<b> [and Heart, Prostate, Breast, Brain, Lymph Nodes, Nerve Ganglia]</b>

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Cancer J Sci Am. 1999 Nov-Dec;5(6):356-61.  
<b>Radiofrequency ablation: a minimally invasive technique with multiple applications.</b>
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<b>Letter from Neil:</b>
Our decision to for Radio Frequency Ablation (RFA) of Bev's two ~5 cm lung tumors was based on our conclusion that there was very little downside risk and that avoiding a thoracotomy was highly desirable. Our rationale was as follows:

1) If the RFA fails surgery can still be done. Doing RFA closes the door to absolutely no other procedure.

2) The RFA procedure is 'trivial' in comparison to the major insult of a thoracotomy; the percutaneous puncture incision for RFA is only 3 mm (1/8").

3) Surgery is done under general anesthesia with its inherent risks of morbidity and mortality; recovery time is typically 3-4 months. RFA is most often done as an outpatient procedure under conscious sedation; you're up on your feet and out and around in a day or two and full recovery time is a week or so.

4) RFA can be done as many times as is necessary - it is not self-limiting in terms of scar tissue, etc. If part of the tumor is missed the first time (unlikely) it's no big deal to go in again for the remainder. If new nodules pop up in the same lung or in the other lung, it's easy to do them as they appear; that's not the case with surgery.

5) In my wife's case a thoracotomy and surgical wedge resection would have taken about 30% of her lung capacity; RFA took about 5%.

6) The journal-published results of RFA on liver/kidney tumors seems quite good - although there is no comparable long-term experience with lung tumors.

7) The new RadioTherapeutics Co-Access Electrode System  seems to solve many problems. It provides a cannula with a removable trochar for percutaneous insertion into the tumor. The RFA electrode is then inserted though the same cannula for the RFA procedure.

 Cordially, Neil December 2001
Do not limit your interest to RFA. Think in broader terms so as to include cryoablation, photodynamic therapy, laser ablation, VATS, etc. All of these minimally invasive procedures have the potential to accomplish some of the things that previously could only be done with the "gold standard" of open surgery. 

Doctordee would also add, as with many procedures, the results will vary with location and size of the tumor/s, <b>as well as with the skill of the pracitioner.  AS ALWAYS she recommends expertise in the person you choose. </b>  For RFA, that would be an Interventional Radiologist.  You can send your scans on CD to more than one Interventional Radiologist, and if they wish to see you because they think they can ablate the tumors, ask them about the results they have so far on recurrence from their RFA ablation, as well as the complication rate, for the site you are considering for RFA.  Get people experienced with the technique.  Surgery remains the gold standard, but RFA can destroy lung tumors and conserve lung tissue.  


<b>What is Radio Frequency Ablation? </b>
Written by Beth C, November 2001
Updated by doctordee November 2003
 
Radio Frequency Ablation (RFA) is a procedure used to destroy undesirable tissue. This procedure is being used to destroy tumors in the liver, lungs, bone, kidney, pancreas, and adrenal gland, as well as heart, prostate, breast, brain, lymph nodes, and nerve ganglia. 

RFA starts by passing radio frequency energy through the lesion. Heat is generated at the site of the lesion through agitation caused by this energy. This heat produces coagulation and cellular destruction --necrosis -- resulting in destruction of the lesion or tissue.   The electrode is heated on the way out, sterilizing the track,  to prevent local recurrences due to implantation seeding of tumor cells. 

Radio Frequency Ablation is a specialized technique, and should be carried out in a specialized treatment center. When using RFA for liver tumors, celiotomy (abdominal incision) or laparoscopic approaches are preferred because they allow IOUS (intra-operative ultrasound), which may demonstrate hidden additional metastases. Operative RFA also allows concomitant resection and/or cryosurgical ablation.

For liver metastases, 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 increases surgical resectability in patients previously judged unresectable. RFA can also be combined with cryosurgical ablation. 

<b>How does it work? </b>
Using conventional imaging methods -- ultrasound, CT scan, or MRI -- an electrode is positioned strategically within the lesion. The electrode is then connected to a radiofrequency generator and the energy is delivered into the tissue. As the cells are heated, they are destroyed. The mechanism of RFA is similar to that of a microwave oven, heating from the inside out. The tissue reabsorbs the destroyed cells over a period of time. 

RFA can be carried out percutaneously --puncturing through the skin-- meaning without a classical 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.  Radio frequency ablation when combined with cryosurgical ablation reduces the morbidity of multiple freezes. RFA is safer than cryosurgical ablation and can be performed via different approaches (percutaneously, laparoscopically, or at celiotomy).

The duration of the procedure depends on a number of factors, including the number of applications and the location of the lesions. RFA may be performed through an open incision or via laparoscopy -- through multiple, small skin incisions. RFA can also be done percutaneously -- through small skin punctures. 

Generally, patients will have IV access through which they will be given medication. The need for general anesthesia, sedation, or pain medication will be determined by the clinical intervention approach. Every effort is made to ensure that patients do not feel pain during the procedure. The length of hospitalization depends on how the procedure is performed, however, patients may only be in the hospital overnight. 

<b>Complications </b>
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, cholecystitis, abcesses, trauma to the liver, and liver failure. Some of the RFA complications can be fatal. Another complication is increased temperature caused by tumor lysis syndrome. This condition results when the destroyed tumor releases enzymes that the body treats as a foreign substance. The body fights these enzymes like it would an infection, causing fever, and less often, mild fatigue. However, within a couple of days the patient's temperature should return to normal. 

RFA is a safe and effective alternative for the attempted ablation of unresectable 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.  Radio frequency ablation alone or combined with surgical resection or cryosurgical ablation resulted in reduced blood loss and shorter hospital stay.
 
<b>Recurrence / Retreatment </b>
Some lesions, especially larger lesions, may require more than one treatment session to destroy the entire tumor. In some patients additional lesions will arise at a later date and these can also be retreated. As long as the lesions are visible via CT Scan or ultrasound, they can be treated using RFA, as many times as necessary. 
Tumors near a major blood vessel often recur locally since the blood vessel itself draws heat away from the area during the treatment in what is known as the "heat sink phenomenon." As a result, the tumor cells next to the blood vessel cannot get hot enough to achieve cellular death.  Tumors too close to vital structures or nerves, can result in the heat damaging closely positioned structures.   For RFA, size and location of the tumors to be ablated are very important.
