Distant infusion of saline may enlarge coagulation volume during radiofrequency ablation of liver tissue using cool-tip electrodes without impairing predictability

An in silico assessment on the potential of using saline infusion to overcome non-confluent coagulation zone during two-probe, no-touch bipolar radiofrequency ablation of liver cancer

No-touch bipolar radiofrequency ablation (bRFA) is known to produce incomplete tumour ablation with a 'butterfly-shaped' coagulation zone when the interelectrode distance exceeds a certain threshold. Although non-confluent coagulation zone can be avoided by not implementing the no-touch mode, doing so exposes the patient to the risk of tumour track seeding. The present study investigates if prior infusion of saline into the tissue can overcome the issues of non-confluent or butterfly-shaped coagulation. A computational modelling approach based on the finite element method was carried out. A two-compartment model comprising the tumour that is surrounded by healthy liver tissue was developed. Three cases were considered; i) saline infusion into the tumour centre; ii) one-sided saline infusion outside the tumour; and iii) two-sided saline infusion outside the tumour. For each case, three different saline volumes were considered, i.e. 6, 14 and 22 ml. Saline concentration was set to 15% w/v. Numerical results showed that saline infusion into the tumour centre can overcome the butterfly-shaped coagulation only if the infusion volume is sufficient. On the other hand, one-sided infusion outside the tumour did not overcome this. Two-sided infusion outside the tumour produced confluent coagulation zone with the largest volume. Results obtained from the present study suggest that saline infusion, when carried out correctly, can be used to effectively eradicate liver cancer. This presents a practical solution to address non-confluent coagulation zone typical of that during two-probe bRFA treatment.

Microwave versus radiofrequency ablation for the treatment of liver malignancies: a randomized controlled phase 2 trial

Microwave (MWA) and radiofrequency ablation (RFA) are main ablative techniques for hepatocellular carcinoma (HCC) and colorectal liver metastasis (MT). This randomized phase 2 clinical trial compares the effectiveness of MWA and RFA as well as morphology of corresponding ablation zones. HCC and MT patients with 1.5–4 cm tumors, suitable for ablation, were randomized into MWA or RFA Groups. The primary endpoint was short-to-long diameter ratio of ablation zone (SLR). Primary technical success (TS) and a cumulative local tumor progression (LTP) after a median 2-year follow-up were compared. Between June 2015 and April 2020, 82 patients were randomly assigned (41 patients per group). For the per-protocol analysis, five patients were excluded. MWA created larger ablation zones than RFA (p = 0.036) although without differences in SLR (0.5 for both groups, p = 0.229). The TS was achieved in 98% (46/47) and 90% (45/50) (p = 0.108), and LTP was observed in 21% (10/47) vs. 12% (6/50) (OR 1.9 [95% CI 0.66–5.3], p = 0.238) of tumors in MWA vs. RFA Group, respectively. Major complications were found in 5 cases (11%) vs. 2 cases (4%), without statistical significance. MWA and RFA show similar SLR, effectiveness and safety in liver tumors between 1.5 and 4 cm.

Radiofrequency ablation with four electrodes as a building block for matrix radiofrequency ablation: Ex vivo liver experiments and finite element method modelling. Influence of electric and activation mode on coagulation size and geometry

PURPOSE

Radiofrequency ablation (RFA) is increasingly being used to treat unresectable liver tumors. Complete ablation of the tumor and a safety margin is necessary to prevent local recurrence. With current electrodes, size and shape of the ablation zone are highly variable leading to unsatisfactory local recurrence rates, especially for tumors >3 cm. In order to improve predictability, we recently developed a system with four simple electrodes with complete ablation in between the electrodes. This rather small but reliable ablation zone is considered as a building block for matrix radiofrequency ablation (MRFA). In the current study we explored the influence of the electric mode (monopolar or bipolar) and the activation mode (consecutive, simultaneous or switching) on the size and geometry of the ablation zone.

MATERIALS AND METHODS

The four electrode system was applied in ex vivo bovine liver. The electric and the activation mode were changed one by one, using constant power of 50 W in all experiments. Size and geometry of the ablation zone were measured. Finite element method (FEM) modelling of the experiment was performed.

