RF ablation results in a higher rate of complete necrosis and requires fewer treatment sessions than percutaneous ethanol injection. However, the complication rate is higher with RF ablation than with percutaneous ethanol injection. RF ablation is the treatment of choice for most patients with HCC.
Index terms: Alcohol, 761.1269 • Liver, interventional procedure, 761.1269 • Liver neoplasms, therapy, 761.1269, 761.323, 761.47 • Radiofrequency (RF) ablation, 761.1269, 761.47
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Introduction |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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To improve on the results that have been obtained with percutaneous ethanol injection and still maintain the principal advantages of this technique over surgery (ie, decreased invasiveness and cost, relative simplicity, repeatability), other percutaneous techniques have been developed. These include thermal methods such as the use of radio frequency (RF) (9), laser (10), or microwaves (11,12). However, to our knowledge, no comparative study of the results obtained with different techniques in similar patient groups has been performed.
We performed a prospective study in which two cohorts of otherwise similar patients with small HCCs were treated with percutaneous ethanol injection or RF ablation. To our knowledge, this study was the first prospective comparison of these two techniques. In addition, to our knowledge, our patient population was the first series of patients with HCC to be treated with internally cooled RF electrodes, a technique that to our knowledge has been used only in patients with hepatic metastases (13).
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Between July 1995 and July 1997, 86 consecutive patients with cirrhosis or chronic hepatitis and HCC (112 lesions 3 cm in diameter) were treated with percutaneous ethanol injection (44 patients with 60 lesions) or RF ablation (42 patients with 52 lesions). The patients had been referred to our centers for treatment with percutaneous ethanol injection but agreed to enter a study in which percutaneous ethanol injection or RF ablation would be selected for them. They were told that results with the two techniques were expected to be roughly the same on the basis of our experience with RF ablation in hepatic metastases (13). However, they were not told which treatment would be performed before agreeing to participate in the study. Seven patients with lesions adjacent to the hepatic hilum or the confluence of the hepatic veins were excluded from RF therapy because of the unknown risk to these vital structures.
The choice of treatment was based solely on the location of the patient's residence relative to the hospital. Patients who lived more than 2 hours from the hospital underwent RF ablation; patients who lived within 2 hours underwent percutaneous ethanol injection. Treatment choice was based on patient location because of the greater number of sessions generally required for percutaneous ethanol injection and the difficulty in scheduling multiple return visits for patients who live a greater distance from the hospital. The two patient groups were otherwise comparable (P > .05) with respect to age, sex, type of cirrhosis, Child-Pugh class, number of lesions, lesion diameter, type of HCC (nodular, contiguous multinodular, or infiltrating), 
-fetoprotein level, and des-
-carboxy-prothrombin level. Thus, there is no reason to believe that this method of determining treatment type would lead to statistically significant bias in the results. The characteristics of both patient groups are reported in the Table.
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-fetoprotein levels were more than 200 ng/mL (>200 µg/L) or des--carboxy-prothrombin levels were abnormal. In patients who underwent RF ablation, the following serologic values were measured before treatment and 24 hours, 48 hours, and 1 month after treatment: levels of transaminases, alkaline phosphatase, bilirubin, electrolytes, hemoglobin, fibrinogen, haptoglobin, and creatinine; prothrombin activity; and complete blood cell count. These values were not measured in the percutaneous ethanol injection group because no important changes in these values were observed in several previous studies (8,14–16).
Techniques
Both procedures were performed under real-time US guidance (model AU 4; Esaote, Genoa, Italy) with a 3.5-MHZ sector probe (model CAB411; Hitachi Medical, Tokyo, Japan). A guide device incorporated into the US probe was used for placement of the needle or RF electrode. Before the procedures, coagulation parameters were checked in all patients. Treatment was not performed in patients with a platelet count below 40,000/mm3 (<40 x 109/L) or less than 40% prothrombin activity. After cleansing of the skin with iodized alcohol (which also served as a contact medium), the most appropriate approach was chosen. For lesions located in the right lobe, an intercostal approach was often preferred; for lesions located in the left lobe, a subcostal approach was generally used.
Percutaneous ethanol injection.—The procedure was performed in the outpatient department by one radiologist (T.L., S.L., F.M., L.S.) and one nurse. No sedative or local anesthetic was given. To inject ethanol, a 20-cm-long, 21-gauge needle with a closed conical tip and three terminal side holes (PEIT needle; Hakko, Tokyo, Japan) was used. Only one needle was used in any one treatment session. Ethanol was injected in a dose of 1–4 mL per session according to the distribution of ethanol, patient compliance, and lesion size. The perfused area was clearly seen as a hyperechoic focus. The ethanol was injected slowly in small boluses (~0.1–0.2 mL), with the diffusion checked by means of real-time US.
