2nd most common cancer type in USA; leading cause of cancer-related death
Estimated 228,820 new cases of lung cancer diagnosed in 2020 in USA
Non-small cell lung cancer (NSCLC) is most common cancer subtype (80-85% of primary lung cancer)
Lungs are 2nd most frequent site of metastatic disease [colorectal, renal cell carcinoma (RCC), breast, sarcomas, germ cell tumors]
TNM staging system
Stage IA
T1: 3 cm surrounded by lung/visceral pleura, not involving main bronchus, no nodal (N0) or metastatic spread (M0)
T1a: ≤ 1 cm; T1b: > 1 cm to ≤ 2 cm; T1c: > 2 cm to ≤ 3 cm
Liver cancer
Epidemiology
Hepatocellular carcinoma (HCC) is most common primary liver malignancy
6th most common newly diagnosed primary malignancy worldwide
Colorectal cancer (CRC)
3rd most common newly diagnosed solid cancer worldwide
Liver is most common site of metastasis
Incidence: 38.9 new diagnoses/100,000 people in North America
Barcelona clinic liver cancer staging system (BCLC)
Used to stratify patients to decide best treatment plan
Consider following
Number and size of hepatic tumors
Patient performance status (PS) using Eastern Cooperative Oncology Group (ECOG) scale
Child-Pugh system
BCLC stages 0, A, B, C, D
Milan criteria
Determines eligibility for liver transplantation
Kidney cancer
Epidemiology
RCC is most common renal malignancy
12th most newly diagnosed primary malignancy worldwide
Incidence: 15.9 new diagnoses/100,000 people in North America
TNM staging system
T1: < 7 cm in greatest dimension, confined to kidney
T1a: < 4 cm, T1b: > 4 cm and < 7 cm
Bone/soft tissue tumors
Epidemiology
Osteoid osteomas are benign tumors that account for 10-12% of benign bone tumors
Symptom onset between 5-24 years of age; male predominance
Bone is 3rd most common site of metastasis
Ablation Modalities
Radiofrequency ablation (RFA)
Physics
Transforms radiofrequency (RF) energy into heat
RF generator ranging from 60-250 W produces alternating current, resulting in agitation of ions surrounding probe tip
Ionic agitation leads to frictional heat, which is deposited within surrounding tissue/tumor
Tissue temperature parameters
Goal of 60-100 °C: Irreversible cellular damage occurs instantly at this temperature; goal temperature should be maintained for ~ 8-16 minutes, depending on RFA system used
50-60 °C: May induce coagulation necrosis in minutes
< 50 °C does not reliably induce necrosis
> 100 °C should be avoided as high temperatures lead to tissue char/vaporization resulting in gas production, which acts as insulator, impeding further heat diffusion within surrounding tumor
Applicator design
Probe diameter range: 14-17.5 Fr
3 types of RF applicators: Single straight needle, cluster straight needles, and multitoned expandable electrodes
Main difference among applicators is size of ablation zones possible in one treatment
Monopolar vs. bipolar RFA: Bipolar RFA allows for use of multiple probes simultaneously, creating larger ablation zones and making it less susceptible to heat sink
Ablation zone
Shape and size of ablation zone depends on both type and number of applicators placed within tumor
Goal is 5- to 10-mm treatment margin beyond suspected tumor border
Advantages
Intrinsic cautery effect may decrease bleeding complications
Disadvantages
Associated with higher procedural pain than microwave ablation (MWA) or Cryo
Variable tissue thermal conductivity may lead to irregular ablation margins
Lung tissue has high impedance and low conduction, thus increasing procedure time
Heat sink effect
Flowing blood in nearby vessels cools tissue, limiting heating of tumor tissue
Presence of vessels or bronchi > 3 mm in diameter within ablation zone may be predictor of incomplete local treatment due to "heat sink" effect
May require slow and lengthy treatment to effectively kill tumor
MWA
Physics
Relies on dielectric heating
Applied electromagnetic field causes water molecules in surrounding tissues to rotate at microwave's frequency
Rapidly oscillating water molecules results in frictional heating, raising tissue temperature surrounding probe tip
Higher water content = better heat absorption and conductivity = larger ablation zone
As with RFA, goal of treatment is to sustain temperatures > 50 °C and ideally > 60 °C
Advantages
More rapid generation of high temperatures
Not limited by increased impedance seen with tissue boiling/charring in RFA: This allows for much higher intratumoral temperatures, leading to larger ablation zones with relatively shorter treatment durations
