Application of curved ablation in liver cancer with special morphology or location: Report of two cases

BACKGROUND Liver cancer is one of the most common malignant tumors with a high incidence and mortality.Hepatitis-liver cirrhosis-liver cancer is known as the trilogy of liver cancer.At present,due to significant development of imaging interventions,they occupy an irreplaceable position in the field of liver cancer treatment,especially ultrasound-guided ablation.Because patients with liver cancer often present with liver cirrhosis,which leads to morphological deformation of the liver,it is difficult to perform a linear ablation of liver cancer in the areas near the phrenic top and within large blood vessels,among others.The present study reports on two cases of liver cancer that have been subjected to curvilinear ablation.After 1 mo,magnetic resonance imaging showed complete ablation,demonstrating that ultrasound-guided curved ablation is feasible and effective in the treatment of liver cancer.CASE SUMMARY Two patients were treated at the Liver Disease Department of the Xixi Hospital Affiliated to Zhejiang University of Chinese Medicine in 2019.Because the first liver cancer patient’s tumor was located close to the diaphragm,it was difficult to complete a straight needle ablation procedure in one session.In order to achieve accurate and minimally invasive treatment of this tumor,a curved needle ablation procedure was designed.The second patient presented with a hepatic cyst in front of the tumor.In order not to damage the hepatic cyst,a looper needle ablation technique was used.The procedure was successfully completed in both cases.CONCLUSION Curved ablation is a new technique that can be used to treat tumors situated in a variety of locations,providing new ideas for interventional techniques.Its operation difficulty is higher and further animal experiments are necessary to improve the operation procedure.     

离体猪肝微波消融灶的弹性变化及其病理意义

目的 探讨微波消融致离体猪肝弹性改变及其与肝组织坏死程度之间的对应关系.方法 以离体猪肝为消融模型,利用弹性超声的色彩显示和应变率比值定量检测对消融前后靶区的弹性进行对照研究,同步观察靶区的组织学变化.结果 随微波功率增大和消融时间加长,消融区的弹性显著降低,硬度增大,同时细胞坏死和碳化程度加重,并以微波功率的影响为著.结论 弹性超声检查提示微波消融令离体猪肝迅速变硬,可从硬变程度推断凝固坏死的程度.

Abstract：

Objective To investigate the elasticity reduction of liver tissue due to microwave ablation and the relevance to the histographic damages. Methods An experimental study using fresh porcine liver was designed. Elasto-ultrasonography scanning both in color display and strain ratio calculations was conducted before and 5 min after microwave ablation ( 2450 MHz) in manner of antenna insertion under ultrasound guidance to determine the alterations of the liver elasticity, in correspondence with the histopathologic assessment of each ROI. Results Elasto-ultrasonography showed a significant elasticity reduction and hardness augment of the targeted liver tissue and the corresponding histopathology revealed increases in the amount of massive coagulative necrosis and coking of liver cells after microwave irradiation,in proportional to the applied field power and working time. Conclusions Elasto-ultrasonography helps to demonstrate microwave-induced lesion in porcine liver got rapidly hardened. It is possible to estimate the tissue necrosis to the changing of tissue hardening.     

激光消融正常活体兔肝的超声表现及影响因素

目的 探讨激光消融活体兔肝的超声表现及影响因素.方法 用Echolaser集成激光介入超声系统消融正常兔肝,观察消融灶坏死程度、病理改变及解剖表现.结果 消融灶呈类椭圆形,二维表现为中心规则强回声及周边稍强回声区,后方有轻度声衰减.超声造影显示消融灶呈"充盈缺损区".解剖后,肉眼观消融灶中间为碎渣样碳化区,周边为褐白色样坏死区.HE染色显示消融灶中心呈"空洞样"无染色剂浸染区,周边呈不规则无核红染区,外围可见浸润的炎性细胞.不同功率及时间对消融效果及消融范围有影响且消融灶的大小与功率和时间呈正相关;3 w 10 min组和5 W 6 min组消融范围稳定、可导致消融区组织的完全坏死且两组间的消融范围差异有统计学意义(t=6.78,P<0.05).结论 激光消融对活体兔肝能造成快速、精准、有效、安全的凝固性坏死,消融灶的大小与功率和时间呈正相关.

