치료적 시술 : 경피적에탄올주입술

김윤준 대한간학회 2013 간학회 싱글토픽 심포지움 Vol.2013 No.2

Percutaneous ethanol injection therapy (PEIT), a potent non-surgical treatment tool for hepatocellular carcinoma (HCC), has been developed to manage small neoplasms. Intratumoral injection of only a few milliliters of ethanol with an ultrasonographic guidance allows PEIT to necrotize tumors completely and to reach reasonable survival rates comparable to radiofrequency ablation or liver resection. Advantages of PEIT include insignificant mortality, minimal damage to normal parenchyma, relatively low cost and easy availability; disadvantages include high local recurrence and minor complications such as fever and portal vein thrombosis. Recently with the introduction of single-session percutaneous ethanol injection, range of indications for PEIT is becoming wider. Furthermore, combined therapy of PEIT with transcatheter arterial chemoembolization (TACE) or other local ablation techniques is now being studied and performed with a satisfactory prospect.

간세포암에 대한 간동맥 화학색전술과 경피적 에타놀 경화요법에 의한 병행치료:예비적 연구

한성태 대한영상의학회 1995 대한영상의학회지 Vol.32 No.1

Purpose : Transcatheter arterial chemoembolization (TACE) and subsequent percutaneous ethanl injection (PEI)was attempted in 8 patients with 9 hepatocellular carcinomas (HCCs) for complete tumor necrosis of HCCs less than5cm in greatest diameter. Materials and methods : PEI was performend with 2-8 ml of absolute (99.9%) ethanol twoweeks after TACE under CT or ultrasound guidance. For each patient PEI was done twice to four times within 4-10days of each procedure. Atter completion of series of PE1, follow up examination (range : 3 months - 1.5 Yearperiod) was done with angiography, CT or ultrasound and correlated with serum alpha-fetoprotein (AFP) level.Results : On follow up angiograms, the lesions completely disappeared or decreased in size without tumor vesselsor staining in 5 of 6 patients. On follow up CT of 6 patients, the lipiodol-laden HCCs were surrounded bynon-enhancing low density and the losion sizes were slightly decreased or not changed. These are suggestive ofnecrosis of tumor ltself and adjacent liver parenchyma. The tumors could not be detected on follow up ultrasoundexamination in 2 patients. Sercum AFP was decreased in 7 patients and was well corresponded to the results ofimaging modalities. Conclusion : The authors concluded that the combined TACE and PEI is an appropriate treatmentfor small HCCs having high surgical risks.

Radiofrequency Ablation Using a Monopolar Wet Electrode for the Treatment of Inoperable Non-Small Cell Lung Cancer: a Preliminary Report

진공용,한영민,Young Sun Lee,이용철 대한영상의학회 2008 Korean Journal of Radiology Vol.9 No.2

Objective: To assess the technical feasibility and complications of radiofrequency ablation (RFA) using a monopolar wet electrode for the treatment of inoperable non-small cell lung malignancies. Materials and Methods: Sixteen patients with a non-small cell lung malignancy underwent RFA under CT guidance. All the patients were non-surgical candidates, with mean maximum tumor diameters ranging from 3 to 6 cm (mean: 4.6 ± 1.1 cm). A single 16-gauge open-perfused electrode with a 2 cm exposed tip was used for the procedure. A 0.9% NaCl saline solution was used as the perfusion liquid with the flow adjusted to 30 mL/h. The radiofrequency energy was applied for 10 40 minutes. The response to RFA was evaluated by performing contrast-enhanced CT immediately after RFA, one month after treatment and then every three months thereafter. Results: Technical failure was observed in six (37.5%) of 16 patients: intractable pain (n = 2) and non-stop coughing (n = 4). The mean follow-up interval was 15 ± 8 months (range: 9 31 months). The mean maximum ablated diameter in the technically successful group of patients ranged from 3.5 to 7.5 cm (mean 5.1 ± 1.3 cm). Complete necrosis was attained for eight (80%) of 10 lesions, and partial necrosis was achieved for two lesions. There were two major complications (2/10, 20%) encountered: a hemothorax (n = 1) and a bronchopleural fistula (n = 1). Conclusion: Although RFA using a monopolar wet electrode can create a large ablation zone, it is associated with a high rate of technical failure when used to treat inoperable non-small cell lung malignancies.

