LETTER TO THE EDITOR

Ultrasound-Guided High-Intensity Focused Ultrasound(USgHIFU) Ablation in Pancreatic Metastasis from Renal CellCarcinoma

Gianluigi Orgera • Miltiadis Krokidis • Lorenzo Monfardini •

Paolo Arnone • Guido Bonomo • Paolo Della Vigna •

Giuseppe Curigliano • Franco Orsi

� Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2011

Dear Editor,

We would like to share our experience of the treatment

of an inoperable renal cell carcinoma (RCC) pancreatic

metastasis with high-intensity focused ultrasound (US-

gHIFU) in a 55-year-old patient. The lesion was unre-

sponsive to chemotherapy. After HIFU ablation, tumor

necrosis and reduction in size was achieved without any

procedure related complications and there was no evidence

of recurrence in the 9-month follow-up. This is a promising

result of USgHIFU, which seems to be safe and effective

for the midterm control of the nonresponsive to chemo-

therapy renal cell carcinoma metastatic disease.

The pancreas is an uncommon location for metastasis

from other primary cancers and pancreatic metastases

account for less than 5% of all pancreatic malignancies [1,

2]. Indeed renal cell carcinoma usually metastasizes to

lymph nodes, lung, liver, and bones, and very rarely to the

pancreas [3, 4].

High-intensity focused ultrasound (HIFU) is a novel

minimally invasive ablative method that is capable of

producing coagulation necrosis at a precise focal point

within the body, without the necessity of a needle insertion

[5–7].

In our case, a 55-year-old woman underwent left

nephrectomy and adrenalectomy in 2008 for a RCC inci-

dentally discovered in a routine ultrasound (US) exami-

nation. The CT characteristics were suggesting a malignant

lesion that was confirmed with histology (RCC—clear cell

variant, middle grade). There was no evidence of other

sites of metastatic disease, and the patient stage was

T3bN0M0.

The patient did not receive any postoperative chemo-

therapy. In the 3-month follow-up CT scan, a 9-mm

solitary nodule was detected in the pancreatic head. The

lesion was enhancing in arterial phase (Fig. 1) and was

considered highly suspicious for metastatic disease.

G. Orgera � M. Krokidis (&) � L. Monfardini � G. Bonomo �P. Della Vigna � F. Orsi

Unit of Interventional Radiology, European Institute

of Oncology, Via Ripamonti 435, 20141 Milan, MI, Italy

e-mail: mkrokidis@hotmail.com

P. Arnone

Division of Senology, European Institute of Oncology,

Via Ripamonti 435, 20141 Milan, MI, Italy

G. Curigliano

Division of Medical Oncology, European Institute of Oncology,

Via Ripamonti 435, 20141 Milan, MI, Italy

Fig. 1 Multidetector CT scan in arterial phase demonstrating the

enhancing lesion in the head of the pancreas (arrows)

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Cardiovasc Intervent Radiol

DOI 10.1007/s00270-011-0291-y

The histological specimen obtained after US-guided biopsy

confirmed metastasis from RCC.

The surgical team did not consider the patient as a

suitable candidate for resection due to the short disease-

free interval from the primary RCC that was suggesting an

aggressive growth pattern of the course of the disease, and

palliation was decided. The lesion also was not considered

suitable for percutaneous ablation due to the potential risk

of thermal injury of the adjacent anatomical structures and

chemotherapy begun.

In the follow-up CT scan at 9 months, local disease

progression was noticed, expressed by slight increase of the

size of the nodule. After a multidisciplinary meeting a

consensus was reached to participate in a phase I study for

HIFU treatment of solid tumors associated with neoadju-

vant systemic therapy using a tyrosine kinase receptor

inhibitor, Sunitinib malate (Pfizer Italia, Milan, Italy), dose

50 mg orally once per day for 4 weeks.

The patient had a Karnofsky performance scale score of

90%, with no contraindication to general anesthesia, which

is necessary for the HIFU procedure. The lesion was

visualized before the procedure using US and contrast-

enhanced ultrasound (CEUS) after injection of 2.4 ml of

sulphur hexafluoride in the form of microbubbles (Sono-

Vue, Bracco, Milan, Italy), which confirmed the enhancing

nodule (Fig. 2) and that no gas interfered in the acoustic

pathway. A purified-water balloon was used to push and

compress bowel loops excluding the presence of air in the

pathway beam and achieving bowel-motion control.

Informed consent was obtained. The patient fasted for 8 h

before the procedure. The skin overlying the lesion was

carefully shaved and degassed to avoid any interference of

hair in the acoustic pathway of HIFU; a urinary catheter

was inserted before beginning the treatment.

The system used for the procedure is the JC-HIFU

system (Chongqing Haifu-HIFU-Tech, Chongqing, China).

The patient was positioned prone on the HIFU table after

being anesthetized, ensuring that the degassed water reci-

pient was in contact with the skin above the lesion. The

procedure was guided by real-time US. The ablation was

performed in a vertical scanning mode with a 5-mm dis-

tance between slices.