RESULTS

In ex vivo liver, a complete and predictable coagulation zone of a 3 × 2 × 2 cm block was obtained most efficiently in the bipolar simultaneous mode due to the combination of the higher heating efficacy of the bipolar mode and the lower impedance by the simultaneous activation of four electrodes, as supported by the FEM simulation.

CONCLUSIONS

In ex vivo liver, the four electrode system used in a bipolar simultaneous mode offers the best perspectives as building block for MRFA. These results should be confirmed by in vivo experiments.

Shape-shifting thermal coagulation zone during saline-infused radiofrequency ablation: A computational study on the effects of different infusion location

BACKGROUND AND OBJECTIVE

The majority of the studies on radiofrequency ablation (RFA) have focused on enlarging the size of the coagulation zone. An aspect that is crucial but often overlooked is the shape of the coagulation zone. The shape is crucial because the majority of tumours are irregularly-shaped. In this paper, the ability to manipulate the shape of the coagulation zone following saline-infused RFA by altering the location of saline infusion is explored.

METHODS

A 3D model of the liver tissue was developed. Saline infusion was described using the dual porosity model, while RFA was described using the electrostatic and bioheat transfer equations. Three infusion locations were investigated, namely at the proximal end, the middle and the distal end of the electrode. Investigations were carried out numerically using the finite element method.

RESULTS

Results indicated that greater thermal coagulation was found in the region of tissue occupied by the saline bolus. Infusion at the middle of the electrode led to the largest coagulation volume followed by infusion at the proximal and distal ends. It was also found that the ability to delay roll-off, as commonly associated with saline-infused RFA, was true only for the case when infusion is carried out at the middle. When infused at the proximal and distal ends, the occurrence of roll-off was advanced. This may be due to the rapid and more intense heating experienced by the tissue when infusion is carried out at the electrode ends where Joule heating is dominant.

CONCLUSION

Altering the location of saline infusion can influence the shape of the coagulation zone following saline-infused RFA. The ability to 'shift' the coagulation zone to a desired location opens up great opportunities for the development of more precise saline-infused RFA treatment that targets specific regions within the tissue.

Roll-Off Displacement in Ex Vivo Experiments of RF Ablation With Refrigerated Saline Solution and Refrigerated Deionized Water

OBJECTIVE

The recurrence rate in the treatment of liver tumors using radio frequency ablation (RFA) is often related to incomplete tissue necrosis and consequently the limitation in the ablation volume. This paper proposes an ablation protocol combined with the infusion of saline solution and deionized water aiming at achieving a time displacement in the roll-off occurrence and consequently increasing the volume of ablation.

METHODS

An infusion of saline solution and deionized water at 5 and 23  ^°C was performed to evaluate the influence of these liquids on the RFA procedure in ex vivo bovine liver pieces. The obtained results were used to propose a mathematical model of the roll-off phenomenon by means of the system identification techniques.

RESULTS

The RFA combined with the infusion of saline solution 0.9% at 5  ^°C presented optimal results, with a time delay of the roll-off occurrence in 27.8% compared to pure RFA ( p = 0.002) and an increase in the necrotic volume of 51.2% ( p = 0.0002). Two Box-Jenkins models were obtained to describe the roll-off phenomenon: 1) pure RFA; and 2) RFA combined with the saline solution 0.9% at 5  ^°C.

CONCLUSION

The RFA therapy combined with the saline solution 0.9% at 5  ^°C increases the time range to the roll-off occurrence, leading to higher necrosis volumes in ex vivo bovine liver samples. The development of a mathematical model to describe the roll-off behavior demonstrated that the transient response is improved by the infusion of the saline solution 0.9% at 5  ^°C.

Increasing radiofrequency ablation volumes with the use of internally cooled electrodes and injected hydrochloric acid in ex vivo bovine livers

PURPOSE

We used an impedance-controlled generator with an internally cooled electrode to perform radiofrequency ablation (RFA) in ex vivo bovine livers, with a single injection of either 38.5% sodium chloride (NaCl) or 10% hydrochloric acid (HCl), to determine the relative effects of these two solutions on tissue impedance, temperature and ablation volume.

