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Percutaneous Tumor Ablation
S. Brandon Hancock, MD; Christos Georgiades, MD, PhD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Post Procedure

        • Procedure

          • Outcomes

            TERMINOLOGY

            • Definitions

              • Ablation: Targeted destruction of mass, most commonly by application of hyper- or hypothermia
                • Thermal ablation (heat) vs. cryoablation (cold)
              • Overall survival (OS): Length of time from either date of diagnosis or start of treatment for disease, such as cancer, to date of death of any cause
                • Usually expressed in median ± standard deviation
              • Cancer-specific survival (CSS): Length of time from either date of diagnosis or start of treatment for disease, such as cancer, to date of death from disease
                • Patients who die from causes unrelated to disease are not counted in this measurement
              • Progression-free survival: Length of time (from set point, usually treatment) that patient demonstrates no disease progression
              • Time to progression: Length of time (from set point, usually treatment) until patient shows disease progression
                • Mortalities are excluded
              • Disease-free survival (DFS): Length of time after treatment, until patient dies or shows evidence for recurrent disease
              • Tumor epidemiology
                • Lung cancer
                  • Most common newly diagnosed primary solid malignancy worldwide
                  • Incidence: 60.4 new tumors/100,000 people in North America
                  • Mortality: 45.0 attributable deaths/100,000 people per year
                  • Most commonly discovered in 7th decade of life
                  • Lung is most common site of secondary neoplastic involvement
                • Liver cancer
                  • Hepatocellular carcinoma (HCC)
                    • Most common primary liver malignancy
                    • 6th most common newly diagnosed primary malignancy worldwide
                    • Incidence: 8.4 new primary tumors/100,000 people in North America
                    • Mortality: 6.3 attributable deaths/100,000 people per year
                  • Colorectal cancer (CRC) metastasis
                    • Liver is most common location
                    • Colon cancer is 3rd most common newly diagnosed solid cancer worldwide
                    • incidence: 38.9 new diagnoses/100,000 people in North America
                    • Mortality: 14.7 attributable deaths/100,000 people per year
                    • Resection/ablation of CRC mets improves CSS
                • Kidney cancer
                  • Renal cell carcinoma (RCC)
                    • Most commonly diagnosed renal malignancy
                    • 12th most commonly newly diagnosed primary malignancy worldwide
                    • Incidence: 15.9 new diagnoses/100,000 people in North America
                    • Mortality: 5 attributable deaths/100,000 people per year
                    • Long-term CSS for stage 1A disease is 95-98%
            • Ablation Modalities

              • Radiofrequency ablation (RFA)
                • Physics
                  • Relies on electrical conduction through tissue for heat generation
                  • Closed circuit necessary for conduction; body acts as resistor
                  • Direct radiofrequency heating
                    • Occurs within millimeters of applicator needle
                  • Thermal conduction
                    • Heat transfer more distally, therefore good thermal conductivity crucial for large ablation
                    • Quick charring (dehydration) of tissue increases resistance, opens circuit, and limits ablation zone
                    • Slow, gradual "cooking" more effective than fast ablation
                  • Common current frequency of 400-500 kHz
                • Disadvantages
                  • Irregular ablation shape, depends on thermal conductivity of tissue
                  • Charring limits effectiveness
                  • Heat sink effect
                    • Flow of blood in nearby vessels cools tissue, limiting effectiveness
                  • Impedance (instead of temperature) regulating systems may lengthen total procedure time and increase ablation zone
                  • Grounding pads required for monopolar systems
                  • May require slow and lengthy treatment to effectively kill tumor
              • Microwave ablation (MWA)
                • Physics
                  • Relies on dielectric heating
                    • Alternating electromagnetic (EM) field applied to imperfect dielectric material (tissue), forces water molecules in tissue to oscillate
                    • Water molecules oscillate out of phase with EM field
                    • Frictional energy loss generates heat
                    • Higher water content = better heat absorption and conductivity = larger ablation zone
                  • Frequencies usually of 30 MHz to 30 GHz
                  • Relative permittivity: How well materials accept EM field (capacitance)
                    • Lower the permittivity, the less the movement of energy from source dispersed through tissues
                    • Low relative permittivity: Bone, spleen
                    • High relative permittivity: Muscle, lung, liver
                  • Effective conductivity: How well tissue absorbs microwave energy
                    • Lower the conductivity, the higher the thermal energy deposited locally and the more effective the ablation around antennae; however, the more shallow the penetration for given frequency
                    • Low conductivity: Bone, lung, liver
                    • High conductivity: Muscle, blood, spleen
                • Advantages
                  • Ablation volume is more predictable, as it does not depend on thermal conductivity of tissue
                  • Can pass through and heat tissue at any temperature or water content
                  • Less susceptible to heat sink by producing larger areas of active heating
                  • Does not require grounding pads
              • Cryoablation
                • Physics
                  • Relies on Joules-Thomson effect
                    • Compressed gas circulates within double-barreled probe
                    • Gas released within probe results in sudden pressure drop
                    • Resultant temperature drop cools surrounding tissues
                  • Process consists of alternate freezing and thawing of tissue (commonly 10 min, 8 min, 10 min)
                  • Multifaceted cellular death mode: Cell membrane fracture, apoptosis, vessel thrombosis/ischemia
                  • Argon gas or nitrogen gas/liquid are required component
                  • Each probe has characteristic isotherms (size and shape of surface with same temperature)
                  • Temperatures drop to ~ -150°C at probe
                  • Heat-pump effect: Nearby vessels may increase temperature and limit ablation margin
                • Advantages
                  • Well tolerated (minimal pain)
                  • High level data supporting its use over RFA/MV in renal tumor ablation (higher efficacy)
                  • Prospective data suggest efficacy comparable to standard of care (partial nephrectomy)
                  • "Ice ball" readily visible with CT (US/MR) guidance
                    • Represents 0°C isotherm (not lethal)
                    • Lethal isotherm (-20°C) ~ 2-3 mm inside visible "ice ball"
                  • Operator can sculpt irregularly shaped ablation zone by altering orientation of multiple probes
                • Disadvantages
                  • 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