If ethanol diffusion was not clearly seen or if most of the ethanol diffused outside the tumor, injection was suspended and the needle was withdrawn. The needle was then repositioned and the injection repeated. To prevent reflux of ethanol along the needle track and leakage into the peritoneum, the needle was left in place for 20–30 seconds after completion of the injection and then slowly withdrawn. The injection site was chosen before each session to ensure perfusion of areas considered not to have been treated. Treatment ended when the perfusion of the neoplastic tissue was considered to be total. We performed two to six sessions per lesion (one treatment cycle) according to lesion size. Treatments were performed two times per week. After each treatment, patients were observed in the waiting room for 1–2 hours.
RF ablation.—The procedure was performed in a hospital procedure room by two radiologists (T.L., S.L., F.M., L.S.) and one nurse. One hour before treatment, the patient received an orally administered sedative and an intravenously administered analgesic. The patient was monitored continuously before, during, and after the procedure. A 20-cm-long, 18-gauge, cooled-tip RF electrode with a 2–3-cm-long exposed metallic tip (Radionics, Burlington, Mass) was used to deliver RF energy. Grounding was achieved by attaching a dispersive pad with a surface area greater than 400 cm2 to each of the patient's thighs. The electrode was then attached to a 500-kHz RF generator (series 3; Radionics) capable of producing 150 W of power.
During lesion ablation, a thermocouple embedded in the electrode tip continuously measured the local temperature. Tissue impedance was monitored continuously by means of circuitry incorporated in the generator. A peristaltic pump (Watson-Marlow, Wilmington, Mass) was used to infuse 0°C normal saline solution into the cooling lumen of the electrode at a rate sufficient to maintain a tip temperature of 20°–25°C. No more than 2 L of saline solution was required for any procedure. After induction of local anesthesia, a 14-gauge needle was inserted through the skin to facilitate introduction of the RF electrode. For each treatment session, a single RF electrode was positioned at the center of the tumor.
RF energy was delivered in the following manner: After measurement of baseline tissue impedance, generator output was slowly increased to 1,000–1,400 mA, and this level was maintained until the end of the procedure. If an increase in impedance equal to or greater than 10 
above baseline was observed, the current was reduced until stable impedance was observed and then increased again. The process of decreasing and increasing generator output was repeated for the remainder of the treatment session to prevent tissue charring, which leads to increased impedance and limited energy deposition. The length of these cycles of increased and decreased generator output varied according to tissue impedance; in general, however, decreased output was maintained for approximately 15 seconds.
During energy deposition, a hyperechoic patch due to vaporization and cavitation effects was observed around the electrode tip; the patch progressively increased to cover all of the neoplastic area or a larger area (Fig 1). Frequently, hyperechoic microbubbles were simultaneously seen in the hepatic veins; occasionally, microbubbles could also be seen in the right atrium. In some cases, the hyperechoic patch did not appear progressively but suddenly, at which time an audible "pop" came from the liver. Several minutes after the end of treatment, the hyperechoic patch cleared and was replaced by a hyperechoic ring, which was usually smaller. RF energy was applied for 10–12 minutes. Only one application of RF energy was used for each tumor (one treatment cycle).
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Assessment of Therapeutic Efficacy
To evaluate the response, contrast-enhanced CT scans were obtained 30–40 days after treatment with the parameters described earlier. In patients who underwent RF ablation, CT was also performed 1 day after treatment to evaluate the short-term effects of the procedure. Repeat CT was performed every 3–4 months. Follow-up ranged from 4 to 28 months (mean, 10 months). At this writing, only 39 of the 86 patients have undergone follow-up CT at 8 months or later. Thus, tumor necrosis was considered complete when no areas of enhancement were seen in the tumor or at the periphery on CT scans obtained 4 months after treatment (Fig 2).
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RESULTS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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RF Ablation
A single treatment cycle was performed in 44 of 52 tumors (85%); in eight tumors (15%), a second treatment cycle was performed because of residual foci of enhancement, which were thought to represent neoplastic tissue. When both the first and (when performed) second treatment cycles were taken into account, an average of 1.2 sessions per tumor was performed. Complete necrosis was achieved in 47 of 52 tumors (90%). Of the five tumors (10%) in which necrosis was incomplete even after the second treatment cycle (ie, second session), three were nodular HCCs, one was a contiguous multinodular HCC, and one was an infiltrating HCC.
Most patients experienced mild to moderate pain during the procedure, especially when the tumor was superficially located. In five patients, treatment was interrupted due to severe pain; an anesthesiologist administered propofol (Diprivan 1%; Zeneca, Milan, Italy) and performed assisted ventilation for the duration of the procedure. Two patients with superficially located tumors (Fig 4) experienced pain for 3–4 days; the pain required administration of analgesics. In all patients, levels of transaminases increased by two to four times over baseline at 24 hours, with an observed decrease (trend to baseline) by 48 hours. No important changes in level of unconjugated bilirubin, complete blood cell count, or platelet count were observed. The mean total procedure time was approximately 45 minutes per session.