Does Artificial Ascites Induce the Heat-Sink Phenomenon during Percutaneous Radiofrequency Ablation of the Hepatic Subcapsular Area?: an in vivo Experimental Study Using a Rabbit Model

김영선,임현철,임효근,최동일 대한영상의학회 2009 Korean Journal of Radiology Vol.10 No.1

Objective: To evaluate the effect of the heat-sink phenomenon induced by artificial ascites on the size of the ablation zone during percutaneous radiofrequency (RF) ablation of the hepatic subcapsular area in an in vivo rabbit model. Materials and Methods: A total of 21 percutaneous rabbit liver RF ablations were performed with and without artificial ascites (5% dextrose aqueous solution). The rabbits were divided into three groups: a) control group (C, n = 7); b) room temperature ascites group (R, n = 7); and c) warmed ascites group (W, n = 7). The tip of a 1 cm, internally cooled electrode was placed on the subcapsular region of the hepatic dome via ultrasound guidance, and ablation was continued for 6 min. Changes in temperature of the ascites were monitored during the ablation. The size of the ablation zones of the excised livers and immediate complications rates were compared statistically between the groups (Mann-Whitney U test, Kruskal-Wallis test, linear-by-linear association, p = 0.05). Results: One rabbit from the “W” group expired during the procedure. In all groups, the ascites temperatures approached their respective body temperatures as the ablations continued; however, a significant difference in ascites temperature was found between groups “W” and “R” throughout the procedures (39.2± 0.4℃in group W and 33.4±4.3℃ in group R at 6 min, p = 0.003). No significant difference was found between the size of the ablation zones (782.4±237.3 mL in group C, 1,172.0±468.9 mL in group R, and 1,030.6±665.1 mL in group W, p = 0.170) for the excised liver specimens. Diaphragmatic injury was identified in three of seven cases (42.9%) upon visual inspection of group “C” rabbits (p = 0.030). Conclusion: Artificial ascites are not likely to cause a significant heat-sink phenomenon in the percutaneous RF ablation of the hepatic subcapsular region. Objective: To evaluate the effect of the heat-sink phenomenon induced by artificial ascites on the size of the ablation zone during percutaneous radiofrequency (RF) ablation of the hepatic subcapsular area in an in vivo rabbit model. Materials and Methods: A total of 21 percutaneous rabbit liver RF ablations were performed with and without artificial ascites (5% dextrose aqueous solution). The rabbits were divided into three groups: a) control group (C, n = 7); b) room temperature ascites group (R, n = 7); and c) warmed ascites group (W, n = 7). The tip of a 1 cm, internally cooled electrode was placed on the subcapsular region of the hepatic dome via ultrasound guidance, and ablation was continued for 6 min. Changes in temperature of the ascites were monitored during the ablation. The size of the ablation zones of the excised livers and immediate complications rates were compared statistically between the groups (Mann-Whitney U test, Kruskal-Wallis test, linear-by-linear association, p = 0.05). Results: One rabbit from the “W” group expired during the procedure. In all groups, the ascites temperatures approached their respective body temperatures as the ablations continued; however, a significant difference in ascites temperature was found between groups “W” and “R” throughout the procedures (39.2± 0.4℃in group W and 33.4±4.3℃ in group R at 6 min, p = 0.003). No significant difference was found between the size of the ablation zones (782.4±237.3 mL in group C, 1,172.0±468.9 mL in group R, and 1,030.6±665.1 mL in group W, p = 0.170) for the excised liver specimens. Diaphragmatic injury was identified in three of seven cases (42.9%) upon visual inspection of group “C” rabbits (p = 0.030). Conclusion: Artificial ascites are not likely to cause a significant heat-sink phenomenon in the percutaneous RF ablation of the hepatic subcapsular region.

