28403099 Visualization

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