Less susceptible to heat sink
Does not require grounding pads
Cryoablation
Physics
Causes tumor necrosis through rapid cell freezing
Multifaceted cellular death: Protein denaturation, cell membrane rupture, vessel thrombosis/ischemia
Joules-Thomson effect
Rapid expansion of argon gas at applicator tip leads to rapid drop in temperature (Joules-Thomson effect), cooling surrounding tissue: Temperatures can range from -80 to -150 °C
To induce thaw cycle, compressed helium is circulated within applicator; expansion of helium at tip leads to rapid increase in temperature
Process consists of alternating freezing and thawing cycles
Triple cycle is typically used in lung (3-minute freeze, 3-minute passive thaw, 7-minute freeze, 3-minute passive thaw, 10-minute freeze followed by variable active/passive thaw to raise temp to 22 °C
Nonlung ablation typically consists of 2 freeze cycles of variable length, depending on "ice ball" growth (10-minute freeze followed by 8-minute thaw cycle common)
Multiple probes can be used to treat large tumors
Advantages
Decreased procedure associated pain
Real-time visualization of treatment area
"Ice ball" readily visible with CT/US/MR guidance
Ablation zone can be modulated by probe placement and modulating freeze power and time of each probe to create shapes that ensure tumor and margin coverage
Data suggests increased efficacy of cryoablation compared to RFA/MWA in treating renal tumors
Prospective data suggests efficacy comparable to partial nephrectomy, which is standard of care
Disadvantages
Longer ablation time than thermal-based techniques
More expensive, as multiple probes may be required
System requires gas availability and storage
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Alternative Procedures/Therapies
Baseline Imaging and Planning
Probe Insertion/Positioning
Ancillary Procedures
Intraprocedural Monitoring of Patient and Treatment
Completion Imaging and Recovery
POST PROCEDURE
Follow-Up
OUTCOMES
Complications
Expected Outcomes
Selected References
Genshaft SJ et al: Society of Interventional Radiology multidisciplinary position statement on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs: endorsed by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology. J Vasc Interv Radiol. 32(8):1241.e1-12, 2021
Genshaft SJ et al: Society of Interventional Radiology quality improvement standards on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs. J Vasc Interv Radiol. 32(8):1242.e1-10, 2021
Gunn AJ et al: Society of Interventional Radiology quality improvement standards on percutaneous ablation in renal cell carcinoma. J Vasc Interv Radiol. 31(2):195-201.e3, 2020
Morris CS et al: Society of Interventional Radiology position statement on the role of percutaneous ablation in renal cell carcinoma: endorsed by the Canadian Association for Interventional Radiology and the Society of Interventional Oncology. J Vasc Interv Radiol. 31(2):189-94.e3, 2020
Izzo F et al: Radiofrequency ablation and microwave ablation in liver tumors: an update. Oncologist. 24(10):e990-1005, 2019
Tafti BA et al: Lung ablation: indications and techniques. Semin Intervent Radiol. 36(3):163-75, 2019
Mouli SK et al: The role of percutaneous image-guided thermal ablation for the treatment of pulmonary malignancies. AJR Am J Roentgenol. 209(4):740-51, 2017
Wallace AN et al: Percutaneous image-guided cryoablation of musculoskeletal metastases: pain palliation and local tumor control. J Vasc Interv Radiol. 27(12):1788-96, 2016
Zhang F et al: Prognostic factors for long-term survival in patients with renal-cell carcinoma after radiofrequency ablation. J Endourol. 30(1):37-42, 2016
Lee H et al: Hepatectomy vs radiofrequency ablation for colorectal liver metastasis: a propensity score analysis. World J Gastroenterol. 21(11):3300-7, 2015
US Cancer Statistics Working Group. United States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. 2015. http://www.cdc.gov/uscs
Ahmed M et al: Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update: supplement to the consensus document. J Vasc Interv Radiol. 25(11):1706-8, 2014
Gunn AJ et al: Percutaneous ablation of the small renal mass-techniques and outcomes. Semin Intervent Radiol. 31(1):33-41, 2014
Hiraki T et al: Radiofrequency ablation for early-stage nonsmall cell lung cancer. Biomed Res Int. 152087, 2014
