Radiofrequency Ablation: Technique and Clinical Applications
Radiofrequency Ablation: Technique and Clinical Applications
Radiofrequency Ablation: Technique and Clinical Applications
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ABSTRACT n last decade, there has been a rapid advancement in the utiliza-
Radiofrequency ablation is the most commonly used percu- tion of percutaneous, image-guided tumor ablation methods.
taneous ablation technique and well-documented in the lit-
erature on focal therapies. It has become the image-guided Radiofrequency (RF) ablation has become the method of choice be-
ablation method of choice because of its efficacy, safety, and cause of its safety and efficacy. Image-guided RF ablation is minimally
ease of use. Radiofrequency ablation has shown promise in
treating selected solid tumors, particularly those involving the invasive and usually appropriate for inoperable patients with other co-
liver, kidneys, lungs, and the musculoskeletal system. It is a morbidities. It requires a minimal hospital stay or can be performed on
minimally invasive technique often used in inoperable patients an outpatient basis. It preserves more normal organ tissue and is less
with other comorbidities. Radiofrequency ablation requires a
minimal hospital stay or can be performed on an outpatient expensive than surgery (1–3). The procedures are generally performed by
basis. The aim of this article is to review radiofrequency abla- using 14–21 G, partially insulated electrodes that are placed under guid-
tion techniques and their clinical applications.
ance (computed tomography [CT], magnetic resonance imaging [MRI],
Key words: • radiofrequency catheter ablation • tumor or ultrasonography [US]) into the tumor to be ablated. In most cases,
• percutaneous
percutaneous RF ablation can be performed in patients under conscious
sedation, by using medications similar to those used with any other in-
terventional radiology procedure. In the clinical arena, RF ablation has
been used for the treatment of various neoplasms, including metastases
from a variety of primary tumors (4, 5), such as hepatocellular carci-
noma (HCC) (6, 7), renal cell carcinoma (RCC) (8, 9), non-small cell lung
cancer (NSCLC) (10, 11), and osteoid osteoma (12, 13). In this article we
review RF ablation techniques and their clinical implications.
508
RF ablation systems
Substantial efforts have been made
to increase heating efficacy, reduce
charring and to achieve larger and
more effective tissue damage. New RF
ablation devices with more powerful
generators (200 watts) are the result of
these efforts. Currently, the following
three major commercial RF ablation
systems are globally available: Cool-
tipTM system (Covidien, Mansfield,
Massachusetts, USA) (Fig. 3), RF 3000®
(Boston Scientific Corporation, Natick,
Massachusetts, USA) (Fig. 4), and Model
1500X RF generator (AngioDynamics,
Latham, New York, USA) (Fig. 5). The
Cool-tipTM system monitors the im-
pedance (electrical resistance) of the
tissue during ablation, automatically
adjusting the power output to assure a
consistent flow of current to the tissue.
Excessive impedance for this device cor-
Figure 1. RF ablation circuit. Both the grounding pad (arrowheads) and needle electrode relates to excessive gas formation in the
(arrow) are active, while the patient acts as a resistor, creating an alternating electric field tissue. RF 3000® also tracks tissue im-
resulting in marked agitation of the ions in the tumor and the surrounding tissue. This ionic pedance for the user. Here, an increase
agitation creates heat. The marked discrepancy between the surface area of the needle
in tissue impedance is taken as a clini-
electrode and the grounding pad causes the generated heat to be concentrated around the
needle electrode. cal endpoint, correlating to a thorough
coagulation of the tissue around the
electrode. Model 1500X RF generator
Table. Tissue reaction for various degrees of thermal injury provides direct multi-point temperature
Temperature (°C) Tissue reaction
measurements throughout the tissue to
allow the user to target a pre-selected
42 More susceptible to chemotherapy or radiation target temperature for the tumor.
45 Irreversible cellular damage in several hours The Cool-tipTM system uses inter-
nally cooled electrodes, which mini-
50–55 Irreversible cellular damage in 4–6 min
mize charring and permit optimal
60–100 Coagulation of tissue energy deposition and deeper tissue
100–110 Vaporization and carbonization of tissue
heating. Multiple probe systems (so-
called cluster or switch box system)
For successful ablation, the tissue temperature should be maintained in the ideal range, which is 60–100°C. can achieve greater coagulation necro-
sis than any individual electrode alone.
Expandable, multi-tined electrodes,
such as the ones used in the RF 3000®,
permit the deposition of energy over a
larger area and decrease the distance
between the tissue and the electrode.
With the Model 1500X RF generator’s
perfused RF electrodes, slow infusions
of saline from the tines into the tissue
around the electrode allow for more
thorough heating.