간세포암 고주파 열치료 후의 경계면 재발: 간피막부터 종양간의 거리와 재발기간과의 상관 관계

이진화,남경진 대한영상의학회 2003 대한영상의학회지 Vol.48 No.2

Purpose: To examine the relationship between distance from hepatic capsule to tumor and recurrence among hepatocellular carcinoma patients in whom marginal recurrence was noted after radiofrequency ablation therapy. Materials and Methods: Between January 2000 and December 2001, hepatocellular carcinoma patients with a tumor 5 cm or less in size and located 2 cm or less from the hepatic capsule underwent radiofrequency ablation therapy. We subsequently selected 37 patients (41 tumors) in whom immediate CT demonstrated complete tumor ablation and follow-up CT showed marginal recurrence. Tumors were grouped according to their distance from the hepatic capsule: Group I, adhered to the capsule; Group II, less than 1 cm from it; Group III, 1-2 cm distant. Of the 41 tumors, 22 were assigned to Group I, six to Group II, and 13 to Group III. Mean tumor size was 3.2 cm, and inter-group variation was small (Group I, 3.3 cm; Group II, 2.9 cm; Group III, 3.1 cm). Follow-up CT was used to determine marginal recurrence, and for inter-group comparison and the assessment of statistical significance, the t test was employed. Results: Marginal recurrence was noted at mean 5.5 months (2.7 months in Group I, 3.0 months in Group II, and 10.5 months in Group III). The t test revealed significant difference between Group I and III (p<0.0001) but not between Groups I and II, or II and III. If '1 cm from hepatic capsule' was the criterion for classification, and Group I and II were combined and compared with Group III, there was significant difference between the two groups (p<0.0001). Conclusion: Tumors which adhered to the hepatic capsule or were less than 1 cm from it recurred sooner than those situated 1-2 cm away. 목적: 간세포암의 고주파 열치료 후 경계면 재발을 보인 환자군에서 종양의 간피막으로 부터의 거리와 재발기간과의 상관관계에 대해 알아보고자 하였다. 대상과 방법: 2000년 1월부터 2001년 12월까지 간세포암으로 고주파 열치료를 받은 환자 중 크기가 5 cm 이하이고 간피막으로 부터의 거리가 2 cm 이하인 종양에 대해 치료직후 CT에서 종양의 완전괴사를 확인한 후 추적 검사 중 경계면 재발을 보인 환자 37명(41종양)을 대상으로 하였다. 종양의 위치를 간피막으로 부터 떨어진 거리에 따라 세 군으로 분류하였으며, 간피막에 붙어있는 경우를 I군, 떨어진 거리가 1 cm 미만인 경우를 II군, 1-2 cm인 경우를 III 군이라 하였다. 41종양 중 I군이 22개, II군이 6개, III군이 13개이었다. 전체 종양의 평균 크기는 3.2 cm이었으며, I군은 3.3 cm, II군은 2.9 cm, III군은 3.1 cm로 각 군간에 종양 크기는 유사하였다. 추적 CT에서 경계면 재발이 있기까지의 기간을 알아보았고, 각 군간의 비교에서 Ttest로 통계적 유의성을 검증하였다. 결과: 전체 종양의 경계면 재발기간 평균은 5.5개월이었고, I군에서는 2.7개월, II군이 3.0개월, III군이 10.5개월이었다. T-test에서 I군과 III군간에는 통계적으로 유의한 차이가 있었으나 (p<0.0001), I군과 II군, II군과 III군간에는 유의한 차이가 없었다. 간피막으로부터의 거리 1 cm을 기준으로 분류하여 I군과 II군을 묶고 III군과 비교하였을 때 두 집단간에 유의한 차이가 있었다(p<0.0001). 결론: 간세포암의 고주파 열치료 후 경계면 재발을 보인 경우 종양의 위치가 간피막에 붙어 있거나 1 cm 미만 떨어진 경우가 1 cm 이상 떨어진 경우보다 재발이 빨리 일어남을 알 수 있었다.

