RFA for big liver tumours

Dr Jean-Brice GAYET
Département d’imagerie médicale
What are we talking about ?
RF Ablation: 1996

Low-power generator (50 W)

3-cm-diameter ablation volume

RF Ablation: 2003

High-power generator (250 W)

5-7 cm diameter Ablation Volume

The Gold Standard

GOLD STANDARD

IS THE

SURGICAL RESECTION
Why ?

The Motto of the surgeons basically is

“IF IN DOUBT, CUT IT OUT!”

Approximately 80% of Liver
Tumours are unresectable

 Bilateral or multiple tumours

 Difficult position
 Liver Health
 Systemic health
 Anything else you can think of
What do you do to commit
tumouricide on the rest?

 Poison them
 Starve them
 Freeze them
 Cook them
Resection is made More Possible if
Combined with Other Techniques

 Resect AND Cook

 Resect AND Freeze
 Resect AND Poison

 Resect AND Poison AND cook

 And so on …
Combine Resection and Other
Modalities

 Ablation treatments do NOT replace all

resections, it enhances the possibility
of resection in combination with them

 Multidisciplinary decisions +++

Back to RFA
First, HEAT it !
 Basic principle : Closed Loop
Circuit
Input current

RF needle

Output current

Generator Dispersive electrode

(ground pad)
Making RF Lesions

 High frequency alternating current

 Ionic agitation
 Frictional heating
 Heat generated concentrated at active electrode

 Tissue near electrode is source of heat

 No heat flows directly from the device
 Principles of RF Energy Delivery

 Radiofrequency Probes heat by ionic

agitation only within 2 mm of the probe
surface

 Tissue heating beyond this is by HEAT

conduction only
Applied to BLT

 Pb of conducting heat against the convection

cooling of blood flow of a larger volume.
 Requires the directly heated tissue (within 2
mm of probe) to be as hot as possible
 Pb of tissue dessication : will not conduct
electricity away from the probe hence
prematurely halting process.
 Stages of RF Ablation

Frictional Conductive
Heating Heating

Conduction Over Time . . .

Key Ablation Process Components
 Heat generation
 Distance (r)

 Current (I)

 Time (T)

 Lesion size
 Temperature

 Electrode size
“The extent and nature of thermal injury are
dependent on two important factors, Temperature
& RF Application Duration.”

(V. Krishnamurthy, Applied Radiology, Oct. 2003)

 Lesion Size Depends on
Electrode Size and Temperature

8 SB XLi
(7 cm)
6 SB XL &
Lesion Size (cm)

Semi- Flex
(5 cm)
4
SB XL &
Cell Semi-Flex
2 Death (3 cm)
Body
StarBurst
0 Temp SDE (2 cm)
30 50 70 90 110

Electrode Temperature (°C)

Souvenirs, souvenirs
Prior to the newer probes

 How (the hell) did people do this ?

The Overlapping Mode …
RF ablation with use of a regular five-sided prism model.
 A, Maximum transverse view of the tumor: Five target sites are determined to
guide electrode insertions.
 B, Same section as A: Five ablations are performed in the middle part of the
tumor.
 C, The section perpendicular to A: Two additional ablations are performed at the
two poles of the tumor. The tumor can be effectively ablated with seven ablation
spheres. x indicates the target site of the ablation—that is, the ablation sphere
center.

Chen VIR 2004

Predictable Lesions “gold
standard”
 Temperature

 Monitor heat
 Thermocouples (Real-time measurement)
 Check temps at end to ensure cell death
 Monitor duration
 Consistent & Reproducible
Methods of Control of Energy
Delivery
 Global impedance measurement, no regional
differentiation.
 Global impedance measurement and indirect
central temperature measurement by cooling
water temperature.
 Direct measurement of regional peripheral
temperatures with power control feedback
system.
 Direct regional peripheral temperature endpoint,
control of rehydration by impedance during full
power application.
A few medical and non-
medical considerations
Radionics / Tyco

 200 Watt generator that works by limiting

power (necessary to prevent desiccation of
tissue, due to excessive temperature, that
aborts the procedure) in two ways

 Duty cycle.
 Internal cooling of the Radionics probe.
 The power is fully switched on & off
frequently, the ratio of on to off giving an
average power.
 This causes shock waves that the patient
can sometimes feel. This is why it was
thought that general anaesthesia was
necessary.
 Excess power is removed by cooling the
tissue immediately in contact with the
probe by cooling the probe itself. This is
analogous to controlling your car’s speed
with the brakes instead of the
accelerator.
 Remember that the energy deposited in the ablation
volume is useless until converted into the heat that
actually does the work
 Measuring temperature is therefore the ONLY way to
know & control what is happening. Radionics’ probes
only measure the temperature of the cooling water, or, if
that is switched off ONLY the temperature of the
CENTRE of the ablation. It is the PERIPHERAL
temperatures that are critical
 Radionics only senses the need to reduce power by total
impedance, not by temperature, nor with any zonal
differential information.
Boston
 Power control is only by total impedance without
any temperature sensing nor any regional
information. Power is manually adjusted by the
physician, needing constant attention.

