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Major Complications after Radio-frequency Thermal Ablation of Hepatic Tumors: Spectrum of Imaging Findings¹

¹ From the Korean Study Group of Radiofrequency Ablation (H.R., K.H.Y., J.M.L., Y.C., J.S.C., S.H.K., W.J.L., H.K.L., G.J.N., S.S.H., Y.H.K., C.M.P., P.N.K., J.Y.B.); the Department of Diagnostic Radiology, Hanyang University Hospital, 17 Haengdang-Dong, Sungdong-Ku, Seoul 133-792, Korea (H.R.); the Department of Radiology, Wonkwang University Hospital, Iksan, Korea (K.H.Y.); the Department of Diagnostic Radiology, Chunbuk University Hospital, Jeonju, Korea (J.M.L.); the Department of Diagnostic Radiology, Korean Veterans Hospital, Seoul (Y.C.); the Department of Diagnostic Radiology, Chungnam University Hospital, Daejon, Korea (J.S.C.); the Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (S.H.K., W.J.L., H.K.L.); the Department of Diagnostic Radiology, Dong-A University Hospital, Busan, Korea (G.J.N.); the Department of Diagnostic Radiology, Inje University Busan Paik Hospital, Busan, Korea (S.S.H.); the Department of Diagnostic Radiology, Korea University Hospital, Seoul (Y.H.K., C.M.P.); the Department of Diagnostic Radiology, Asan Medical Center, Seoul, Korea (P.N.K.); and the Department of Diagnostic Radiology, Catholic University Hospital of Korea, Seoul (J.Y.B.). Recipient of a Cum Laude award for an education exhibit at the 2001 RSNA scientific assembly. Received March 12, 2002; revision requested April 29 and received June 20; accepted June 21. Address correspondence to H.R. (e-mail: rhimhc@hanyang.ac.kr).

View larger version (37K): [in a new window]   Figure 1.  Broad spectrum of major complications after RF ablation for hepatic tumors according to the survey data of the Korean Study Group of Radiofrequency Ablation. One procedure-related death occurred (due to peritoneal hemorrhage).

View larger version (139K): [in a new window]   Figure 2a.  Hepatic abscess in a 55-year-old man with hepatocellular carcinoma. (a) Contrast material-enhanced CT scan obtained before RF ablation shows a 1.5-cm-diameter hyperattenuating nodule of hepatocellular carcinoma (arrow) in segment VI. The patient was readmitted due to abrupt development of a fever 1 week after ablation. (b) One-week follow-up CT scan shows a gas-forming abscess (arrow) in the ablated area with a perihepatic fluid collection. The abscess was successfully managed with US-guided percutaneous catheter drainage. (c) One-week follow-up CT scan shows moderate improvement of the abscess (arrow).

View larger version (150K): [in a new window]   Figure 2b.  Hepatic abscess in a 55-year-old man with hepatocellular carcinoma. (a) Contrast material-enhanced CT scan obtained before RF ablation shows a 1.5-cm-diameter hyperattenuating nodule of hepatocellular carcinoma (arrow) in segment VI. The patient was readmitted due to abrupt development of a fever 1 week after ablation. (b) One-week follow-up CT scan shows a gas-forming abscess (arrow) in the ablated area with a perihepatic fluid collection. The abscess was successfully managed with US-guided percutaneous catheter drainage. (c) One-week follow-up CT scan shows moderate improvement of the abscess (arrow).

View larger version (143K): [in a new window]   Figure 2c.  Hepatic abscess in a 55-year-old man with hepatocellular carcinoma. (a) Contrast material-enhanced CT scan obtained before RF ablation shows a 1.5-cm-diameter hyperattenuating nodule of hepatocellular carcinoma (arrow) in segment VI. The patient was readmitted due to abrupt development of a fever 1 week after ablation. (b) One-week follow-up CT scan shows a gas-forming abscess (arrow) in the ablated area with a perihepatic fluid collection. The abscess was successfully managed with US-guided percutaneous catheter drainage. (c) One-week follow-up CT scan shows moderate improvement of the abscess (arrow).

View larger version (130K): [in a new window]   Figure 3.  Peritoneal bleeding in a 75-year-old man with hepatocellular carcinoma. Contrast-enhanced CT scan obtained immediately after RF ablation of a hepatocellular carcinoma nodule in the caudate lobe shows peritoneal hemorrhage in the perihepatic space (arrows). The bleeding was managed with transfusion.

