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High-intensity focused ultrasound provides palliation for liver metastasis causing gastric outlet obstruction: case report

Journal of Therapeutic Ultrasound volume 1, Article number: 9 (2013) Cite this article

Abstract

Background

Surgery is the standard of care in several oncologic diseases. However, when non-surgical candidates are not suitable for radical treatment, palliation must be achieved at least. High-intensity focused ultrasound uses ultrasound power that can be sharply focused for highly localised application, as it is a completely non-invasive procedure. Its non-invasiveness appears to be of paramount importance in critically ill patients.

Case description

We describe the use of ultrasound-guided high-intensity focused ultrasound for a large liver metastasis from breast cancer causing gastric outlet obstruction in a metastatic disease. The left liver deposit did not allow the stomach to empty due to its large volume, and the patient was unable to eat properly. The tumour was metastatic, resistant to chemotherapy and had a size that contraindicated an ablation percutaneous technique. To improve the patient's quality of life, ultrasound-guided high-intensity focused ultrasound ablation seemed the only and most suitable option. Therefore, a high-intensity focused ultrasound treatment was performed, no complications occurred and the patient's general condition has improved since the early post-procedural period. Three months after treatment, two body mass index points were gained, and the lesion decreased by 72% in volume as detected through multi-detector computed tomography follow-up.

Discussion and conclusion

Quality of life is an unquestionable goal to achieve, and palliation must be achieved while causing as little harm as possible. In this view, debulking surgery and percutaneous ablation technique seemed not appropriate for our patient. Instead, high-intensity focused ultrasound combined several advantages, no lesion size limit and a totally non-invasive treatment. Thus, this technique proved to be a clinically successful procedure, offering better disease control and quality of life. In circumstances where other alternatives clearly seem to fail or are contraindicated, high-intensity focused ultrasound can be used and can provide benefits. We recommend its use and development in several oncologic diseases, not only for therapeutic purposes but also for the improvement of patient's quality of life.

Background

Surgery is the standard of care for selected patients with solid tumours of the liver, offering the chance of a complete cure by tumour removal. Unfortunately, the majority of patients are unfit for surgical resections because of the sites of their tumour, advanced disease or poor general condition. Clinicians have been trying to develop new standards of care in these circumstances, such as radiofrequency ablation, percutaneous ethanol injection, cryoablation, microwave coagulation, laser-induced interstitial thermotherapy and, finally, high-intensity focused ultrasound (HIFU).

HIFU uses ultrasound power that can be sharply focused for highly localised application, as it is a completely non-invasive procedure. The liver is one of the first areas where focused ultrasounds have been used [1]. Several groups have used ultrasound-guided high-intensity focused ultrasound (USgHIFU) to treat hepatic neoplasms including primary neoplasms [2, 3] or secondary deposits [4], regardless of tumour location [5, 6].

HIFU non-invasiveness appears to be of paramount importance in critically ill patients at very high risk for surgery. Moreover, in addition to the advantage gained from a curative point of view, HIFU may improve quality of life, reducing or eliminating tumour-related pain and providing a debulking of large neoplastic lesions [7–10]. The case we describe is primarily related to the improvement of quality of life for a large liver metastasis causing gastric outlet obstruction in metastatic disease.

Case description

A 49-year-old female with previously diagnosed breast cancer was referred to us with metastasis, bilaterally and extensively in the lung, in the left acetabulum and in the liver, primarily in the left lobe and in the right (segments 5 to 8 and segment 8, respectively). Three years previously, she had undergone a wide excision and axillary lymph node dissection for a ductal carcinoma pT3N1M0. After the surgery, she was treated with an adjuvant radiotherapy regimen of 50 GY in 25 fractions over 5 weeks and first line chemotherapy agents, such as anthracyclines, taxanes (docetaxel) and cyclophosphamide. She completed a long course of endocrine therapy with tamoxifen.