MATERIALS AND METHODS

We performed 10 ablations each with injections of NaCl (NaCl-RFA), HCl (HCl-RFA) or nothing (RFA-alone), with a power setting of 200 W for 15 minutes. We recorded tissue impedance before and after injection. We logged temperatures obtained from thermocouple probes positioned 5, 10, 15 and 20 mm from the internally cooled RF electrode. After ablation, we measured ablation zone longitudinal and transverse diameters, and we calculated a spherical ratio (SR) for each ablation.

RESULTS

Mean post-injection impedance of 30.3 (standard deviation [SD] 2.5) ohms for HCl was significantly lower than that of 55.4 (SD 3.5) ohms for NaCl (p < .001). Mean maximum temperatures recorded at each respective distance from the RFA electrode were all highest for HCl-RFA and lowest for RFA-alone (p < .001). Mean longitudinal and transverse diameters after HCl-RFA (5.50 [SD 0.25] cm and 5.28 [SD 0.22] cm, respectively) were significantly larger than those after NaCl-RFA (4.24 [SD 0.35] cm and 3.55 [SD 0.43] cm, respectively) and after RFA-alone (3.60 [SD 0.10] cm and 2.70 [SD 0.13] cm, respectively) (p < .001). Mean SR after HCl-RFA (0.93, SD 0.02) was significantly higher than mean SR after NaCl-RFA (0.76, SD 0.06) and RFA-alone (0.72, SD 0.04) (p < .001).

CONCLUSION

Monopolar, impedance-controlled RFA, with an internally cooled electrode and a single 10% HCl injection may allow larger tumors to be treated, potentially resulting in improved patient outcomes.

Comparison between the treatment area of electrode used for radiofrequency ablation of liver cancer focusing on 15G cooled-tip and CWT electrode

Objectives:

To analyze the comparison between the treatment area of 15Gage internally cooled electrodes and 17 Gage Cool Wet-tip(CWT) electrodes. They are manufactured to broaden treatment area of the tumor in the radiofrequency ablation of hepatocellular carcinoma(HCC).

Methods:

The study was designed for 62 patients with a mean age of 61, ranging from 44 to 87 years. The sample comprised of patients who used 15 G internally cooled electrodes and 17 G CWT electrodes respectively. Computed tomography (CT) images obtained after the procedure were observed, however, for the ablation lesion, the volume was determined by measuring complete necrotic tissue that did not contrast enhancement in the image.

Results:

The treatment area of the tumor after radiofrequency ablation was 17.26±6.02 in the CWT, which was bigger than 15G. The treatment area ratio of the treatment before or after was significant at 581.85±339.56 in the CWT. After radiofrequency ablation, the treatment area got bigger, as 15G electrodes went toward CWT electrodes. Treatment area per electrode was 1.34 times higher in CWT than in 15G while the treatment area ratio of the treatment before or after was 1.001 times higher in the CWT than 15G.

Conclusions:

Ablation is more common for the safety margin in stable tumor and CWT type electrodes that can make larger ablation to reduce the number of times ablation is required for residual tumor and it decreases recurrence, ablation time and reoperation. Therefore it is considered t useful to reduce patients’ pain.

Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes.

Theoretical and experimental study on RF tumor ablation with internally cooled electrodes: when does the roll-off occur?

The Cool-tip is one of the most widely employed electrodes in radiofrequency (RF) ablation (RFA) of hepatic tumors. This electrode creates reliable geometry and coagulation zones. Despite the advantages of this electrode, during the ablation is produced a phenomenon called roll-off in which impedance increases, energy deposition completely stops and the lesion size cannot be increased. Consequently, the thermal lesion size is smaller and the tumors which can be ablated are smaller too. In this research we studied theoretical and experimentally the electrical-thermal performance of the Cool-tip electrode during RFA of hepatic tissue. Mainly, we were interested in the occurrence of the roll-off and its relationship with the tissue temperatures around the electrode. The theoretical model included the vaporization of the tissue and the variation of the thermal and electrical conductivities with temperature. The model was solved numerically using COMSOL Multiphysics software. For the experimental part we conducted a study in ex vivo liver tissue. The experimental and theoretical results showed that the roll-off is totally related when temperatures around 100 °C surrounds the tissue close to the center of the Cool-tip. The knowledge of this fact brings a powerful tool to analyze alternative methods or techniques to avoid the roll-off.