RF Ablation: indication, technique and imaging follow-up
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1 RF Ablation: indication, technique and imaging follow-up Trongtum Tongdee, M.D. Radiology Department, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
2 Objective Basic knowledge of thermal ablation Indications Technique Imaging during and after ablation
3 Treatment for lung cancer Surgery Thoracotomy, Mini-thoracotomy, Minimal Invasive (VATS/Robotic) Lobar (pneumonectomy, lobectomy) Sub-lobar Resection Chemotherapy Target Therapy Radiation Stereotactic radiotherapy
4 Ablation is not limited to Radiofrequency Thermal ablation Radiofreqeuncy Microwave HIFU Cryoablation Non thermal Irreversible electro poration (IRE)
5 Thermal Ablation Basic Concepts Apply heat to specific area with intention of tissue destruction Thermal injury to cell begin at 45 C 8 minutes at 46 C to kill malignant cell 2 minutes at 51 C Protein denature at 60 C Typical RFA > 100 C
6 How to generate heat?
7 High frequency alternating electrical current heating tissue surrounding electrode
8 How to send heat to specific area? Electromagnetic energy khz Variety of available electrode Monopolar or bipolar system
9 Thermal Ablation : Best Practice Destroy tumor : Heat tissue C for more than 8 minutes 5-10 mm ablation margin to cover microscopic tumor extension Not disrupt overall functional reserve
10 Indication Primary Lung Cancer NSCLC stage IA and IB size < 3 cm curative > 5 cm : non curative Metastatic < 4 cm, number < 5 Colorectal Hepatocellular carcinoma Chest wall Bone metastasis (pain relief)
11 Contraindications Uncontrolled Coagulopathy Predominant endobronchial lesion Relative Tumor near large bronchus, blood vessel or heart FEV1 < 0.8 Cardiac Pacemaker
12 Ideal Lesion Small tumor : < 3 cm Peripheral : > 2 cm from mediastinum Surround by lung parenchyma
13 Pre Procedure CT : Size, Number, location, proximity of vital structure PET : assess for nodal or extra-thoracic disease
14 During Procedure Image Guidance Ultrasound CT, CT fluoroscopy Moderate sedation RFA electrode place into center of tumor
15
16 Ablation zone : CT Findings Ground Glass Opacity (Safety Margin) Edema Hemorrhage Cavitation Lack of enhancement < 15 HU
17 Imaging Follow up CT with contrast 1-2 months Rim enhancement is normal May increase size within 3 months FDG-PET-CT 3-6 months
18 Complete Response GGO surrounding tumor in all planes is best predictor Lack of enhancement show complete necrosis Cavitation seen in 25% and appears 1-4 months Fluid filled Linear strands or bubble lucencies may appeared
19 77 yo Male, HCC with sub pleural metastasis
20 3 months 6 months 3 years 4 years 5 years
21 56 yo Female, CA colon with lung metastasis
22
23 GGO Surrounding nodule
24 3 months F/U : Lack of central enhancement
25 3 months 6 months 12 months 24 months
26 37 yo male, HCC with Lung Metastasis
27
28
29 Cavitation
30 3 months F/U: Linear Strand
31 10 months F/U
32 75 yo Female, Primary lung cancer
33 2 months F/U : Tumor necrosis
34 2 nd session : pneumothorax with chest tube
35 Incomplete Response Enlargement of ablation zone after 6 months Increase enhancement > 15 HU Nodular enhancement FDG advidity Seeding or satellite nodule
36 38 yo Female, HCC with lung metastasis
37 2 separation session
38 1 month F/U
39 3 months F/U : Nodular Enhancement
40 55 yo Male, CA Colon with lung metastasis
41
42 Pneumothorax
43 1 year F/U : Enlargement after 6 months
44
45 57 yo male, HCC with lung metastasis
46
47
48
49
50 1 months F/U
51 2 months F/U
52 6 months F/U : Recurrence????
53 14 months F/U
54 Complication Pneumothorax Pleural effusion Hemorrhage Subcutaneous emphysema Bronchopleural fistula
55
56 60 yo Male, HCC with multiple lung metastasis
57
58
59
60 Hemorrhage along tract
61 1 months F/U
62 76 yo, male checkup
63
64 Biopsy
65 RFA in same session
66
67 1 month F/U
68 45 yo Female, CA thyroid with chest wall mets
69
70
71 Pre 3 months 8 months
72 52 yo male, right adrenal metastasis
73
74
75 3 months F/U
76 6 months F/U
77 Take Home Message Thermal ablation is relative recent minimal invasive modality to treat limited volume lung tumor/chest wall Promising long-term survival and local tumor control Imaging findings different between post ablation and tumor progression
78
79 77 yo Male, HCC with lung metastasis
80 During RFA
81 1 months 4 months
82 2 months F/U
83 6 months F/U
84
85 12 months F/U
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