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RFA for big liver tumoursRFA for big liver tumours
Dr Jean-Brice GAYETDr Jean-Brice GAYET
Dpartement dimagerie mdicaleDpartement dimagerie mdicale
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What are we talking about ?
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RF Ablation: 1996RF Ablation: 1996
Low-power generator (50 W)
3-cm-diameter ablation volume
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RF Ablation: 2003RF Ablation: 2003
High-power generator (250 W)
5-7 cm diameter Ablation Volume
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The Gold StandardThe Gold Standard
GOLD STANDARD
IS THE
SURGICAL RESECTION
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Why ?Why ?
The Motto of the surgeons basically is
IF IN DOUBT, CUT IT OUT!
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Approximately 80% of LiverApproximately 80% of Liver
Tumours are unresectableTumours are unresectable
Bilateral or multiple tumours
Difficult position Liver Health
Systemic health
Anything else you can think of
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What do you do to commitWhat do you do to commit
tumouricide on the rest?tumouricide on the rest?
Poison them
Starve them
Freeze them
Cook them
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Resection is made More Possible ifResection is made More Possible if
Combined with Other TechniquesCombined with Other Techniques
Resect AND Cook Resect AND Freeze
Resect AND Poison
Resect AND Poison AND cook
And so on
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Combine Resection and OtherCombine Resection and Other
ModalitiesModalities
Ablation treatments do NOT replace allresections, it enhances the possibility
of resection in combination with them
Multidisciplinary decisions +++
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Back to RFA
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First, HEAT it !
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Basic principle : Closed LoopBasic principle : Closed Loop
CircuitCircuit
Generator Dispersive electrode(ground pad)
RF needle
Input current
Output current
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Making RF LesionsMaking 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
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Principles of RF Energy DeliveryPrinciples 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
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Applied to BLTApplied to BLT
Pb of conducting heat against the convection
cooling of blood flow of a larger volume.
Requires the directly heated tissue (within 2mm of probe) to be as hot as possible
Pb of tissue dessication : will not conduct
electricity away from the probe hence
prematurely halting process.
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Stages of RF AblationStages of RF Ablation
Frictional
Heating
Conductive
Heating
Conduction Over Time . . .
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Key Ablation Process ComponentsKey Ablation Process Components
Heat generation Distance (r)
Current (I) Time (T)
Lesion size
Temperature Electrode size
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The extent and nature of thermal injury aredependent on two important factors, Temperature
& RF Application Duration.
(V. Krishnamurthy, Applied Radiology, Oct. 2003)
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Lesion Size Depends onLesion Size Depends on
Electrode Size and TemperatureElectrode Size and Temperature
0
2
4
6
8
30 50 70 90 110
Body
Temp
Cell
Death
Lesion
Size(cm)
Electrode Temperature (C)
SB XL &
Semi-Flex
(3 cm)
StarBurstSDE (2 cm)
SB XL &Semi- Flex
(5 cm)
SB XLi
(7 cm)
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Souvenirs, souvenirsSouvenirs, souvenirs
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Prior to the newer probesPrior to the newer probes
How (the hell) did people do this ?
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The Overlapping Mode The Overlapping Mode
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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 asA: Five ablations are performed in the middle part of the
tumor. C, The section perpendicular toA: Two additional ablations are performed at the
two poles of the tumor. The tumor can be effectively ablated with seven ablationspheres.xindicates the target site of the ablationthat is, the ablation spherecenter.
Chen VIR 2004Chen VIR 2004
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Predictable Lesions goldPredictable Lesions gold
standardstandard Temperature
Monitor heat Thermocouples (Real-time measurement) Check temps at end to ensure cell death
Monitor duration Consistent & Reproducible
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Methods of Control of EnergyMethods of Control of Energy
DeliveryDelivery Global impedance measurement, no regional
differentiation. Global impedance measurement and indirect
central temperature measurement by coolingwater temperature. Direct measurement of regional peripheral
temperatures with power control feedbacksystem.
Direct regional peripheral temperature endpoint,control of rehydration by impedance during fullpower application.
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A few medical and non-medical considerations
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Radionics / Tyco
200 Watt generator that works by limiting
power (necessary to prevent desiccation of
tissue, due to excessive temperature, thataborts the procedure) in two ways
Duty cycle.
Internal cooling of the Radionics probe.
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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.
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Excess power is removed by cooling the
tissue immediately in contact with the
probe by cooling the probe itself. This isanalogous to controlling your cars speed
with the brakes instead of the
accelerator.
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Remember that the energy deposited in the ablationvolume is useless until converted into the heat thatactually does the work
Measuring temperature is therefore the ONLY way toknow & control what is happening. Radionics probesonly measure the temperature of the cooling water, or, ifthat is switched offONLY the temperature of theCENTRE 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 zonaldifferential information.
