To the Editors:
Hepatocellular carcinoma (HCC) is a neoplasm with worldwide increasing incidence. Curative therapies such as resection and liver transplantation are the exception rather than the rule. Globally, liver transplantation is indicated in patients with less than 3 nodules less than 3 cm or a single nodule less than 5 cm. In countries with a long waiting time for liver transplantation, transcatheter arterial embolization and radiofrequency ablation (RFA) have been proposed as adjuvant therapy before liver transplantation. A critical issue is the “bridge” treatment to control tumor growth while the patients with HCC are waiting to undergo liver transplantation. The waiting time has been progressively increasing and nowadays can reach 2.5 years in our country.
We present a case of a 62-year-old man with hepatitis C virus (HCV)–related cirrhosis, Child's B, who underwent percutaneous RFA therapy of a CHC while waiting to undergo liver transplantation. The tumor was located between segments III and IV (Fig 1), 4 cm from the biliary confluence. The procedure was not complicated, and the patient was discharged 2 days later. On the thirty-fifth day after the RFA, he was seen in the emergency department with an upper gastrointestinal hemorrhage and abdominal pain. On gastroduodenoscopic examination, the esophagus, stomach, and duodenal bulbus did not show active bleeding, but blood flowing from the papilla of Vater was seen. Because digital subtraction angiography confirmed hemobilia, the patient was successfully treated with selective coil and Gelfoam embolization as close as possible to the bleeding site. The bleeding recurred 2 days later, and a new attempt to embolize was performed (Fig 2). The patient had development of respiratory, kidney, and liver failure; he died 4 days after hemobilia occurred, 39 days after undergoing RFA.
Treatment-related major complications of RFA are quite rare, including subcapsular hematoma, hemothorax, and intraperitoneal bleeding.
1.Others authors highlight a caution in the use of RFA in transplant candidates, because of an increased risk of tumor seeding, especially in the needle tract after RFA.
- Curley A.S.
- Izzo F.
- Ellis L.M.
- Nicolas Vauthey J.
- Vallone P.
Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis.
Ann Surg. 2000; 232: 381-391
2.Among studies including almost 1000 treated patients, no fatal complication had been reported until May 2003. The first reported death in the literature was due to a colonic perforation by heat diffusion 24 days after RFA for a segment 5–located HCC.
- Llovet J.M.
- Vilana R.
- Brú C.
- Bianchi L.
- Salmeron J.M.
- Boix L.
- et al.
Increase risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma.
Hepatology. 2001; 33: 1124-1129
- Casaril A.
- Hilal M.A.
- Ciola M.
- Invernizzi L.
- Campagnaro T.
- Nicoli N.
One death after radiofrequency thermal ablation for hepatocellular carcinoma in a cirrhotic patient.
Surgery. 2003; 133: 598
Recently others authors described RFA-related hemobilia, but without fatal complication.
4.An increasing proportion of the causes of hemobilia have been of iatrogenic origin caused by therapeutic or diagnostic procedures. Massive hemobilia is a relatively rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. The case described emphasizes that the RFA may cause not only localized tumor destruction or injury of the liver parenchyma and biliary system but also thermally mediated damage of vascular structures. The number of cases is likely to increase as RFA therapy becomes more common.
- Yamamoto T.
- Kubo S.
- Hirohashi K.
- Tanaka S.
- Uenishi T.
- Ogawa M.
- et al.
Secondary hemocholecyst after radiofrequency ablation therapy for hepatocellular carcinoma.
J Gastroenterol. 2003; 38: 399-403
- Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis.Ann Surg. 2000; 232: 381-391
- Increase risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma.Hepatology. 2001; 33: 1124-1129
- One death after radiofrequency thermal ablation for hepatocellular carcinoma in a cirrhotic patient.Surgery. 2003; 133: 598
- Secondary hemocholecyst after radiofrequency ablation therapy for hepatocellular carcinoma.J Gastroenterol. 2003; 38: 399-403
© 2004 Elsevier Inc. Published by Elsevier Inc. All rights reserved.