Liver Ablation

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Overview

Overview content for Liver Ablation is not yet available.

Pre-Procedure

Different types of thermal ablation:
• Radiofrequency ablation
• Microwave ablation
• Cryoablation - less common for liver
• Irreversible electroporation (IRE): non-thermal ablation

Operator preference
Some prefer microwave because:
• Faster
• Larger ablation volume
• Less susceptible to heat sink
• Multiple probes have synergistic effect
• Microwave ablation travels through all tissues: charred tissue
• Tissue contraction which can work to your advantage

Indications:
• HCC - potentially curative for lesions <3 cm. Potential to downstage tumor to fall within Milan criteria
• Unresectable hepatic metastases
• Curative vs. Palliative intent

Ideal patient:
• Size less than 3 cm
• Safe distance from vasculature and vital structures (central bile ducts)
Non-ideal patients:
• Consider other therapy
• Within 2 cm of liver hilum
• Lesions in close proximity to bowel that cannot be effectively hydrodissected

Contraindications:
• Life expectancy <6 months
• Child-Pugh class C
• ECOG 3 or 4
• Active infection
• Bile duct or major vessel invasion
• Uncorrectable coagulopathy
• No safe approach

Preoperative evaluation:
• H&P
• Labs: coagulation, LFTs
• Prior imaging - CT and/or MRI
Consider involving anesthesia early
• Anesthesia with paralytics can be helpful for breath hold maneuvers

Procedure

Antibiotic prophylaxis:
• Recommended, especially for high-risk patients (biliary-enteric anastomosis, cirrhosis, diabetes)
• For low risk patients: 1-2 g cefazolin (Ancef) IV
• Multiple regimens for high risk patients: 1.5 g ampicillin/sulbactam (Unasyn) IV is simplest
• Vancomycin or clindamycin for Gram-positive coverage (PCN allergy) and gentamicin for Gram-negative coverage

Planning for procedure:
Margins are key
• Circumferential: Example: 2 cm met needs 4 cm ablation zone
• 10 mm for metastatic lesions
• 5 mm for HCC
Can use US, CT, angiography with cone beam CT or combination of modalities
Percutaneous approach
• Will depend on tumor location, orientation, vital structures and size
• Largest ablation zone will be along long axis of probe. Can use to operator advantage by orienting probe along long axis of the tumor
• Target temperature: 60° for microwave

Patient positioning key
• Plan ahead to make procedure easier
• Using combination of US and CT often faster than using each modality alone
Mark skin site and prep large area

Insert probes
• Depending on lesion size, strongly consider multiple probes and bracketing tumor
• If one the fence about extra probe, use extra probe
• Try and maintain parallel probe orientation
• Probes cannot be too close or too far apart
• Probes typically need to be within 1-2 cm from each other
• Know equipment and ablation zone which will vary between manufacturer and probes

Protective techniques if needed
• Hydrodissection most common: can use D5W, sterile water, 0.9% normal saline
• Pneumodissection: CO2
• Balloon interposition
• Gallbladder or stomach lavage

Ablate
• Can use intermittent CT scans to check ablation zones
• Can watch live with US if lesion visible and watch ablation zones coalesce
Ablate tract with probe removal

Following ablation, helpful to obtain diagnostic CT (outside of US, contrast enhanced US)
• Evaluate ablation zones
• Evaluate adjacent structures
• Establish new baseline
• Retreat if necessary

Post-Procedure

Complications:
• Hemorrhage
• Vascular complications: portal vein thrombosis, hepatic venous thrombosis, infarct, AV fistula and pseudoaneurysm
• Pain
• Abscess formation/Infection
• Biloma or bile leak
• Post-ablation syndrome - fever, fatigue, nausea, myalgia 7-10 days following procedure. Occurs 30-60% of patients.
• Extrahepatic complications: depends on location. Examples: diaphragm injury, bowel injury

Postoperative care:
• Many patients can be discharged same day
• Monitor patient for at least 2 hours for development of pain, signs of bleeding, or extrahepatic injury
• Schedule follow up clinic visit and imaging.
• For liver tumor follow up CT or MRI in 1-2 months.
• Helpful to maintain consistency with pre and post imaging. MR often preferred over CT
• Follow tumor markers and LFTs

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References

[1] Glassberg MB, Ghosh S, Clymer JW, Wright GWJ, Ferko N, Amaral JF. Microwave ablation compared with hepatic resection for the treatment of hepatocellular carcinoma and liver metastases: a systematic review and meta-analysis. World J Surg Oncol. 2019;17(1):98. Published 2019 Jun 10. doi:10.1186/s12957-019-1632-6
[2] Vogl TJ, Nour-Eldin NA, Hammerstingl RM, Panahi B, Naguib NNN. Microwave Ablation (MWA): Basics, Technique and Results in Primary and Metastatic Liver Neoplasms - Review Article. Mikrowellenablation (MWA): Grundlagen, Technik und Ergebnisse in primären und sekundären Lebertumoren – Übersichtsarbeit. Rofo. 2017;189(11):1055‐1066. doi:10.1055/s-0043-117410
[3] Hinshaw JL, Lubner MG, Ziemlewicz TJ, Lee FT Jr, Brace CL. Percutaneous tumor ablation tools: microwave, radiofrequency, or cryoablation--what should you use and why?. Radiographics. 2014;34(5):1344‐1362. doi:10.1148/rg.345140054
[4] Yu H, Burke CT. Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors. Semin Intervent Radiol. 2014;31(2):129‐137. doi:10.1055/s-0034-1373788
[5] Kim KR, Thomas S. Complications of image-guided thermal ablation of liver and kidney neoplasms. Semin Intervent Radiol. 2014;31(2):138‐148. doi:10.1055/s-0034-1373789
[6] Lubner MG, Brace CL, Ziemlewicz TJ, Hinshaw JL, Lee FT Jr. Microwave ablation of hepatic malignancy. Semin Intervent Radiol. 2013;30(1):56‐66. doi:10.1055/s-0033-1333654
[7] Groeschl RT, Wong RK, Quebbeman EJ, et al. Recurrence after microwave ablation of liver malignancies: a single institution experience. HPB (Oxford). 2013;15(5):365‐371. doi:10.1111/j.1477-2574.2012.00585.x

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Percutaneous Microwave Ablation of Liver Metastasis

 

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Literature

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Journal of Vascular and Interventional Radiology (Aug 2010)

Microwave Tumor Ablation: Mechanism of Action, Clinical Results, and Devices

An analysis of the advantages and disadvantages of microwave tumor ablation.

World Journal of Hepatology (Jul 2017)

Imaging Guided Percutaneous Interventions in Hepatic Dome Lesions Tips and Tricks

A review of techniques that can enhance the success and safety of percutaneous interventions for treating lesions in the hepatic dome.

Seminars in Interventional Radiology (Jun 2014)

Comparison of Percutaneous Ablation Technologies in the Treatment of Malignant Liver Tumors

Because there exist significant differences in underlying technological bases, understanding each mechanism of action is essential for achieving desirable outcomes. In this article, the authors review the current state of each ablation method including technological and clinical considerations.

Seminars in Interventional Radiology (Mar 2013)

Microwave Ablation of Hepatic Malignancy

This article reviews microwave ablation as a valuable alternative to radiofrequency ablation in the treatment of hepatic malignancies, taking into account technical and clinical considerations.

 

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