Initially, she was started on a monoclonal antibody therapy with bevacizumab. The disease progressed notwithstanding the chemotherapy treatment.

The patient, with a KPS of 70%, presented with anorexia, right upper quadrant pain, weight of loss body mass index (BMI) of 16, vomiting and right coxalgia. A full-body CT scan showed multiple liver and lung deposits, and an osteolytic metastases of the left acetabulum (Figure 1a). A 3D rendering of the pre-HIFU reconstruction clearly showed the extent of the disease (Figure 1b).

Figure 1
figure 1

CT of patient before treatment. (a) Contrast-enhanced multi-detector CT. A 10 cm × 7 cm liver lesion (blue arrows with main diameters) completely occupying the left lobe in a multi-deposit disease is compressing and dislocating the stomach (red arrows). (b) 3D rendering image pre-treatment.

Full size image

The gastric outlet obstruction was due to a left liver metastasis with a volume of 10 cm × 7 cm × 10 cm, corresponding to 365,6993 cm3. The lesion volume was calculated by a volumetric semi-automatic segmentation technique analysis on CT scan with slices of 2 mm thin. This lesion caused the most severe symptom upon referral, compressing the duodenum and delaying gastrointestinal transit. Pre-treatment oesophagogastroduodenoscopy confirmed an external obstruction with normal gastric mucosa. To improve patient's quality of life effectively without harm, an HIFU procedure seemed to be the most feasible option for debulking.

HIFU technique

Informed consent was obtained from the patient, and approval was gained from Azienda Ospedaliero-Universitaria Careggi local ethics committee. Pre-treatment planning was performed with US, and no gas interference in the acoustic pathway was discovered (Figure 2).

Figure 2
figure 2

US pre-treatment images. Left liver deposit (blue arrows) is in the target area, being completely in the centre of the US scan. There was no gas interference in the acoustic pathway.

Full size image

The day before the procedure, bowel preparations had been administered from late morning (MOVIPREP® (Norgine Italia S.r.l., Milan, Italy) - Macrogol 3350/sodium sulphate, anhydrous/sodium chloride/potassium chloride/ascorbic acid/sodium ascorbate plus PANAMIR V (D.M.G. Italia S.r.l. (Rome, Italy) - simethicone), and the patient was put on a full liquid diet. The skin overlying the lesion was carefully shaved to avoid any potential hair interference. General anaesthesia with endotracheal intubation and mechanical ventilation was performed, thus permitting control of the pulmonary inflation. So providing provisional suspension of respiration, it was possible to match the rate of sonication delivery, keeping the target tumour within the therapeutic zone. Nonetheless, the lesion was partially behind the rib cage.

A degassed water balloon was used to push and compress the bowel loops to avoid any unexpected presence of air in the beam pathway and to provide bowel-movement control. A nasogastric tube was inserted and left in place to optimise the acoustic pathway and to detect any gastric damage. The patient was carefully positioned in the prone position, placing the skin overlying the target lesion in contact with the degassed water. A vertical scanning mode was chosen with a 5-mm distance between each slice. HIFU ablation was conducted with safe margins of 10 mm within the lesion using the JC200-HIFU system (Chongqing Haifu-HIFU-Tech, Chongqing, China). Therapeutic US energy was produced by a transducer with a diameter of 20 cm, a focal length of 15 cm and a frequency of 0.8 MHz. The MyLab70 US imaging device (ESAOTE, Genova, Italy) was used as a real-time imaging unit, using an integral central 3.5-MHz diagnostic ultrasound probe located in the centre of the HIFU transducer. By scanning with the HIFU beam, the targeted region of each section was ablated. This process was repeated on a section-by-section basis to achieve complete lesion ablation. Real-time US scans showed changes in the echogenicity of the treated regions. Comparing gray-scale changes obtained on the diagnostic images after each HIFU exposure, we assessed and monitored the extent of treatment. If any unexpected residual non-ablated portion of the tumour was found at the site of the treated lesion, an additional HIFU ablation was performed. Total time (preparation and treatment) was 5 h and 30 min. Total treatment time was 3 h and 58 min, with a sonication time of 1 h and 19 min; both of these respective times were related to lesion size and blood supply. The focal peak intensities ranged between 400 and 150 W; however, mainly higher intensity energies were used. The total ablated volume was 80% (Figure 3).