                      • Baseline Imaging and Planning

                        • Probe Insertion/Positioning

                          • Added Maneuvers

                            • Intraprocedural Monitoring of Patient and Treatment

                              • Completion Imaging

                                • Recovery

                                  • Things to Avoid

                                    • Alternative Procedures/Therapies

                                      POST PROCEDURE

                                      • Things to Do

                                        • Follow-Up

                                          OUTCOMES

                                          • Complications

                                            • Expected Outcomes

                                              Selected References

                                              1. Zhang F et al: Prognostic factors for long-term survival in patients with renal-cell carcinoma after radiofrequency ablation. J of Endourol; 30(1):37-42, 2016
                                              2. Lee H et al: Hepatectomy vs radiofrequency ablation for colorectal liver metastasis: A propensity score analysis. World Journal of Gastroenterology: WJG;21(11):3300-3307, 2015
                                              3. U.S. 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. http://www.cdc.gov/uscs. 2015
                                              4. Hiraki T et al: Radiofrequency ablation for early-stage non small cell lung cancer. Biomed Res Int; 152087, 2014
                                              5. 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
                                              6. Hiraki T et al: Radiofrequency ablation for early-stage nonsmall cell lung cancer. Biomed Res Int. 2014:152087, 2014
                                              7. Ridge CA et al: Epidemiology and staging of renal cell carcinoma. Semin Intervent Radiol. 31(1):3-8, 2014
                                              8. Cucchetti A et al: Systematic review of surgical resection vs radiofrequency ablation for hepatocellular carcinoma. World Journal of Gastroenterology: WJG. 19(26):4106-4118, 2013
                                              9. 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
                                              10. Howlader N et al: SEER cancer statistics review, 1975-2012. http://seer.cancer.gov/csr/1975_2012/.
                                              11. Vogl TJ et al: Microwave ablation therapy: clinical utility in treatment of pulmonary metastases. Radiology. 261(2):643-51, 2011
                                              12. Hong K et al: Radiofrequency ablation: mechanism of action and devices. J Vasc Interv Radiol. 21(8 Suppl):S179-86, 2010
                                              13. 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
                                              14. 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
                                              15. 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
                                              16. Nahum Goldberg S et al: Image-guided tumor ablation: Standardization of terminology and reporting criteria. Radiology 235:3, 728-739, 235:3, 728-739
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Preprocedure

