
Surgical Resection remains the therapeutic option of choice in the treatment of liver tumors. 

However, the majority of primary and metastatic tumors of the liver are not amenable to surgical resection at presentation. Radiofrequency ablation (RFA) is a new modality for local tumor destruction with minimal local and systemic complications. Radiofrequency heat ablation is useful as a primary treatment for unresectable liver cancers. The procedure can be used to treat the small residual tumor load in the contralateral [other side] lobe following liver resection in those considered unresectable at the first presentation. This new therapeutic strategy increases surgical resectability in patients previously judged unresectable. RFA can also be combined with cryoablation. Percutaneous RFA should be considered in high-risk patients or those with small local recurrences.

Radiofrequency Ablation is a specialized technique, and should be carried out in a specialized liver treatment center. Celiotomy [abdominal incision] or laparoscopic approaches are preferred for RFA because they allow IOUS [intraoperative ultrasound], which may demonstrate hidden additional metastases. Operative RFA also allows concomitant resection, Cryoablation, or placement of a hepatic artery infusion pump, and isolation of the liver from adjacent organs. Laparoscopy and intraoperative ultrasound are essential in staging patients with hepatic malignant neoplasms. 

RFA can be carried out percutaneously [through the skin--meaning without a surgical incision.] Percutaneous RFA should be reserved for patients at high risk for anesthesia, those with recurrent or progressive lesions, and those with smaller lesions sufficiently isolated from adjacent organs. 

Radiofrequency ablation when combined with Cryoablation reduces the morbidity of multiple freezes. Although RFA is safer than Cryoablation and can be performed via different approaches (percutaneously, laparoscopically, or at celiotomy); it is usually limited by tumor size (<3 cm).  However, in some organs, RFA is used to "nibble" at large tumors, and can ablate them in skilled hands. 

Complications of RFA can include bleeding into the chest or abdominal cavities or other structures, burns of vascular structures or skin or diaphragm, persistent pain, pleural effusions [water on the lung], cholecystitis [gall bladder inflammation], abcesses, trauma to the liver, and liver failure. Some of the RFA complications can be fatal. 

RFA is a safe and effective alternative for the attempted ablation of unresectable hepatic malignancies and when used along with it, can reduce the morbidity of cryosurgery. Percutaneous and laparoscopic RFA can be performed effectively with less than 24 hours of hospitalization. Radiofrequency ablation alone or combined with Surgical Resection or Cryoablation resulted in reduced blood loss and shorter hospital stay. 

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References for this section are below.


<b>RFA and Liver Metastases 
Selected Medical Journal Article Annotated References</b>
[For the full abstract, use the links provided, or search on Pubmed.  Ed.]


Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2000 Nov;172(11):905-10 
<b>[Percutaneous radiofrequency ablation of hepatic neoplasms using a "cluster" electrode--first clinical results].</b> [Article in German] Trubenbach J, Konig CW, Duda SH, Schick F, Huppert PE, Claussen CD, Pereira PL. 
Abteilung fur Radiologische Diagnostik, Eberhard-Karls-Universitat Tubingen. jochen.truebenbach@med.uni-tuebingen.de 

 ... A total of 17 percutaneous RFA was performed. The mean total procedure time was 2.0 h (1.5-2.5 h). Placement of the clustered electrode within the neoplasms using a inter- or subcostal approach under local anesthesia was possible in all cases. Complications related to percutaneous treatment and technical problems were not encountered. Diameter of the ablated areas ranged between 3.0-7.0 cm. Technical success was observed in 13 of 15 neoplasms (86.6%). During a mean follow-up of 7.25 months (range 3-12 months) 8 of 12 neoplasms showed a complete necrosis...... Percutaneous RFA using a clustered electrode is a feasible, safe and effective procedure for the treatment of hepatic neoplasms up to 6 cm in size. Clinical trial 
&&url PMID: 11142123 


Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2000 Aug;172(8):692-700 
<b>[MRI-guided percutaneous radiofrequency ablation of hepatic neoplasms--first technical and clinical experiences]</b>. [Article in German] 
Huppert PE, Trubenbach J, Schick F, Pereira P, Konig C, Claussen CD. Abteilung fur Radiologische Diagnostik, Eberhard-Karls-Universitat Tubingen. PeterHuppert@t-online.de 