Figure 3
figure 3

US images during the treatment. The yellow lines represent the focal points treated on a single slice. Repeating this process on each slice, we achieve a complete lesion ablation.

Full size image

The osteolytic metastasis of the left acetabulum was treated with Cyberknife (Accuray Company, Sunnyvale, USA) stereotactic radiosurgery. Four CT-guided gold fiducials were positioned percutaneously.

Results

After treatment, the patient started feeding carefully with clear fluid; 3 days later, she was discharged from our hospital with no symptoms remaining and on a semi-liquid diet, with more frequent small meals advised after at least 2 weeks had passed.

The results were considered to be satisfactory based on necrotic tissue formation in the lesion as well as patient clinical signs and symptoms. No ablation-related complications occurred. Laboratory studies showed normal liver function tests 24 h after the procedure.

Three months after the procedure, the patient had a BMI of 18. Two additional points of improvement were shown by post-procedural multi-detector computed tomography (MDCT); the lesion hypodensity with the presence of a residual enhancement rim had decreased in size by approximately 72% (6 cm × 6 cm × 6.5 cm, corresponding to 101.9223 cm3), and the lack of enhancement persisted, suggesting successful local tumour control (Figure 4a). A 3D rendering of the post-HIFU reconstruction clearly showed the disease entity (Figure 4b).

Figure 4
figure 4

CT of patient 3 months after treatment. (a). Contrast-enhanced multi-detector CT. A 6 cm × 6 cm liver lesion (blue arrows) is identified, showing a decrease in size of 72%. (b) 3D rendering image post-treatment.

Full size image

Discussion

The liver is a primary site of metastasis for tumours originating at many sites [11], and liver metastasis develops in approximately half of women with metastatic breast cancer [12]. Therapies for patients with metastatic breast cancer include systemic chemotherapy [13], hormone therapy or both [14]. Immunotherapies, commonly cyclooxygenase-2 or vascular endothelial growth factor inhibitors such as bevacizumab [15, 16], are gaining wide acceptance as adjuvant agents in a chemotherapy regimen, but not as a standard treatment.

Our patient unfortunately showed disease progression notwithstanding chemotherapy treatments, such as anthracyclines, taxanes (docetaxel), cyclophosphamide, tamoxifen and monoclonal antibody therapy (bevacizumab).

Quality of life is an unquestionable goal to achieve in these patients. In our experience, we found that the left liver metastasis was the cause of an outlet obstruction syndrome. Palliation must be achieved while causing as little harm as possible. Thus, surgery plays a role if in-depth knowledge of non-surgical palliative treatments is not available. Moreover, surgeons must consider the risk of potentially shortening or reducing the quality of the patient's remaining time due to surgical complications [17, 18].

In our experience, HIFU non-invasiveness is of paramount importance. In fact US waves can penetrate skin and tissue layers without causing damage to them, thereby reaching a target further inside the body [19]. At the focal point, the clinical effect occurs by the following two main mechanisms: the thermal effect, wherein temperatures can reach 60°C, with cell death occurring at 56°C for > 1 s [20], and the cavitation-induced cellular damage mechanical effect which is due to mechanical stress [21]. Consequently, the target tissue is destroyed by protein coagulation.

HIFU is gaining increasing interest for the treatment of solid neoplasms [22]. In recent years, many trials have been conducted proving the efficacy and feasibility of HIFU ablation in different clinical applications [23–27]. Liver tumours have been treated when considered as primary neoplasms [2, 3] or secondary deposits [4] regardless of tumour location [5, 6]. Moreover, in addition to the advantage gained from a curative point of view, HIFU may improve quality of life with uterine fibroids [7], reduce or eliminate tumour-related pain in pancreatic cancer [8, 9] or provide debulking of large neoplastic lesions [10].

