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+A 60-year-old man presented with a retroperitoneal metastatic lymph node in magnetic resonance (MR) imaging with a history of right liver resection in 2010, pulmonary wedge resection in 2012, and transarterial chemoembolization twice in 2014, in which the postoperative pathology suggested the mixed liver cancer, and poorly differentiated lung cancer from liver metastasis.
+At examination, the tumor was very close to the duodenum, pancreas, stomach, and hepatic portal vein.
+The patient with unresectable masses had hypertension over 10 years and chronic HBV-related cirrhosis for 30 years when he was treated with lamivudine 100 mg qd, and adefovir dipivoxil 10 mg qd for 6 years.
+He kept a constant body temperature of 37 °C, the blood pressure of 148/96 mm Hg, and the pulse of 77 beats every minute.
+The patient had no obvious sense of abdominal pain, abdominal distention, nausea, and vomiting.
+On a test of tumor markers levels, the results were normal, which showed carcinoembryonic antigen 3.7 ng/mL, alpha fetoprotein 17.3 ng/mL, and carbohydrate antigen 19–9 levels 6.1 U/mL.
+In this study, the procedure was approved by the ethics committee of the First Affiliated Hospital of Zhejiang University.
+The efficacy of local ablation was estimated with Choi criteria, which appraised the variations both in tumor size and lesion density on computed tomography (CT) imaging: complete response, disappearance of all lesions and no new lesions; partial response (PR), a decrease in size of 10% or a decrease in tumor density over 15% on CT and no new lesions; stable disease, not fit for complete response, PR, or progressive disease; and progressive disease, an increase in tumor size over 10% and not fit for PR by tumor density on CT or new lesions.[19]
+Preoperative MR imaging scan showed a mass of 2.8 × 3.5 cm in size close to the duodenum, pancreas, and blood vessels (Fig.1A).
+During substance phase, MR images indicated mildly high signal intensity around the tumor and intermediate low signal intensity in the solid component and in the walls (Fig.1B).
+Before the initial ablation, there was a retroperitoneal mild hyperechoic area on axial US image (Fig.1C).
+In this study, the inpatient underwent percutaneous transhepatic biopsies and ablations to avoid the nearby blood vessels, the procedure of which was performed about 40 minutes under local anesthesia and mild sedation.
+We used ultrasonography to real-timely guide the inserting of 2 Nd:YAG laser fibers (Echolaser X4, ESAOTE, Italy) in 0.3 mm diameter through a 21-gauge Chiba needle into the lesions (Fig.1D).
+Although part of the heat ran off by blood flow,[20] ablation could keep valid area from 12 to 15 mm with the power of 5 W in 5 to 6 minutes.
+Subsequently, immediate ultrasonography showed that the whole lesion was covered with hyperechoic zone (Fig.​(Fig.1E and F).
+However, the next day contrast-enhanced ultrasound (CEUS) revealed an abnormal residual of proximal part of the pancreatic head (Fig.2A).
+At 5-day follow-up contrast-enhanced CT images, the lower mass had low signal intensity and upper tumor revealed intermediate high signal intensity of residual in substance phase (Fig.2B and C).
+Surprizingly, 1-week follow-up CEUS image showed an enlarged retroperitoneal lymph node located near the pancreatic head, which could be fusion of these residuary small nodules (Fig.2D).
+Then the patient undergoing the 2nd ablation with 2 laser fibers showed the lesions well-defined hyperechoic zone (Fig.2E and F).
+On the 2nd day, postoperative CEUS images showed they were still remanent (Fig.2G and I).
+At the corresponding MR imaging, it also showed this in left of tumor (Fig.2H).
+Thus, the 3rd laser ablation was performed (Fig.2J)2J) and 3 days later CEUS found that there was still a minor lesion located in the separation gap of last 2 needles (Fig.3A).
+Subsequently the patient had the 4th ablation along this separation gap until hyperechoic overlay (Fig.3B–D), then 3 days later, based on these 4 treatments, enhanced CT image of the retroperitoneal mass suggested complete necrosis (Fig.3E–G).3E–G).
+After the following 1 month, substance phase MR revealed low-intensity signal of tumor necrosis with resolution of his problems (Fig.3H).
+Until 5 months after 4 ablations, CT showed the tumor PR with little enhanced recurrence (yellow arrows), which located in the left lower edge of original lesions (Fig.4A and B).
+On laboratory test of tumor markers, the levels of carcinoembryonic antigen, alpha fetoprotein, and carbohydrate antigen 19–9 indicated 3.6 ng/mL, 26.7 ng/mL, and 8.1 U/mL, respectively.
+No obvious side effects were discovered in this case during these procedures.