                                                  • Post Procedure

                                                    • Procedure

                                                      • Outcomes

                                                        TERMINOLOGY

                                                        • Definitions

                                                          • Ablation: Targeted destruction of mass, most commonly by application of hyper- or hypothermia
                                                            • Thermal ablation (heat) vs. cryoablation (cold)
                                                          • Overall survival (OS): Length of time from either date of diagnosis or start of treatment for disease, such as cancer, to date of death of any cause
                                                            • Usually expressed in median ± standard deviation
                                                          • Cancer-specific survival (CSS): Length of time from either date of diagnosis or start of treatment for disease, such as cancer, to date of death from disease
                                                            • Patients who die from causes unrelated to disease are not counted in this measurement
                                                          • Progression-free survival: Length of time (from set point, usually treatment) that patient demonstrates no disease progression
                                                          • Time to progression: Length of time (from set point, usually treatment) until patient shows disease progression
                                                            • Mortalities are excluded
                                                          • Disease-free survival (DFS): Length of time after treatment, until patient dies or shows evidence for recurrent disease
                                                          • Tumor epidemiology
                                                            • Lung cancer
                                                              • Most common newly diagnosed primary solid malignancy worldwide
                                                              • Incidence: 60.4 new tumors/100,000 people in North America
                                                              • Mortality: 45.0 attributable deaths/100,000 people per year
                                                              • Most commonly discovered in 7th decade of life
                                                              • Lung is most common site of secondary neoplastic involvement
                                                            • Liver cancer
                                                              • Hepatocellular carcinoma (HCC)
                                                                • Most common primary liver malignancy
                                                                • 6th most common newly diagnosed primary malignancy worldwide
                                                                • Incidence: 8.4 new primary tumors/100,000 people in North America
                                                                • Mortality: 6.3 attributable deaths/100,000 people per year
                                                              • Colorectal cancer (CRC) metastasis
                                                                • Liver is most common location
                                                                • Colon cancer is 3rd most common newly diagnosed solid cancer worldwide
                                                                • incidence: 38.9 new diagnoses/100,000 people in North America
                                                                • Mortality: 14.7 attributable deaths/100,000 people per year
                                                                • Resection/ablation of CRC mets improves CSS
                                                            • Kidney cancer
                                                              • Renal cell carcinoma (RCC)
                                                                • Most commonly diagnosed renal malignancy
                                                                • 12th most commonly newly diagnosed primary malignancy worldwide
                                                                • Incidence: 15.9 new diagnoses/100,000 people in North America
                                                                • Mortality: 5 attributable deaths/100,000 people per year
                                                                • Long-term CSS for stage 1A disease is 95-98%
                                                        • Ablation Modalities

                                                          • Radiofrequency ablation (RFA)
                                                            • Physics
                                                              • Relies on electrical conduction through tissue for heat generation
                                                              • Closed circuit necessary for conduction; body acts as resistor
                                                              • Direct radiofrequency heating
                                                                • Occurs within millimeters of applicator needle
                                                              • Thermal conduction
                                                                • Heat transfer more distally, therefore good thermal conductivity crucial for large ablation
                                                                • Quick charring (dehydration) of tissue increases resistance, opens circuit, and limits ablation zone
                                                                • Slow, gradual "cooking" more effective than fast ablation
                                                              • Common current frequency of 400-500 kHz
                                                            • Disadvantages
                                                              • Irregular ablation shape, depends on thermal conductivity of tissue
                                                              • Charring limits effectiveness
                                                              • Heat sink effect
                                                                • Flow of blood in nearby vessels cools tissue, limiting effectiveness
                                                              • Impedance (instead of temperature) regulating systems may lengthen total procedure time and increase ablation zone
                                                              • Grounding pads required for monopolar systems
                                                              • May require slow and lengthy treatment to effectively kill tumor
                                                          • Microwave ablation (MWA)
                                                            • Physics
                                                              • Relies on dielectric heating
                                                                • Alternating electromagnetic (EM) field applied to imperfect dielectric material (tissue), forces water molecules in tissue to oscillate
                                                                • Water molecules oscillate out of phase with EM field
                                                                • Frictional energy loss generates heat
                                                                • Higher water content = better heat absorption and conductivity = larger ablation zone
                                                              • Frequencies usually of 30 MHz to 30 GHz
                                                              • Relative permittivity: How well materials accept EM field (capacitance)
                                                                • Lower the permittivity, the less the movement of energy from source dispersed through tissues
                                                                • Low relative permittivity: Bone, spleen
                                                                • High relative permittivity: Muscle, lung, liver
                                                              • Effective conductivity: How well tissue absorbs microwave energy
                                                                • Lower the conductivity, the higher the thermal energy deposited locally and the more effective the ablation around antennae; however, the more shallow the penetration for given frequency
                                                                • Low conductivity: Bone, lung, liver
                                                                • High conductivity: Muscle, blood, spleen
                                                            • Advantages
                                                              • Ablation volume is more predictable, as it does not depend on thermal conductivity of tissue
                                                              • Can pass through and heat tissue at any temperature or water content
                                                              • Less susceptible to heat sink by producing larger areas of active heating
                                                              • Does not require grounding pads
                                                          • Cryoablation
                                                            • Physics
                                                              • Relies on Joules-Thomson effect
                                                                • Compressed gas circulates within double-barreled probe
                                                                • Gas released within probe results in sudden pressure drop
                                                                • Resultant temperature drop cools surrounding tissues
                                                              • Process consists of alternate freezing and thawing of tissue (commonly 10 min, 8 min, 10 min)
                                                              • Multifaceted cellular death mode: Cell membrane fracture, apoptosis, vessel thrombosis/ischemia
                                                              • Argon gas or nitrogen gas/liquid are required component
                                                              • Each probe has characteristic isotherms (size and shape of surface with same temperature)
                                                              • Temperatures drop to ~ -150°C at probe
                                                              • Heat-pump effect: Nearby vessels may increase temperature and limit ablation margin
                                                            • Advantages
                                                              • Well tolerated (minimal pain)
                                                              • High level data supporting its use over RFA/MV in renal tumor ablation (higher efficacy)
                                                              • Prospective data suggest efficacy comparable to standard of care (partial nephrectomy)
                                                              • "Ice ball" readily visible with CT (US/MR) guidance
                                                                • Represents 0°C isotherm (not lethal)
                                                                • Lethal isotherm (-20°C) ~ 2-3 mm inside visible "ice ball"
                                                              • Operator can sculpt irregularly shaped ablation zone by altering orientation of multiple probes
                                                            • Disadvantages
                                                              • 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