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On CT scans obtained 1 day after treatment, a hyperattenuating ring around the coagulated region was apparent in most cases. This ring was thought to be related to hyperemia and disappeared progressively during follow-up. The diameter of the hyperechoic patch seen during treatment was usually 5–10 mm larger than the diameter of the necrotic area on CT scans. However, the hyperechoic ring seen after the procedure was generally comparable in size with the necrotic area seen at CT.
The size and shape of the necrotic area were different in cirrhotic and neoplastic tissue. In cirrhotic tissue, the necrotic area was cylindric with a diameter of 1.7–2.0 cm; in neoplastic tissue of the most common type (ie, nodular), the size and shape of the necrotic area generally reproduced those of the tumor, as if a mold of the tumor had been made. This kind of response, which will be discussed later, was termed the oven effect (Figs 3b, 5). In infiltrating and contiguous multinodular tumors, the size and shape of the necrotic area were irregular and did not always conform to those of the tumor.
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Although a formal cost-effectiveness analysis was not performed as part of this study, we believe that the greater success in achieving a total response coupled with the need for fewer treatment sessions make RF ablation the preferred treatment for most patients with HCC. Nevertheless, given the well-established efficacy of percutaneous ethanol injection (confirmed in this study), percutaneous ethanol injection should remain the primary treatment option when RF ablation is not available. In addition, there was a difference between percutaneous ethanol injection and RF ablation related to the hospital stay associated with RF ablation in this study. This finding was the result of our conservative therapeutic regimen, which was due to the experimental nature of RF ablation. Indeed, we currently observe patients for only 24 hours. The occurrence of some adverse events suggests such a course of action until greater experience is obtained.
An interesting finding of this study was that the size and shape of the necrotic area generally conformed to the size and shape of the tumor, with a coagulation diameter larger than expected within the tumor and smaller than expected in surrounding cirrhotic tissue. According to previous experimental work in the liver in normal animals, the mean diameter of the necrotic area produced with the RF ablation technique used in this study should have been approximately 2.4 cm (17). In many cases, however, a necrotic area of up to 3.0 cm in diameter was seen in the tumor, whereas the necrotic area was generally limited to 1.7–2.0 cm in diameter in cirrhotic tissue (when the electrode extended beyond the tumor). We attribute this difference to the so-called oven effect. In essence, the cirrhotic tissue around the tumor might behave like a thermal insulator, increasing heat retention within the tumor and preventing heating outside the tumor.
The oven effect may also help explain the difference in results between tumor types. Both percutaneous ethanol injection and RF ablation demonstrated decreased efficacy in the treatment of contiguous multinodular HCC. For percutaneous ethanol injection, the decreased efficacy was likely due to the fibrosis surrounding the small neoplastic nodules, which limits ethanol diffusion and prevents homogeneous distribution throughout the tumor. This intratumoral fibrosis may also influence heat diffusion (the oven effect in reverse) and thereby limit the efficacy of RF ablation (Fig 6). Fortunately, the importance of this unfavorable occurrence is minimized by the low frequency of this type of HCC.
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The results of this study, along with ongoing advances in the techniques for in situ tumor ablation, may ultimately change the overall approach to management of nonadvanced HCC. For many years, surgical resection was considered the only curative option for HCC in cirrhosis because the neoplasm can be completely removed. More recently, however, it has been understood that HCC is a multifocal disease in due time (18,19). In other words, the first lesion to be detected is only the prelude to other neoplasms. For this reason and because of the relatively high complication rate associated with surgery, percutaneous ethanol injection has gained an increasing role in the treatment of HCC detected with screening US.
According to historic data, the mean 5-year survival rate for patients with Child-Pugh class A HCC and a single lesion 5 cm in diameter or smaller is 49% after surgery and 48% after percutaneous ethanol injection (20). The comparability of these results probably reflects a balance between the success of surgery in completely removing the tumor (vs the 70%–80% rate for percutaneous ethanol injection) and the repeatability (because of the tendency of HCC to recur), lack of liver damage (there is substantial loss of hepatic tissue in some resections), and absence of mortality (vs the mean mortality rate of 7% reported by experienced surgeons) associated with percutaneous ethanol injection (5). The most important predictors of a favorable result with surgery, as determined by the Liver Cancer Study Group of Japan (21), are young age, a single focus of disease, no portal involvement, compensated cirrhosis, and a low -fetoprotein level. Except for patients who are candidates for liver transplantation, surgical resection is likely to be the best choice for patients with only favorable prognostic factors; all other patients are generally better treated with percutaneous ethanol injection (5).
Because our study demonstrated that RF ablation enables complete tumor necrosis in more patients than does percutaneous ethanol injection (90% vs 80%), it is possible that the indications for surgery may be decreased even further. Accordingly, we believe that nodular HCC with favorable prognostic factors can be effectively treated with RF ablation, with surgery being reserved for those patients in whom RF ablation fails. However, surgery still remains the treatment of choice for contiguous multinodular HCC due to the unsatisfactory results of percutaneous ethanol injection or RF ablation in this tumor type.
