PMC6452817_01
Preoperative imaging workup of the left-sided liver tumor.. Notes: (A) Contrast-enhanced ultrasonography shows three liver space-occupying diseases (as indicated by the arrows), with a maximum size of 12.1 cm x7.1 cm. The second image illustrates the overall image, and the first, third, and fourth images illustrate the amplification image. (B) Contrast-enhanced magnetic resonance cholangiopancreatography further delineates the anatomy of the liver tumors in four livers, with a maximum dimension of 8.9 cm x5.5 cm. The white arrows represent the liver tumors in four livers.
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Contrast-enhanced upper abdominal ultrasonography revealed multiple liver tumors involving the left liver lobe and the left-right lobe junction, with the maximum dimensions of 12.1 cm x7.1 cm (Figure 1A). Further magnetic resonance cholangiopancreatography was performed to delineate the anatomy of the left-sided liver tumor (Figure 1B) as contrast-enhanced computed tomography was contraindicated due to hypersensitivity to radiographic contrast medium.
Pre-RFA contrast-enhanced ultrasonography of recurrent ICC.. Notes: Three recurrent diseases (as indicated by the arrows) are identified and located in segments V, VII, and VIII: (A-C), belonging to one recurrent disease; (D) is the second recurrent disease; and (E) is the third recurrent disease, therefore, three recurrent diseases are shown here.. Abbreviations: ICC, intrahepatic cholangiocarcinoma; RFA, radiofrequency ablation.
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Follow-up upper abdominal ultrasonography on the eighth postoperative week identified three recurrent diseases located in the right lobe, involving Couinaud segments V, VII, and VIII, with sizes of 1.5 cm x1.3 cm, 1.2 cm x1.0 cm, and 0.9 cm x1.0 cm, respectively (Figure 2A-E).
Follow-up contrast-enhanced ultrasonography on the third day after the first session of RFA.. Notes: (A-C) The ablated recurrent disease shows no enhancement and manifests as a filling defect (as indicated by the white arrows). (D) A hypoechogenic mass residual (1.0 cm x0.8 cm) is located in segment VIII (as indicated by the small green arrow).. Abbreviation: RFA, radiofrequency ablation.
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Follow-up ultrasound scan on post-RFA day 3 identified a filling defect in the ablated area (Figure 3A-C) and a 1.0 cm x0.8 cm hypoechogenic residual mass located in segment VIII (Figure 3D).
In-patient changes in liver function test.. Notes: (A) Serum ALT and AST; (B) serum albumin; and (C) serum TBIL, CB, and UCB.. Abbreviations: ALB, albumin; ALT, alanine transferase; AST, asparate transferase; CB, conjugated bilirubin; TBIL, total bilirubin; UCB, unconjugated bilirubin; RFA, radiofrequency ablation.
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On the second day of the repeated RFA, the patient became febrile (39.2 C); hematology showed hemoglobin 80 g/L (110-160 g/L) (Figure not shown) and white cell count 10.4x109/L (4-10x109/L) (Figure not shown); liver biochemistry showed alanine transferase 5,304 IU/L (0-42 IU/L), asparate transferase 7,906 IU/L (0-42 IU/L) (Figure 4A), albumin 30.7 g/L (38-51 g/L) (Figure 4B), and total bilirubin 38.9 mumol/L (6-21 mumol/L) (Figure 4C); and coagulation function test showed prothrombin time 22.4 seconds and international normalized ratio 1.91. The liver function test also showed a steady improvement from the fifth week after RFA (Figure 4A-C).
Contrast-enhanced magnetic resonance imaging scan on the first day after the second session of RFA.. Notes: Extensive liver parenchymal necrosis is present on the (A-C) transverse and (D and E) coronal planes.. Abbreviation: RFA, radiofrequency ablation.
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Emergency contrast-enhanced magnetic resonance imaging scan showed extensive liver necrosis (Figure 5A-E); therefore, a diagnosis of RFA-associated ALF was established.
Follow-up bedside chest plain X-ray examination.. Notes: (A) Bilateral extensive pulmonary inflammatory changes with elevation of the right-sided diaphragm on the third day after the second session of RFA. (B) Worsening bilateral extensive pulmonary inflammatory changes with complicating pleural effusion on the seventh day. (C) Resolving bilateral pulmonary inflammatory changes on the tenth day. (D) Significant improvement in bilateral pulmonary inflammatory changes with complicating right-sided pleural effusion and lower lobe atelectasis (as indicated by the arrow).. Abbreviation: RFA, radiofrequency ablation.
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Repeated chest X-ray and ultrasound scan revealed progressively improving pulmonary sepsis and pleural effusion (Figure 6A-D), and the patient was weaned from the ventilator 2 weeks after hospitalization in the RCU.