In our case, a debulking procedure was needed, but the size of the lesion (10 cm × 7 cm × 10 cm) was a contraindication to local ablative therapies, such as radiofrequency ablation [28], percutaneous ethanol injection [29], cryoablation [30], microwave coagulation [31], and laser-induced interstitial thermotherapy [32]. USgHIFU was our last chance to non-invasively treat the liver metastasis. HIFU has been shown to provide ablation of large liver tumours ranging in size from 5 to 12 cm in diameter [33], with the maximum size reached 4 to 14 cm in diameter and an average diameter of 8.18 ± 3.37 cm [34]. Almost the entire lesion was ablated in our case (80% of the lesion), with a decrease in size of approximately 72% at 3 months by MDCT, with the presence of residual enhancement rim. Our goal was a palliative debulking, and this goal was achieved here.

No complications were detected in our case; in fact, outside the focal region, the ultrasound intensity is substantially lower, thus minimising the risk of unintended injury to the surrounding structures. Generally, HIFU is well tolerated, even in severe conditions [35], and this result was confirmed by our case.

Conclusions

HIFU proved to be a clinically successful procedure, offering better disease control and quality of life. The patient became symptom-free, and no complications occurred. In circumstances where other alternatives clearly seem to fail or are contraindicated, HIFU can be used and provides benefits. We recommend its use and development in several oncologic diseases, not only for therapeutic purposes but also for the improvement of patient's quality of life.

Abbreviations

HIFU:

High-intensity focused ultrasound

USgHIFU:

Ultrasound-guided high-intensity focused ultrasound

BMI:

Body mass index

MDCT:

Multi-detector computed tomography.

References

  1. Taylor KJ, Connolly CC: Differing hepatic lesions caused by the same dose of ultrasound. J Pathol. 1969, 98 (4): 291-293. 10.1002/path.1710980410.

    Article  CAS  PubMed  Google Scholar 

  2. Wu F, Wang Z, Chen W: Pathological study of extracorporeally ablated hepatocellular carcinoma with high-intensity focused ultrasound. Zhonghua Zhong Liu Za Zhi. 2001, 23 (3): 237-239. 10.1016/S0301-5629(01)00389-1. [Article in Chinese]

    CAS  PubMed  Google Scholar 

  3. Wu F, Wang ZB, Chen WZ, Zou JZ, Bai J, Zhu H, Li KQ, Jin CB, Xie FL, Su HB: Advanced hepatocellular carcinoma: treatment with high-intensity focused ultrasound ablation combined with transcatheter arterial embolization. Radiology. 2005, 235 (2): 659-667. 10.1148/radiol.2352030916.

    Article  PubMed  Google Scholar 

  4. Illing RO, Kennedy JE, Wu F, ter Haar GR, Protheroe AS, Friend PJ, Gleeson FV, Cranston DW, Phillips RR, Middleton MR: The safety and feasibility of extracorporeal high-intensity focused ultrasound (HIFU) for the treatment of liver and kidney tumours in a Western population. Br J Cancer. 2005, 93 (8): 890-895. 10.1038/sj.bjc.6602803.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  5. Zhang L, Zhu H, Jin C, Zhou K, Li K, Su H, Chen W, Bai J, Wang Z: High-intensity focused ultrasound (HIFU): effective and safe therapy for hepatocellular carcinoma adjacent to major hepatic veins. Eur Radiol. 2009, 19 (2): 437-445. 10.1007/s00330-008-1137-0.