View larger version (126K): [in a new window]   Figure 4a.  Intrahepatic bleeding in an 87-year-old man with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3.0-cm hyperattenuating tumor (arrow) in segment VIII of the liver. (b) CT scan shows an expandable RF electrode (arrow), which was used to perform RF ablation. (c) Doppler US scan shows massive intrahepatic bleeding (arrow) from the margin of the ablated area. (d) Angiogram shows that the bleeding was controlled with placement of coils (arrow). (e) Three-month follow-up CT scan shows complete ablation of the tumor. Note the metallic areas of increased attenuation (arrow) adjacent to the tumor margin.

View larger version (151K): [in a new window]   Figure 4b.  Intrahepatic bleeding in an 87-year-old man with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3.0-cm hyperattenuating tumor (arrow) in segment VIII of the liver. (b) CT scan shows an expandable RF electrode (arrow), which was used to perform RF ablation. (c) Doppler US scan shows massive intrahepatic bleeding (arrow) from the margin of the ablated area. (d) Angiogram shows that the bleeding was controlled with placement of coils (arrow). (e) Three-month follow-up CT scan shows complete ablation of the tumor. Note the metallic areas of increased attenuation (arrow) adjacent to the tumor margin.

View larger version (178K): [in a new window]   Figure 4c.  Intrahepatic bleeding in an 87-year-old man with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3.0-cm hyperattenuating tumor (arrow) in segment VIII of the liver. (b) CT scan shows an expandable RF electrode (arrow), which was used to perform RF ablation. (c) Doppler US scan shows massive intrahepatic bleeding (arrow) from the margin of the ablated area. (d) Angiogram shows that the bleeding was controlled with placement of coils (arrow). (e) Three-month follow-up CT scan shows complete ablation of the tumor. Note the metallic areas of increased attenuation (arrow) adjacent to the tumor margin.

View larger version (113K): [in a new window]   Figure 4d.  Intrahepatic bleeding in an 87-year-old man with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3.0-cm hyperattenuating tumor (arrow) in segment VIII of the liver. (b) CT scan shows an expandable RF electrode (arrow), which was used to perform RF ablation. (c) Doppler US scan shows massive intrahepatic bleeding (arrow) from the margin of the ablated area. (d) Angiogram shows that the bleeding was controlled with placement of coils (arrow). (e) Three-month follow-up CT scan shows complete ablation of the tumor. Note the metallic areas of increased attenuation (arrow) adjacent to the tumor margin.

View larger version (149K): [in a new window]   Figure 4e.  Intrahepatic bleeding in an 87-year-old man with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3.0-cm hyperattenuating tumor (arrow) in segment VIII of the liver. (b) CT scan shows an expandable RF electrode (arrow), which was used to perform RF ablation. (c) Doppler US scan shows massive intrahepatic bleeding (arrow) from the margin of the ablated area. (d) Angiogram shows that the bleeding was controlled with placement of coils (arrow). (e) Three-month follow-up CT scan shows complete ablation of the tumor. Note the metallic areas of increased attenuation (arrow) adjacent to the tumor margin.

View larger version (129K): [in a new window]   Figure 5a.  Bile duct injury in a 55-year-old woman with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3-cm-diameter hypervascular mass (arrow) in segment VIII of the liver. (b) Follow-up CT scan obtained immediately after RF ablation shows complete ablation with a 1-cm safety margin (arrow). (c) Six-month follow-up CT scan shows contraction of the ablated area without marginal recurrence. However, mild dilatation of an intrahepatic bile duct (arrow) is noted in the left lobe. There was mild jaundice at admission. (d) Endoscopic retrograde cholangiopancreatogram shows moderate dilatation of the intrahepatic bile duct (arrow) with normal size of the extrahepatic bile duct. (e) Follow-up CT scan obtained 2 weeks after biliary drainage with a percutaneous catheter (arrow) shows improvement of the biliary dilatation.

View larger version (129K): [in a new window]   Figure 5b.  Bile duct injury in a 55-year-old woman with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3-cm-diameter hypervascular mass (arrow) in segment VIII of the liver. (b) Follow-up CT scan obtained immediately after RF ablation shows complete ablation with a 1-cm safety margin (arrow). (c) Six-month follow-up CT scan shows contraction of the ablated area without marginal recurrence. However, mild dilatation of an intrahepatic bile duct (arrow) is noted in the left lobe. There was mild jaundice at admission. (d) Endoscopic retrograde cholangiopancreatogram shows moderate dilatation of the intrahepatic bile duct (arrow) with normal size of the extrahepatic bile duct. (e) Follow-up CT scan obtained 2 weeks after biliary drainage with a percutaneous catheter (arrow) shows improvement of the biliary dilatation.