 The expanding probe tines are one third the

thickness of RITA’s which carry electrical circuits for
the temperature sensors and/or saline for infusion.
They are much more easily diverted from the
expected deployment pattern.
 The probe has to be fully deployed at all times, so
different ablation sizes can only be accomplished by
using multiple probes, unlike RITA’s probes which can
be scaled to different deployments (sizes) even during
an ablation if the clinical situation requires it.

 There is no “Cool-Down” quality control (no temperature

sensing), so immediate contrast scanning is the only
way to ensure complete ablation without risking another
later procedure.
RITA
 The whole unique point of RITA’s technology is the
use of peripheral temperature sensing and feedback
power control.

 RITA uses analogue power controlled by temperature

feedback and on commencement only uses enough power
to raise tissue temperatures by 1.5 C per second to prevent
shock waves. So local anaesthesia (& conscious sedation)
is usual when using RITA routinely in the liver.
 Because of the volumes & geometry involved
coagulating the periphery is much more difficult
than the centre of the lesion. This is why
PERIPHERAL temperature sensors are important.
If the cooling effect of blood flow has, more easily
initially, been stopped in the centre, then it is
easier to ablate the periphery

 by quickly & easily coagulating the centre first,

subsequent extentions of the ablation outwards
proceed more easily so the entire ablation takes
less time.
Gold Standard of Lesion Formation
Temperature Monitoring
 Direct measurement of thermal cell death

 In neurology “… temperature monitoring has proven

itself safer and more effective than other
techniques…” (Cosman, Appl Neurophysiol 1988)
 Cardiac catheter lesion size best correlated with
tissue-electrode interface temperature (Langberg,
Circulation 1992)
 In liver ablation electrode tip temperature is an
important index for efficient power control. (Chung,
invest Radiol 1997)
Now, you still need to
COOL it down
Micro-Infusion Enhanced Ablation
 Purpose
 Larger ablations (7cm)
 Shorter ablation times
 Use
 Conduction (saline solution)
 Tissue hydration
 Temperature
 Precision
 Reliability
 Consistency
 Practical Limit to Size of Single
Ablation
 Non-microinfusion expanding probes 5 cm
 Non-microinfusion non-expanding
(cluster) cooled probes 5 cm
 Micro-infusion expanding probes 7 cm

 Macro-infusing non-expanding probes uncontrolled

location & size
XLi infusion antennae
(RITA)
Was it REALLY useful ?
Remember that one ?
Other solutions
De Baere AJR 2001
 Bipolar / multipolar
 no grounding pad (an active electrode and a closely
placed grounding electrode).

 The heat is generated not only around the active

electrode, but also around the grounding electrode and
in the space between the two.
 This is in contrast to the monopolar electrode, where heat is
generated only at the active electrode.
 Early clinical experience demonstrates that bipolar needles
produce a larger coagulation volume of 3-cm diameter by a
single application alone.

 Absence of a grounding pad eliminates the risk of

grounding pad burns.
 Pulse RF ablation
 increasing the volume of coagulation by increasing the
RF energy deposition.

 In this technique, higher energy deposition is alternated with

lower energy deposition.
 During periods of low energy deposition, the tissue around the
electrode cools down, allowing for even higher energy
deposition during the next cycle of ablation.

 This method allows for deeper heat penetration,

creating a larger ablation zone.
Combine Treatment
RFA – Angiographic Balloon
Occlusion

 Metastasis

 Vascular occlusion choice :

 size of the metastasis
 localisation / vessel

de Baere. AJR 2002

 TACE + RFA
PRE RFA
 Large tumors

 Larger necrosis
 more important « Post
RFA » syndrome
POST TACE + RFA
 To-be resolved question: how and when ?

 TACE then RFA

 TACE + RFA

 RFA then TACE (15 days later)

For What Big Tumours ?
 Indications
 HCC
 Colo-rectal Liver Metastasis

 Limited number of lesions

 Size < 5 cm
 Non resectable tumor
 No extra hepatic lesions
Metastasis - CI to Surgery

 Lower rate compared to HCC cirrhotic

patients

 Major liver resection

 with or without portal embolisation
 Re-hepatectomy for patients with colon
cancer
Metastasis
 Surgery
 Before
 During
 After
 Chemotherapy
Metastasis

IVb segment C+CT immediately

after procedure
Chopra AJR 2003
Other

 Hepatic adenoma / adenocarcinoma

 Endocrine Metastasis ?

 Rare Unique Liver Breast Metastasis ?

 What about complications ?

45 mm HCC Bilioma 44 months

Kim AJR 2004

Conclusion

 Lack of Datas specifically on Large

Liver Tumour RFA

 Combined Treatments

 Technological Advances