Despite all these advancement, RF ab-
lation techniques still have some limita-
tions regarding ablation size, procedure
time, and heat sink effect from adjacent
vessels. This resulted in substantial work
to develop other tumor ablation tech-
nologies such as microwave ablation.
Clinical applications
Figure 2. Schematic illustration of the heat-sink effect. Blood flow within adjacent vessels is a In the last decade, there has been a
major factor for heat loss. rapid advancement in the utilization
Figure 3. a, b. The internally cooled needle-like electrodes (a) of the Cool-tip™ system (Covidien, formerly Radionics). An electrode is
electrically insulated along its shaft except for the final 1–3 cm, which is the exposed “active” tip. On the left is a “single” 17 G electrode with
a 3 cm active tip; on the right is a “cluster” electrode comprised of three 2.5 cm tipped single electrodes incorporated into one handle. The
RF generator (Covidien) (b) with a peristaltic pump to drive cooled saline to the electrode prevents charring. The generator provides up to 2
amps of RF electrical current, which is delivered at a power of up to 200 watts. The numeric displays on the front control panel allow the user to
observe the electrical impedance in the tissue, the current and power, and the probe temperature as well as the elapsed time.
a b
Figure 4. a, b. The LeVeen electrode (Boston Scientific Corporation) (a). This array-type of electrode is expandable and multi-tined. When it
is placed in the tumor under image guidance, the non-insulated “tines” of the electrode are deployed and extend from the distal tip of the
cannula. The photo shows a deployed electrode. The array diameters are available in a range of 2–5 cm. The RF 3000® Generator (b) provides
up to 2 amps of current and can provide a power of up to 200 watts, which is typical of currently-used systems. The level of power delivered
is controlled by the user. The power level is set low to start and is steadily increased to allow for a gradual heating of the tumor volume. When
heating is sufficient to coagulate the target tumor volume, the numeric display in the center of the control panel (reading 42 ohms) shows a
marked increase in tissue impedance by an order of magnitude.
a b
Figure 5. a, b. The Starburst electrode (AngioDynamics, formerly Rita Medical) (a). This is an array-type electrode, which is expandable and
multi-tined. After the active tines have been deployed as shown, the array diameters can be adjusted between 2 and 5 cm. Alternating tines of
the array have built-in thermal sensors and are able to detect the temperature in the tissue, providing feedback to the generator. The Model
1500X RF generator (b) provides up to 2 amps of RF current at up to 200 watts. The operator selects a target temperature for the tissue (such
as 105°C seen in the left numeric display). The device then adjusts the power that is delivered to the tissue until the thermocouples “see” that
temperature. Temperatures are displayed in the five numeric displays in the circular area on the right. Thereafter, the temperature is held for
several minutes to assure tissue necrosis.
d e f
of percutaneous, image-guided tumor RF ablation in liver tumors (6, 14). Furthermore, RF ablation com-
ablation methods, and RF ablation has Surgery is accepted as the first-line pares reasonably well with survival
been the method of choice because treatment for HCC and colorectal me- rates of surgery in patients with smaller
of its availability, safety, efficacy, and tastases that are limited in number. RF (≤3 cm) tumors (7, 15).
cost. In the clinical setting, RF ablation ablation has been shown to be an effec- RF ablation yields better results for
has shown promise for treating solid tive treatment option for patients with tumors surrounded by nontumor liver
tumors, particularly those involving primary and metastatic liver tumors, parenchyma. Tumors surrounded by
the liver (6, 7), kidneys (8, 9), lungs who are not surgical candidates due to cirrhotic parenchyma have the ad-
(10, 11, 4, 5), and the musculoskeletal tumor location, poor hepatic reserve, vantage of being insulated and can be
system (12, 13). other comorbidities, or advanced age coagulated better (Fig. 6). Subcapsular
Figure 7. a–c. A 72-year-old woman with a biopsy-proven NSCLC, who was not a surgical candidate due to severe chronic obstructive
pulmonary disease, and was referred for percutaneous RF ablation. The mass (arrowhead) was 2.5×2 cm in size, pleural-based, and located in
the left upper lobe on CT (a). It was ablated using CT guidance and a 3 cm expandable, multi-tined RF ablation electrode (Boston Scientific
Corporation) (b). RF energy was applied according to the standard vendor’s protocol, starting from 40 watts and gradually increasing up to
150 watts over a total of 22 min. Follow-up MRI (c) obtained the next day showed no residual tumor (arrowhead) in the ablation zone. There
was no recurrence at 12 months follow-up (not shown here).