Abstract：

Objective To explore the ultrasound performance and related factors on the role of normal living rabbit's liver by laser ablation. Methods The rabbit's liver tissue were ablated by Echolaser integrated laser interventional ultrasound system, and the necrosis of the lesion and performance of pathology and anatomy were observed. Results The outline of the lesion was ellipse like. The two-dimensional US showed regular hyperecho area in the center, mild strong echo in the peripheral and mild attenuation backward. Contrast enhanced ultrasound (CEUS) showed a "filling defect" of contrast media in the ablated area. After dissection, the center of the lesion was slag-like carbon, the peripheral was necrosis area; HE staining showed: the center of the lesion was cavity like and dye-free,peripheral area was irregular red staining, the surrounding area was infiltrative inflammatory cells. Different power and time leaded to differences of the ablative effect and lesion size:the more power and time,the bigger of the ablative size. The ablative effect and lesion size was stable in 3 W 10 min and 5 W 6 min groups and caused the complete necrosis of the zone, there existed statistical differences among the two groups. Conclusions Laser ablation can cause fast, precise, effective and safe necrosis of the liver tissue, and the more power and time, the bigger of the ablative size.     

Irreversible electroporation for liver metastasis from pancreatic cancer: A case report

BACKGROUND Pancreatic cancer has a poor prognosis;40%–50% of patients have liver metastases at the time of initial diagnosis and only 15%–20% undergo surgical resection. Irreversible electroporation(IRE) is a new, non-thermal local ablation method for solid tumors, which can induce cell membrane permeabilization,resulting in unrecoverable nanoscale perforation and apoptotic cell death without damaging the structural components of tissues.CASE SUMMARY We report the case of a 66-year-old female patient with liver metastasis from pancreatic cancer with a pathological diagnosis of poorly differentiated adenocarcinoma. Carbohydrate antigen 19-9 was elevated to 420.3 U/m L.Computed tomography showed a pancreas mass of 2.7 cm × 2.5 cm and single liver metastasis of 1.4 cm × 1.1 cm in the S6 area. The patient underwent IRE and arterial infusion chemotherapy and received tegafur. The therapeutic effect of the combination treatment has been evaluated as complete response. To date, the patient has survived for > 12 mo and is receiving tegafur as maintenance therapy(at the time this case report was written).CONCLUSION IRE plus arterial infusion chemotherapy and tegafur may be synergistic,providing a reference for treating liver metastasis from pancreatic cancer.     

Long-term survival of two patients with recurrent pancreatic acinar cell carcinoma treated with radiofrequency ablation: A case report

BACKGROUND Pancreatic acinar cell carcinoma (PACC) is a rare type of malignant pancreatic cancer that represents approximately 1%of all pancreatic neoplasms.Due to its very low incidence,only a few retrospective studies are available.Although surgery is the first choice for treatment,most patients experience recurrence(mainly in the liver) and there are no clear recommendations for patients with advanced disease.CASE SUMMARY We report two patients with PACC treated with sturgery who experienced tumour recurrence in the liver.Patient 1 carried a germline mutation in the APC gene.Both patients were treated with gemcitabine plus oxaliplatin and gemcitabine plus capecitabine as first-and second-line therapies,respectively.After a favoturable response to chemotherapy,the patients underwent radiofrequency ablation of the remaining liver metastases.For patient 1,we documented a relapse in the liver after a disease-free period of 9 mo,and treatment with gemcitabine plus capecitabine was restarted.The patient achieved a complete response,and he remains alive without evidence of disease recurrence after six years.After radiofrequency ablation,patient 2 experienced disease-free survival for 21 mo,when peritoneal relapse was diagnosed and treated with chemotherapy.The patient achieved a stable disease state for nearly two years;nevertheless,further progressive disease was documented,and he died seven years after the first relapse.CONCLUSION PACC presents different biological behaviours than pancreatic adenocarcinoma.Multidisciplinary treatment involving local ablative therapies may be considered for PACC.     

