|Year : 2020 | Volume
| Issue : 2 | Page : 258-262
Analysis of imaging-guided thermal ablation puncture routes for tumors of the hepatic caudate lobe
Yuan Yan, Zheng-Yu Lin, Jin Chen
Department of Interventional Radiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
|Date of Submission||17-May-2019|
|Date of Decision||07-Nov-2019|
|Date of Acceptance||15-Nov-2019|
|Date of Web Publication||28-May-2020|
Department of Intervention, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005
Source of Support: None, Conflict of Interest: None
Aims: The goal of this study was to analyze the puncture routes of imaging-guided thermal ablation for tumors of the hepatic caudate lobe.
Materials and Methods: The imaging-guided thermal ablation puncture routes of 12 cases of hepatic caudate lobe tumors were collected in our hospital from January 2013 to February 2019. The puncture routes were retrospectively analyzed, and the experience of thermal ablation therapy for hepatic caudate lobe tumors was summarized.
Results: Among the 12 cases of hepatic caudate lobe tumors, puncture routes were divided into the anterior (through the left lobe of the liver) approach (six cases), the right hepatic approach (five cases), and the transthoracic approach (one case). Different ablation electrodes were selected according to the puncture route and method of guiding. No serious postoperative complications were noted.
Conclusion: The hepatic caudate lobe is surrounded by the inferior vena cava, hepatic vein, and hepatic hilum, leading to great difficulties and risks in performing minimally invasive treatment of hepatic caudate lobe malignancies. Therefore, selecting an appropriate puncture route is an important factor in the success of the treatment.
Keywords: Hepatic caudate lobe, malignancy, puncture route, thermal ablation
|How to cite this article:|
Yan Y, Lin ZY, Chen J. Analysis of imaging-guided thermal ablation puncture routes for tumors of the hepatic caudate lobe. J Can Res Ther 2020;16:258-62
| > Introduction|| |
The hepatic caudate lobe is located in the center of the dorsal live. The anterior boundary is the fissure for ligamentum venosum; the posterior boundary is the groove for inferior vena cava; the upper boundary is the root of the hepatic vein where it joins the inferior vena cava; the lower boundary is unbonded, covered by the hepatoduodenal ligament and lesser omentum., Tumors located in the caudate lobe are less common than those in other parts of the liver. Due to the anatomy, resection or minimally invasive treatment of tumors in the caudate lobe is extremely dangerous., This study retrospectively analyzed the thermal ablation therapy of 12 hepatic caudate lobe tumor cases which were collected from January 2013 to February 2019, and discussed the selection of puncture routes.
| > Materials and Methods|| |
From January 2013 to February 2019, a total of 12 patients with hepatic caudate lobe tumors underwent computed tomography (CT)/magnetic resonance imaging (MRI)-guided percutaneous thermal ablations at our hospital. Among them, there were six cases of primary liver tumors and six cases of secondary liver tumors (four cases originating from intestinal carcinoma, one case from thymic carcinoma, and one case from nasopharyngeal carcinoma). There were 14 lesions in total, and the average length of the lesions was 1.66 ± 1.34 cm (0.3–4.5 cm). There were 11 male patients and 1 female patient, whose ages ranged from 44 to 78 years, with an average age of 61.83 ± 11.34 years. No serious postoperative complications were noted. The ethics committee for research involving human participants at our university approved this study. Written informed consent was obtained from all patients.
Inclusion and exclusion criteria of patients
Patients with no functional failure of the heart, brain, kidney, lung or other important organs, an ECOG score of 0–2, liver function of Grade A or B, and no more than five intrahepatic lesions with diameter <5 cm were included in the study.
Instruments and equipment
Seven patients in this study underwent procedures that were guided by a CT scan (120 KV, 80–120 mAs, layer thickness of 5 mm). Five patients underwent procedures that were guided by 1.5T MRI because the CT scan failed to generate clear images. The most frequently used MRI sequences were as follows: (1) three-dimensional dynamic T1-weighted (3D-Dyn T1WI, TR/TE = 4.8 ms/1.1 ms, FA = 45°, SL/GAP = 3 mm/1 mm); (2) fat-suppressed fast recovery fast spin echo sequence T2-weighted (fs FRFSE T2WI, TR/TE = 6000.0 ms/87.0 ms, FA 90°, SL/GAP = 5 mm/1 mm); and (3) T1-weighted fast spoiled gradient recalled (T1WI FSPGR, TR/TE = 165.0 ms/2.2 ms, FA = 25°, SL/GAP = 5.0 mm/1 mm).
The ablation generators used in our hospital are as follows:
250W Radiofrequency Generator Model 1500X, AngioDynamics INC, U.S.A (RITA XL Ablation Electrode, 10 cm, US); VIVA Radio Frequency Ablation Generator (STARmed Ablation Electrode, 15 cm, Korea); Microwave ablation therapy device MTC-3C (water-cooled microwave ablation needle compatible with magnetic resonance, 15 cm, Nanjing VisonMedical).