    Article  PubMed  Google Scholar 

  6. Orsi F, Zhang L, Arnone P, Orgera G, Bonomo G, Vigna PD, Monfardini L, Zhou K, Chen W, Wang Z, Veronesi U: High-intensity focused ultrasound ablation: effective and safe therapy for solid tumors in difficult locations. AJR Am J Roentgenol. 2010, 195 (3): W245-W252. 10.2214/AJR.09.3321.

    Article  PubMed  Google Scholar 

  7. Voogt MJ, Trillaud H, Kim YS, Mali WP, Barkhausen J, Bartels LW, Deckers R, Frulio N, Rhim H, Lim HK, Eckey T, Nieminen HJ, Mougenot C, Keserci B, Soini J, Vaara T, Köhler MO, Sokka S, van den Bosch MA: Volumetric feedback ablation of uterine fibroids using magnetic resonance-guided high intensity focused ultrasound therapy. Eur Radiol. 2012, 22 (2): 411-417. 10.1007/s00330-011-2262-8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  8. Zhao H, Yang G, Wang D, Yu X, Zhang Y, Zhu J, Ji Y, Zhong B, Zhao W, Yang Z, Aziz F: Concurrent gemcitabine and high-intensity focused ultrasound therapy in patients with locally advanced pancreatic cancer. Anticancer Drugs. 2010, 21 (4): 447-452. 10.1097/CAD.0b013e32833641a7.

    Article  CAS  PubMed  Google Scholar 

  9. Xiong LL, Hwang JH, Huang XB, Yao SS, He CJ, Ge XH, Ge HY, Wang XF: Early clinical experience using high intensity focused ultrasound for palliation of inoperable pancreatic cancer. JOP. 2009, 10 (2): 123-129.

    PubMed  Google Scholar 

  10. Jolesz FA, Hynynen K, McDannold N, Tempany C: MR imaging-controlled focused ultrasound ablation: a noninvasive image-guided surgery. Magn Reson Imaging Clin N Am. 2005, 13 (3): 545-560. 10.1016/j.mric.2005.04.008.

    Article  PubMed  Google Scholar 

  11. Groeschl RT, Nachmany I, Steel JL, Reddy SK, Glazer ES, de Jong MC, Pawlik TM, Geller DA, Tsung A, Marsh JW, Clary BM, Curley SA, Gamblin TC: Hepatectomy for noncolorectal non-neuroendocrine metastatic cancer: a multi-institutional analysis. J Am Coll Surg. 2012, 214 (5): 769-777. 10.1016/j.jamcollsurg.2011.12.048.

    Article  PubMed  Google Scholar 

  12. Selzner M, Morse MA, Vredenburgh JJ, Meyers WC, Clavien PA: Liver metastases from breast cancer: long-term survival after curative resection. Surgery. 2000, 127 (4): 383-389. 10.1067/msy.2000.103883.

    Article  CAS  PubMed  Google Scholar 

  13. Nicolini A, Giardino R, Carpi A, Ferrari P, Anselmi L, Colosimo S, Conte M, Fini M, Giavaresi G, Berti P, Miccoli P: Metastatic breast cancer: an updating. Biomed Pharmacother. 2006, 60 (9): 548-556. 10.1016/j.biopha.2006.07.086.

    Article  CAS  PubMed  Google Scholar 

  14. Elias D, Di Pietroantonio D: Surgery for liver metastases from breast cancer. HPB (Oxford). 2006, 8 (2): 97-99. 10.1080/13651820500471871.

    Article  Google Scholar 

  15. Ignoffo RJ: Overview of bevacizumab: a new cancer therapeutic strategy targeting vascular endothelial growth factor. Am J Health Syst Pharm. 2004, 61 (21 Suppl 5): S21-S26.

    CAS  PubMed  Google Scholar 

  16. Saji S, Hirose M, Toi M: Novel sensitizing agents: potential contribution of COX-2 inhibitor for endocrine therapy of breast cancer. Breast Cancer. 2004, 11 (2): 129-133. 10.1007/BF02968291.