... 16 hepatic neoplasms (1.3-3.0 cm in diameter) in 11 patients were treated by 22 percutaneous RFA sessions during a prospective study. .... Pretreatment studies, evaluation of tumor necrosis (one week after last RFA), and further follow-up studies every 3 months were performed using 1.5 Tesla MR systems. ... The mean procedure time was 2.8 (1.5-3.3) h. Complications related to percutaneous treatment were not encountered. 14 of 16 neoplasms (87%) showed no CM enhancement during MRI after the last RFA and were judged to be completely necrotic. In 11 tumors one treatment session was necessary, in 4 tumors two and in one tumor three. Follow-up studies revealed persistent complete necrosis in 13 of 14 (93%) tumors during a period of 3-18 (median: 11.8) months. In 5 patients new intrahepatic tumors developed that were not suitable for further RFA treatment because of their number, size and location. CONCLUSION: MR-guided RFA using single cooled tip electrodes is safe and technically effective for treatment of hepatic neoplasms up to 3 cm in size, however further improvements are necessary. Publication Types: Clinical trial  
&&url PMID: 11013611 


Ann Surg Oncol 2000 Sep;7(8):593-600 
<b>Radiofrequency ablation of 231 unresectable hepatic tumors: indications, limitations, and complications. </b>
Wood TF, Rose DM, Chung M, Allegra DP, Foshag LJ, Bilchik AJ. Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California 90404, USA. 

... Radiofrequency ablation (RFA) is increasingly used for the local destruction of unresectable hepatic malignancies. There is little information on its optimal approach or potential complications. ...: Since late 1997, we have undertaken 91 RFA procedures to ablate 231 unresectable primary or metastatic liver tumors in 84 patients. RFA was performed via celiotomy (n = 39), laparoscopy (n = 27), or a percutaneous approach (n = 25). ...

...Intraoperative ultrasound (IOUS) detected intrahepatic disease not evident on the preoperative scans of 25 of 66 patients (38%) undergoing RFA via celiotomy or laparoscopy. In 38 of 84 patients (45%), RFA was combined with resection or cryosurgical ablation (CSA), or both. RFA was used to treat an average of 2.8 lesions per patient, and the median size of treated lesions was 2 cm (range, 0.3-9 cm). The average hospital stay was 3.6 days overall (1.8 days for percutaneous and laparoscopic cases). Ten patients underwent a second RFA procedure (sequential ablations) and, in one case, a third RFA procedure for large (one patient), progressive (seven patients), and/or recurrent (three patients) lesions. Seven (8%) patients had complications: one skin burn; one postoperative hemorrhage; two simple hepatic abscesses; one hepatic abscess associated with diaphragmatic heat necrosis following sequential percutaneous ablations of a large lesion; one postoperative myocardial infarction; and one liver failure. There were three deaths, one (1%) of which was directly related to the RFA procedure. Three of the complications, including one RFA-related death, occurred after percutaneous RFA. At a median follow-up of 9 months (range, 1-27 months), 15 patients (18%) had recurrences at an RFA site, and 36 patients (43%) remained clinically free of disease. 
... Celiotomy or laparoscopic approaches are preferred for RFA because they allow IOUS, which may demonstrate occult hepatic disease. Operative RFA also allows concomitant resection, CSA, or placement of a hepatic artery infusion pump, and isolation of the liver from adjacent organs. Percutaneous RFA should be reserved for patients at high risk for anesthesia, those with recurrent or progressive lesions, and those with smaller lesions sufficiently isolated from adjacent organs. Complications may be minimized when these approaches are applied selectively. Publication Types: Clinical trial Clinical trial, phase ii 
&&url PMID: 11005558 


Eur Radiol 2000;10(6):926-9 
<b>Hemobilia, intrahepatic hematoma and acute thrombosis with cavernomatous transformation of the portal vein after percutaneous thermoablation of a liver metastasis. </b>
Francica G, Marone G, Solbiati L, D'Angelo V, Siani A. 
Divisione di Gastroenterologia, Ospedale Cardinale Ascalesi, Naples, Italy. giampierofrancica@libero.it 

... The case described emphasizes that radio-frequency interstitial hyperthermia may cause not only traumatic injury of the liver parenchyma but also thermally mediated damage of vascular structures. 
&&url PMID: 10879704 


Arch Surg 2000 Jun;135(6):657-62; discussion 662-4 
<b>Cryosurgical ablation and radiofrequency ablation for unresectable hepatic malignant neoplasms: a proposed algorithm. </b>
Bilchik AJ, Wood TF, Allegra D, Tsioulias GJ, Chung M, Rose DM, Ramming KP, Morton DL. 
John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, Calif 90404, USA. bilchika@jwci.org 

