Palliation of Painful Perineal Metastasis Treated with Radiofrequency Thermal Ablation L. Thanos, S. Mylona, V. Kalioras, M. Pomoni, N. Batakis Radiology Department, ‘‘Korgialeneio-Benakeio’’, Red-Cross Hospital of Athens, Athanasaki 1 st, 11526 Athens, Greece Abstract We report a case of painful perineal metastasis from urinary bladder carcinoma in a 73-years-old woman, treated with CT- guided radiofrequency ablation (RFA). The pain was immediately relieved and follow-up at 1 and 6 months showed total necrosis of the mass. One year later, the patient has no pain and her quality of life is improved. Key words: Metastasis—Minimally invasive therapy—Radiofre- quency ablation (RFA)—Urinary bladder carcinoma Percutaneous radiofrequency ablation (RFA) under CT guidance is a minimally invasive technique that has been used for over a decade for the treatment of primary and secondary liver tumors [1, 2]. It is a low-cost method that provides treatment on an outpatient basis. (Some centers performing RFA require patients to stay overnight in the hospital.) This procedure has been rapidly adopted and, in some cases, it is chosen over surgery because it requires less resources, time, recovery and cost, but especially because it can provide complete tumor eradication in properly selected can- didates and may improve patientsÕ prognosis. It reduces morbidity and mortality and provides amelioration of the patientÕs quality of life. The complications are minimal in experienced hands [3–5]. In recent years RFA has been used for the treatment of lung [6, 7], renal [8, 9], brain [10], bone [11–13], prostate [14] and breast [15] primary or metastatic tumors with promising results [3]. As RFA has also been used successfully for the treatment of painful osteoid osteomas [11] and bone metastases [12] we decided to use it for the treatment of a painful perineal metastasis from urinary bladder carcinoma. Case Report A 73-year-old woman presented to our hospital complaining of severe pain at the perineum, with no response to analgesic medication. The patient suffered from urinary bladder carcinoma and had undergone bladder excision 5 years previously, followed by chemotherapy. After the clinical examination, a dual-phase abdominal CT scan re- vealed a soft tissue mass in the perineal fat adjacent to the right ischium, with no bone involvement (Fig. 1A). Because of the patientÕs medical history and the CT results we decided, in consultation with her physician, to proceed to core needle biopsy of this pelvic lesion under CT guidance (informed consent was obtained). The histologic result showed ‘‘metastasis from bladder carcinoma.’’ Surgical excision and radiation therapy was recommended. Since the pa- tient refused to undergo the recommended therapy, we suggested percuta- neous CT-guided RFA as alternative treatment. She accepted and we proceeded to ablation after we obtained her informed consent. RFA was carried out by a consultant radiologist specializing in biopsies and RFA. Prior to RFA, the patient had screening blood tests that included measurements of the international normalized ratio (INR), partial throm- boplastin time (PTT) and platelet count. The day of the session, 45 min before the procedure, analgesic medical treatment was administered (as the whole procedure was under local anesthesia): one pill of 3 mg bromazepan (Lexotanil, Roche) per os and 0.05 g pethidine hydrochloride intramuscularly. Using spiral CT (Picker 5000, Philips Medical Systems, The Nether- lands) we started the preprocedural CT scan with 5 mm contiguous slices. The patient was placed in the prone position. Once the inlet was chosen we performed local anesthesia (15 ml of 2% lidocaine hydrochloride). We removed the anesthetic needle and cleaned the skin with povidone iodine 10% in preparation for the insertion of the RFA needle. The depth from the skin to the edge of the lesion was calculated from the appropriate CT image. After the patientÕs preparation had been completed, one dispersive electrode was applied to her skin. We used an electrosurgical generator (Electrotom HiTT 106, Berchtold Holding, 78505 Tuttlingen, Germany) and a HiTT (high-frequency induced thermotherapy) needle applicator, perfusable with 0.9% NaCl solution (EZ 703-20: outer diameter 2.0 mm, shaft length 150 mm, electrode length 20 mm). Controls were set according to the manufacturerÕs instructions. The device was inserted from the inlet in a stepwise fashion, while the position of the tip was controlled repeatedly with three contiguous 5 mm CT images. After confirming that the tip of the needle was centered at the lesion (Fig. 1B) we connected the dispersive electrode and the needle to the generator. RFA energy (50 W), was applied for 10 min, according to the manu- facturerÕs instructions for the management of this type and size of lesion. When the ablation was finished we checked the necrosis of the ablated lesion with dual-phase spiral CT after intravenous contrast medium administration (Iomeron 300, Bracco, Milan, Italy) (Fig. 1C). The patient was hospitalized for 24 hr with no complications. Next day she went home with instructions. She had immediate relief of her pain symptoms. The follow-up at 1 and 6 months showed total necrosis of the mass. One year later (Fig. 1D) the patient has no pain and her subjective quality of life has been improved. Discussion Cancer is one of the leading causes of death. A great number of patients with cancer develops metastatic disease and over 50% of Correspondence to: L. Thanos; email: loutharad@yahoo.com ª Springer Science+Business Media, Inc. 2005 Published Online: 12 April 2005 CardioVascular and Interventional Radiology Cardiovasc Intervent Radiol (2005) 28:381–383 DOI: 10.1007/s00270-004-9250-1