    Article  PubMed  Google Scholar 

  17. Dunn GP: Palliative surgical outcomes: are we looking through a keyhole?. Ann Surg Oncol. 2012, 19 (12): 3637-3638. 10.1245/s10434-012-2507-z.

    Article  PubMed  Google Scholar 

  18. Podnos YD, Juarez G, Pameijer C, Choi K, Ferrell BR, Wagman LD: Impact of surgical palliation on quality of life in patients with advanced malignancy: results of the decisions and outcomes in palliative surgery (DOPS) trial. Ann Surg Oncol. 2007, 14 (2): 922-928. 10.1245/s10434-006-9238-y.

    Article  PubMed  Google Scholar 

  19. Jenne JW, Preusser T, Günther M: High-intensity focused ultrasound: principles, therapy guidance, simulations and applications. Z Med Phys. 2012, 22 (4): 311-322. 10.1016/j.zemedi.2012.07.001.

    Article  PubMed  Google Scholar 

  20. Kennedy JE, Ter Haar GR, Cranston D: High intensity focused ultrasound: surgery of the future?. Br J Radiol. 2003, 76 (909): 590-599. 10.1259/bjr/17150274.

    Article  CAS  PubMed  Google Scholar 

  21. Leslie TA, Kennedy JE: High-intensity focused ultrasound principles, current uses, and potential for the future. Ultrasound Q. 2006, 22 (4): 263-272. 10.1097/01.ruq.0000237259.25885.72.

    Article  PubMed  Google Scholar 

  22. Orsi F, Arnone P, Chen W, Zhang L: High intensity focused ultrasound ablation: a new therapeutic option for solid tumors. J Cancer Res Ther. 2010, 6 (4): 414-420. 10.4103/0973-1482.77064.

    Article  PubMed  Google Scholar 

  23. Wu F, Wang ZB, Chen WZ, Wang W, Gui Y, Zhang M, Zheng G, Zhou Y, Xu G, Li M, Zhang C, Ye H, Feng R: Extracorporeal high intensity focused ultrasound ablation in the treatment of 1038 patients with solid carcinomas in China: an overview. Ultrason Sonochem. 2004, 11 (3–4): 149-154. 10.1016/j.ultsonch.2004.01.011.

    Article  CAS  PubMed  Google Scholar 

  24. Ren XL, Zhou XD, Zhang J, He GB, Han ZH, Zheng MJ, Li L, Yu M, Wang L: Extracorporeal ablation of uterine fibroids with high-intensity focused ultrasound: imaging and histopathologic evaluation. J Ultrasound Med. 2007, 26 (2): 201-212.

    PubMed  Google Scholar 

  25. Zhang L, Wang ZB: High-intensity focused ultrasound tumor ablation: review of ten years of clinical experience. Front Med China. 2010, 4 (3): 294-302. 10.1007/s11684-010-0092-8.

    Article  PubMed  Google Scholar 

  26. Ritchie RW, Leslie T, Phillips R, Wu F, Illing R, ter Haar G, Protheroe A, Cranston D: Extracorporeal high intensity focused ultrasound for renal tumours: a 3-year follow-up. BJU Int. 2010, 106 (7): 1004-1009. 10.1111/j.1464-410X.2010.09289.x.

    Article  PubMed  Google Scholar 

  27. Chen W, Zhu H, Zhang L, Li K, Su H, Jin C, Zhou K, Bai J, Wu F, Wang Z: Primary bone malignancy: effective treatment with high-intensity focused ultrasound ablation. Radiology. 2010, 255 (3): 967-978. 10.1148/radiol.10090374.

    Article  PubMed  Google Scholar 

  28. Kornprat P, Jarnagin WR, DeMatteo RP, Fong Y, Blumgart LH, D'Angelica M: Role of intraoperative thermoablation combined with resection in the treatment of hepatic metastasis from colorectal cancer. Arch Surg. 2007, 142 (11): 1087-1092. 10.1001/archsurg.142.11.1087.