View larger version (134K): [in a new window]   Figure 5c.  Bile duct injury in a 55-year-old woman with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3-cm-diameter hypervascular mass (arrow) in segment VIII of the liver. (b) Follow-up CT scan obtained immediately after RF ablation shows complete ablation with a 1-cm safety margin (arrow). (c) Six-month follow-up CT scan shows contraction of the ablated area without marginal recurrence. However, mild dilatation of an intrahepatic bile duct (arrow) is noted in the left lobe. There was mild jaundice at admission. (d) Endoscopic retrograde cholangiopancreatogram shows moderate dilatation of the intrahepatic bile duct (arrow) with normal size of the extrahepatic bile duct. (e) Follow-up CT scan obtained 2 weeks after biliary drainage with a percutaneous catheter (arrow) shows improvement of the biliary dilatation.

View larger version (152K): [in a new window]   Figure 5d.  Bile duct injury in a 55-year-old woman with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3-cm-diameter hypervascular mass (arrow) in segment VIII of the liver. (b) Follow-up CT scan obtained immediately after RF ablation shows complete ablation with a 1-cm safety margin (arrow). (c) Six-month follow-up CT scan shows contraction of the ablated area without marginal recurrence. However, mild dilatation of an intrahepatic bile duct (arrow) is noted in the left lobe. There was mild jaundice at admission. (d) Endoscopic retrograde cholangiopancreatogram shows moderate dilatation of the intrahepatic bile duct (arrow) with normal size of the extrahepatic bile duct. (e) Follow-up CT scan obtained 2 weeks after biliary drainage with a percutaneous catheter (arrow) shows improvement of the biliary dilatation.

View larger version (152K): [in a new window]   Figure 5e.  Bile duct injury in a 55-year-old woman with hepatocellular carcinoma. (a) Contrast-enhanced CT scan shows a 3-cm-diameter hypervascular mass (arrow) in segment VIII of the liver. (b) Follow-up CT scan obtained immediately after RF ablation shows complete ablation with a 1-cm safety margin (arrow). (c) Six-month follow-up CT scan shows contraction of the ablated area without marginal recurrence. However, mild dilatation of an intrahepatic bile duct (arrow) is noted in the left lobe. There was mild jaundice at admission. (d) Endoscopic retrograde cholangiopancreatogram shows moderate dilatation of the intrahepatic bile duct (arrow) with normal size of the extrahepatic bile duct. (e) Follow-up CT scan obtained 2 weeks after biliary drainage with a percutaneous catheter (arrow) shows improvement of the biliary dilatation.

View larger version (104K): [in a new window]   Figure 6a.  Biloma in a 46-year-old woman with hepatocellular carcinoma. (a) Doppler US scan obtained 45 days after RF ablation shows a 4-cm-diameter biloma (arrow) in the left lobe of the liver. Note the faint Doppler signal from the biloma. (b) Close-up US scan of the abdominal wall obtained with a high-frequency linear transducer shows a biconvex fluid collection (arrow) adjacent to the biloma. (c) Doppler US scan shows a fistulous communication (arrow) between the biloma and the subcutaneous collection.

View larger version (110K): [in a new window]   Figure 6b.  Biloma in a 46-year-old woman with hepatocellular carcinoma. (a) Doppler US scan obtained 45 days after RF ablation shows a 4-cm-diameter biloma (arrow) in the left lobe of the liver. Note the faint Doppler signal from the biloma. (b) Close-up US scan of the abdominal wall obtained with a high-frequency linear transducer shows a biconvex fluid collection (arrow) adjacent to the biloma. (c) Doppler US scan shows a fistulous communication (arrow) between the biloma and the subcutaneous collection.

View larger version (191K): [in a new window]   Figure 6c.  Biloma in a 46-year-old woman with hepatocellular carcinoma. (a) Doppler US scan obtained 45 days after RF ablation shows a 4-cm-diameter biloma (arrow) in the left lobe of the liver. Note the faint Doppler signal from the biloma. (b) Close-up US scan of the abdominal wall obtained with a high-frequency linear transducer shows a biconvex fluid collection (arrow) adjacent to the biloma. (c) Doppler US scan shows a fistulous communication (arrow) between the biloma and the subcutaneous collection.

