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The NeuWave Microwave Ablation System: A Quick Start Guide for IRs

Author Ronak Patel covers The NeuWave Microwave Ablation System: A Quick Start Guide for IRs on BackTable VI

Ronak Patel • Jun 20, 2023 • 328 hits

Interventional radiologist Dr. Josh Kuban shares his workflow with the NeuWave microwave ablation system, and provides his review of specific features, including the system interface, the ability to draw customizable margins, and the ability to upload mid-procedural scans. Dr. Kuban claims that these attributes streamline his procedural workflow and enhance procedural efficiency, while also providing more precise ablation endpoints and data for him to share with referring physicians. This article features excerpts from the BackTable Vascular & Interventional Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.

The BackTable Brief

• The NeuWave ablation workflow involves five steps: uploading the base scan (usually venous phase CT with contrast), defining the tumor, placing the probes, performing the ablation, and confirming the ablation.

• The system's capacity to fuse probe images with pre-images provides real-time guidance for probe placement and trajectory adjustments. The system can also accommodate mid-procedure scan uploads, aiding especially in the management of smaller, less visible lesions.

• Ablation confirmation involves a further scan (pre-arteriovenous) and the merging of this scan with the prescan using the "create tool." This fusion provides an overlay of the segmented tumor, margin, and ablation zone. This technique has the potential to lower recurrence rates significantly.

• Once proficient, the time investment for ablation confirmation is around 3-4 minutes. Proficiency can be achieved after approximately three dedicated learning cases, according to Dr. Kuban.

• Visual feedback from the procedure can improve both technique and understanding of the ablation process. The goal for every ablation case should be achieving A0 ablation (complete tumor eradication).

The NeuWave Microwave Ablation System: A Quick Start Guide for IRs

Table of Contents

(1) NeuWave Microwave Ablation: Steps & Strategies for Success

(2) The Impact of NeuWave Ablation on Practice Efficiency, Technical Endpoints & Practice Building

NeuWave Microwave Ablation: Steps & Strategies for Success

Dr. Josh Kuban steps through a typical procedure with the NeuWave microwave ablation system, highlighting the features that help him streamline his workflow and optimize therapy. He clarifies that the system, with its two-screen setup, provides an accessible interface comprising five clear steps for scan uploading, tool application, and tumor delineation. A valuable feature of the system is the ability to define specific margins around the tumor, assisting in a more accurate ablation process. Moreover, the NeuWave system can enhance the verification of probe positioning by merging images taken before and during the procedure, which supports the ability to adjust in real-time for optimal targeting. Finally, the system defines the ablation zone using a specific "create tool", subsequently fusing pre-ablation and post-ablation scans to confirm successful ablation.

[Dr. Christopher Beck]:
Will you unpack it a little bit? What does it look like from a user perspective?

[Dr. Josh Kuban]:
Yes. The normal NeuWave device has one screen. Their newer versions have two. It just looks like a second ablation screen. Your normal one on the left is going to be your power and wattage. On the right, it's just going to be a very similar user interface where you go through five steps to bring in scans, and then you do all the tools, use all your tools on that screen.

The first thing you do is you upload your base scan. I usually get a CT scan with contrast, pre-arterial venous, but usually upload the venous phase for everyone I bring it into the system. I use that first tool to define my tumor, and that's pretty fast. I do that while I'm marking with the text. I'm going to do a CT guide or whatever. While they're prepping, I go over there, and I think, initially, that took a couple of minutes, and now it's like 30 seconds. It's very fast. I use a sphere tool or create tool to really define my tumor.

The cool part about that versus, sometimes, when that wasn't available, I was using Siemens software just to make my own segmentation, but you can't add margins to that one. With the NeuWave device, you can set what margins you want. For certain things like, "Hey, I want to get a centimeter margin, or I only want a five-millimeter margin." It shows you the tumor and then it gives you what your margin is.

Then I set it aside at that point, and I start placing my probes. I don't know, there's two different flavors here. There's the cases that you can't see the lesion. I'm sure you've had this before. You see it for arterial phase or venous phase. Then you start getting your probe anywhere near it, and you have no idea where you are, like a 1-centimeter lesion. Those, I actually go back to the AC, like halfway through, and I upload a scan midway through, and the upload is super easy. You just drag it over.

[Dr. Christopher Beck]:
Nice.

[Dr. Josh Kuban]:
That is going to show you where your probe is. It's going to fuse your probe image for your pre-image. It'll fuse those two images and show you your probe over where that you segmented that tumor, so you can see, "Oh, perfect, I'm right on trajectory." or "I got it." A lot of times you'll see, like, "Oh, wow, I'm there, but I'm a little bit on the top left. I'll burn here, pull back, and do a redirect." or "On my next probe, I went a little bit anterior here, so I'll go a little bit posterior on the next one," but it helps to know, "Okay, that lesion didn't disappear. I know where it is. I can target it, I can adjust, and you can continue to see it.