    Article  PubMed  Google Scholar 

  29. Tanaka K, Nakamura S, Numata K, Kondo M, Morita K, Kitamura T, Saito S, Kiba T, Okazaki H, Sekihara H: The long term efficacy of combined transcatheter arterial embolization and percutaneous ethanol injection in the treatment of patients with large hepatocellular carcinoma and cirrhosis. Cancer. 1998, 82 (1): 78-85. 10.1002/(SICI)1097-0142(19980101)82:1<78:AID-CNCR9>3.0.CO;2-G.

    Article  CAS  PubMed  Google Scholar 

  30. Seifert JK, Morris DL: Prognostic factors after cryotherapy for hepatic metastases from colorectal cancer. Ann Surg. 1998, 228 (2): 201-208. 10.1097/00000658-199808000-00009.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  31. Qian J: Interventional therapies of unresectable liver metastases. J Cancer Res Clin Oncol. 2011, 137 (12): 1763-1772. 10.1007/s00432-011-1026-9.

    Article  PubMed  Google Scholar 

  32. Vogl TJ, Mack M, Straub R, Eichler K, Engelmann K, Roggan A, Zangos S: Percutaneous interstitial thermotherapy of malignant liver tumors. Rofo. 2000, 172 (1): 12-22. 10.1055/s-2000-12145. [Article in German]

    Article  CAS  PubMed  Google Scholar 

  33. Wu F, Chen WZ, Bai J, Zou JZ, Wang ZL, Zhu H, Wang ZB: Tumor vessel destruction resulting from high-intensity focused ultrasound in patients with solid malignancies. Ultrasound Med Biol. 2002, 28 (4): 535-542. 10.1016/S0301-5629(01)00515-4.

    Article  PubMed  Google Scholar 

  34. Wu F, Wang ZB, Chen WZ, Zhu H, Bai J, Zou JZ, Li KQ, Jin CB, Xie FL, Su HB: Extracorporeal high intensity focused ultrasound ablation in the treatment of patients with large hepatocellular carcinoma. Ann Surg Oncol. 2004, 11 (12): 1061-1069. 10.1245/ASO.2004.02.026.

    Article  PubMed  Google Scholar 

  35. Cheung TT, Chu FS, Jenkins CR, Tsang DS, Chok KS, Chan AC, Yau TC, Chan SC, Poon RT, Lo CM, Fan ST: Tolerance of high-intensity focused ultrasound ablation in patients with hepatocellular carcinoma. World J Surg. 2012, 36 (10): 2420-2427. 10.1007/s00268-012-1660-7.

    Article  PubMed Central  PubMed  Google Scholar 

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Authors and Affiliations

  1. Surgical Endoscopy Unit, Careggi Academic and Regional Hospital of Florence, Florence, 50134, Italy

    Michele Rossi & Riccardo Naspetti

  2. Interventional Radiology Unit, Careggi Academic and Regional Hospital of Florence, Florence, 50134, Italy

    Claudio Raspanti & Ernesto Mazza

  3. Radiology Department, Careggi Academic and Regional Hospital of Florence, Florence, 50134, Italy

    Ilario Menchi

  4. Department of Anesthesia and Critical Care, Careggi Academic and Regional Hospital of Florence, Florence, 50134, Italy

    Angelo Raffaele De Gaudio

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Authors’ contributions

MR and RN designed the research; CR, EM and IM contributed to the data acquisition and analysis. ARDG contributed to data interpretation. MR, RN and ARDG wrote the paper. All authors read and approved the final manuscript.

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Rossi, M., Raspanti, C., Mazza, E. et al. High-intensity focused ultrasound provides palliation for liver metastasis causing gastric outlet obstruction: case report. J Ther Ultrasound 1, 9 (2013). https://doi.org/10.1186/2050-5736-1-9

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Journal of Therapeutic Ultrasound

ISSN: 2050-5736