...Thermal ablation of unresectable hepatic tumors can be achieved by cryosurgical ablation (CSA) or radiofrequency ablation (RFA). The relative advantages and disadvantages of each technique have not yet been determined.
 ...Laparoscopy identified extrahepatic disease in 12% of patients, and intraoperative hepatic ultrasound identified additional lesions in 33% of patients, despite extensive preoperative imaging. Radiofrequency ablation alone or combined with resection or CSA resulted in reduced blood loss (P<.05), thrombocytopenia (P<.05), and shorter hospital stay compared with CSA alone (P<.05). Median ablation times for lesions greater than 3 cm were 60 minutes with RFA and 15 minutes with CSA (P<.001). Local recurrence rates for lesions greater than 3 cm were also greater with RFA (38% vs 17%). 
CONCLUSIONS: Laparoscopy and intraoperative ultrasound are essential in staging patients with hepatic malignant neoplasms. Radiofrequency ablation when combined with CSA reduces the morbidity of multiple freezes. Although RFA is safer than CSA and can be performed via different approaches (percutaneously, laparoscopically, or at celiotomy), it is limited by tumor size (<3 cm). Percutaneous RFA should be considered in high-risk patients or those with small local recurrences. 
&&url PMID: 10843361   


Radiology 2000 Mar;214(3):761-8 
<b>Hepatocellular carcinoma: radio-frequency ablation of medium and large lesions.</b>
Livraghi T, Goldberg SN, Lazzaroni S, Meloni F, Ierace T, Solbiati L, Gazelle GS. 
Department of Radiology, Ospedale Civile, Vimercate, Italy. lalivra@tin.it 

PURPOSE: To study local therapeutic efficacy, side effects, and complications of radio-frequency (RF) ablation in the treatment of medium and large hepatocellular carcinoma (HCC) lesions in patients with cirrhosis or chronic hepatitis. ... One-hundred fourteen patients who were under conscious sedation or general anesthesia had 126 HCCs greater than 3.0 cm in diameter treated with RF by using an internally cooled electrode. Eighty tumors were medium (3.1-5.0 cm), and 46 were large (5.1-9.5 cm). The mean diameter for all tumors was 5.4 cm. At imaging, 75 tumors were considered noninfiltrating, and 51 were considered infiltrating. 
...Complete necrosis was attained in 60 lesions (47.6%), nearly complete (90%-99%) necrosis in 40 lesions (31.7%), and partial (50%-89%) necrosis in the remaining 26 lesions (20.6%). Medium and/or noninfiltrating tumors were treated successfully significantly more often than large and/or infiltrating tumors. Two major complications (death, hemorrhage requiring laparotomy) and five minor complications (self-limited hemorrhage, persistent pain) were observed. The single death was due to a break in sterile technique rather than to the RF procedure itself. CONCLUSION: RF ablation appears to be an effective, safe, and relatively simple procedure for the treatment of medium and large HCCs.  
&&url PMID: 10715043 


Am J Surg 1999 Dec;178(6):592-9 
<b>Intraoperative radiofrequency ablation or cryoablation for hepatic malignancies.</b> 
Pearson AS, Izzo F, Fleming RY, Ellis LM, Delrio P, Roh MS, Granchi J, Curley SA. 
Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA. 

... The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, multifocality, or inadequate functional hepatic reserve. Cryoablation has become a common treatment in select groups of these patients with unresectable liver tumors. However, hepatic cryoablation is associated with significant morbidity. Radiofrequency ablation (RFA) is a technique that destroys liver tumors in situ by localized application of heat to produce coagulative necrosis. In this study, we compared the complication and early local recurrence rates in patients with unresectable malignant liver tumors treated with either cryoablation or RFA. ... ...Treatment-related complications, including 1 postoperative death, occurred in 22 of the 54 patients treated with cryoablation ... In contrast, there were no treatment-related deaths and only 3 complications after RFA (3.3% complication rate, P<0.001). With a median follow-up of 15 months in both patient groups, tumor has recurred in 3 of 138 lesions treated with RFA (2.2%), versus 12 of 88 tumors treated with cryoablation (13.6%, P<0.01). ... RFA is a safe, well-tolerated treatment for patients with unresectable hepatic malignancies. This study indicates that (1) complications occur much less frequently following RFA of liver tumors compared with cryoablation of liver tumors, and (2) early local tumor recurrence is infrequent following RFA. 
&&url PMID: 10670879 


Cancer J Sci Am 1999 Nov-Dec;5(6):356-61 
<b>Radiofrequency ablation: a minimally invasive technique with multiple applications. </b>
Bilchik AJ, Rose DM, Allegra DP, Bostick PJ, Hsueh E, Morton DL. 
John Wayne Cancer Institute at Saint John's Health