Kurup AN: Percutaneous ablation for small renal masses-complications. Semin Intervent Radiol. 31(1):42-9, 2014
Ridge CA et al: Epidemiology and staging of renal cell carcinoma. Semin Intervent Radiol. 31(1):3-8, 2014
Belfiore G et al: Patients' survival in lung malignancies treated by microwave ablation: our experience on 56 patients. Eur J Radiol. 82(1):177-81, 2013
Cucchetti A et al: Systematic review of surgical resection vs radiofrequency ablation for hepatocellular carcinoma. World J Gastroenterol. 19(26):4106-18, 2013
Howlader N et al: SEER cancer statistics review, 1975-2012. http://seer.cancer.gov/csr/1975_2012/
Kashima M et al: Complications after 1000 lung radiofrequency ablation sessions in 420 patients: a single center's experiences. AJR Am J Roentgenol. 197(4):W576-80, 2011
Vogl TJ et al: Microwave ablation therapy: clinical utility in treatment of pulmonary metastases. Radiology. 261(2):643-51, 2011
Hong K et al: Radiofrequency ablation: mechanism of action and devices. J Vasc Interv Radiol. 21(8 Suppl):S179-86, 2010
Brace CL: Radiofrequency and microwave ablation of the liver, lung, kidney, and bone: what are the differences? Curr Probl Diagn Radiol. 38(3):135-43, 2009
Gervais DA et al: Society of Interventional Radiology position statement on percutaneous radiofrequency ablation for the treatment of liver tumors. J Vasc Interv Radiol. 20(7 Suppl):S342-7, 2009
Lencioni R et al: Response to radiofrequency ablation of pulmonary tumours: a prospective, intention-to-treat, multicentre clinical trial (the RAPTURE study). Lancet Oncol. 9(7):621-8, 2008
Hiraki T et al: Pneumothorax, pleural effusion, and chest tube placement after radiofrequency ablation of lung tumors: incidence and risk factors. Radiology. 241(1):275-83, 2006
Goldberg SN et al: Image-guided tumor ablation: standardization of terminology and reporting criteria. Radiology. 235(3):728-39, 2005
Solbiati L et al: Percutaneous radio-frequency ablation of hepatic metastases from colorectal cancer: long-term results in 117 patients. Radiology. 221(1):159-66, 2001
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Preprocedure
Procedure
Post Procedure
Outcomes
TERMINOLOGY
Definitions
Lung cancer
Epidemiology
2nd most common cancer type in USA; leading cause of cancer-related death
Estimated 228,820 new cases of lung cancer diagnosed in 2020 in USA
Non-small cell lung cancer (NSCLC) is most common cancer subtype (80-85% of primary lung cancer)
Lungs are 2nd most frequent site of metastatic disease [colorectal, renal cell carcinoma (RCC), breast, sarcomas, germ cell tumors]
TNM staging system
Stage IA
T1: 3 cm surrounded by lung/visceral pleura, not involving main bronchus, no nodal (N0) or metastatic spread (M0)
T1a: ≤ 1 cm; T1b: > 1 cm to ≤ 2 cm; T1c: > 2 cm to ≤ 3 cm
Liver cancer
Epidemiology
Hepatocellular carcinoma (HCC) is most common primary liver malignancy
6th most common newly diagnosed primary malignancy worldwide
Colorectal cancer (CRC)
3rd most common newly diagnosed solid cancer worldwide
Liver is most common site of metastasis
Incidence: 38.9 new diagnoses/100,000 people in North America
Barcelona clinic liver cancer staging system (BCLC)
Used to stratify patients to decide best treatment plan
Consider following
Number and size of hepatic tumors
Patient performance status (PS) using Eastern Cooperative Oncology Group (ECOG) scale
Child-Pugh system
BCLC stages 0, A, B, C, D
Milan criteria
Determines eligibility for liver transplantation
Kidney cancer
Epidemiology
RCC is most common renal malignancy
12th most newly diagnosed primary malignancy worldwide
Incidence: 15.9 new diagnoses/100,000 people in North America
TNM staging system
T1: < 7 cm in greatest dimension, confined to kidney
T1a: < 4 cm, T1b: > 4 cm and < 7 cm
Bone/soft tissue tumors
Epidemiology
Osteoid osteomas are benign tumors that account for 10-12% of benign bone tumors
Symptom onset between 5-24 years of age; male predominance
Bone is 3rd most common site of metastasis
Ablation Modalities
Radiofrequency ablation (RFA)
Physics
Transforms radiofrequency (RF) energy into heat
RF generator ranging from 60-250 W produces alternating current, resulting in agitation of ions surrounding probe tip
Ionic agitation leads to frictional heat, which is deposited within surrounding tissue/tumor
Tissue temperature parameters
