Kim DS, Lee SG, Jun SY, Kim KW, Ha TY, Kim KK.

Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.

Abstract

The following reports a rare case of primary localized malignant mesothelioma of the liver. A 53-year-old man with no history of exposure to asbestos was admitted to our department for evaluation of incidentally detected liver mass. Computed tomography and hepatic angiogram showed a tumor at the dome of the liver, which was fed mainly through the inferior phrenic artery. The mass was resected, including a portion of the diaphragm. Microscopically, the tumor was composed of cord-like or trabecular arrangements of epithelioid cells having abundant eosinophilic cytoplasm and prominent nucleoli. Immunohistochemically, the tumor cells were strongly positive for calretinin and cytokeratin 5 and negative for hepatocyte markers. These findings were consistent with our diagnosis of epithelioid mesothelioma. A local recurrence was noted 15 months after surgery, which was treated by radiofrequency ablation. At 23 months after initial surgery, locally recurrent masses with direct invasion of the diaphragm and a solitary intrahepatic metastasis were noted, which was treated by partial excision of the diaphragm with intraoperative RFA after transarterial chemoembolization.

Eric vanSonnenberg^1,2, Sridhar Shankar^1,2,3, Paul R. Morrison¹, Rashmi T. Nair^1,2, Stuart G. Silverman^1,2, Michael T. Jaklitsch^4,5, Franklin Liu^1,2,6, Lawrence Cheung^1,2, Kemal Tuncali^1,2, Arthur T. Skarin⁷ and David J. Sugarbaker^4,5

1. Department of Radiology, Brigham and Women’s Hospital, Boston, MA 02115.
2. Department of Radiology, Dana Farber Cancer Institute, Harvard Medical School, 44 Binney St., Boston, MA 02115.
3. Present address: Department of Radiology, University of Massachusetts Medical Center, Worcester, MA.
4. Department of Surgery, Brigham and Women’s Hospital, Boston, MA 02115.
5. Department of Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA 02115.
6. Present address: University of Washington Medical Center, Seattle, WA.
7. Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA 02115.

Abstract

Objective. The purpose of our study was to report our initial experience with patients who underwent percutaneous imaging-guided radiofrequency ablation of thoracic lesions, and to emphasize technical and multidisciplinary issues and adjunctive procedures specific to thoracic tumor ablation.

Materials and Methods. Our cohort consisted of 30 patients with a spectrum of primary (n = 18) and secondary (n = 11) lung tumors, mesothelioma (n = 1), and five secondarily eroded, painful ribs who underwent ablation of 36 total lesions (one patient had two ablations). Patients either were nonsurgical candidates because of medical comorbidities or extent of disease, or had exhausted chemotherapy and radiation therapy options, or had refused surgery or undergone unsuccessful surgery. Patients were treated with radiofrequency ablation after agreement among oncologists, thoracic surgeons, and interventional radiologists. An array-style electrode under impedance control was used to treat 29 thoracic tumors and the adjacent rib metastases (n = 5). A cool-tip radiofrequency probe was used for two patients. CT guidance and general anesthetic were used for all but one patient. Sonographic guidance and IV conscious sedation were used in one patient. Pain (n = 11) and tumor cure or control (n = 19) were the primary indications for the procedures. Adjunctive procedures to the radiofrequency ablations included the creation of saline or water windows (n = 3); establishment of transosseous and transchondral routes (n = 4); use of intercostal and paravertebral nerve blocks (n = 15); and use of an intraprocedural catheter (n = 1), needle (n = 1), or sheath (n = 3) for treatment of pneumothoraces. Follow-up was from 2 to 26 months.

Results. All ablations were technically successful. No periprocedural mortality occurred. Necrosis of tumor was greater than 90% in 26 of 30 lesions based on short-term follow-up imaging (CT, PET, MRI). In the 11 patients who underwent ablation for pain, relief was complete in four and partial in the other seven. One patient developed a local skin burn, four patients had self-limited hemoptysis up to 4 days after ablation, one had transient atrial fibrillation, one developed hoarseness, and two patients were transiently reintubated after extubation. Eight pneumothoraces developed; one patient underwent placement of a chest tube. Four patients died within 1 year of ablation from extrathoracic spread of tumor.

Conclusion. Radiofrequency ablation for a variety of thoracic tumors can be performed safely and with a high degree of efficacy for pain control and tumor killing. The effect of ablation can be assessed with CT, MRI, or PET. Various technical issues differentiate thoracic tumor ablation from standard abdominal ablations. Numerous other thoracic interventional radiology procedures are beneficial to assist the radiofrequency ablation. A multidisciplinary approach offers valuable expertise for patient care.