Percutaneous Radiofrequency Ablation of Hepatocellular Carcinoma against the Diaphragm: Is Artificial Ascites Necessary?


Purpose: To evaluate the utility of artificial ascites induction for radiofrequency ablation (RFA) of peridiaphragmatic hepatocellular carcinoma (HCC) through retrospective cohort analysis comparing characteristics and complications of peridiaphragmatic HCC without the use of artificial ascites to non-peridiaphragmatic HCC. Materials and Methods: IRB approval was obtained. From September 2003 to December 2008, 150 consecutive patients with hepatic tumors received percutaneous RFA. 110 patients had presumed HCC, and of those 21 had lesions abutting the diaphragm. Of the remaining 89 patients with non-peridiaphragmatic HCC lesions, 21 were randomly selected for the comparison group. RFA volume, major and minor complication rates, pain, technical success, and recurrence rates were compared between the two groups. Results: There was no statistical difference in RFA volume (P = 0.962), overall major complication rate (P = 0.343) and minor complication rate (P = 0.118) between the two groups. However, the peridiaphragmatic group that underwent RFA with a clustered-needle demonstrated a statistically significant higher proportion of major complications compared to the non-peridiaphragmatic clustered-needle group (P = 0.033). There was no statistical difference in pain severity (P = 0.8802) or pain location (P = 0.15). There was no statistical difference in technical success rates (P = 1), local tumor progression rates (P = 1), or time to local tumor recurrence (P = 0.67). Conclusion: Artificial ascites induction for RFA of HCC lesions adjacent to the diaphragm may not be necessary, although clustered electrode technique should be avoided in this location as they present with a higher complication rate.

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Khong, K. , Nguyen, H. , Li, C. , Cheng, D. and McGahan, J. (2014) Percutaneous Radiofrequency Ablation of Hepatocellular Carcinoma against the Diaphragm: Is Artificial Ascites Necessary?. Open Journal of Radiology, 4, 32-43. doi: 10.4236/ojrad.2014.41005.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Goldberg, S.N., Hahn, P.F., Halpern, E.F., Fogle, R.M. and Gazelle, G.S. (1998) Radio-Frequency Tissue Ablation: Effect of Pharmacologic Modulation of Blood Flow on Coagulation Diameter. Radiology, 209, 761-767.
[2] Goldberg, S.N., Solbiati, L., Hahn, P.F., et al. (1998) Large-Volume Tissue Ablation with Radio Frequency by Using a Clustered, Internally Cooled Electrode Technique: Laboratory and Clinical Experience in Liver Metastases. Radiology, 209, 371-379.
[3] Livraghi, T., Goldberg, S.N., Lazzaroni, S., Meloni, F., Solbiati, L. and Gazelle, G.S. (1999) Small Hepatocellular Carcinoma: Treatment with Radio-Frequency Ablation versus Ethanol Injection. Radiology, 210, 655-661.
[4] McGahan, J.P. and Dodd III, G.D. (2001) Radiofrequency Ablation of the Liver: Current Status. American Journal of Roentgenology, 176, 3-16.
[5] Rhim, H., Goldberg, S.N., Dodd III, G.D., et al. (2001) Essential Techniques for Successful Radio-Frequency Thermal Ablation of Malignant Hepatic Tumors. Radiographics, 21, S17-S35.
[6] Rossi, S., Buscarini, E., Garbagnati, F., et al. (1998) Percutaneous Treatment of Small Hepatic Tumors by an Expandable RF Needle Electrode. American Journal of Roentgenology, 170, 1015-1022.
[7] Head, H.W., Dodd III, G.D., Dalrymple, N.C., et al. (2007) Percutaneous Radiofrequency Ablation of Hepatic Tumors against the Diaphragm: Frequency of Diaphragmatic Injury. Radiology, 243, 877-884.
[8] Mendiratta-Lala, M., Brook, O.R., Midkiff, B.D., et al. (2010) Quality Initiatives: Strategies for Anticipating and Reducing Complications and Treatment Failures in Hepatic Radiofrequency Ablation. Radiographics, 30, 1107-1122.
[9] de Baere, T., Risse, O., Kuoch, V., et al. (2003) Adverse Events during Radiofrequency Treatment of 582 Hepatic Tumors. American Journal of Roentgenology, 181, 695-700.
[10] Dodd III, G.D., Soulen, M.C., Kane, R.A., et al. (2000) Minimally Invasive Treatment of Malignant Hepatic Tumors: At the Threshold of a Major Breakthrough. Radiographics, 20, 9-27.
[11] Gillams, A.R. and Lees, W.R. (2000) Radiofrequency Ablation of Liver Tumor 1 Year’s Experience with the Lastest Technology [abstr]. European Radiology, 10, D22.
[12] Iannitti, D.A., Dupuy, D.E., Mayo-Smith, W.W. and Murphy, B. (2002) Hepatic Radiofrequency Ablation. Archives of Surgery, 137, 422-426.
[13] Kim, Y.S., Rhim, H., Sung, J.H., et al. (2005) Bronchobiliary Fistula after Radiofrequency Thermal Ablation of Hepatic Tumor. Journal of Vascular and Interventional Radiology, 16, 407-410.