If you have a lesion you can see really well, or using ultrasound, at that point, I don't really use it on the way. I place my probes in my normal way, and then I'll confirm it if I'm not sure. If I place it with ultrasound, then I'll do another one of those fusions. "Okay, it is where I thought it was," but if you can really see it, sometimes, I don't even do the probe placement step. I just skip that, do my ablation, and then go to the ablation confirmation. [crosstalk] The third big bun-- oh, go ahead.

[Dr. Christopher Beck]:
I wanted to ask you about the prescan. Does the prescan have to be the same day of the procedure or the prescan is just like any CT that happens within the last day?

[Dr. Josh Kuban]:
I've only done it with the same day. [crosstalk] I think you can upload them. There's a method for bringing in PET scans and MRIs, but I don't know if you ever tried to use any of these 3D loops and registrations from different days.

[Dr. Christopher Beck]:
Mixed results.

[Dr. Josh Kuban]:
It's mixed results, and even if you're off by just a few millimeters, it's a huge difference. I always do it the same day, and if I can see really well, no contrast, great, I can skip that step, but, otherwise, I almost always get a pre-CT scan now. I think it's just much more accurate when you're doing the fusion, to not have that uncertainty.

[Dr. Christopher Beck]:
Plus, I think that how often are your patients perfectly supine, arms up? A lot of times you'll have them in a different position to drop down on the lesion or open up something. All right, so you were staying-- I think you were on step three of ablation or one other is the way you use ablation confirmation.

[Dr. Josh Kuban]:
Yes. Step three is-- The first one, obviously, define tumor, place your probes, third one is actually confirm you got the ablation. That's the meat and potatoes of it. I usually do attract ablation for my cases, take my probes all the way out if I'm in the plane, but, sometimes, if I'm doing a really steep out of plane, I had to come from really low to get up to a dome lesion, you can actually keep some of your probe in the liver, and it won't distort your ablation confirmation software too much-- or not your software but your images.

I'll either take the probe all the way out or get it out of my field of view so I can have a clean CT of my tumor bed. Then I'll do another scan, and that's arterial venous. Pre-arteriovenous, you're looking for bleeding arterial, very rare. Then the venous phase, that's when you're going to upload that to AC. You go back to step three, which is bring that scan over, you drag it over, and now the computer is going to merge those two.

It's going to take your scan and the prescan and merge them. What you do right before that is you just define your ablation zone. It has a really cool feature. It's called "The create tool." It kind of uses Hounsfield units and a little computer algorithm to figure out what your ablation zone is, and it's very accurate. Where it's not perfect and, sometimes, if you have multiple probes or redirects, and it's not a great shape, you can just use one of those ROI functions to carve it a little bit, but I don't know. Perfect is the enemy of good here. I want to have a nice ablation zone, but I don't want to add 20 minutes to my case either.

The create function does really good job, just giving you what you need. Then you ask computer to fuse it, and that's the magic of it. It fuses those two, and then you get a scan overlaying your segment to tumor with your margin and your ablation zone. You get to see, "Did I get it? Did I get my tumor? Did I get my ablation zone? Did I get my margin?" That's it. You can then know, for sure, that you got what you came to get. If you do not, then you can make a mark there and use that to target and do a re-ablation, but most of the time, having used it for a while, I had pretty good results of getting it the first time, but if not, I go back in, no problem.

[Dr. Christopher Beck]:
That was my question. If you have something, say, you left over a little bit of tumor on the inferior margin, things are distorted now, like, the ablation zone is contracted, but you can use the ablation confirmation software to say, "Okay, this is where the bottom part of the lesion is." Do you then use the ablation confirmation software to get back at that spot, or do you just use the CT landmarks that you already have formed from the ablation zone?

[Dr. Josh Kuban]:
This version of AC, you don't use them to target but what I do is I'll go to the same slice, "Okay, at this slice, which you can correlate over to your image acquisition machine, whatever it is, and say, "Okay, the lesion was here. This is where I left margin. Now put an ROI at that spot on that slice," and I go back in. That's something that's different, but if you were a family member getting ablation and you knew you still had margin left, you'd obviously want them to go back in.

They're already in procedure. They already made the trip there. They're already getting it on the table. It's like a surgeon doing a procedure, checking the margin with pathology, be like, "Oh, there's a little bit like a couple of cells here. I think we'll be okay. We'll keep an eye on it." No, you go back in, you clean that part out. I think that's an established thing to do in surgery. It's not really in IR. It's just quick, quick, get done, but I think the times where you do have to go back in, it's worth it. You just don't have the recurrences. You're able to prove that you got what you came to get for and have that A0 ablation, that get-everything-the-first-time kind of approach.

