Percutaneous Radiofrequency Ablation of Liver Tumors
Percutaneous radiofrequency (RF) ablation (RFA) is an exciting approach to destroying inoperable primary tumors or metastases in the liver. [1, 2] In the treatment of hepatocellular carcinoma (HCC), fewer than 40% of patients are candidates for surgery, and the rate of recurrence after curative surgery is high. Percutaneous techniques like RFA are, therefore, very important. RFA is widely used for metastatic and small primary tumors.  It serves as a bridge for transplant candidates, especially in relation to small primary lesions. 
Percutaneous RFA is a minimally invasive, repeatable procedure with few complications. It is performed under radiologic guidance. Randomized controlled trials showed that RFA is superior to ethanol injection in the treatment of small HCCs.  RFA results in a higher rate of complete necrosis and requires fewer treatment sessions than percutaneous ethanol injection (PEI). [6, 7, 8]
Long-term survival rates are also better with RFA. A randomized clinical trial showed that RFA yields a significantly better 1-year complete response rate than does PEI.  RFA in combination with transcatheter arterial chemoembolization (TACE) is also an effective treatment for inoperable hepatic tumors.  RFA combined with TACE also appears to be safe and effective in the treatment of breast cancer with liver metastasis. 
Studies comparing percutaneous RFA and percutaneous microwave coagulation therapy (PMCT) showed better results with RFA in treatment of small tumors. RFA results in better survival rates, fewer complications, and significantly lower local recurrence rates. [11, 12]
In RFA, a needle is inserted into the liver, usually under the guidance of ultrasonography or computed tomography (CT). Once the needle is placed within the tumor, a generator is used to deliver a rapidly alternating current (RF energy). This needle may be bipolar or unipolar; the latter requires grounding pads placed on the patient’s thighs. Heat is generated at the site of the lesion through frictional heat produced by rapid agitation of adjacent cells and produces destruction (liquefactive necrosis) of the tumor.
This technology is used widely in Europe and the United States. Shiina et al noted that by 2007, at least 1500 institutes in Japan had introduced RFA in the treatment of liver tumors. 
Contraindications for percutaneous RFA of liver tumors include the following:
One randomized controlled trial showed that the 2-year recurrence rate of HCC was significantly lower with RFA than with percutaneous ethanol injection (PEI). When compared with surgical resection, the recurrence rate is higher after RFA, with less time to recurrence.  Recurrence is more common with the percutaneous approach as compared with open or laparoscopic RFA. The rate of recurrence is also higher with lesions larger than 3 cm. 
In a study by Toshimori et al, the local recurrence rates after percutaneous RFA for HCC were 2.2% at 1 year, 7.4% at 3 years, and 9.5% at 5 years.  Factors that predisposed to local recurrence included large tumor size (>2 cm), tumor location adjacent to the major portal branch or hepatic vein), and a small (<3 mm) ablated margin.
Shady et al assessed factors affecting outcome in patients with colorectal cancer liver metastases who were treated with percutaneous RFA.  On multivariate analysis, factors predictive of shorter local tumor progression-free survival were a tumor size exceeding 3 cm and a margin size of 5 mm or less; factors predictive of shorter overall survival were a tumor size exceeding 3 cm and the the presence of more than one site of extra-hepatic disease.
Yamao et al compared the survival impacts of RFA (n = 33) and hepatic resection (n = 71) as initial treatment of HCC in 104 patients with liver damage B as defined by the Liver Cancer Study Group of Japan.  Whereas overall survival (OS) tended to be better in the RFA group, disease-free survival (DFS) did not differ significantly between groups. Subgroup analyses found OS with RFA to be significantly better in patients with aspartate aminotransferase above 35 IU/L, serum albumin below 3.5 g/dL, and 99mTc-galactosyl human serum albumin below 0.85.
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Badar Bin Bilal Shafi, MBBS, MRCP, FRCR, CCT, EBIR Consultant Interventional Radiologist, South Mersey Vascular Centre and Countess of Chester Hospital, UK
Badar Bin Bilal Shafi, MBBS, MRCP, FRCR, CCT, EBIR is a member of the following medical societies: Radiological Society of North America, Royal College of Physicians, Royal College of Radiologists, Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, British Society of Interventional Radiology
Disclosure: Nothing to disclose.
R H Bilal, MBBS, MRCS Specialist Registrar in Cardiothoracic Surgery, North West Cardiothoracic Rotation, UK
R H Bilal, MBBS, MRCS is a member of the following medical societies: British Medical Association
Disclosure: Nothing to disclose.
Jonathan C Evans, MBChB, MRCP, DMRD, FRCR Radiologist, Interventional Radiology and GI Imaging, Royal Liverpool University Hospital, UK
Jonathan C Evans, MBChB, MRCP, DMRD, FRCR is a member of the following medical societies: Royal College of Radiologists
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Percutaneous Radiofrequency Ablation of Liver Tumors
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