In conclusion, in 86 patients who underwent percutaneous ethanol injection or RF ablation of HCC, RF ablation was more effective and enabled tumor necrosis in fewer treatment sessions, albeit with a higher rate of complications. On the basis of these results, we currently prefer to use RF ablation in the majority of patients, reserving percutaneous ethanol injection for HCCs that are difficult to approach or located in areas where RF ablation is considered unsafe. Use of RF ablation might decrease the indications for surgery. Improvements in the technique of RF ablation may further increase the efficacy and decrease the complications. Identification of the oven effect has persuaded us to treat tumors of increasingly larger size, and preliminary results encourage us to continue in this direction.
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Footnotes |
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Abbreviations: HCC = hepatocellular carcinoma RF = radio frequency
Author contributions: Guarantors of integrity of entire study, T.L., G.S.G.; study concepts, T.L.; study design, T.L., S.L., L.S.; definition of intellectual content, T.L.; literature research, T.L.; clinical studies, T.L., S.L., F.M., L.S.; experimental studies, S.N.G., G.S.G.; data acquisition, T.L., S.L., F.M., L.S.; data analysis, T.L., G.S.G.; statistical analysis, G.S.G.; manuscript preparation, T.L., G.S.G., S.N.G., L.S.; manuscript editing, G.S.G., S.N.G.; manuscript review, T.L., G.S.G., S.N.G.
Received February 6, 1998;
revision requested April 14, 1998; revision received July 8, 1998;
accepted September 8, 1998.
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References |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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A. Shibuya, T. Nakazawa, K. Saigenji, K. Furuta, and K. Matsunaga Diaphragmatic hernia after radiofrequency ablation therapy for hepatocellular carcinoma. Am. J. Roentgenol., May 1, 2006; 186(5 Suppl): S241 - S243. [Full Text] [PDF]
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M. Hirooka, H. Iuchi, T. Kumagi, S. Shigematsu, A. Hiraoka, T. Uehara, K. Kurose, N. Horiike, and M. Onji Virtual Sonographic Radiofrequency Ablation of Hepatocellular Carcinoma Visualized on CT but Not on Conventional Sonography. Am. J. Roentgenol., May 1, 2006; 186(5 Suppl): S255 - S260. [Abstract] [Full Text] [PDF]
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Y. K. Kim, C. S. Kim, G. H. Chung, Y. M. Han, S. Y. Lee, G. Y. Jin, and J. M. Lee Radiofrequency ablation of hepatocellular carcinoma in patients with decompensated cirrhosis: evaluation of therapeutic efficacy and safety. Am. J. Roentgenol., May 1, 2006; 186(5 Suppl): S261 - S268. [Abstract] [Full Text] [PDF]
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P.-Y. Brillet, V. Paradis, G. Brancatelli, A.-S. Rangheard, Y. Consigny, A. Plessier, F. Durand, J. Belghiti, D. Sommacale, and V. Vilgrain Percutaneous radiofrequency ablation for hepatocellular carcinoma before liver transplantation: a prospective study with histopathologic comparison. Am. J. Roentgenol., May 1, 2006; 186(5 Suppl): S296 - S305. [Abstract] [Full Text] [PDF]
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S. H. Kim, H. K. Lim, D. Choi, W. J. Lee, S. H. Kim, M. J. Kim, C. K. Kim, Y. H. Jeon, J. M. Lee, and H. Rhim Percutaneous radiofrequency ablation of hepatocellular carcinoma: effect of histologic grade on therapeutic results. Am. J. Roentgenol., May 1, 2006; 186(5 Suppl): S327 - S333. [Abstract] [Full Text] [PDF]
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 S. Rossi, R. Dore, A. Cascina, V. Vespro, F. Garbagnati, L. Rosa, V. Ravetta, A. Azzaretti, P. Di Tolla, G. Orlandoni, et al. Percutaneous computed tomography-guided radiofrequency thermal ablation of small unresectable lung tumours. Eur. Respir. J., March 1, 2006; 27(3): 556 - 563. [Abstract] [Full Text] [PDF]
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L. M. Sutherland, J. A. R. Williams, R. T. A. Padbury, D. C. Gotley, B. Stokes, and G. J. Maddern Radiofrequency ablation of liver tumors: a systematic review. Arch Surg, February 1, 2006; 141(2): 181 - 190. [Abstract] [Full Text] [PDF]