Goal of 60-100 °C: Irreversible cellular damage occurs instantly at this temperature; goal temperature should be maintained for ~ 8-16 minutes, depending on RFA system used
50-60 °C: May induce coagulation necrosis in minutes
< 50 °C does not reliably induce necrosis
> 100 °C should be avoided as high temperatures lead to tissue char/vaporization resulting in gas production, which acts as insulator, impeding further heat diffusion within surrounding tumor
Applicator design
Probe diameter range: 14-17.5 Fr
3 types of RF applicators: Single straight needle, cluster straight needles, and multitoned expandable electrodes
Main difference among applicators is size of ablation zones possible in one treatment
Monopolar vs. bipolar RFA: Bipolar RFA allows for use of multiple probes simultaneously, creating larger ablation zones and making it less susceptible to heat sink
Ablation zone
Shape and size of ablation zone depends on both type and number of applicators placed within tumor
Goal is 5- to 10-mm treatment margin beyond suspected tumor border
Advantages
Intrinsic cautery effect may decrease bleeding complications
Disadvantages
Associated with higher procedural pain than microwave ablation (MWA) or Cryo
Variable tissue thermal conductivity may lead to irregular ablation margins
Lung tissue has high impedance and low conduction, thus increasing procedure time
Heat sink effect
Flowing blood in nearby vessels cools tissue, limiting heating of tumor tissue
Presence of vessels or bronchi > 3 mm in diameter within ablation zone may be predictor of incomplete local treatment due to "heat sink" effect
May require slow and lengthy treatment to effectively kill tumor
MWA
Physics
Relies on dielectric heating
Applied electromagnetic field causes water molecules in surrounding tissues to rotate at microwave's frequency
Rapidly oscillating water molecules results in frictional heating, raising tissue temperature surrounding probe tip
Higher water content = better heat absorption and conductivity = larger ablation zone
As with RFA, goal of treatment is to sustain temperatures > 50 °C and ideally > 60 °C
Advantages
More rapid generation of high temperatures
Not limited by increased impedance seen with tissue boiling/charring in RFA: This allows for much higher intratumoral temperatures, leading to larger ablation zones with relatively shorter treatment durations
Less susceptible to heat sink
Does not require grounding pads
Cryoablation
Physics
Causes tumor necrosis through rapid cell freezing
Multifaceted cellular death: Protein denaturation, cell membrane rupture, vessel thrombosis/ischemia
Joules-Thomson effect
Rapid expansion of argon gas at applicator tip leads to rapid drop in temperature (Joules-Thomson effect), cooling surrounding tissue: Temperatures can range from -80 to -150 °C
To induce thaw cycle, compressed helium is circulated within applicator; expansion of helium at tip leads to rapid increase in temperature
Process consists of alternating freezing and thawing cycles
Triple cycle is typically used in lung (3-minute freeze, 3-minute passive thaw, 7-minute freeze, 3-minute passive thaw, 10-minute freeze followed by variable active/passive thaw to raise temp to 22 °C
Nonlung ablation typically consists of 2 freeze cycles of variable length, depending on "ice ball" growth (10-minute freeze followed by 8-minute thaw cycle common)
Multiple probes can be used to treat large tumors
Advantages
Decreased procedure associated pain
Real-time visualization of treatment area
"Ice ball" readily visible with CT/US/MR guidance
Ablation zone can be modulated by probe placement and modulating freeze power and time of each probe to create shapes that ensure tumor and margin coverage
Data suggests increased efficacy of cryoablation compared to RFA/MWA in treating renal tumors
Prospective data suggests efficacy comparable to partial nephrectomy, which is standard of care
Disadvantages
Longer ablation time than thermal-based techniques
More expensive, as multiple probes may be required
System requires gas availability and storage
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Alternative Procedures/Therapies
Baseline Imaging and Planning
Probe Insertion/Positioning
Ancillary Procedures
Intraprocedural Monitoring of Patient and Treatment
Completion Imaging and Recovery
POST PROCEDURE
Follow-Up
OUTCOMES
Complications
Expected Outcomes
Selected References
