Christopher J. Dobzyniak, M.D., presents a case featuring a 65-year old female with a history of Hepatitis C, who presented with a hepatocellular carcinoma. Dr. Dobzyniak performs microwave ablation therapy to treat this lesion.
Hi there. I'm dr Christopher Dobson Yak and the chief of interventional radiology and medical center radiologist and the medical director of interventional radiology uh center Norfolk General. Um Today we're gonna discuss a microwave ablation case. The specific patient we're gonna discuss today is a 65 year old female with the history of hepatitis C. Who presented with a solitary segment eight uh happen to cellular carcinoma. We initially decided to do an angiogram on this patient in anticipation of staining the legion with capital in hopes that it would become more visible when we came back to do an ablation here. You can see a subsequent follow up non contrast ct and the same patient after lap a little infusion which is sort of a fatty oil that gets deposited in the tumor. The tumor doesn't have the cells the cup for cells to clean out the capital. So it stays there basically forever. This is the day of the ablation now. So we're just sort of scrolling through our initial ct kind of picking our spot. We've then imported that information into the microwave ablation device. This specific device has what we call operation confirmation software. So once we import that, that ct data, we can draw a region of interest around the lesion and then we can sort of model that in three dimensions. It helps us sort of pick where we're going to have our skin entry site, where we're anticipating kind of our needle ending up and then allowing us to ultimately confirm that positioning before we're ready to oblate. So now we've sort of switched to real time Ct Flora Skopje were sort of lining up where we want to go. The specific ablation pro we're gonna use today is what's called the new wave PR program is sort of an interesting probe. Most ablation probes to be a cry ablation mike, revelation or radio frequency ablation. We'll have a energy generator of some sort sort of at the distal end of the needle, but not necessarily the tip. And then just sort of the ablation extends out from that. This specific probe burned specifically back from the tip, so we can position the tip of the probe up against structures. We don't want to damage the gall bladder, large blood vessels, bowel colon. Um And as long as the tip is against those structures, we know the ablation defect is gonna is gonna go back from that tip. Um So we can sort of protect those areas and still get treatment of lesions. So it allows us to treat lesions in very challenging locations. So now as we go, we're just sort of making some fine adjustments with intermittent flora. Skopje. We're then gonna report that information back into the device and we can see here the green line here indicates the position of our needle. We're sort of at the top end of the lesion with a small lesion like this would probably be okay to go ahead and oblate and be comfortable getting everything. But we made the decision to place a second probe, sort of along more the inferior aspect of legion, just to make sure we were gonna bracket it and get everything and not leave anything behind. These probes are cooled with CO two, so CO two is going to circulate through this thing. So we put the tip in a little bit of saline. Circulate The Co two through just to make sure there's no cracks or defects in the probe that might keep it from not working properly. Gonna make about a two or three millimeter incision here, so that we can place the second needle and again, we're just gonna sort of proceed under Ct Flora Skopje. Once we're sort of confident we're going to put that information again, back into the device. This is again that ablation confirmation software we can see here are original green needle in our second blue needle, sort of more at the inferior margin Of the lesion. So now we feel a pretty good spot comfortable to oblate. We can look at this and rotate in any way we want. Once we decide we're ready to oblate with this specific probe, we can oblate with a power up to 65 watts and we sort of determine the time of the ablation just depending on the size of lesion location of lesion, number of probes who put in this is a relatively small lesion. So we're gonna treat for about five minutes with these two probes. Uh Now, while we're treating, we're just gonna sort of monitor the patient. Um make sure everything is looking fine. We're gonna do some intermittent fluoroscope. PCT Flora Skopje as we go, we're looking for sort of gas accumulation around the lesion to indicate that the ablation is incorporating the lesion in a small area around the lesion as well. Once we're done, we're gonna take the needles out. I'm gonna recap these, we're gonna do another cT scan right now. Uh You know, if there's anything left over, we've got the needles to come back rather than having to open in a couple of new ones. Um But hopefully everything looks good and we're done. So just a quick clean up here and you can see you can barely tell that we were there. She'll get a couple of band aids will keep overnight. Just make sure she's doing okay and get her out the next day. This is our follow up MRI. About a month later. This is arterial phase MRI. And you can see, we just sort of have this black defect. If we go back to the original image, we sort of saw that enhancement. Now, we don't see any of that. This is what we want to see. This indicates that the ablation was successful and that there's no residual tumor follow up. We'll go for about three months and we'll repeat another Emory to make sure things are still looking good, uh and and make sure she's doing okay.