돼지 간문맥 관통 후 고주파치료의 합병증: 영상의학적 소견

김승훈,임효근,전용환,최동일,박길선 대한영상의학회 2007 대한영상의학회지 Vol.57 No.1

Purpose: To evaluate complications after radiofrequency ablation (RFA) of the porcine liver through portal vein penetration. Materials and Methods: Twelve pigs were divided into two groups. In group I (n=11) animals, the portal veins were directly penetrated with an electrode, and in the group II (n=16) animals, the portal veins were located within the expected ablation area. For the group I pigs, RFA were performed for seven minutes after complete portal vein passing of the exposed tip. Gray-scale and Doppler ultrasonography, and CT were performed before and after RFA on the procedure day, and on day two. If any complications were found, the same studies were performed at day seven. We analyzed the presence and extent of thrombotic occlusion, the vascular stricture, the arterioportal shunt, and the presence of an intra-abdominal hemorrhage. We applied Fisher's exact test to compare the complication rate between the two groups;, a value was considered statistically significant if the p-value was less than 0.05. Results: In the group I animals (n=11), three had complete thrombotic occlusion of the portal vein. Among these three animals,, one had a segmental infarction, and one animal showed a partial occlusion. In the group II animals (n=16), complications were not identified. Statistical analysis revealed the complication rate of group I was significantly higher than that of group II (p=.019). Conclusion: The portal vein occlusion rate was significantly higher in the portal vein penetrating group than in the non-penetrating group. 목적: 고주파전극으로 간문맥을 관통한 후 소작을 시행하는 경우 발생하는 합병증에 대하여 평가하고자 하였다. 대상과 방법: 돼지 12마리를 2개 군으로 나누었다. 간문맥을 전극으로 관통한 경우(n=11)를 I군, 소작범위 내에 문맥이 위치하게 한 경우(n=16)를 II군으로 하였다. I군에서는 전극의 노출부위가 혈관을 지나게 하고 7분 동안 소작하였다. 회색조 및 도플러 초음파검사와 전산화단층촬영을 시술 당일 소작 전후와 2일째 시행하여 합병증 유무를 확인하였고, 합병증이 의심되는 소견이 있는 경우 7일째 같은 검사를 시행하였으며, 관통된 간문맥의 혈전에 의한 폐색 유무와 정도, 협착 유무, 동문맥단락 유무, 복강 내 출혈 등을 분석하였다. Fisher exact test로 합병증 발생률에 차이가 있는지를 비교하였고 p-value가 0.05 이하인 경우 유의한 것으로 간주하였다. 결과: I군에 포함된 11개의 혈관 중 혈전에 의한 혈관의 완전 폐색이 3예, 부분 폐색이 1예였고 완전 폐색이 있었던 3예 중 1예에서 간분절 괴사가 있었다. II군에 포함된 16개의 혈관에서는 합병증이 발생하지 않았다. 전체 합병증의 발생 빈도는 혈관을 관통한 군에서 혈관을 관통하지 않은 군보다 유의하게 높았다(p=.019). 결론: 간문맥분지를 관통한 다음 고주파치료를 시행하는 경우 혈전에 의한 혈관폐색의 발생률 이 관통하지 않은 군보다 높은 것을 알 수 있었다.

