RF Ablation

Last Updated 10/18/02

RFA is a relatively new technique where a heated probe is placed inside tumors to "cook" them, with minimal damage to surrounding tissues. Initially applied only to tumors in the liver, lately its application is extending to tumors anywhere in the body, including lung and bone . Keep in mind that only a few innovative doctors appear to actually be doing these extended (extrahepatic) applications in practice, so that you may have to travel to their location (may be out of state depending on where you are) if you're interested. For a "quick" intro to RFA, see Steve Dunn's site .

There are three methods by which RFA can be done: Percutaneously (RFA needles go thru the skin, no surgery), Laproscopically (RFA needles inserted into an organ during laproscopic surgery), or during Open Surgery. The second two methods may have an advantage in that the surgeon can "look around" for other metastatic disease not seen on scans (e.g. it is well known that peritoneal metastases do not show up well on any scans, MRI, CT, or PET until they are quite large at which time it may be difficult to do anything about them). The percutaneous RFA is obviously the "easiest", having less recovery time.

The NIH site gives an excellent intro to RFA, what it is and how it works - also see USCF Liver Tumor Program . Livertumor.org has a good summary of treatment options for liver tumors, as well as a find a physician section which has a list of doctors experienced in the procedure.

Given a choice of RFA or surgery for liver metastases, I think most surgeons would prefer to do hepatic resection assuming it is possible. However, at least one report - Abstract suggests that percutaneous RFA might actually be prefered over a second liver resection if tumors recur, e.g. "CONCLUSION: Percutaneous RF treatment increases the number of patients eligible for curative treatment. It should be preferred to repeat hepatectomy when feasible and safe because it is less invasive. Repeat hepatectomy is indicated only when percutaneous RF ablation is contraindicated or fails".

Rita Medical Systems seems to be the primary RFA equipment manufacturer, and their website has further information about this. It is important to have a surgeon doing the procedure who is using the latest equipment, because some of the earlier machines were only able to treat "very small" tumors (under 3cm or so), and the current versions are much better. There is an Events Calander on the Rita Medical site which you could also use to find names of surgeons giving presentations about RFA - they are likely to be among the top in the field. Use Google.com to find contact numbers and/or e-mail addresses if these are not given in the calander.

Duke University also has an excellent website about RFA. Note that it says "Tumors adjacent to a major blood vessel often recur locally since the blood vessel itself draws heat away from the area during the treatment, the so-called 'heat sink phenomenon'. As a result, the tumor cells next to the blood vessel cannot get hot enough to acheive cellular death.". In such cases, the less well known Stereotactic Radioablation may offer a better chance of complete local tumor eradication.

Two well known surgeons with a lot of experience in RFA are Dr. Steven Curley of MD Anderson, who did a lot of early work with the technique in the 1990's, and Dr. Allen Siperstein at the Cleveland Clinic. Although these two doctors have much experience with RFA for liver tumors, I am not sure if they will treat extrahepatic disease.

Johns Hopkins is doing some interesting experimental stuff with RFA, using a Robotic Arm to actually perform the procedure. A good paper (pdf file) about this is Robotically Assisted Percutaneous Local Therapy and Biopsy .

An example of a surgeon who will perform RFA for tumors anywhere in the body is Dr. Sewell at the University of Mississippi Cancer Center. Also see this Article about Dr. Sewell and this Patient Story from last year (2001). Some other patient stories are here , indicating perhaps RFA might have a role in extending survival without much harm to the patient.

NOTE: Someone has written me that Dr. Sewell no longer accepts patients with lung metastases but only primary lung cancer patients. The same individual said that he knew patients who HAVE had lung mets from colon cancer treated at Wake Forest in North Carolina. I HAVE NOT verified this information! I would suggest calling Dr. Sewell anyway if you are looking for lung met treatment by RFA, as (1) the info I heard MAY not be correct, and (2) Even if it is, he may still be able to give you valuable info/advice!

Other cancer centers doing extrahepatic RFA include the Rhode Island Hospital , "At Rhode Island Hospital, we have taken RFA a step further by broadening its application. RFA has been used successfully to combat breast, kidney, liver, lung, adrenal and bone cancer. In the two years following FDA approval, more than 90 patients have undergone radiofrequency ablation here. To date this is the largest use of RFA in treating malignancy in North America. At a meeting of the Radiological Society of North America, Dupuy's scientific exhibit, 'RFA of Extra-Hepatic Malignancies,' received a highly prestigious magna cum laude award". There appears to be a clinical trial at Brown University which Dr. Dupuy and Dr. Safran are involved with. The University of South Alabama also does extrahepatic RFA, and if you search the Clinical Trials you may also have success in locating some other locations doing RFA for hepatic/extrahepatic disease.