Selection of puncture routes
In general, the anterior (through the left lobe of the liver) approach or the right hypochondrial approach is used. The posterior approach is used in the case of a hypertrophic caudate lobe. When other important organs or vessels are in the way and a common approach is unsuitable, a transosseous approach can be used.
Depending on the location of the lesion, an appropriate patient position (supine, lateral, or prone) was selected for breathing exercises. According to the intraoperative imaging, the appropriate puncture route (a short route avoiding adjacent vital organs and large blood vessels) was selected. Furthermore, the appropriate ablation electrode was selected according to the guiding method and the puncture route. After disinfection, surgical draping, and local anesthesia, the needle was gradually inserted into the lesion under CT/MRI guidance, and the corresponding ablation parameters were selected according to the selected ablation equipment and lesion size. Heart rate changes were monitored in real time during the ablation process. Immediately after surgery, the ablation zone was evaluated. If the lesion was large or was not completely removed, supplemental ablation was necessary (the ablation zone should cover a safety margin of 0.5–1.0 cm or more). If the result of therapeutic evaluation of the ablation was satisfactory, the needle was removed.
The transosseous approach
The patient was placed in the prone position and a preoperative scan was performed to determine the puncture route. A 9G bone biopsy needle (15 cm, Gallini Srl, Italy) was gradually advanced through the pedicle according to the designed route to establish a transosseous passage. After penetrating the cortical bone, the bone biopsy needle was withdrawn, and the 17G ablation electrode (15 cm, STARmed, Korean) was gradually inserted into the caudate lobe lesion through the osseous passage.
Local efficacy assessment was performed using the enhanced upper abdominal CT/MRI examination to evaluate whether the target tumor was completely ablated, and whether there was local progression or new lesions. Immediate efficacy assessment was performed using the technical success rate; this term simply addressed whether the tumor was treated according to protocol and was enclosed completely in the ablation zone. Short-term efficacy assessment was performed using the technical effectiveness rate; this term evaluated whether “complete ablation” of a macroscopic tumor, as shown through imaging follow-up (or another specified endpoint), was achieved at a prospectively defined timepoint (i.e., immediately following the last course of a defined ablation protocol, 1 month after treatment).
| > Results|| |
In this study, there were 12 cases of thermal ablation in hepatic caudate lobe tumors (four cases of radiofrequency ablation and eight cases of microwave ablation) with 14 total lesions. Ten of these patients were treated with single-site ablation, and two patients were treated with two-site ablation because they had lesions >4 cm. The procedures were guided by CT in seven cases and were guided by MRI in five cases. Puncture routes, including the anterior (through the left lobe of the liver) approach in six cases, the right hepatic approach in five cases, and the transthoracic approach in one case, were selected according to the location of the lesions. There was a small amount of thoracic hemorrhage in 1 case after operation, and no serious complications were noted such as massive hemorrhage, abdominal cavity or biliary tract infection, liver abscess, tumor dissemination and implantation. The average follow-up time was 15.78 months (2–63 months), the technical success rate was 100%, the technical efficacy rate was 91.67%, and the local recurrence rate was 8.33% [Table 1].
| > Discussion|| |
The hepatic caudate lobe, located between the porta hepatis and the inferior vena cava, consists of the Spiegel's lobe, the caudate process, and the paracaval portion. Surgical resection of hepatic caudate lobe malignancies is difficult, and the incidence of postoperative complications and recurrence rate are high. Percutaneous thermal ablation is becoming recognized by clinicians for its minimal invasion, precision, fewer complications, and confirmative curative effect. Common routes for caudate lobe thermal ablation are percutaneous puncture, open surgery, and laparoscopic surgery. Among them, the common routes of percutaneous puncture are the left hepatic approach, the right hypochondrial approach, the left and right combined approach, and the dorsal approach (via the hypertrophic caudate lobe or retroperitoneal space).,
The anterior (through the left lobe of the liver) approach has a short path and goes through minimal liver tissue. However, the gastrointestinal tract and the fissure for ligamentum venosum may be damaged during the puncture. This approach is more suitable for tumors in Spiegel's lobe [Figure 1]. The right hypochondrial approach is suitable for tumors located beside the vena cava, in the caudate process, or in the case where the left lobe of liver has been resected [Figure 2] because damage to other organs can be avoided. However, the needle path is long and important blood vessels and tissues such as the right branch of the portal vein, the inferior vena cava, the hepatic artery, and the common bile duct must be avoided. This approach is difficult to perform and has a high risk of bleeding. If necessary, the approach can be achieved by changing the patient's position to a lateral or prone position.,, The posterior approach is more commonly used in patients with caudate lobe hypertrophy. The puncture route passes through the costophrenic angle and retroperitoneal space and avoids the inferior vena cava. It may lead to complications such as pneumothorax, intercostal vascular injury, and diaphragmatic vascular injury.,
