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Case Report |
1 Brown Medical School, Box G 8159, Providence, RI 02912.
2 Department of Diagnostic Imaging, Brown Medical School, Rhode Island Hospital,
593 Eddy St., Providence, RI 02903.
Received December 7, 2001;
accepted after revision March 19, 2002.
Address correspondence to D. E. Dupuy.
Introduction
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Even with invasive treatment options, the natural course of this disease underscores the importance of developing new, less invasive treatment modalities. Such treatment would permit local tumor control and palliation while avoiding the difficulties of repetitive invasive surgery. We report a case of adenoid cystic carcinoma of the head and neck treated via percutaneous CT-guided radiofrequency ablation.
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Six days later, the patient underwent an excisional biopsy, during which a tumor was observed in the mastoid tip. Surgical resection was not possible, so the gross tumor was left behind. Findings at pathology revealed adenoid cystic carcinoma (T4 N0 M0).
The patient was treated with a course of adjuvant radiotherapy; a total dose of 5440 cGy was administered at 160 cGy per fraction. He responded well to treatment and at 1-month follow-up was deemed to have reached at least a partial response to radiation: No evidence of gross disease was seen at physical examination; the patient's pain was well controlled and had decreased by 90-95%. However, his facial paralysis had not improved.
The patient did well over the next 1 year 3 months, but then he had recurrent symptoms. CT revealed local tumor progression. A fairly localized but extensive destructive mass involving the right temporal bone extended posteriorly to the brainstem and posterior fossa (Fig. 1A). Outpatient radiofrequency ablation was determined to be the best option for this patient because he had previously undergone external beam radiotherapy and no effective chemotherapy was available. No prior chemotherapy had been attempted.
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The initial CT images confirmed the presence of a destructive mass measuring approximately 3 x 4 x 4 cm. The mass involved the right skull base and extended from the petrous portion of the temporal bone inferiorly to the soft tissues deep relative to the sternocleidomastoid. Direct routes to the tumor were identified on CT, allowing a percutaneous approach to be undertaken with minimal damage to vital structures. Although the tumor extended toward the right cerebellar hemisphere, potential thermal injury to this region was thought to be clinically irrelevant because the patient had lost his lower extremities in a prior accident.
The patient was put under conscious sedation with midazolam and fentanyl citrate, and the area was prepared for surgery and draped in sterile fashion and anesthetized with 1% lidocaine. A single 3-cm active Cool-tip radiofrequency electrode (Radionics, Burlington, MA) was placed along the anterior margin of the tumor under fluoroscopic CT guidance (Fig. 1B). Use of this electrode creates a predictable treatment area corresponding to a cylinder measuring 3.8 cm in length with an unknown radius [2]. A 12-min radiofrequency lesion was created with a maximum current of 1000 mA. The needle was repositioned posteriorly just adjacent to the right cerebellar hemisphere, and a second 12-min radiofrequency lesion was created with a maximum current of 1000 mA. Given the tumor dimensions, the two overlapping treatments were thought to be necessary to encompass the entire tumor field. Intraprocedural monitoring consisted of telemetry and continuous pulse oximetry; vital signs were recorded every 5 min. The patient tolerated the procedure well and had no immediate complications. He was discharged in stable condition.
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Follow-up MR imaging revealed a central, nonenhancing area measuring 2.8 x 3.0 x 3.0 cm that was consistent with radiofrequency ablation—induced thermocoagulation (Fig. 1C). Comparison with prior studies revealed that most of the viable tumor appeared to have been replaced with nonviable necrotic tissue. The treatments resulted in approximately 70% necrosis. Residual peripheral enhancement was consistent with residual disease or granulation tissue. After the procedure, the patient's facial pain resolved. Intensity-modulated radiotherapy was planned for the following month to boost the treatment area and extend the treatment field to the skull base near the midline. The patient's symptoms of ear pain and facial paralysis did not recur during the ensuing 6 months of follow-up. He survived an additional 18 months after the ablation before he died as a result of pulmonary metastases.
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Percutaneous imaging-guided ablative therapies using thermal energy sources such as radiofrequency have received much attention recently as minimally invasive strategies to treat neoplasms. Radiofrequency-induced tissue coagulation has been used in early clinical trials for the treatment of liver tumors, both primary and metastatic [4, 5]. Extrahepatic radiofrequency ablation has been investigated in several small studies involving the lung and kidney [6, 7]. Successful local control of well-differentiated thyroid cancer in the head and neck region has been reported [8]. Thus, radiofrequency ablation may offer patients with persistent adenoid cystic carcinoma an alternative treatment measure.
With this idea in mind, we report our experience with percutaneous CT-guided radiofrequency ablation to treat an adenoid cystic carcinoma; to our knowledge, ours is the first report of its kind. Although the patient did eventually die (18 months after radiofrequency ablation), it appeared that his treatment afforded him much-needed palliation toward the end of his life. Given that our report describes a single patient, it is difficult to predict what benefit, if any, radiofrequency ablation may offer for altering the natural progression of adenoid cystic carcinomas. Future studies to that end are needed. However, the observation that radiofrequency ablation provided some level of palliation is promising and suggests that this procedure holds potential as an alternate treatment modality for local tumor control and palliation in the head and neck region.
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T.C. Schirmang, L.M. Davis, P.T. Nigri, and D.E. Dupuy Solitary Fibrous Tumor of the Buccal Space: Treatment with Percutaneous Cryoablation AJNR Am. J. Neuroradiol., October 1, 2007; 28(9): 1728 - 1730. [Abstract] [Full Text] [PDF]
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