非消融超声预辐射对高强度聚焦超声消融兔肝VX-2瘤疗效的影响

目的 比较不同强度非消融聚焦超声预辐射对高强度聚焦超声(HIFU)疗效的影响,探讨提高HIFU消融效率的新方法.方法 40只肝VX2瘤兔分为预辐射组30只和对照组10只,预辐射组又分为60 W组、80 W组、100 W组,每组10只,采用不问功率较低强度HIFU预辐射处理;每组各取5只于次日行HIFU辐射,每组共辐射14条线段,24 h后取材行三苯氯化四氮唑(TTC)染色观察线性消融体积;其他动物于上述HIFU辐射的同时取材行苏木精伊红(HE)、琥珀酸脱氧酶(SDH)、TTC染色观察肿瘤组织结构和活性.结果 HIFU辐射后各组消融体积随预辐射强度增加而增大,能效因子(EEF)的变化则相反,其中100 W组消融效率最高;各组预辐射超声干预均未致肿瘤组织发生凝固性坏死,但80 W组和100 W组国组织结构和功能状态均有所改变,60 W组未见明显改变.结论 适当强度的非消融超声预辐射能显著提高HIFU消融效率.

Abstract：

Objective To assess the influence of pre-exposure to non-ablating ultrasound on the effect of high intensity focused ultrasound(HIFU)ablation.Methods Forty rabbits with transplanted VX2 tumors on their livers were divided into three pre-exposure groups(60 W,80 W and 100 W)and a control group(O W),with 10 rabbits in each group.Each group was pre-exposed to lower intensity focused ultrasound at the corresponding power.From each group,5 rabbits were randomly selected to be exposed to HIFU on the next day.Each group received 14scans.The rabbits were sacrificed 24 h later to take tissue samples for tfipheny tetrazolium chloride(TTC)staining to measure the amount of coagulative necrosis.Hematoxylin and eosin(HE)staining and succinate dehydrogenase (SDH)were also measured to observe the structure and activation of pre-exposed tumors.Results After HIFU exposure,the ablated volumes increased with pre-exposure acoustic intensity,and all volumes were larger than those in the control group.The ablating efficiency in the 100 W group was the highest.The pre-exposure did not itself ablate tumor tissue,but in the 80 W and 100 W groups the structure and activation of the tissues changed.Those in the 60 W group were not obviously altered.Conclusion Prior exposure to non-ablating ultrasound can highly enhance the efficacy of HIFU ablation.     

Hydrochloric acid enhanced radiofrequency ablation for treatment of large hepatocellular carcinoma in the caudate lobe:Report of three cases

BACKGROUND To report on the use of percutaneous hydrochloric acid(HCl) enhanced radiofrequency ablation(HRFA) for the treatment of large(maximum diameter ≥5 cm) hepatocellular carcinoma(HCC) in the caudate lobe.CASE SUMMARY Between August 2013 and June 2016, three patients with a large HCC(maximum diameter: 5.0, 5.7, and 8.1 cm) in the caudate lobe were treated by transarterial chemoembolization followed by computer tomography(CT) guided RFA using a monopolar perfusion RF electrode, which was enhanced by local infusion of 10%HCl at 0.2 mL/min(total volume, 3 to 12 mL). The output power of HRFA reached 100 W, and the average ablation time was 39 min(range, 15 to 60 min).Two patients each underwent one session of HRFA and one patient two sessions.After treatment, CT/magnetic resonance imaging showed that all the three lesions were completely ablated. There was no major complication. Two patients had asymptomatic bile duct dilatation. One patient died of tongue cancer 24 mo after ablation. The remaining two patients were alive and no area of enhancement is detected in the caudate lobe at 28 and 60 mo after ablation, respectively.CONCLUSION Percutaneous CT-guided HRFA is safe and efficacious in treating large HCC in the caudate lobe.     