General References

4/01/02 Search of ExperimentalandUnconventional RF Ablation
1/20/02 RF Ablation Patient Stories
5/14/01 Radiofrequency Ablation Surpasses Cryoablation as the Treatment of Choice for Localized, Unresectable Liver Malignancies March 2000 MD Anderson, Dr Curley
5/14/01 Promising Radio Frequency Treatment New Option for Patients with Unresectable Liver Tumors March 1998 MD Anderson, Dr Curley
5/14/01 Turning Up the Heat on Liver Tumors Viewing the Operation RF Ablation 1999
5/14/01 One Patient's Experience with RFA RF Ablation
5/14/01 Central Florida Liver Cancer Institute Cancer Treatment - Personal Stories RF Ablation 4. Liver Treatment www.liverinstitute.com The doctor in charge is Dr. Gary Onik.
4/01/02 RITA Medical Systems, Inc. Makes RF ablation equipment.
4/01/02 Livertumor.org Site sponsored by Rita Medical Systems. Has list of doctors performing RF Ablation using Rita equipment
5/18/01 Radiofrequency(RF) Ablation: A New Minimally-Invasive Treatment for Cancer Dr. Rendon C. Nelson Duke Universtiy
4/24/01 U of Minnesota physicians use heating device to treat liver cancer U of Minn Cancer Center. Physicians at the University of Minnesota are using a new minimally invasive heating device called radiofrequency ablation to treat liver cancer.
9/15/01 An Appraisal of Percutaneous Treatment of Liver Metastases Alighieri Mazziotti, Gian Luca Grazi, Andrea Gardini, Matteo Cescon, Filippo Pierangeli, Giorgio Ercolani, Elio Jovine, and Antonino Cavallari Vol. 4, Issue 4, pp. 271-275, July 1998 This small series of liver resections in patients who had previously undergone percutaneous treatment led us to express doubt about the long-term efficacy of such treatment. The lesions treated were on initial presentation small and mostly single. At the time of surgery, the lesions had increased in size in all cases. In 2 patients, the diaphragm was infiltrated in an area in which there was no corresponding extension of the tumor on Glisson's capsule, and the infiltration corresponded to a tumoral seeding along the pathway of the needle. In all these patients, the histologic examination of the resected specimen revealed the presence of vital tumoral tissue. Areas of necrotic tissue were observed in only two cases of carcinoid metastases, which show a different behavior with respect to adenocarcinoma metastases, the former being highly vascularized and sensitive to other locoregional treatments that induce ischemia

Technical References

The literature seems to indicate a preference for surgical hepatic resection over RF ablation for patients in whom surgery is possible. However, a new paper indicated a preference for RF Ablation over a second hepatic resection in cases of recurrence. This may be related to the belief among some doctors that follow-up after a resection of primary colorectal malignancies does not favourably influence patient outcome , i.e. "it doesn't make any difference what you do", an idea which may have extended to followup after first resection of hepatic tumors. My personal feeling is that this idea is totally incorrect for at least a subset of patients with second recurrences.