악성 종양 환자에서 발생한 하지 심부 정맥 혈전증의 혈관 내 중재적 치료

정수진,김재규,장남규,한승민,강형근,최수진나 대한영상의학회 2009 대한영상의학회지 Vol.61 No.1

Purpose: To evaluate the efficacy of endovascular management of lower extremity deep vein thrombosis (DVT) in patients with malignant disease. Materials and Methods: Between January 2002 and January 2008, six consecutive patients (5 male and 1 female, mean age-65 years) with lower extremity DVT and malignant disease underwent endovascular management. The duration of symptoms lasted 4-120 days (mean-31 days; 20 days or less in four patients and more than 20 days in two). A catheter-directed thrombolysis was performed via the ipsilateral popliteal vein or common femoral vein, used alone or combined with a percutaneous mechanical thrombectomy. Angioplasty or stent placement was performed in residual stenosis or occlusion of the vein. The follow-up period lasted 1-14 months (mean 7.6 months) and was performed via a color Doppler ultrasonography or computed tomographic venography. Results: Technical success and relief from symptoms was achieved within two days was achieved in five patients. Minor hemorrhagic complications occurred in two cases: hematuria and a hematoma at the puncture site. Upon follow-up, a recurrent DVT occurred in three patients as well as a patent venous flow in two. One patient died within 1 month due to a metastatic mediastinal lymphadenopathy. Conclusion: Endovascular management of the lower extremity DVT is effective for quickly eliminating a thrombus, relieving symptoms, and decreasing hemorrhagic complications in patients with malignant disease. 목적: 악성 종양 환자에서 발생한 하지 심부 정맥 혈전증의 혈관 내 중재적 치료의 유용성에 대해 알아보고자 하였다. 대상과 방법: 2002년 1월부터 2008년 1월까지 하지 부종과 동통을 주소로 촬영한 전산화단층 정맥조영술에서 하지 심부 정맥 혈전증으로 진단되어 중재적 치료를 받은 74명 중 악성 종양이 동반된 6명을 대상으로 하였다. 나이는 56-80세(평균 65세)이며 남자 5명, 여자 1명이었다. 시술 전 증상 기간은 4-120일(평균 31일)이었으며 증상 발생 후 20일 이전은 4예, 20일 이후는 2예였다. 동측의 슬와정맥 또는 총대퇴정맥을 천자한 후 카테터를 통해 혈전용해제를 주입하고 필요한 경우 흡입 혈전 제거술을 이용하여 혈전을 제거하였다. 남아 있는 정맥의 협착이나 폐쇄에 대하여 경피적 혈관 성형술과 스텐트 삽입술을 시행하였다. 추적 관찰 기간은 1-14개월(평균 7.6개월)로 전산화단층 정맥조영술 또는 색도플러 초음파로 검사하였다. 결과: 시술 후 83%(5/6)에서 완전한 정맥 재개통을 보였으며 2일 내에 83%(5/6)에서 증상의 호전을 보였다. 시술에 따른 합병증은 33%(2/6)에서 있었으며 혈뇨와 천자 부위의 혈종이 있었다. 혈전의 재발이 50%(3/6), 정맥 개통 유지가 33%(2/6), 종격동림프절 전이로 인한 사망이 1예였다. 결론: 악성 종양 환자에서 발생한 하지 심부 정맥 혈전증의 중재적 치료는 단시간 내에 혈전을 제거하여 빠른 증상의 개선과 출혈 위험을 감소시킬 수 있을 것으로 보인다.

수술이 불가능한 췌장암에 대한 고강도집속초음파 응고술(하이프)