[14] Koda, M., Ueki, M., Maeda, N. and Murawaki, Y. (2003) Diaphragmatic Perforation and Hernia after Hepatic Radiofrequency Ablation. American Journal of Roentgenology, 180, 1561-1562.
[15] Lim, H.K., Han, S., et al. (2001) Major Complications after Radiofrequency Thermal Ablation of Hepatic Tumors: A Report of the Korean RF Study Group [abstr]. Radiology, 221, 248.
[16] Livraghi, T., Goldberg, S.N., Solbiati, L., Meloni, F., Ierace, T. and Gazelle, G.S. (2001) Percutaneous Radio-Frequency Ablation of Liver Metastases from Breast Cancer: Initial Experience in 24 Patients. Radiology, 220, 145-149.
[17] Livraghi, T., Melone, F., et al. (2000) Complications after Cool-Tip RF Ablation of Liver Cancer: Initial Report of the Italian Multicenter Cooled-Tip RF Study Group [abstr]. Radiology, 217, 27.
[18] Moumouh, A., Hannequin, J., Chagneau, C., et al. (2005) A Tamponade Leading to Death after Radiofrequency Ablation of Hepatocellular Carcinoma. European Radiology, 15, 234-237.
[19] Mulier, S., Mulier, P., Ni, Y., et al. (2002) Complications of Radiofrequency Coagulation of Liver Tumours. British Journal of Surgery, 89, 1206-1222.
[20] Raman, S.S., Lu, D.S., Vodopich, D.J., Sayre, J. and Lassman, C. (2000) Creation of Radiofrequency Lesions in a Porcine Model: Correlation with Sonography, CT, and Histopathology. American Journal of Roentgenology, 175, 12531258.
[21] Rao, M.P. and Bell, R. (2003) Pulmonary Hemorrhage after Radioablation of Liver Metastases. Anesthesia & Analgesia, 97, 684-686.
[22] Wood, T.F., Rose, D.M., Chung, M., Allegra, D.P., Foshag, L.J. and Bilchik, A.J. (2000) Radiofrequency Ablation of 231 Unresectable Hepatic Tumors: Indications, Limitations, and Complications. Annals of Surgical Oncology, 7, 593600.
[23] Kapoor, B.S. and Hunter, D.W. (2003) Injection of Subphrenic Saline during Radiofrequency Ablation to Minimize Diaphragmatic Injury. CardioVascular and Interventional Radiology, 26, 302-304.
[24] Raman, S.S., Aziz, D., Chang, X., Sayre, J., Lassman, C. and Lu, D. (2004) Minimizing Diaphragmatic Injury during Radiofrequency Ablation: Efficacy of Intraabdominal Carbon Dioxide Insufflation. American Journal of Roentgenology, 183, 197-200.
[25] Raman, S.S., Lu, D.S., Vodopich, D.J., Sayre, J. and Lassman, C. (2002) Minimizing Diaphragmatic Injury during Radio-Frequency Ablation: Efficacy of Subphrenic Peritoneal Saline Injection in a Porcine Model. Radiology, 222, 819823.
[26] Kang, T.W., Rhim, H., Kim, E.Y., et al. (2009) Percutaneous Radiofrequency Ablation for the Hepatocellular Carcinoma Abutting the Diaphragm: Assessment of Safety and Therapeutic Efficacy. Korean Journal of Radiology, 10, 34-42.
[27] Kim, Y.S., Rhim, H. and Paik, S.S. (2006) Radiofrequency Ablation of the Liver in a Rabbit Model: Creation of Artificial Ascites to Minimize Collateral Thermal Injury to the Diaphragm and Stomach. Journal of Vascular and Interventional Radiology, 17, 541-547.
[28] Lee, S., Rhim, H., Kim, Y.S., et al. (2009) Percutaneous Radiofrequency Ablation of Hepatocellular Carcinomas: Factors Related to Intraprocedural and Postprocedural Pain. American Journal of Roentgenology, 192, 1064-1070.
[29] Rhim, H. (2005) Complications of Radiofrequency Ablation in Hepatocellular Carcinoma. Abdom Imaging, 30. 409418.
[30] Rhim, H., Dodd III, G.D., Chintapalli, K.N., et al. (2004) Radiofrequency Thermal Ablation of Abdominal Tumors: Lessons Learned from Complications. Radiographics, 24, 41-52.
[31] Kondo, Y., Yoshida, H., Shiina, S., Tateishi, R., Teratani, T. and Omata, M. (2006) Artificial Ascites Technique for Percutaneous Radiofrequency Ablation of Liver Cancer Adjacent to the Gastrointestinal Tract. British Journal of Surgery, 93, 1277-1282.
[32] Chen, M.H., Yang, W., Yan, K., et al. (2008) Radiofrequency Ablation of Problematically Located Hepatocellular Carcinoma: Tailored Approach. Abdom Imaging, 33, 428-436.