There appears to be a general consensus that RFA is safe and effective for the particular lesions treated. However, there seems to be considerable question regarding the extent to which RF ablation contributes to increased survival time for many patients due to further recurrence outside the ablated site. Some authors suggest RFA be combined with other treatment modalities such as chemotherapy or HAI to increase effectiveness. Another approach might be to followup RFA with cancer vaccines or other alternative antiangiogenesis therapies.
8/4/02 Radiofrequency Ablation of Malignant Liver Tumors By Steven Curley, MD Anderson -FULL TEXT ARTICLE- The Oncologist, Vol. 6, No. 1, 14-23, February 2001
8/4/02 Percutaneous radiofrequency thermoablation as an alternative to surgery for treatment of liver tumour recurrence after hepatectomy. Br J Surg 2002 Jun;89(6):752-6 PMID: 12027986 CONCLUSION: Percutaneous RF treatment increases the number of patients eligible for curative treatment. It should be preferred to repeat hepatectomy when feasible and safe because it is less invasive. Repeat hepatectomy is indicated only when percutaneous RF ablation is contraindicated or fails.
8/4/02 Hepatocellular carcinoma: a case of extrahepatic seeding after percutaneous radiofrequency ablation using an expandable needle electrode Hepatogastroenterology 2002 Jul-Aug;49(46):897-9 PMID: 12143236 To prevent tumor seeding, using thermocoagulation when retracting the needle electrode may be useful.
8/4/02 Local, intrahepatic, and systemic recurrence patterns after radiofrequency ablation of hepatic malignancies J Gastrointest Surg 2002 Mar-Apr;6(2):255-63 PMID: 11992812 Forty-five patients with 143 lesions and a minimum follow-up of 6 months (median 19.5 months) were treated. Overall, 7.7% of treated lesions had local recurrence. New intrahepatic disease was seen in 49% of patients, and 24% had evidence of new systemic tumor progression. Patients with colorectal metastatic lesions > or =4 cm at the time of the first RFA were more likely to present with local recurrence (P = 0.048). Complications occurred in 27% of patients. Although RFA has a satisfactory local failure rate and safety profile, the patient population being treated is at high risk of developing new disease. Multimodality adjuvant therapy will be necessary to realize the full potential of hepatic malignancy control with RFA.
8/4/02 Ultrasound-guided radiofrequency thermal ablation of liver tumors: percutaneous, laparoscopic, and open surgical approaches J Gastrointest Surg 2001 Sep-Oct;5(5):477-89 PMID: 11985998 During a mean follow-up period of 20.5 months, local tumor recurrence at the RFA site was diagnosed in 18 (8.8%) of 204 tumors. The risk factors for local recurrence included large tumor size and major vessel invasion: recurrence rates for tumors less than 4 cm, 4 to 10 cm, and greater than 10 cm, and for those with vessel invasion were 3.3%, 14.7%, 50%, and 47.8%, respectively. Ten of 18 tumors recurring locally were retreated by RFA, and eight of them showed no further recurrence. Ultrasound-guided RFA is a relatively safe, well-tolerated, and versatile treatment option that offers excellent local control of primary and metastatic liver tumors. The appropriate use of percutaneous, laparoscopic, and open surgical RFA is beneficial in the management of patients with liver tumors in a variety of situations.
8/4/02 Treatment of liver metastases, an update on the possibilities and results. Eur J Cancer 2002 May;38(7):1023-33 PMID: 11978527 For the moment, local tumour ablative therapies such as cryotherapy and radiofrequency therapy should be considered as an adjunct to hepatic resection in those cases in which resection can not deal with all of the tumour lesions. In these cases, there seems a beneficial effect of a combined treatment consisting of resection and local tumour ablation. At this stage, there are no randomised data that local tumour ablation is as effective as resection.
8/4/02 Radiofrequency ablation of hepatic metastases. Semin Oncol 2002 Apr;29(2):168-82 PMID: 11951215 RFA has been shown to be safer and better tolerated than other ablative techniques and has been associated with a low rate of local recurrence when performed properly. RFA also has shown some promise in combination with surgical resection and other therapies. Patients who undergo RFA still suffer from progressive metastatic disease, reinforcing the premise that local therapies have little impact on the natural history of aggressive cancers
8/4/02 [Radiofrequency ablation in primary and secondary liver tumors] Chir Ital 2002 Jan-Feb;54(1):83-6 PMID: 11942016 None of the patients undergoing ultrasonography and CT follow-up examinations after 6 months presented recurrence of hepatic metastases. This treatment, though its use has so far been limited to only a few cases with a short follow-up, opens up new prospects for the surgical treatment of primary and secondary malignancies, also in the light of experience based on a substantial number of patients, recently reported in the literature.
8/4/02 Radiofrequency ablation of hepatocellular carcinoma. Minerva Chir 2002 Apr;57(2):165-76 PMID: 11941292 For tumors smaller than 2.0 cm in diameter, one or two deployments of the monopolar multiple array needle electrode is sufficient to produce complete coagulative necrosis of the tumor. However, with increasing size of the tumor, there is a concomitant increase in the number of deployments of the needle electrode and the overall time necessary to produce complete coagulative necrosis of the tumor. In general, RFA is a safe, well-tolerated, effective treatment for unresectable hepatic malignancies less than 6.0 cm in diameter. Effective treatment of larger tumors awaits the development of more powerful, larger array monopolar and bipolar RFA technologies