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 J. K. Kim, K.-H. Han, J. T. Lee, Y. H. Paik, S. H. Ahn, J. D. Lee, K. S. Lee, C. Y. Chon, and Y. M. Moon Long-term Clinical Outcome of Phase IIb Clinical Trial of Percutaneous Injection with Holmium-166/Chitosan Complex (Milican) for the Treatment of Small Hepatocellular Carcinoma Clin. Cancer Res., January 15, 2006; 12(2): 543 - 548. [Abstract] [Full Text] [PDF]
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T. Shibata, T. Shibata, Y. Maetani, H. Isoda, and M. Hiraoka Radiofrequency Ablation for Small Hepatocellular Carcinoma: Prospective Comparison of Internally Cooled Electrode and Expandable Electrode Radiology, January 1, 2006; 238(1): 346 - 353. [Abstract] [Full Text] [PDF]
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Y. K. Kim, H. S. Kwak, C. S. Kim, G. H. Chung, Y. M. Han, and J. M. Lee Hepatocellular Carcinoma in Patients with Chronic Liver Disease: Comparison of SPIO-enhanced MR Imaging and 16-Detector Row CT Radiology, December 21, 2005; (2005) 2381042193. [Abstract] [Full Text]
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J. R. Haaga, A. A. Exner, Y. Wang, N. T. Stowe, and P. J. Tarcha Combined Tumor Therapy by Using Radiofrequency Ablation and 5-FU-Laden Polymer Implants: Evaluation in Rats and Rabbits Radiology, December 1, 2005; 237(3): 911 - 918. [Abstract] [Full Text] [PDF]
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A. M. Lutz, J. K. Willmann, K. Goepfert, B. Marincek, and D. Weishaupt Hepatocellular Carcinoma in Cirrhosis: Enhancement Patterns at Dynamic Gadolinium- and Superparamagnetic Iron Oxide-enhanced T1-weighted MR Imaging Radiology, November 1, 2005; 237(2): 520 - 528. [Abstract] [Full Text] [PDF]
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M. Akahane, H. Koga, N. Kato, H. Yamada, K. Uozumi, R. Tateishi, T. Teratani, S. Shiina, and K. Ohtomo Complications of Percutaneous Radiofrequency Ablation for Hepato-cellular Carcinoma: Imaging Spectrum and Management RadioGraphics, October 1, 2005; 25(suppl_1): S57 - S68. [Abstract] [Full Text] [PDF]
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J. M. Lee, S. H. Choi, H. S. Park, M. W. Lee, C. J. Han, J.-i. Choi, J.-Y. Choi, S. H. Hong, J. K. Han, and B. I. Choi Radiofrequency Thermal Ablation in Canine Femur: Evaluation of Coagulation Necrosis Reproducibility and MRI-Histopathologic Correlation Am. J. Roentgenol., September 1, 2005; 185(3): 661 - 667. [Abstract] [Full Text] [PDF]
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 S-M Lin, C-J Lin, C-C Lin, C-W Hsu, and Y-C Chen Randomised controlled trial comparing percutaneous radiofrequency thermal ablation, percutaneous ethanol injection, and percutaneous acetic acid injection to treat hepatocellular carcinoma of 3 cm or less Gut, August 1, 2005; 54(8): 1151 - 1156. [Abstract] [Full Text] [PDF]
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G. D. Dodd III, D. Napier, J. D. Schoolfield, and L. Hubbard Percutaneous Radiofrequency Ablation of Hepatic Tumors: Postablation Syndrome Am. J. Roentgenol., July 1, 2005; 185(1): 51 - 57. [Abstract] [Full Text] [PDF]
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D. A. Gervais, F. J. McGovern, R. S. Arellano, W. S. McDougal, and P. R. Mueller Radiofrequency Ablation of Renal Cell Carcinoma: Part 1, Indications, Results, and Role in Patient Management over a 6-Year Period and Ablation of 100 Tumors Am. J. Roentgenol., July 1, 2005; 185(1): 64 - 71. [Abstract] [Full Text] [PDF]
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D. Choi, H. K. Lim, M. J. Kim, S. J. Kim, S. H. Kim, W. J. Lee, J. H. Lim, S. W. Paik, B. C. Yoo, M. S. Choi, et al. Liver Abscess After Percutaneous Radiofrequency Ablation for Hepatocellular Carcinomas: Frequency and Risk Factors Am. J. Roentgenol., June 1, 2005; 184(6): 1860 - 1867. [Abstract] [Full Text] [PDF]
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K. K. Ng, C. M. Lam, R. T. Poon, T. W. Shek, W. C. Yu, J. Y. To, Y. H. Wo, C. P. Lau, T. C. Tang, D. W. Ho, et al. Porcine Liver: Morphologic Characteristics and Cell Viability at Experimental Radiofrequency Ablation with Internally Cooled Electrodes Radiology, May 1, 2005; 235(2): 478 - 486. [Abstract] [Full Text] [PDF]
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P. Liang, B. Dong, X. Yu, D. Yu, Y. Wang, L. Feng, and Q. Xiao Prognostic Factors for Survival in Patients with Hepatocellular Carcinoma after Percutaneous Microwave Ablation Radiology, April 1, 2005; 235(1): 299 - 307. [Abstract] [Full Text] [PDF]
