Ultrasound-guided, video-assisted transdiaphragmatic radiofrequency ablation for primary liver malignancy or metastatic nodules

OBJECTIVE:: Percutaneous radiofrequency ablation (RFA) is among the best options in the treatment of primary liver malignancy and metastases because it is a highly effective and minimally invasive alternative to resection in small, nonresectable tumors or in poor surgical candidates and is associated with low morbidity and mortality. We evaluated the clinical feasibility and safety of thoracoscopic, ultrasound (US)-guided RFA of subdiaphragmatic liver malignancies in advanced cirrhotic patients awaiting transplantation. METHODS:: Two patients (one female and one male) with end-stage cirrhosis who developed hepatocellular carcinoma were treated thoracoscopically by US-guided RFA. An endoscopic US probe was inserted into the right pleural space through a 10-mm working channel. An RF-operating needle applicator was inserted through a second 10-mm working port after identification of the lesion, penetrating the diaphragm toward the lesion. The procedure duration, applied energy, and generator output were recorded during the intervention. The treatment result and procedure-related complications were analyzed. RESULTS:: The procedure duration was 74 and 92 minutes, respectively. A mean energy deposition of 353 joules resulted in a mean coagulation volume of 115 cm. Tumor ablation was achieved as determined by the postinterventional lack of contrast enhancement in the target region at the follow-up computed tomographic scans performed after 4 months. CONCLUSIONS:: RFA offers definite possibilities in the management of small-sized tumors. Thoracoscopic, US-guided transdiaphragmatic RFA has proven to be clinically feasible and safe and can be an effective modality for treating subdiaphragmatic liver lesions. Its minimally invasive nature is the most important advantage compared with surgical resection, especially for patients with high operative risk.