|Figure 1: A male patient, 67-year-old, with primary liver cancer who has successively undergone interventional embolization, radiofrequency ablation, and radioactive seed implantation. Follow-up alpha-fetoprotein: 92.6 ng/mL. (a) Preoperative enhanced magnetic resonance imaging scan, enhancement of nodular lesions was seen in the Spiegel's lobe during the arterial phase; (b) After the microwave ablation, the sagittal T1WI image showed that the magnetic resonance-compatible ablation electrode successively passed through the left liver and the lesser omentum to reach the lesion, and the original lesion was surrounded by high signals, showing complete ablation; (c) Follow-up was performed 3 months after operation, and no enhancement was found in the original lesion area. Follow-up alpha-fetoprotein was normal|
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|Figure 2: A female patient, 75-year-old, with a diagnosis of primary liver cancer. One-month before the microwave ablation, she was treated once with embolization. (a) Magnetic resonance imaging scan before microwave ablation. T2WI sequence showed the lumpish long T2 signals in the caudate lobe of the liver; (b) computed tomography image of cross-sectional scanning before microwave ablation. The ablation electrode reached the lesion through the right hepatic approach; (c) computed tomography image of oblique coronal position before microwave ablation, showing the complete needle path. Intraoperative ablation power was 50 W, a total of 2 ablations were performed on the lesion (effective ablation time was 5 min and 4 min)|
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The transosseous approach was used in one patient in this study [Figure 3], which is relatively rare in relevant literature reports.,, The lesion was located in the Spiegel's lobe. Because the left hepatic lobe was atrophied, the anterior approach was blocked by the gastrointestinal tract, the right branch of the portal vein was in the way of the right approach, and there was no obvious applicable dorsal approach, the transthoracic approach was used with the patient in a prone position. The transosseous approach is slightly more complicated than the above-mentioned approaches, but it can avoid damaging important tissues and blood vessels, greatly reducing the occurrence of serious complications such as hemorrhage, pneumothorax, and gastrointestinal damage. The surgical trauma is small and well tolerated. It can be used for biopsy or treatment of tumors located at specific parts of the liver, such as hepatic caudate lobe, retroperitoneum, and mediastinum. During the procedure, it should be noted that the bone biopsy needle is consistent with the designed needle path, which allows the soft tissue biopsy needle to reach the target area. Meanwhile, before penetrating the cortical bone, it is necessary to grasp the downward penetrating power to avoid damage to vital organs and tissues behind the bone. In this study, a sharp and hard Korean STARmed ablation electrode (15 cm) was used to avoid breakage of the ablation electrode during puncture, preventing ablation failure or other accidental damage.
|Figure 3: A male patient, 60-year-old, diagnosed with gastric cancer, who has successively undergone surgery, chemotherapy, and targeted therapy. Follow-up carcinoembryonic antigen: 60.86 ng/mL (a) Preoperative enhanced computed tomography scan, the arrow indicates the metastatic carcinoma during the portal vein phase; (b) The patient was placed in the prone position during surgery, and the 9G bone biopsy needle was used to establish an osseous passage through the thoracic vertebra; (c) 17G ablation electrode reached the caudate lobe lesion through the osseous passage; an autopulse program was set with 8 min of effective ablation time; (d) Follow-up was performed 9 months after the operation, there was no obvious enhancement in the original lesion area, and carcinoembryonic antigen gradually decreased to normal|
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The hepatic caudate lobe is located in the center of the liver and is surrounded by the inferior vena cava, hepatic vein, and hepatic hilum. Because of its special anatomical position, percutaneous minimally invasive thermal ablation targeting the caudate lobe is risky. The puncture process should avoid important organs and tissues such as the gastrointestinal tract, portal vein, inferior vena cava, and ligamentum venosum., Therefore, the design of a reasonable puncture route during the treatment process can often result in better outcomes., There are many treatments for hepatic caudate lobe tumors. Sometimes, a single treatment method cannot achieve satisfactory results; therefore, multiple nonresection methods can also be combined for treatment. Further exploration to improve the therapeutic efficacy of hepatic caudate lobe tumors in clinical practice is needed., As a preliminary study, the sample size of this study was small, the diameter of the lesions was small, and the study lacks the efficacy comparison between thermal ablation and other treatment methods. Furthermore, the guiding methods of the procedure and selected ablation electrodes of the cases were complicated, leaving only the puncture routes to be analyzed. In future studies, the sample size will be increased and thermal ablation will be compared with other treatment methods in order to more accurately evaluate the efficacy and clinical value of percutaneous thermal ablation of hepatic caudate lobe tumors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]