8/4/02 Hepatic radiofrequency ablation Arch Surg 2002 Apr;137(4):422-6; discussion 427 PMID: 11926946 DESIGN: Case series of 123 patients with unresectable hepatic tumors or tumors with histological findings not traditionally treated by means of hepatic resection were considered for hepatic RFA. Median follow-up was 20 months RESULTS: Initial treatment sessions were percutaneous in 87 patients, open operations in 33, and laparoscopic in 3. Repeated sessions were percutaneous in all but 2 patients. The mean number of lesions treated per session was 2.7 (range, 1-24). Mean tumor size was 5.2 cm (range, 0.5-15.0 cm). One death occurred within 30 days of a procedure. No hepatic bleeds, bile leaks, or adult respiratory distress syndrome occurred. Overall morbidity was 7.1%. Complications included hepatic abscesses in 4 patients, transient liver insufficiency in 3, segmental hepatic infarcts in 2, diaphragm paralysis in 1, hepatic artery-to-portal vein fistula in 1, and systemic hemolysis in 1
8/4/02 Locoregional therapies for hepatocellular carcinoma: a critical review from the surgeon's perspective Ann Surg 2002 Apr;235(4):466-86 PMID: 11923602 The advent of more versatile radiofrequency probes has allowed ablation of HCCs larger than 5 cm. Recent studies have suggested that combined transarterial embolization and heat ablation is a promising strategy for large HCCs. Thus far, no randomized trials comparing various thermoablative therapies have been reported. It is also uncertain whether a percutaneous route, laparoscopy, or open surgery affords the best approach for these therapies. Thermoablative therapies have been combined with resection or used to treat postresection recurrence, and they have also been used as a pretransplant therapy. However, the value of such strategies requires further evaluation. CONCLUSIONS: Advances in locoregional therapies have led to a major breakthrough in the management of unresectable HCC, but the exact role of the various modalities needs to be defined by randomized studies. Novel thermoablative techniques provide the surgeon with an exciting opportunity to participate actively in the management of unresectable HCC. Locoregional therapies are also useful adjuncts in the management of patients with resectable or transplantable disease. Hence, surgeons must be equipped with the latest knowledge and techniques of ablative therapy to provide the most appropriate treatment for the wide spectrum of patients with HCC.
8/4/02 Percutaneous tumor ablation with radiofrequency Cancer 2002 Jan 15;94(2):443-51 PMID: 11900230 RESULTS: Recent refinements in ablation technology enable large tumor volumes to be treated with image-guided needle placement, either percutaneously, laparoscopically, or with open surgery. Local disease control potentially could result in improved survival, or enhanced operability. CONCLUSIONS: Consensus indications in oncology are ill-defined, despite widespread proliferation of the technology. A brief review is presented of the current status of image-guided tumor ablation therapy. More rigorous scientific review, long-term follow-up, and randomized prospective trials are needed to help define the role of RFA in oncology.
8/4/02 Complications from radiofrequency ablation of liver metastases Am Surg 2002 Feb;68(2):204-9 PMID: 11845810 A total of 43 radiofrequency ablation procedures were studied. There was one (2%) mortality related to a hepatic abscess development 8 days after the procedure. One patient (3%) required a blood transfusion. Three patients (8%) developed severe upper abdominal or pleuritic chest pain that persisted several days after the procedure. We conclude that radiofrequency ablation of liver metastases is associated with a low rate of serious complications (two of 38; 5%). Complications requiring treatment usually develop several days after the procedure
6/4/01 TITLE: [Thermal ablation of liver metastases. Current status and prospects] AUTHOR: Vogl T, Mack M, Straub R, Zangos S, Woitaschek D, Eichler K, Engelmann K SOURCE: Radiologe; 41(1):49-55 2001 UI: 21115577
Different technical procedures of thermal ablation and online monitoring are used, as there are the MR-guided laser induced thermotherapy (LITT) and the radiofrequency ablation thermotherapy (RF). CONCLUSION: MR-guided LITT results in a high local tumor control rate with improved survival.
6/4/01 TITLE: Usefulness of intraoperative radiofrequency thermoablation of liver tumours associated or not with hepatectomy. AUTHOR: Elias D, Goharin A, El Otmany A, Taieb J, Duvillard P, Lasser P, de Baere T SOURCE: Eur J Surg Oncol; 26(8):763-9 2000 UI: 20541679
. The purpose of this study was to undertake a prospective estimation of the benefit of RF thermoablation of liver tumours during hepatic and extrahepatic resections aimed at obtaining an R0 status in patients in whom disease is notoriously considered unresectable CONCLUSION: Intraoperative use of RF to destroy unresectable liver tumours increases the rate of curative resections. Future progress in RF technology and adequate vascular clamping during RF should increase this rate.
6/4/01 TITLE: Radiofrequency ablation of unresectable primary and metastatic hepatic malignancies: results in 123 patients. AUTHOR: Curley SA, Izzo F, Delrio P, Ellis LM, Granchi J, Vallone P, Fiore F, Pignata S, Daniele B, Cremona F SOURCE: Ann Surg; 230(1):1-8 1999 UI: 99325616
CONCLUSIONS: RFA is a safe, well-tolerated, and effective treatment to achieve tumor destruction in patients with unresectable hepatic malignancies. Because patients are at risk for the development of new metastatic disease after RFA, multimodality treatment approaches that include RFA should be investigated.

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