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M. Morimoto, A. Nozawa, K. Numata, K. Shirato, K. Sugimori, A. Kokawa, N. Tomita, T. Saitou, Y. Nakatani, T. Imada, et al. Evaluation Using Contrast-Enhanced Harmonic Gray Scale Sonography After Radio Frequency Ablation of Small Hepatocellular Carcinoma: Sonographic-Histopathologic Correlation J. Ultrasound Med., March 1, 2005; 24(3): 273 - 283. [Abstract] [Full Text] [PDF]
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T. D. Atwell, D. J. Brandhagen, J. W. Charboneau, D. M. Nagorney, M. R. Callstrom, and M. A. Farrell Successful Treatment of Hepatocellular Adenoma with Percutaneous Radiofrequency Ablation Am. J. Roentgenol., March 1, 2005; 184(3): 828 - 831. [Abstract] [Full Text] [PDF]
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M. D. Beland, D. E. Dupuy, and W. W. Mayo-Smith Percutaneous Cryoablation of Symptomatic Extraabdominal Metastatic Disease: Preliminary Results Am. J. Roentgenol., March 1, 2005; 184(3): 926 - 930. [Abstract] [Full Text] [PDF]
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R. Lencioni, D. Cioni, L. Crocetti, C. Franchini, C. D. Pina, J. Lera, and C. Bartolozzi Early-Stage Hepatocellular Carcinoma in Patients with Cirrhosis: Long-term Results of Percutaneous Image-guided Radiofrequency Ablation Radiology, March 1, 2005; 234(3): 961 - 967. [Abstract] [Full Text] [PDF]
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D. S. K. Lu, N. C. Yu, S. S. Raman, P. Limanond, C. Lassman, K. Murray, M. J. Tong, R. G. Amado, and R. W. Busuttil Radiofrequency Ablation of Hepatocellular Carcinoma: Treatment Success as Defined by Histologic Examination of the Explanted Liver Radiology, March 1, 2005; 234(3): 954 - 960. [Abstract] [Full Text] [PDF]
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A. Giorgio, L. Tarantino, G. de Stefano, C. Coppola, and G. Ferraioli Complications After Percutaneous Saline-Enhanced Radiofrequency Ablation of Liver Tumors: 3-Year Experience with 336 Patients at a Single Center Am. J. Roentgenol., January 1, 2005; 184(1): 207 - 211. [Abstract] [Full Text] [PDF]
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Y.-C. Lin, J.-H. Chen, K.-W. Han, and W.-C. Shen Ablation of Liver Tumor by Injection of Hypertonic Saline Am. J. Roentgenol., January 1, 2005; 184(1): 212 - 219. [Abstract] [Full Text] [PDF]
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O. Seror, G. N'Kontchou, D. Haddar, M. Dordea, Y. Ajavon, N. Ganne, J. C. Trinchet, M. Beaugrand, and N. Sellier Large Infiltrative Hepatocellular Carcinomas: Treatment with Percutaneous Intraarterial Ethanol Injection Alone or in Combination with Conventional Percutaneous Ethanol Injection Radiology, January 1, 2005; 234(1): 299 - 309. [Abstract] [Full Text] [PDF]
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G. S. Gazelle, P. M. McMahon, M. T. Beinfeld, E. F. Halpern, and M. C. Weinstein Metastatic Colorectal Carcinoma: Cost-effectiveness of Percutaneous Radiofrequency Ablation versus That of Hepatic Resection Radiology, December 1, 2004; 233(3): 729 - 739. [Abstract] [Full Text] [PDF]
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S. H. Kim, H. K. Lim, D. Choi, W. J. Lee, S. H. Kim, M. J. Kim, S. J. Lee, and J. H. Lim Changes in Bile Ducts after Radiofrequency Ablation of Hepatocellular Carcinoma: Frequency and Clinical Significance Am. J. Roentgenol., December 1, 2004; 183(6): 1611 - 1617. [Abstract] [Full Text] [PDF]
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D. Choi, H. K. Lim, M. J. Kim, S. H. Kim, W. J. Lee, S. H. Kim, J. H. Lim, S. W. Paik, K. C. Koh, and B. C. Yoo Therapeutic Efficacy and Safety of Percutaneous Radiofrequency Ablation of Hepatocellular Carcinoma Abutting the Gastrointestinal Tract Am. J. Roentgenol., November 1, 2004; 183(5): 1417 - 1424. [Abstract] [Full Text] [PDF]
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S. Shankar, E. vanSonnenberg, P. R. Morrison, K. Tuncali, and S. G. Silverman Combined Radiofrequency and Alcohol Injection for Percutaneous Hepatic Tumor Ablation Am. J. Roentgenol., November 1, 2004; 183(5): 1425 - 1429. [Abstract] [Full Text] [PDF]