Listen to the Full Podcast

Microwave Ablation for Liver Lesions with Dr. Josh Kuban on the BackTable VI Podcast)
Ep 257 Microwave Ablation for Liver Lesions with Dr. Josh Kuban
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The Impact of NeuWave Ablation on Practice Efficiency, Technical Endpoints & Practice Building

Dr. Josh Kuban underscores the importance of precision and accuracy in the procedure, emphasizing the necessity of achieving A0 ablation in every case. He highlights that the learning curve for mastering this technique is relatively short, noting the user-friendliness of systems such as NeuWave. Dr. Kuban also advocates for careful and deliberate margin monitoring, a practice facilitated by ablation confirmation that allows real-time, intra-procedural observation of treatment effects and ensures the removal of the entire tumor during the initial procedure. This approach helps significantly lower recurrence rates, thereby building confidence in ablation procedures. Additionally, the 3D visualization offered by this technique serves as a powerful tool for practice building, effectively communicating case success to referring providers.

[Dr. Christopher Beck]:
What's the time commitment? I get there's like a running up period when you're learning it or the reps demonstrating it with your text, but, ballpark, what does it add to a straightforward ablation for you?

[Dr. Josh Kuban]:
Now?

[Dr. Christopher Beck]:
Yes, now that you got proficient at it.

[Dr. Josh Kuban]:
If I'm not going back in, maybe three, four minutes. It's really fast now, but if you have to go back in and re-ablate, then that's an extra 15 minutes.

[Dr. Christopher Beck]:
But that's like–

[Dr. Josh Kuban]:
That's different.

[Dr. Christopher Beck]:
Yes, that's different because, then, you're going back. I think that's what I was trying to draw. If it's a straightforward ablation where you're just trying to check and your margins are good, but it's invaluable, and I don't think any interventional radiologist would fault you, like, "Oh, if you left margin behind, I got to go in and ablate it."

[Dr. Josh Kuban]:
Of course, you got to go back in and get it right. I think what happened was my rep went on maternity leave, so I had to really learn it fast. It takes, I don't know, maybe three cases of really committing to learn it, and it's pretty easy. It's not anything different than any Nuke software or dosimetry. It's just ROIs, defining things for a computer, and putting images together. It's not that different from anything we're all trained to do.

[Dr. Christopher Beck]:
The NeuWave stuff seems pretty user-friendly in terms of the interface, in my experience. It's like big fat buttons that my big dumb hands can seem to manage to work around. I know we touched on it, but I just want to make sure I ask a question specifically. What has been the impact of the ablation confirmation specifically on your practice and your patients?

[Dr. Josh Kuban]:
I think every case should be an A0 ablation. You really shouldn't do any ablation unless you're going to be able to get the whole thing when you're trying to do these curative type procedures, or these procedures where you're trying to remove tumor, versus palliation. If your goal is to get it all the first time, you really have to get margins. In order to get margins, you have to look at them.

For me, the availability of AC has allowed me to look at my margins and look at my treatment effect, real-time, in the room while they're still asleep, and to be able to provide a more complete treatment the first time so that you're not coming back. I don't think I had a really high recurrence rate before, but there were obviously recurrences. If you follow someone, 12 months, 18 months, 24 months, those are the ones that you're really trying to prevent. Every ablation looks good at 3 months, but when you follow them long-term, that's when you're really going to pick them up.

I think that since I've started using this, my recurrence rate has been very low. I think even when I did, I've been able to say, "Hey, look, we got the margin there. We did everything we could to do this the best way we knew how to do it." It's given me more confidence in ablation. It's made me, actually, faster in the end because I've been able to adjust the way I do things because of the experience I've gotten from looking at my zones and being like, "Oh wow, that was an undercooking" or "I didn't need to go that high."

[Dr. Christopher Beck]:
Sure.

[Dr. Josh Kuban]:
It's made me better at doing the procedure, knowing what I know from that information. Then it's nice for practice build. I have to say I take screenshots every time, and I did. I take a picture of it in 3D, and I send them to my referring providers, and I say, "Hey, case went great. Here's some pictures. Got a nice margin. Thanks for their referral. I'll continue to follow." I send that same email trail at three months, in six months, in nine months. For practice building, that's huge. They know that I'm doing the same things that they're doing with their surgeon, in terms of ablation, and it looks very similar to like a rad, hunk picture where they're able to show there was a tumor borne and be like, "Oh, here's our dose plan." We're like, "Okay, well here's my ablation and my margins, and it looks great."

Podcast Contributors

Dr. Josh Kuban discusses Microwave Ablation for Liver Lesions on the BackTable 257 Podcast

Dr. Josh Kuban

Dr. Josh Kuban is an interventional radiologoist and associate professor with MD Anderson Cancer Center in Texas.

Dr. Christopher Beck discusses Microwave Ablation for Liver Lesions on the BackTable 257 Podcast

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Cite This Podcast

BackTable, LLC (Producer). (2022, October 31). Ep. 257 – Microwave Ablation for Liver Lesions [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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