 ...RFA is a safe and effective alternative for the ablation of unresectable hepatic malignancies and when used adjunctively can reduce the morbidity of cryosurgery. Percutaneous and laparoscopic RFA can be performed effectively with less than 24 hours of hospitalization. Intraoperative ultrasonography is essential for accurate staging. 
&&url PMID: 10606477 


Am Surg 1999 Nov;65(11):1009-14 
<b>Radiofrequency ablation: a novel primary and adjunctive ablative technique for hepatic malignancies.</b> 
Rose DM, Allegra DP, Bostick PJ, Foshag LJ, Bilchik AJ. 
John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA. 

The majority of primary and metastatic tumors of the liver are not amenable to surgical resection at presentation. Radiofrequency ablation (RFA) is a new modality for local tumor destruction with minimal local and systemic complications. We prospectively reviewed the experience with RFA at a single institute as a primary or adjunctive ablative technique in the treatment of hepatic malignancies. .... RFA is a safe and effective method of tumor ablation for hepatic malignancies. This technique can be performed laparoscopically, at celiotomy, or percutaneously and can be used as a primary technique or in conjunction with other interventional procedures. 
&&url PMID: 10551746 


Ann Surg 1999 Jul;230(1):1-8
<b>Radiofrequency ablation of unresectable primary and metastatic hepatic malignancies: results in 123 patients. </b>
Curley SA, Izzo F, Delrio P, Ellis LM, Granchi J, Vallone P, Fiore F, Pignata S, Daniele B, Cremona F. 
Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA. 

... To describe the safety and efficacy of radiofrequency ablation (RFA) to treat unresectable malignant hepatic tumors in 123 patients. ... The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, or multifocality or inadequate functional hepatic reserve. Local application of heat is tumoricidal; therefore, the authors investigated a novel RFA system to treat patients with unresectable hepatic cancer. ... All treated tumors were completely necrotic on imaging studies after completion of RFA treatments. With a median follow-up of 15 months, tumor has recurred in 3 of 169 treated lesions (1.8%), but metastatic disease has developed at other sites in 34 patients (27.6%). ... 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. Publication Types: Clinical trial 
&&url PMID: 10400029 


Am J Surg 1999 Apr;177(4):303-6 
<b>Clinical short-term results of radiofrequency ablation in primary and secondary liver tumors. </b>
Jiao LR, Hansen PD, Havlik R, Mitry RR, Pignatelli M, Habib N.
 Liver Surgery Section, Imperial College School of Medicine, The Hammersmith Hospital, London, England, U.K. 

... Radiofrequency ablation (RFA) is emerging as a new therapeutic method for management of solid tumors. We report here our experience in the use of this technique for management of primary and secondary unresectable liver cancers. ...Radiofrequency heat ablation is useful as a primary treatment for unresectable liver cancers. The procedure can be used to treat the small residual tumor load in the contralateral lobe following liver resection in those considered unresectable at the first presentation. This new therapeutic strategy seems to increase surgical resectability in patients judged unresectable. Publication Types: Clinical trial 
&&url PMID: 10326848 


Radiology 1999 Mar;210(3):655-61 
<b>Small hepatocellular carcinoma: treatment with radio-frequency ablation versus ethanol injection. </b>
Livraghi T, Goldberg SN, Lazzaroni S, Meloni F, Solbiati L, Gazelle GS. Department of Radiology, Ospedale Civile, Vimercate, Italy. 

PURPOSE: To compare the effectiveness of radio-frequency (RF) ablation with that of percutaneous ethanol injection in the treatment of small hepatocellular carcinoma (HCC). ...: Complete necrosis was achieved in 47 of 52 tumors with RF ablation (90%) and in 48 of 60 tumors with percutaneous ethanol injection (80%). These results were obtained with an average of 1.2 sessions per tumor with RF ablation and 4.8 sessions per tumor with percutaneous ethanol injection. One major complication (hemothorax that required drainage) and four minor complications (intraperitoneal bleeding, hemobilia, pleural effusion, cholecystitis) occurred in patients treated with RF ablation; no complications occurred in patients treated with percutaneous ethanol injection. ... RF ablation results in a higher rate of complete necrosis and requires fewer treatment sessions than percutaneous ethanol injection. However, the complication rate is higher with RF ablation than with percutaneous ethanol injection. RF ablation is the treatment of choice for most patients with HCC. 
&&url PMID: 10207464 
