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Case Report |
1 All authors: Second Department of Internal Medicine, Faculty of Medicine, Tottori University, Yonago, 683-8504, Tottori, Japan.
Received August 8, 2002;
accepted after revision November 19, 2002.
Address correspondence to M. Koda.
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-feto-protein, 9.6 ng/mL; protein induced by absence of vitamin K or
antagonist II, 0.108 arbitrary units per milliliter (according to Eitest
PIKVA-II, Eisai, Tokyo, Japan). The patient's hepatic function was given a
Child-Pugh score of 9 points. Radiofrequency ablation was selected for treatment because of the patient's poor liver function. A 15-gauge expandable radiofrequency ablation device with an array diameter of 3 cm (Le Veen Needle Electrode, RadioTherapeutics, Mountain View, CA) was used with 10 retractable curved electrodes. The radiofrequency current generator used was the RF 2000 generator system (Radiotherapeutics). During application, the grounding pads were placed on the patient's thighs. After local anesthesia was administered, the radiofrequency needle was positioned in the tumor, and radiofrequency was increased by 10 W until peak power (75 W) was attained. The device was maintained at 75 W for several minutes until it "impeded out"; it was then restarted at 50 W. Radiofrequency was again increased to 75 W, and the cycle was repeated. During ablation, microbubbles were observed using sonography. Although the smaller tumor in segment VIII was adjacent to the diaphragm, we could not observe whether any of the 10 electrodes were in contact with the diaphragm. All three lesions were treated with radiofrequency ablation. Dynamic CT on the 10th day after radiofrequency ablation showed that the viable part of the hepatocellular carcinoma lesion in segment VIII remained. Radiofrequency ablation was performed using the same technique for the viable tumor 1 week later. Dynamic CT revealed that the tumor and the surrounding area no longer enhanced (Fig. 1A).
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In October 2001, the patient was admitted to the hospital with dyspnea. Chest CT revealed a massive right pleural effusion. This effusion was effectively treated with diuretics and percutaneous drainage. In March 2002, the patient presented to our outpatient clinic with dyspnea. Barium enema and MR imaging revealed pleural effusion and herniation of the large intestine into the right pleural cavity through a hole in the diaphragm (Fig. 1B). MR imaging revealed that this hole was approximately 2 cm in diameter. The pleural effusion was effectively treated by conservative therapy, but the herniation of the intestine remained. In June 2002, the herniation of the large intestine caused ileus, and the patient underwent surgery to close the hole in the diaphragm. The hole measured 5 cm in diameter and was in contact with the hepatocellular carcinoma lesion that had been treated by radiofrequency ablation (Fig. 1C). No invasion of the diaphragm by the hepatocellular carcinoma was observed. The patient died of hemorrhage from rupture of the hepatocellular carcinoma 1 month later.
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Hepatocellular carcinoma nodules adjacent to the diaphragm are frequently treated by radiofrequency ablation percutaneously or through a thoracoscope, but to our knowledge no report of diaphragmatic perforation has been published. We present a case of diaphragmatic perforation and hernia as a consequence of radiofrequency ablation. The mechanisms responsible for this diaphragmatic perforation include the use of an expandable type of radiofrequency ablation needle and the inability to confirm the position of the 10 solid retractable curved electrodes using sonography. The electrodes may have been placed in the diaphragm and may have directly heated it.
Also, the poor liver function of the patient (Child-Pugh score, 9 points; serum albumin level, 2.4 g/dL) may have prevented the injured tissue from healing adequately. Complications such as ascites and pleural effusion may also promote tissue damage.
Several months passed before the diaphragmatic perforation was detected. We speculate that the radiofrequency ablation resulted in a small hole in the diaphragm. This hole gradually became larger because of the pleural effusion, abdominal pressure, the pressure of the intestine, and the herniation of the intestine. The hole increased in size from 2 cm in March 2002 to 5 cm in June 2002.
We recommend that hepatocellular carcinoma nodules adjacent to surrounding organs be treated using procedures such as artificial ascites or a laparoscopic approach to separate the lesion from surrounding organs (diaphragm, abdominal wall, or the bowel). In addition, infiltrating hepatocellular carcinoma, which has no capsule, should be treated by other procedures such as chemoembolization, as Meloni et al. [6] describe.
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