Non-Invasive management of invasive cervical resorption associated with periodontal pocket: A case report

BACKGROUND Invasive cervical resorption(ICR), a commonly misdiagnosed condition, is an aggressive form of external tooth resorption that contributes to periodontal tissue inflammation and deepening of the periodontal pockets. Herein we report the case of a patient, exhibiting ICR and elaborate the effects of a non-surgical approach in the amelioration of this condition.CASE SUMMARY A 21-year-old female reporting intermittent pain at the upper left side, multiple restorations, no trauma history, and having received orthodontic treatment was studied. Localized erythematous swelling was noted at the buccal interdental papilla between the left maxillary first molar and second premolar. The diseased pulp and tissue in resorption were removed and the root canal system including the defect were sealed using gutta percha/AH Plus and mineral trioxide aggregate(MTA). At the one-year recall, the tooth showed no symptoms and responded normally to percussion and palpation. The surrounding periodontium exhibited a normal color and the probing depth was normal. Radiographic examination showed a restoration of crestal alveolar bone and good adaption to MTA.CONCLUSION Non-surgical root canal treatment in conjunction with resorption defect orthograde repair with MTA was found to be an effective treatment option in the elimination of ICR. Early diagnoses are recommended in order to employ nonsurgical approaches for management of ICR instead of surgical interventions.     

Robot-assisted gallbladder-preserving hepatectomy for treating S5 hepatoblastoma in a child: A case report and review of the literature

BACKGROUND Hepatoblastoma(HB) is the most common hepatic malignant tumour in children,accounting for approximately 50%-60% of primary hepatic malignant tumours in children, mostly in children under 3 years old. In Western countries, the incidence of hepatoblastoma is approximately 1-2/100000. Da Vinci surgical system is fast becoming a key instrument in microinvasive surgery. The past decade has seen the rapid development of robot-assisted laparoscopy, which expends many fields including the liver surgery. This paper discusses the significance and feasibility of robot-assisted gallbladder-preserving hepatectomy for treating S5 hepatoblastoma in children. The aim of this essay is to compare the safety and effectiveness of robotic surgery with conventional laparoscopic surgery, and explore the meaning of preservation of the gallbladder by sharing this case.CASE SUMMARY A 3-year-old child with a liver mass in the 5 th segment was treated using the Da Vinci surgical system, and the gallbladder was retained. The child was admitted to the hospital for 20 d for the discovery of the right hepatic lobe mass.Ultrasonography revealed a low echo mass, 46 mm × 26 mm × 58 mm in size,indicating hepatoblastoma in the right lobe, and enhanced computed tomography showed continuous enhancement of iso-low-density lesions with different sizes and nodules and unclear boundaries, without the dilation of the intrahepatic bile duct, no enlargement of the gallbladder, and uniform thickness of the wall. The diagnosis was "liver mass, hepatoblastoma". It was decided to perform S5 liver tumour resection. During surgery, the tumour and gallbladder were isolated first, and the gallbladder could be completely separated from the tumour surface without obvious infiltration; therefore, the gallbladder was preserved. The cutting line was marked with an electric hook. The hepatic duodenal ligament was blocked with a urethral catheter using the Pringle method, and the tumour and part of the normal liver tissue were completely resected with an ultrasound knife along the incision. The hepatic portal interdiction time was approximately 25 min. An abdominal drainage tube was inserted. The auxiliary hole was connected to the lens, and the specimen was removed. The patient's status was uneventful, and the operation time was 166 min. The robotic time was 115 min, and the bleeding amount was approximately 200 mL. In total, 300 mL of red blood cell suspension and 200 mL of plasma were injected. No serious complications occurred. Pathological findings confirmed fetal hepatoblastoma and R0 resection. A gallbladder contraction test was performed two weeks after surgery.CONCLUSION Robot-assisted S5 hepatectomy with gallbladder preservation is safe and feasible for specific patients.     

Argon-helium cryoablation for thoracic vertebrae with metastasis of hepatocellular carcinoma-related hepatitis B: A case report

BACKGROUND Spinal metastasis of hepatocellular carcinoma(HCC) is rare, with an extremely poor prognosis and results in severe pain. Argon-helium cryotherapy is a local ablation method for HCC.CASE SUMMARY A 54-year-old man was diagnosed with HCC related to hepatitis B one year ago and underwent surgical tumor resection and tenofovir antiviral treatment.However, a new lesion developed on the right liver after 1 mo. Transarterial chemoembolization was performed four times. One month ago, the patient developed back pain, and metastasis on the 11 th thoracic vertebra was detected.Argon-helium cryoablation was performed to treat the right occupancy and metastatic lesion, which immediately alleviated the pain and prolonged survival.CONCLUSION The use of argon-helium cryoablation for thoracic vertebrae with metastasis of HCC achieved favorable results.