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Boston
Power control is only by total impedance withoutany temperature sensing nor any regionalinformation. Power is manually adjusted by the
physician, needing constant attention.
The expanding probe tines are one third thethickness of RITAs which carry electrical circuits forthe temperature sensors and/or saline for infusion.They are much more easily diverted from theexpected deployment pattern.
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The probe has to be fully deployed at all times, sodifferent ablation sizes can only be accomplished byusing multiple probes, unlike RITAs probes which canbe scaled to different deployments (sizes) even duringan ablation if the clinical situation requires it.
There is no Cool-Down quality control (no temperaturesensing), so immediate contrast scanning is the onlyway to ensure complete ablation without risking anotherlater procedure.
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RITARITA
The whole unique point of RITAs technology is theuse of peripheral temperature sensing and feedbackpower control.
RITA uses analogue power controlled by temperaturefeedback and on commencement only uses enough powerto raise tissue temperatures by 1.5 C per second to preventshock waves. So local anaesthesia (& conscious sedation)
is usual when using RITA routinely in the liver.
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Because of the volumes & geometry involvedcoagulating the periphery is much more difficultthan the centre of the lesion. This is why
PERIPHERAL temperature sensors are important.If the cooling effect of blood flow has, more easilyinitially, been stopped in the centre, then it iseasier to ablate the periphery
by quickly & easily coagulating the centre first,subsequent extentions of the ablation outwardsproceed more easily so the entire ablation takesless time.
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Gold Standard of Lesion FormationGold Standard of Lesion Formation
Temperature MonitoringTemperature Monitoring Direct measurement of thermal cell death
In neurology temperature monitoring has provenitself 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)
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Now, you still need toCOOL it down
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Micro-Infusion Enhanced AblationMicro-Infusion Enhanced Ablation
Purpose Larger ablations (7cm) Shorter ablation times
Use Conduction (saline solution) Tissue hydration
Temperature
Precision Reliability Consistency
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Practical Limit to Size of SinglePractical Limit to Size of Single
AblationAblation 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 uncontrolledlocation & size
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XLi infusion antennae(RITA)
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Was it REALLY useful ?
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Remember that one ?Remember that one ?
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Other solutionsOther solutions
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De Baere AJR 2001De Baere AJR 2001
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Bipolar / multipolar
no grounding pad (an active electrode and a closelyplaced grounding electrode).
The heat is generated not only around the activeelectrode, but also around the grounding electrode andin 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 asingle application alone.
Absence of a grounding pad eliminates the risk of
grounding pad burns.
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Pulse RF ablation
increasing the volume of coagulation by increasing theRF energy deposition.
In this technique, higher energy deposition is alternated withlower energy deposition.
During periods of low energy deposition, the tissue around theelectrode cools down, allowing for even higher energydeposition during the next cycle of ablation.
This method allows for deeper heat penetration,creating a larger ablation zone.
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Combine TreatmentCombine Treatment
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RFA Angiographic BalloonRFA Angiographic Balloon
OcclusionOcclusion
Metastasis
Vascular occlusion choice : size of the metastasis
localisation / vessel
de Baere. AJR 2002
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TACE + RFATACE + RFA
Large tumors
Larger necrosis
more important Post
RFA syndromePOST TACE + RFAPOST TACE + RFA
PRE RFAPRE RFA
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To-be resolved question: how and when ?
TACETACE thenthen RFARFA
TACE + RFATACE + RFA
RFARFA thenthen TACETACE (15 days later)(15 days later)
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For What Big Tumours ?
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IndicationsIndications
HCC
Colo-rectal Liver Metastasis
Limited number of lesions
Size < 5 cm
Non resectable tumor
No extra hepatic lesions
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Metastasis - CI to SurgeryMetastasis - 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
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MetastasisMetastasis
Surgery Before
During
After Chemotherapy
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Chopra AJR 2003Chopra AJR 2003
C+CT immediatelyC+CT immediately
after procedureafter procedure
MetastasisMetastasis
IVb segmentIVb segment
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OtherOther
Hepatic adenoma / adenocarcinomaHepatic adenoma / adenocarcinoma
Endocrine Metastasis ?Endocrine Metastasis ?
Rare Unique Liver Breast Metastasis ?Rare Unique Liver Breast Metastasis ?
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What about complications ?What about complications ?
45 mm HCC Bilioma45 mm HCC Bilioma 44 months44 months
Kim AJR 2004
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ConclusionConclusion
Lack of Datas specifically on Large
Liver Tumour RFA
Combined Treatments
Technological Advances