Genshaft SJ et al: Society of Interventional Radiology multidisciplinary position statement on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs: endorsed by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology. J Vasc Interv Radiol. 32(8):1241.e1-12, 2021
Genshaft SJ et al: Society of Interventional Radiology quality improvement standards on percutaneous ablation of non-small cell lung cancer and metastatic disease to the lungs. J Vasc Interv Radiol. 32(8):1242.e1-10, 2021
Gunn AJ et al: Society of Interventional Radiology quality improvement standards on percutaneous ablation in renal cell carcinoma. J Vasc Interv Radiol. 31(2):195-201.e3, 2020
Morris CS et al: Society of Interventional Radiology position statement on the role of percutaneous ablation in renal cell carcinoma: endorsed by the Canadian Association for Interventional Radiology and the Society of Interventional Oncology. J Vasc Interv Radiol. 31(2):189-94.e3, 2020
Izzo F et al: Radiofrequency ablation and microwave ablation in liver tumors: an update. Oncologist. 24(10):e990-1005, 2019
Tafti BA et al: Lung ablation: indications and techniques. Semin Intervent Radiol. 36(3):163-75, 2019
Mouli SK et al: The role of percutaneous image-guided thermal ablation for the treatment of pulmonary malignancies. AJR Am J Roentgenol. 209(4):740-51, 2017
Wallace AN et al: Percutaneous image-guided cryoablation of musculoskeletal metastases: pain palliation and local tumor control. J Vasc Interv Radiol. 27(12):1788-96, 2016
Zhang F et al: Prognostic factors for long-term survival in patients with renal-cell carcinoma after radiofrequency ablation. J Endourol. 30(1):37-42, 2016
Lee H et al: Hepatectomy vs radiofrequency ablation for colorectal liver metastasis: a propensity score analysis. World J Gastroenterol. 21(11):3300-7, 2015
US Cancer Statistics Working Group. United States Cancer Statistics: 1999–2012 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. 2015. http://www.cdc.gov/uscs
Ahmed M et al: Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update: supplement to the consensus document. J Vasc Interv Radiol. 25(11):1706-8, 2014
Gunn AJ et al: Percutaneous ablation of the small renal mass-techniques and outcomes. Semin Intervent Radiol. 31(1):33-41, 2014
Hiraki T et al: Radiofrequency ablation for early-stage nonsmall cell lung cancer. Biomed Res Int. 152087, 2014
Kurup AN: Percutaneous ablation for small renal masses-complications. Semin Intervent Radiol. 31(1):42-9, 2014
Ridge CA et al: Epidemiology and staging of renal cell carcinoma. Semin Intervent Radiol. 31(1):3-8, 2014
Belfiore G et al: Patients' survival in lung malignancies treated by microwave ablation: our experience on 56 patients. Eur J Radiol. 82(1):177-81, 2013
Cucchetti A et al: Systematic review of surgical resection vs radiofrequency ablation for hepatocellular carcinoma. World J Gastroenterol. 19(26):4106-18, 2013
Howlader N et al: SEER cancer statistics review, 1975-2012. http://seer.cancer.gov/csr/1975_2012/
Kashima M et al: Complications after 1000 lung radiofrequency ablation sessions in 420 patients: a single center's experiences. AJR Am J Roentgenol. 197(4):W576-80, 2011
Vogl TJ et al: Microwave ablation therapy: clinical utility in treatment of pulmonary metastases. Radiology. 261(2):643-51, 2011
Hong K et al: Radiofrequency ablation: mechanism of action and devices. J Vasc Interv Radiol. 21(8 Suppl):S179-86, 2010
Brace CL: Radiofrequency and microwave ablation of the liver, lung, kidney, and bone: what are the differences? Curr Probl Diagn Radiol. 38(3):135-43, 2009
Gervais DA et al: Society of Interventional Radiology position statement on percutaneous radiofrequency ablation for the treatment of liver tumors. J Vasc Interv Radiol. 20(7 Suppl):S342-7, 2009
Lencioni R et al: Response to radiofrequency ablation of pulmonary tumours: a prospective, intention-to-treat, multicentre clinical trial (the RAPTURE study). Lancet Oncol. 9(7):621-8, 2008
Hiraki T et al: Pneumothorax, pleural effusion, and chest tube placement after radiofrequency ablation of lung tumors: incidence and risk factors. Radiology. 241(1):275-83, 2006
Goldberg SN et al: Image-guided tumor ablation: standardization of terminology and reporting criteria. Radiology. 235(3):728-39, 2005
Solbiati L et al: Percutaneous radio-frequency ablation of hepatic metastases from colorectal cancer: long-term results in 117 patients. Radiology. 221(1):159-66, 2001
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