| Objectives:1.To explore the value of contrast-enhanced ultrasound(CEUS)in assessing the real size of the lesion before radio frequency ablation(RFA)treatment and necrotic area after the treatment.2.To evaluate the treatment effect of complicated hepatic malignant neoplasms by individualized Radio Frequency Ablation.3.To explore the safety of RFA in patients with difficult complicated hepatic malignant neoplasms。Methods:A total of 100 lesions of 39 patients with hepatic malignant neoplasms who underwent RFA treatment at the Second Affiliated Hospital of Kunming Medical University from January 25,2014 to January 16,2017 were selected as subjects.All patients were diagnosed with PLC or MHC before RFA treatment by operation or biopsy.The subjects were divided into two groups:complicated treating group and control group.10 lesions of 7 patients were recruited in complicated treating group,30 lesions of 16 patients were recruited in control group.From the last 60 lesions of 16 patients,we select 32 lesions into complicated treating group and 28 lesions into control group.So 42 lesions of 23 patients in complicated treating group,including 16 males and 7 females with an average age of(58.8 ± 12.0)years.A total of 58 lesions of 32 patients in control group,including 23 males and 9 females with an average age of(59.8 ± 10.7)years.Adopt Phillips IU22 color ultrasonic diagnostic apparatus as ultrasonic instrument using 5.0～12.0MHz probe.Chose ultrasound SonoVue produced by Italy Bracco company as contrast agent.RFA-I multi-polar radio frequency ablation instrument and RFA1315 electrode produced by Beijing blade opto-electrongic technology development limited company was used to treat the lesions.(1)The conventional ultrasound examination method:according the location of the lesion in the liver,ask the patient supine or left lateral position and with appropriate breathing.Confirm the location of the lesion by scanning the liver comprehensively,evaluate the size,shape,echo,the sound color flow signal and the spectral characteristics of the lesion,the relationship between the lesion and the important tissue structure,record the related measurement data at the same time.(2)CEUS examination:when start the CEUS examination,ask the same patients to take the the conventional ultrasound examination position,select the largest view of the lesion,transfer the instrument to the contrast model to track and analyze the images,set mechanical to 0.06.At the beginning of CEUS,inject SonVue suspension 2.4ml every time through antecubital vein,followed by injection of 5ml saline tube.When the CEUS start,we began to observe the lesion enhancement in real time and store the image as well and keep 6 minutes.(3)Ultrasonographic image analysis method:After the end of CEUS,analysis the images by doctors who have CEUS experience to confirm whether the lesion enhanced,whether there is feeding vessels and then measure the size of the enhanced lesion or necrosis.All the data were recorded in detail.(4)Ultrasound-guided radio frequency ablation therapy:① preoperative preparation:all lesions before treatment must be diagnosed as PLC or MHC clinically.Complete the patient preoperative test include the complete blood count,coagulation,biochemical routine,tumor markers,ECG and other related checks.Take the patient breath training so that in the treatment process with a better cooperation of RFA.Take a detail conversation with the patients and their families before the RFA to inform the risk of the operation and CEUS,to make sure they clearly know the complications may occur in the process or after the operation.Finally,ask them to sign informed consent.② Anesthesia:Select local anesthesia or general anesthesia.③ Design the best ablation strategy:Based on the actual situation of the lesion,select different methods to put the needle into the lesion,individualized ablation strategy is used for treating the lesions which was complicated.④The treatment process:ask the patient to take the supine position,or the left lateral position when the lesion in the right hepatic lobe.Establish venous pathway and monitor the ECG.Connect the radio frequency ablation equipment and then attach the negative plate to the right thigh skin of the patient.Disinfect the surgical area with iodophor,pave sterile sheet.After the anesthesia work out,cut the skin,put the multi-polar needle into the lesion guided by ultrasound according to the actual situation of the lesion in accordance with the preoperative ablation strategy.Start the therapy after open the multi-polar needle and observe the ablation device temperature-power curve.According the curve,evaluate whether the temperature of the target area is consistent with the standard and whether the treatment is effective indirectly.Finish the treatment until the lesion is covered by high echo completely and then take back the inner needle till the electrode needle temperature below 42 ℃,withdraw the multi-polar needle as well as control the system "coagulation"button to ablation pathway and stanch bleeding.The question that whether the lesion is going to be treated need to be discussed with the result of the CEUS examination in evaluating the necrosis.After RFA,scan the treatment area and the important organ structure,confirm there is no serious complications,disinfect the wound and bandage it by gauzea and salt bag.Ask the patient to rest on bed 24 hours.The abdomen situation need to be observe by the clinician.⑤The follow-up:return to the ward after the patient is stable,monitoring blood pressure,blood oxygen saturation and other vital signs and abdominal conditions.Give some medicine routinely to stanch bleeding,pain relief,liver protectant,anti-inflammatory.⑥One month after RFA,CEUS is performed to evaluate whether the lesion was completely ablated.Results:(1)There was no significant difference about the size of the lesion measured by conventional ultrasound between the complicated treating group and the control group(P>0.05).(2)There was no significant difference about the size of the lesion measured by CEUS between the complicated treating group and the control group(P>0.05).(3)The size of the lesion measured by CEUS is larger than that measured by conventional ultrasound in complicated treating group(P<0.05),the difference was statistically significant.(4)The size of the lesion measured by CEUS is larger than that measured by conventional ultrasound in the control group(P<0.05),the difference was statistically significant.The size of the control group under conventional ultrasound and ultrasound contrast measurement under the contrast(P<0.05),the difference was statistically significant.(5)The size of necrosis is larger than the size of the lesion measured by CEUS in complicated treating group(P<0.05),the difference was statistically significant.(6)The size of necrosis is larger than the size of the lesion measured by CEUS in control group(P<0.05),the difference was statistically significant.(7)There was no significant difference between the two groups(P>0.05)in the rate of CR after RFA one month.(8)There was no significant difference between the two groups(P>0.05)in the rate of complications.Conclusion:(1)CEUS is a necessary and critical examination before the treatment of RFA in hepatic malignant tumors.CEUS can more objectively reflect the real size of the lesion and the relationship with the surrounding important organs.(2)It’s effective to treat the complicated lesions by the individualized Radio Frequency Ablation strategy,and the short-term complete response have no statistically significant than others.(3)CEUS have a certain value in evaluating the necrosis after RFA treatment immediately,it can objectively reflect the situation of ablation,clearly show the size of the necrosis,and guide the subsequent treatment.(4)Because it’s relatively safety for RFA to treat the complicated hepatic malignant neoplasms,we suggest to take these lesions into relative indications rather than relative contraindications in RFA. |