                                                                  • Baseline Imaging and Planning

                                                                    • Probe Insertion/Positioning

                                                                      • Added Maneuvers

                                                                        • Intraprocedural Monitoring of Patient and Treatment

                                                                          • Completion Imaging

                                                                            • Recovery

                                                                              • Things to Avoid

                                                                                • Alternative Procedures/Therapies

                                                                                  POST PROCEDURE

                                                                                  • Things to Do

                                                                                    • Follow-Up

                                                                                      OUTCOMES

                                                                                      • Complications

                                                                                        • Expected Outcomes

                                                                                          Selected References

                                                                                          1. Zhang F et al: Prognostic factors for long-term survival in patients with renal-cell carcinoma after radiofrequency ablation. J of Endourol; 30(1):37-42, 2016
                                                                                          2. Lee H et al: Hepatectomy vs radiofrequency ablation for colorectal liver metastasis: A propensity score analysis. World Journal of Gastroenterology: WJG;21(11):3300-3307, 2015
                                                                                          3. U.S. 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. http://www.cdc.gov/uscs. 2015
                                                                                          4. Hiraki T et al: Radiofrequency ablation for early-stage non small cell lung cancer. Biomed Res Int; 152087, 2014
                                                                                          5. 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
                                                                                          6. Hiraki T et al: Radiofrequency ablation for early-stage nonsmall cell lung cancer. Biomed Res Int. 2014:152087, 2014
                                                                                          7. Ridge CA et al: Epidemiology and staging of renal cell carcinoma. Semin Intervent Radiol. 31(1):3-8, 2014
                                                                                          8. Cucchetti A et al: Systematic review of surgical resection vs radiofrequency ablation for hepatocellular carcinoma. World Journal of Gastroenterology: WJG. 19(26):4106-4118, 2013
                                                                                          9. 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
                                                                                          10. Howlader N et al: SEER cancer statistics review, 1975-2012. http://seer.cancer.gov/csr/1975_2012/.
                                                                                          11. Vogl TJ et al: Microwave ablation therapy: clinical utility in treatment of pulmonary metastases. Radiology. 261(2):643-51, 2011
                                                                                          12. Hong K et al: Radiofrequency ablation: mechanism of action and devices. J Vasc Interv Radiol. 21(8 Suppl):S179-86, 2010
                                                                                          13. 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
                                                                                          14. 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
                                                                                          15. 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
                                                                                          16. Nahum Goldberg S et al: Image-guided tumor ablation: Standardization of terminology and reporting criteria. Radiology 235:3, 728-739, 235:3, 728-739