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A. Hines-Peralta and S. N. Goldberg Review of Radiofrequency Ablation for Renal Cell Carcinoma Clin. Cancer Res., September 15, 2004; 10(18): 6328S - 6334S. [Abstract] [Full Text] [PDF]
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E Caturelli, L Solmi, M Anti, S Fusilli, P Roselli, A Andriulli, F Fornari, C Del Vecchio Blanco, and I de Sio Ultrasound guided fine needle biopsy of early hepatocellular carcinoma complicating liver cirrhosis: a multicentre study Gut, September 1, 2004; 53(9): 1356 - 1362. [Abstract] [Full Text] [PDF]
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A R Gillams Liver ablation therapy Br. J. Radiol., September 1, 2004; 77(921): 713 - 723. [Full Text] [PDF]
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M. Koda, M. Ueki, Y. Maeda, K.-i. Mimura, K. Okamoto, Y. Matsunaga, M. Kawakami, K. Hosho, and Y. Murawaki Percutaneous Sonographically Guided Radiofrequency Ablation with Artificial Pleural Effusion for Hepatocellular Carcinoma Located Under the Diaphragm Am. J. Roentgenol., September 1, 2004; 183(3): 583 - 588. [Abstract] [Full Text] [PDF]
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Y. Minami, M. Kudo, T. Kawasaki, H. Chung, C. Ogawa, and H. Shiozaki Treatment of Hepatocellular Carcinoma with Percutaneous Radiofrequency Ablation: Usefulness of Contrast Harmonic Sonography for Lesions Poorly Defined with B-Mode Sonography Am. J. Roentgenol., July 1, 2004; 183(1): 153 - 156. [Abstract] [Full Text] [PDF]
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S. S. Raman, D. Aziz, X. Chang, M. Ye, J. Sayre, C. Lassman, and D. S. K. Lu Minimizing Central Bile Duct Injury during Radiofrequency Ablation: Use of Intraductal Chilled Saline Perfusion--Initial Observations from a Study in Pigs Radiology, July 1, 2004; 232(1): 154 - 159. [Abstract] [Full Text] [PDF]
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 T.-I. Huo, Y.-H. Huang, J.-C. Wu, P.-C. Lee, F.-Y. Chang, and S.-D. Lee Induction of complete tumor necrosis may reduce intrahepatic metastasis and prolong survival in patients with hepatocellular carcinoma undergoing locoregional therapy: a prospective study Ann. Onc., May 1, 2004; 15(5): 775 - 780. [Abstract] [Full Text] [PDF]
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R. T.-P. Poon, K. K.-C. Ng, C.-M. Lam, V. Ai, J. Yuen, and S.-T. Fan Radiofrequency Ablation for Subcapsular Hepatocellular Carcinoma Ann. Surg. Oncol., March 1, 2004; 11(3): 281 - 289. [Abstract] [Full Text] [PDF]
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R. T. P. Poon, K. K. C. Ng, C.-M. Lam, V. Ai, J. Yuen, and S.-T. Fan Effectiveness of Radiofrequency Ablation for Hepatocellular Carcinomas Larger Than 3 cm in Diameter Arch Surg, March 1, 2004; 139(3): 281 - 287. [Abstract] [Full Text] [PDF]
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M. Ahmed, Z. Liu, K. S. Afzal, D. Weeks, S. M. Lobo, J. B. Kruskal, R. E. Lenkinski, and S. N. Goldberg Radiofrequency Ablation: Effect of Surrounding Tissue Composition on Coagulation Necrosis in a Canine Tumor Model Radiology, March 1, 2004; 230(3): 761 - 767. [Abstract] [Full Text] [PDF]
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T. J. Vogl, R. Straub, K. Eichler, O. Sollner, and M. G. Mack Colorectal Carcinoma Metastases in Liver: Laser-induced Interstitial Thermotherapy--Local Tumor Control Rate and Survival Data Radiology, February 1, 2004; 230(2): 450 - 458. [Abstract] [Full Text] [PDF]
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S. M. Lobo, K. S. Afzal, M. Ahmed, J. B. Kruskal, R. E. Lenkinski, and S. N. Goldberg Radiofrequency Ablation: Modeling the Enhanced Temperature Response to Adjuvant NaCl Pretreatment Radiology, January 1, 2004; 230(1): 175 - 182. [Abstract] [Full Text] [PDF]
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H. Rhim, G. D. Dodd III, K. N. Chintapalli, B. J. Wood, D. E. Dupuy, J. L. Hvizda, P. E. Sewell, and S. N. Goldberg Radiofrequency Thermal Ablation of Abdominal Tumors: Lessons Learned from Complications RadioGraphics, January 1, 2004; 24(1): 41 - 52. [Abstract] [Full Text] [PDF]
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D. Choi, H. K. Lim, M. J. Kim, S. H. Lee, S. H. Kim, W. J. Lee, J. H. Lim, J.-W. Joh, and Y. I. Kim Recurrent Hepatocellular Carcinoma: Percutaneous Radiofrequency Ablation after Hepatectomy Radiology, January 1, 2004; 230(1): 135 - 141. [Abstract] [Full Text] [PDF]