The transducer characteristics were: diameter 20 cm,

focal length 15 cm, frequency 0.8 MHz. At the center of

the HIFU transducer a 1.0–8.0 MHz imaging probe was

located for the real-time imaging. The power used range

was between 360 and 410 W. Real-time imaging was

processed with a MyLab70 US imaging device (Esaote,

Genova, Italy).

The focal point used was 3.3-mm long by 1.1-mm wide.

The process was repeated on a section-by-section (point-

by-point) basis to achieve complete lesion ablations. Total

time (preparation and treatment) was 3 h and 30 min.

Procedural time (time from the lesion localization to the

last sonication) was 2 h and 10 min. We also calculated

total sonication time, defined as the exposure time, which is

related to the lesion size and the blood supply, and it was

1,100 s.

Fig. 2 A US scan previous treatment. The lesion appears hypoechoic.

B Contrast-enhanced ultrasound showing the lesion prior to treatment

(arrows). The lesion appears enhancing in the late arterial phase

G. Orgera et al.: Ultrasound-Guided High-Intensity Focused Ultrasound

123

The lesion echogenicity change was used as an indicator

of treatment during the ablation process. When the lesion

became hyperechoic, satisfactory coagulation necrosis of

the tissue was assumed.

To evaluate the immediate therapeutic response to

ultrasound-guided high-intensity focused ultrasound,

CEUS was performed at the end of procedure with the

evidence of a completely nonvascular area, indicating the

end of the procedure (Fig. 3). The temperature was not

measured.

Multidetector CT (MDCT) scan 24 h after treatment

showed complete lack of enhancement, without any evi-

dence of injury in the nearby structures. The result was

considered satisfactory, assuming the formation of necrotic

tissue, and the patient was discharged the next day.

Treatment with Sunitinib, dose 50 mg orally once per

day for 4 weeks with interruption for 2 weeks, was initially

scheduled, but severe immune suppression occurred and

development of herpes simplex and oral candidosis asso-

ciated with severe diarrhea and vomiting; therefore, the

treatment was interrupted after 2 weeks for 2 weeks. Then,

a second cycle with 25-mg oral dose was performed but

with similar adverse effects; therefore, no further chemo-

therapy was given. Follow-up MDCT performed at 1, 3, 6,

and 9 months later showed decreased size of the mass

without residual enhanced tissue, suggesting successful

lesion ablation (Fig. 4).

Ablative therapies have an established role in pancreatic

tumor management and may be a solution in such cases as

the one described. RFA ablation is an established and

widely accepted treatment method for various solid tumors

[8] but not for pancreatic malignancies. In such challenging

anatomical sites, RFA might be difficult and may be

associated with complications. In a report from Elias et al.

[9], RFA was used to treat two patients with pancreatic

metastases of renal cell carcinomas. Both patients had

major complications; the first had a pancreatico-cutaneous

fistula that required laparotomy and the second a severe

necrotizing pancreatitis. Apart from RFA, there are other

ablative techniques, such as microwave ablation, cryo-

therapy, or photodynamic therapy, which may play a role

in the future [10]. However, ablation in this delicate area

needs to be very precise due to the high risk of injury of the

rest of the pancreatic parenchyma, predisposing to pan-

creatitis or the adjacent structures, such as the duodenum

and the common bile duct.

With the focused US energy offered by HIFU, the

ablation result may be satisfactory even when the lesion is

located adjacent to major hepatic blood vessels [5–7].

There is no necessity of needle insertion; high-acoustic

energy is delivered to a precise spot and absorbed by the

lesion, causing damage due to cavitation and coagulation

necrosis. The fact that the energy beam is focused spares

the surrounding tissues from advert events. Nevertheless,

sensible structures, such as the bowel, need to be avoided

due to the risk of severe injury. A clear acoustic pathway is

necessary, but deep tissues may be reached with HIFU in

difference to RFA.

There is limited experience; nevertheless in two previ-

ous reports, it was shown that HIFU is safe and effective

for the treatment of pancreatic lesions [11, 12].

In the case described, HIFU appears to be a valid option,

considering the location of the lesion and the local exper-

tise. Nine-month control of disease without evidence of

recurrence was obtained, which is satisfactory.

Fig. 3 A Intraprocedural US scan showing the lesion. Note the

change in the echogenicity (from hypoechoic to hyperechoic)

indication satisfactory tissue ablation. B Contrast-enhanced US at

the end of the procedure shows no enhancement of the lesion in

neither of the vascular phases

G. Orgera et al.: Ultrasound-Guided High-Intensity Focused Ultrasound

123

Conflict of interest The authors declare no conflict of interest.

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Fig. 4 Arterial phase of follow-

up MDCT performed at 1 and

9 months, showing decreased

size of the lesion without

residual enhancing tissue

G. Orgera et al.: Ultrasound-Guided High-Intensity Focused Ultrasound

123