View larger version (111K): [in a new window]   Figure 7.  Skin burns in a 62-year-old man with hepatocellular carcinoma. Photograph shows third-degree skin burns (arrows) that developed at the ground pad site after RF ablation of multiple hepatocellular carcinoma nodules in segment VI, which had been treated with iodized oil (Lipiodol; Guerbet, Roissy, France). The patient received skin grafts after conservative treatment for 1 month.

View larger version (88K): [in a new window]   Figure 8.  Pneumothorax in a 47-year-old woman with hepatocellular carcinoma. Chest CT scan obtained after RF ablation of a tumor in segment VIII of the liver shows pneumothorax (arrow) in the right hemithorax. The pneumothorax was self-limited.

View larger version (126K): [in a new window]   Figure 9.  Hemothorax in a 47-year-old woman with hepatocellular carcinoma. Chest CT scan obtained after massive RF ablation of a tumor in segment VII of the liver shows a fluid collection of relatively high attenuation (arrow) in the right hemithorax, a finding indicative of hemothorax. The hemothorax was self-limited.

View larger version (137K): [in a new window]   Figure 10a.  Bowel injury in a 55-year-old woman with hepatocellular carcinoma. (a) Contrast-enhanced CT scan obtained before RF ablation shows a hyperattenuating 1.5-cm-diameter hepatocellular carcinoma nodule (arrow) in segment V. The patient experienced abdominal pain and fever after the procedure. (b) Follow-up CT scan obtained immediately after ablation shows intraperitoneal free air (arrow) around the hepatic flexure of the colon adjacent to the ablated tumor. Emergent exploratory laparotomy revealed a 0.5-cm-diameter colonic perforation at the hepatic flexure. Segmental resection of the colon was required. The pathologic diagnosis was focal transmural ischemic necrosis with perforation.

View larger version (128K): [in a new window]   Figure 10b.  Bowel injury in a 55-year-old woman with hepatocellular carcinoma. (a) Contrast-enhanced CT scan obtained before RF ablation shows a hyperattenuating 1.5-cm-diameter hepatocellular carcinoma nodule (arrow) in segment V. The patient experienced abdominal pain and fever after the procedure. (b) Follow-up CT scan obtained immediately after ablation shows intraperitoneal free air (arrow) around the hepatic flexure of the colon adjacent to the ablated tumor. Emergent exploratory laparotomy revealed a 0.5-cm-diameter colonic perforation at the hepatic flexure. Segmental resection of the colon was required. The pathologic diagnosis was focal transmural ischemic necrosis with perforation.

View larger version (132K): [in a new window]   Figure 11a.  Tumor seeding in a 55-year-old woman with hepatocellular carcinoma. (a) Follow-up CT scan obtained immediately after a second session of RF ablation for a marginal recurrent mass in the left lateral segment of the liver shows a nonenhancing ablated area (arrow), which indicates complete ablation. (b) Follow-up CT scan obtained 1 month after the second session of RF ablation shows a small enhancing nodule in the extrahepatic space (arrow), a finding suggestive of tumor seeding along the needle tract. (c) Arteriogram shows that the internal mammary artery supplies the tumor nodule (arrows).

View larger version (127K): [in a new window]   Figure 11b.  Tumor seeding in a 55-year-old woman with hepatocellular carcinoma. (a) Follow-up CT scan obtained immediately after a second session of RF ablation for a marginal recurrent mass in the left lateral segment of the liver shows a nonenhancing ablated area (arrow), which indicates complete ablation. (b) Follow-up CT scan obtained 1 month after the second session of RF ablation shows a small enhancing nodule in the extrahepatic space (arrow), a finding suggestive of tumor seeding along the needle tract. (c) Arteriogram shows that the internal mammary artery supplies the tumor nodule (arrows).

View larger version (129K): [in a new window]   Figure 11c.  Tumor seeding in a 55-year-old woman with hepatocellular carcinoma. (a) Follow-up CT scan obtained immediately after a second session of RF ablation for a marginal recurrent mass in the left lateral segment of the liver shows a nonenhancing ablated area (arrow), which indicates complete ablation. (b) Follow-up CT scan obtained 1 month after the second session of RF ablation shows a small enhancing nodule in the extrahepatic space (arrow), a finding suggestive of tumor seeding along the needle tract. (c) Arteriogram shows that the internal mammary artery supplies the tumor nodule (arrows).