송인호,정승은,한성태,장진희,조세현,한준열,김진일,이지영,성춘호 대한영상의학회 2007 대한영상의학회지 Vol.56 No.6

Purpose: We wanted to evaluate the levels of effect and safety of high-intensity focused ultrasound ablation (HIFU) for treating patients with advanced pancreatic cancer. Materials and Methods: Nineteen sessions of HIFU, with the patients under general anesthesia, were performed in 18 patients with advanced pancreatic cancer. The change of the gray-scale of the target lesion was analyzed during HIFU, and MRI was performed before and after HIFU. We assessed the extent of coagulative necrosis, the change of pain and the complications after HIFU. The change of tumor size and the survival of patients were also evaluated. Results: The average size of tumor was 4 cm in diameter. Eighty nine percent of the target tumors showed increased echogenicity. On MRI, necrosis of the entire target tumor occurred in 79% of the patients. After treatment, effective pain relief was noted in 89% of the patients. There were no major complications. No size increase of the treated tumor was noted during 24 weeks of follow-up for 10 patients. Six patients among 12 patients who were available for follow-up are still alive and they are receiving chemotherapy. Six patients expired due to other disease or progression of metastasis. Conclusion: HIFU is a safe method without any major complications, and it is effective for inducing tumor necrosis and achieving pain control for patients with advanced pancreatic cancer. 목적: 수술이 불가능한 췌장암에서 고강도집속초음파응고술(high-intensity focused ultrasound system, HIFU, 하이프)의 효과와 안전성을 알아보고자 한다. 대상과 방법: 수술이 불가능한 췌장암으로 진단받은 18명의 환자에서 전신 마취하에 19번의 하이프 시술을 하였다. 치료 중 초음파로 치료 구역의 회색도 변화를 분석하였다. 시술 전후에 MRI를 시행하여 응고괴사범위를 치료계획 범위와 비교하였다. 시술 전후 췌장암으로 인한 통증의 변화를 분석하였고, 합병증의 유무를 확인하였으며 추적 검사를 통해 췌장암 종괴의 크기변화와 환자의 생존 여부를 알아보았다. 결과: 종괴의 시술 전 크기는 최대 지름이 평균 4 cm이었다. 치료 중 초음파에서 치료 구역의 고에코의 회색도 변화는 89%에서 나타났다. 2주 후 추적 MRI 영상에서 79%에서 치료계획 범위 전체가 응고괴사되었다. 89%에서는 시술 후 통증이 경감하거나 소실되었다. 시술 후 경미한 합병증은 있었으나, 중대한 합병증은 없었다. 두 번 이상 영상 추적검사를 시행한 10명의 환자에서 추적 검사기간은 평균 24주였고, 치료한 종양의 크기 증가는 뚜렷하지 않았다. 추적검사가 가능했던 12명의 환자에서 현재 6명의 환자가 항암치료를 받으며 생존해 있다. 하이프치료 후 사망한 6명은 다른 질환이나, 전이암이 진행되어 사망하였다. 결론: 수술이 불가능한 췌장암에서 하이프 시술은 종양의 응고 괴사와 통증 조절에 효과적이며, 중대한 합병증이 없는 안전한 방법이다.

결절성 간세포암의 경도관동맥화학색전술 후 경피적에타놀주입요법 : 치료 결과의 분석

용환석,김영남,박상우,서형석,박철민,차인호 대한초음파의학회 1998 ULTRASONOGRAPHY Vol.17 No.4

수막종의 수술 전 색전술의 유용성 평가

박성태,서대철,이효규,최충곤,이명준,지은경,신병석,김창진,김종욱 대한영상의학회 1998 대한영상의학회지 Vol.39 No.1

Purpose : To evaluate the efficacy and safety of preoperative embolization of intrancranial meningioma.Materials and Methods : We retrospectively reviewed intrancranial meningioma patients (n=37) who underwent preoperative embolization. They were categorized into two groups, skull base lesions (n=22) and non-skull base lesions (n=15), according to tumor location. In addition, embolization results were classified by comparison between pre-and post-embolization angiography as complete (residual tumor staining<10 or 30 %) or incomplete(residual tumor staining$\geq$10 or 30%). In each group, estimated blood loss (EBL) was estimated by amount of intra operative transfusion with pre- and post-operative hemoglobin level. Tumor resectability was evaluated by follow-up computed tomography. New symptoms occurring within 24 hours of embolization were considered to be those associated with embolization ; symptoms improved by conservative treatment were regarded as mild, while those resulting in new deficits were considered severe. Results : In the group with skull base lesions (n=22), complete embolization with the criteria of residual tumor staining of less than 30% was performed in 14 patients(EBL=1770ml ; complete surgical removal in nine patients and incomplete removal four). Incomplete embolization was performed in eight patients (EBL=3210ml; complete and incomplete removal each in four patients). In the group with non-skull base lesions, complete embolization with the criteria of residual tumor staining of less than 10% was performed in five patients (EBL=970ml) and incomplete embolization in ten (EBL=2260ml). Complete tumor removal was possible in this group regardless of the completeness of preoperative tumor embolization. In a case of intraventricular meningioma (3%), intratumoral hemorrage occurred on the day following embolization. Other mild post-embolization complications occurred in three cases (8%). Conclusion : Preoperative embolization can be an effective and safe procedure for meningioma and may reduce intraoperative blood loss. Its effectiveness may depend on tumor location and the degree of embolization, though the procedure seems to be helpful for lseions at the skull base.