a b c
Figure 8. a–c. A 65-year-old woman with a 2×2 cm right kidney mass, which was found incidentally. The patient has a pacemaker due to heart
block. Axial CT image (a) shows an enhancing mass (arrowhead) in the medial aspect of the upper pole of the right kidney. Percutaneous RF
ablation (b) was performed using CT guidance and a 3 cm expandable, multi-tined RF ablation electrode (Boston Scientific Corporation). RF
energy was applied starting from 40 watts and gradually increased to 150 watts over 13.5 min, including a booster dose. After the procedure,
the patient developed mild hematuria, which subsided spontaneously. Follow-up CT (c), which was obtained the next day, showed good tumor
coverage with no evidence of suspicious enhancement (arrowhead) in the tumor to suggest residue.
the central airway carry a risk of injury not surgical candidates (8), and there Renal RF ablation is a safe procedure
of the bronchus, resulting in cavita- is increasing evidence that it can be with a serious complication rate of <1%
tion, abscess formation, and broncho- a curative treatment option for these (18). The complications depend on the
pleural fistula (5). patients, sparing them the risk of mor- location of the tumor. In peripherally
tality and substantial morbidity as- located tumors, there is a potential for
RF ablation in kidney tumors sociated with surgery (9). RF ablation thermal injury to adjacent bowel, and
The incidence of RCC has signifi- seems to provide the lowest rate of in more central or medial lower pole tu-
cantly increased in the USA, with an renal impairment compared to extir- mors, injury to the collecting system is
expected incidence of more than 50 pative treatment options (37), which more common (18). Patient positioning
000 new cases each year (36). Surgery is particularly important in patients and hydrodissection may help to dis-
is the method of choice for localized with a solitary kidney. RF ablation has place the adjacent bowel to prevent in-
RCC; however, there are a significant also been used effectively for treatment jury. Prophylactic placement of ureteral
number of patients who are not suit- of multiple renal cell cancers such as stents can be considered in patients with
able for surgery because of comorbid those seen in von Hippel-Lindau pa- a tumor near the ureter, carrying high
illnesses. RF ablation is emerging as a tients. Peripheral, exophytic and small risk of ureter injury. The stent is placed
safe and effective alternative for elderly (<3 cm) tumors are more suitable for prior to the ablation and stays in place
patients with early-stage RCC who are RF ablation (Fig. 8). until 4–6 weeks after the procedure.
RF ablation in bone tumors presents with nocturnal pain and re- CT guidance and then the RF elec-
Painful bone metastases are a com- sponds to anti-inflammatory drugs. trode is inserted through the penetra-
mon cause of morbidity in cancer Surgical removal has been the estab- tion needle. If needed, a biopsy needle
patients. Metastatic bone disease gen- lished treatment method for many can be placed through the penetration
erally indicates limited life expect- years. Utilization of RF ablation for needle and specimen can be obtained
ancy; therefore, a safe, effective, and osteoid osteoma was first reported in for histopathological evaluation. The
tolerable local treatment is essential 1992 by Rosenthal et al. (40), and sev- RF electrode should be selected to be
for providing local pain control and eral studies have shown effects of RF long enough so that the penetration
to increase quality of life. Radiation ablation in treatment of osteoid osteo- needle can be withdrawn by at least a
therapy, systemic chemotherapy, ma since then. In a recent prospective few centimeters from the tip of the RF
hormonal therapy, surgery and pain trial by Hoffman et al. (12), 38 patients electrode, to prevent skin burn along
medications have been used to control were successfully treated with RF abla- the shaft of the needle.
pain in these patients (38). RF abla- tion with only three recurrences dur-
tion is a practical alternative to treat ing an average follow-up of 32 months, Other clinical applications for RF ablation
painful bone metastases that are not all of which were treated with a second A solitary metastasis from a variety
responding to standard measures such RF ablation. Currently, RF ablation has of primary tumors to the adrenal gland
as narcotics or radiation therapy (Fig. been shown to be effective in as many can be treated with percutaneous abla-
9). There is growing evidence on the as 90% of cases (13). It has replaced tion (41). Ablation of normal adrenal
effectiveness and durability of pain surgery in many centers and is now gland tissue may cause a hypertensive
palliation via RF ablation. The recent- considered a standard of care. crisis during the procedure and pre-
ly reported ACRIN (American College During RF ablation of osteoid os- medication with and/or blockers
of Radiology Imaging Network) trial teoma or any other skeletal tumors, may be helpful.
demonstrated that pain intensity de- RF electrodes can be placed into the Although RF ablation is typically
creased by 26.92 and 14.16 points (on tumors with help of a bone biopsy sys- used to treat cancer patients with vir-
a scale of 0–100 points) in one and tem such as the Binopty (Radi Medical tually any solid primary and meta-
three months, respectively (39). Systems, Uppsala, Sweden). First, a 14 static organ tumors, it can be utilized
Osteoid osteoma is a benign bone G penetration set of this bone biopsy beyond oncology, such as for ligation
tumor of young adults which typically system is placed into the tumor under of the umbilical cord of fetuses with