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D. Choi, H. K. Lim, W. J. Lee, S. H. Kim, Y. H. Kim, S. H. Kim, and J. H. Lim Early Assessment of the Therapeutic Response to Radio Frequency Ablation for Hepatocellular Carcinoma: Utility of Gray Scale Harmonic Ultrasonography With a Microbubble Contrast Agent J. Ultrasound Med., November 1, 2003; 22(11): 1163 - 1172. [Abstract] [Full Text] [PDF]
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H.-X. Xu, X.-Y. Yin, M.-D. Lu, X.-Y. Xie, Z.-F. Xu, and G.-J. Liu Usefulness of Three-dimensional Sonography in Procedures of Ablation for Liver Cancers: Initial Experience J. Ultrasound Med., November 1, 2003; 22(11): 1239 - 1247. [Abstract] [Full Text] [PDF]
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T.-I. Huo, Y.-H. Huang, J.-C. Wu, J.-H. Chiang, P.-C. Lee, F.-Y. Chang, and S.-D. Lee Sequential transarterial chemoembolization and percutaneous acetic acid injection therapy versus repeated percutaneous acetic acid injection for unresectable hepatocellular carcinoma: a prospective study Ann. Onc., November 1, 2003; 14(11): 1648 - 1653. [Abstract] [Full Text] [PDF]
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B. H.-H. Lang, R. T.-P. Poon, S.-T. Fan, and J. Wong Perioperative and Long-term Outcome of Major Hepatic Resection for Small Solitary Hepatocellular Carcinoma in Patients With Cirrhosis Arch Surg, November 1, 2003; 138(11): 1207 - 1213. [Abstract] [Full Text] [PDF]
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F. Burdio, A. Guemes, J. M. Burdio, A. Navarro, R. Sousa, T. Castiella, I. Cruz, O. Burzaco, and R. Lozano Bipolar Saline-enhanced Electrode for Radiofrequency Ablation: Results of Experimental Study of in Vivo Porcine Liver Radiology, November 1, 2003; 229(2): 447 - 456. [Abstract] [Full Text] [PDF]
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M. Kitamoto, M. Imagawa, H. Yamada, C. Watanabe, M. Sumioka, O. Satoh, M. Shimamoto, M. Kodama, S. Kimura, K. Kishimoto, et al. Radiofrequency Ablation in the Treatment of Small Hepatocellular Carcinomas: Comparison of the Radiofrequency Effect With and Without Chemoembolization Am. J. Roentgenol., October 1, 2003; 181(4): 997 - 1003. [Abstract] [Full Text] [PDF]
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T. de Baere, O. Risse, V. Kuoch, C. Dromain, C. Sengel, T. Smayra, M. G. E. Din, C. Letoublon, and D. Elias Adverse Events During Radiofrequency Treatment of 582 Hepatic Tumors Am. J. Roentgenol., September 1, 2003; 181(3): 695 - 700. [Abstract] [Full Text] [PDF]
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T. S. Kim, H. K. Lim, K. S. Lee, Y. C. Yoon, C. A Yi, and D. Han Imaging-Guided Percutaneous Radiofrequency Ablation of Pulmonary Metastatic Nodules Caused by Hepatocellular Carcinoma: Preliminary Experience Am. J. Roentgenol., August 1, 2003; 181(2): 491 - 494. [Abstract] [Full Text] [PDF]
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N. Waguri, T. Suda, M. Nomoto, H. Kawai, Y. Mita, T. Kuroiwa, M. Igarashi, M. Kobayashi, Y. Fukuhara, and Y. Aoyagi Sensitive and Specific Detection of Circulating Cancer Cells in Patients with Hepatocellular Carcinoma; Detection of Human Telomerase Reverse Transcriptase Messenger RNA after Immunomagnetic Separation Clin. Cancer Res., August 1, 2003; 9(8): 3004 - 3011. [Abstract] [Full Text] [PDF]
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Y. L. Wen, M. Kudo, R. Q. Zheng, Y. Minami, H. Chung, Y. Suetomi, H. Onda, M. Kitano, T. Kawasaki, and K. Maekawa Radiofrequency Ablation of Hepatocellular Carcinoma: Therapeutic Response Using Contrast-Enhanced Coded Phase-Inversion Harmonic Sonography Am. J. Roentgenol., July 1, 2003; 181(1): 57 - 63. [Abstract] [Full Text] [PDF]
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R. A. Lencioni, H.-P. Allgaier, D. Cioni, M. Olschewski, P. Deibert, L. Crocetti, H. Frings, J. Laubenberger, I. Zuber, H. E. Blum, et al. Small Hepatocellular Carcinoma in Cirrhosis: Randomized Comparison of Radio-frequency Thermal Ablation versus Percutaneous Ethanol Injection Radiology, July 1, 2003; 228(1): 235 - 240. [Abstract] [Full Text] [PDF]
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