[33] Rhim, H. and Lim, H.K. (2009) Radiofrequency Ablation for Hepatocellular Carcinoma Abutting the Diaphragm: The Value of Artificial Ascites. Abdom Imaging, 34, 371-380.
[34] Rhim, H., Lim, H.K., Kim, Y.S. and Choi, D. (2008) Percutaneous Radiofrequency Ablation with Artificial Ascites for Hepatocellular Carcinoma in the Hepatic Dome: Initial Experience. American Journal of Roentgenology, 190, 91-98.
[35] Lee, E.J., Rhim, H., Lim, H.K., Choi, D., Lee, W.J. and Min, K.S. (2008) Effect of Artificial Ascites on Thermal Injury to the Diaphragm and Stomach in Radiofrequency Ablation of the Liver: Experimental Study with a Porcine Model. American Journal of Roentgenology, 190, 1659-1664.
[36] Song, I., Rhim, H., Lim, H.K., Kim, Y.S. and Choi, D. (2009) Percutaneous Radiofrequency Ablation of Hepatocellular Carcinoma Abutting the Diaphragm and Gastrointestinal Tracts with the Use of Artificial Ascites: Safety and Technical Efficacy in 143 Patients. European Radiology, 19, 2630-2640.
[37] Perrault, J., McGill, D.B., Ott, B.J. and Taylor, W.F. (1978) Liver Biopsy: Complications in 1000 Inpatients and Outpatients. Gastroenterology, 74, 103-106.
[38] Nam, S.Y., Rhim, H., Kang, T.W., et al. (2010) Percutaneous Radiofrequency Ablation for Hepatic Tumors Abutting the Diaphragm: Clinical Assessment of the Heat-Sink Effect of Artificial Ascites. American Journal of Roentgenology, 194, W227-W231.
[39] McGahan, J.P., Loh, S., Boschini, F.J., et al. (2010) Maximizing Parameters for Tissue Ablation by Using an Internally Cooled Electrode. Radiology, 256, 397-405.
[40] McCaffery, M. and Beebe, A. (1993) Pain: Clinical Manual for Nursing Practice. V.V. Mosby Company, Baltimore.
[41] Kaplan, E.L. and Meier, P. (1958) Nonparametric Estimation fro Incomplete Observations. Journal of the American Statistical Association, 53, 457-448.
[42] Cox, D.D.R. (1972) Regression Models and Life-Tables. Journal of the Royal Statistical Society, Series B (Methodological), 34, 187-220.
[43] Curley, S.A., Marra, P., Beaty, K., et al. (2004) Early and Late Complications after Radiofrequency Ablation of Malignant Liver Tumors in 608 Patients. Annals of Surgery, 239, 450-458.
[44] de Baere, T., Dromain, C., Lapeyre, M., et al. (2005) Artificially Induced Pneumothorax for Percutaneous Transthoracic Radiofrequency Ablation of Tumors in the Hepatic Dome: Initial Experience. Radiology, 236, 666-670.
[45] Shibata, T., Maetani, Y., Kubo, T., Itoh, K., Togashi, K. and Hiraoka, M. (2004) Transthoracic Percutaneous Radiofrequency Ablation for Liver Tumors in the Hepatic Dome. Journal of Vascular and Interventional Radiology, 15, 1323-1327.
[46] Toyoda, M., Kakizaki, S., Horiuchi, K., et al. (2006) Computed Tomography-Guided Transpulmonary Radiofrequency Ablation for Hepatocellular Carcinoma Located in Hepatic Dome. World Journal of Gastroenterology, 12, 608-611.
[47] Goldberg, S.N., Hahn, P.F., Tanabe, K.K., et al. (1998) Percutaneous Radiofrequency Tissue Ablation: Does Perfusion-Mediated Tissue Cooling Limit Coagulation Necrosis? Journal of Vascular and Interventional Radiology, 9, 101111.
[48] Lu, D.S., Raman, S.S., Vodopich, D.J., Wang, M., Sayre, J. and Lassman, C. (2002) Effect of Vessel Size on Creation of Hepatic Radiofrequency Lesions in Pigs: Assessment of the “Heat Sink” Effect. American Journal of Roentgenology, 178, 47-51.
[49] Hayes, D.L., Charboneau, J.W., Lewis, B.D., Asirvatham, S.J., Dupuy, D.E. and Lexvold, N.Y. (2001) Radiofrequency Treatment of Hepatic Neoplasms in Patients with Permanent Pacemakers. Mayo Clinic Proceedings, 76, 950-952.
[50] Llovet, J.M., Vilana, R., Bru, C., et al. (2001) Increased Risk of Tumor Seeding after Percutaneous Radiofrequency Ablation for Single Hepatocellular Carcinoma. Hepatology, 33, 1124-1129.
[51] de Baere, T., Denys, A., Wood, B.J., et al. (2001) Radiofrequency Liver Ablation: Experimental Comparative Study of Water-Cooled versus Expandable Systems. American Journal of Roentgenology, 176, 187-192.
[52] Muller Botha, G.S. (1957) The Anatomy of Phrenic Nerve Termination and the Motor Innervation of the Diaphragm. Thorax, 12, 50-56.

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