The sonographerís role in RFA therapy of liver lesions
1 Department of Radiology, The Alfred Hospital, Melbourne, Australia
2 School of Medical Sciences, RMIT University, Melbourne, Australia
Interventional techniques using ultrasound guidance, such
as Radio Frequency Ablation (RFA) of liver lesions, are the domain of the
radiologist. However, real time ultrasound imaging as performed by the
sonographer, is critical in monitoring the successful insertion and placement
of the RFA needle. RFA is used to create a localised and controlled application
of heat in order to induce necrosis of cells within the liver lesions.
The role of the sonographer is to assist in establishing
the criteria for RFA therapy. This includes assessing the liver to establish
how easily the lesion can be identified; the size of the lesion; its proximity
to large blood vessels and adjacent vital organs and the access route to the
lesion itself. In essence, in this discussion, the focus will be on the
sonographic techniques in the assessment of the liver prior to RFA and the RFA
procedure itself. A brief review of the clinical role that can be provided by
Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) is also included.
© 2009 Biomedical Imaging and Intervention Journal. All rights reserved.
Keywords: Radio frequency ablation; sonographer
An extensive screening program is ideal to ascertain
patientsí various aetiologies suspecting hepatic pathology or its progression.
Suspicious lesions are followed up by triphasic Computed Tomography (CT) and a
treatment plan organised based on the patientís individual circumstance.
Ultrasound is the ideal imaging modality to perform Radio
Frequency Ablation (RFA) on liver lesions in patients for whom surgical
resection is either not an option or not the preferred method of treatment.
Ultrasound provides real time, non-ionising imaging to the clinician.
Ultrasound is also suited for patients with breathing issues or back problems
as the patient does not have to lie completely supine as with CT or Magnetic
Resonance Imaging (MRI). CT can also be used in conjunction with ultrasound; or
in a small number of cases such as advanced cirrhosis, CT may be the preferred
The focus of this article will be on the sonographerís
role in RFA therapy and the technique of RFA in treating liver lesions.
Selection criteria for RFA
The sonographer assumes an important role in ensuring the
RFA selection criteria are adhered to. This section details the factors
critical to the success of RFA liver therapy.
For those lesions which are not located peripherally in
the liver, conscious sedation and analgesia are provided. In such instances,
the patientís ability to suspend respiration when required is of utmost
importance. It is possible to perform this procedure under General Anaesthetic
(GA) but the ultimate aim is to treat the lesion with minimally invasive
Liver lesions located peripherally are best treated under
GA with an anaesthetist present. RFA of these lesions is considered too painful
both during and after the procedure and as such may affect patientís ability to
Solid lesions of any description with a hypoechoic halo
have always been regarded as suspicious and have a high association with
malignancy. Most commonly these lesions are characteristic of metastases or
Hepato Cellular Carcinomas (HCCís). Although not an absolute indicator of
tumour, lesions with a hypoechoic halo often require further investigation and
or treatment of some type regardless of the patientís health or symptoms. Due
to the sonographic properties of some lesions which are highly vascularised,
they are more likely to appear hyperechoic. Typically the tumours most often
treated by RFA are echogenic foci within the liver. These are classic examples
for colon metastases as well as neuroendocrine and vascular primaries. HCCís
are also echogenic . These are generalised descriptions of liver lesions
typical of HCCís or Colo Rectal Carcinoma (CRC) metastases; however, these
tumours can appear in any combination of the above or appear totally different
to these typical descriptions.
Nature of the Lesion
Surgical resection of HCCís detected in their early stage
within a relatively healthy liver is the optimal choice. However if the patient
is a non-surgical candidate, then RFA is the next most suitable therapy if the
patient has normal bilirubin (both conjugated and unconjugated) and has no
significant portal hypertension . Liver lesions amenable to RFA treatment
can be either primary hepatic lesions such as HCCís or secondary metastases
from CRC. However only those secondary liver metastases with no extrahepatic
spread are considered for RFA.
The location of liver lesions to be treated affects the
success of the RFA procedure. Lesions that are too close to or invading the
walls of major vessels within the liver, are unlikely to be treated
successfully. This is because the moving blood draws the heat created by RFA
away via convection and so it is not possible to ensure that the liver lesion
has been coagulated by the heat effectively. Hence, liver lesions that are 3 cm
or more in diameter which are abutting vessels will not be treated successfully
Lesions located close to gastric or intestinal walls may
endure heat related injury or even perforation if they are located within the
ablation zone. If bowel injury is a possibility, an intraperitoneal injection
of dextrose to displace bowel can be performed . As the gastric wall is
thicker than the intestinal wall, the gastric wall may be more resilient to
heating necrosis during RFA treatment .
Proximity of the gall bladder within the necrosis zone is
also undesirable as irritation of the gallbladder wall causes pain and possibly
an iatrogenically induced cholecystitis. Those tumours located close to larger
portal triads are also at risk of damaging the nearby bile ducts and causing
the patient great pain .
Peripherally located liver lesions also require extra care
and preparation. At this centre GA is recommended as the pain is too intense
under standard sedation and analgesia. Lesions at the dome of the liver have
the added complication of potential damage to the diaphragm. The use of an
artificial pleural effusion for RFA of these lesions will help to avoid
diaphragm damage .
Size and Number of Lesions
Most radiologists will treat lesions in liver if:
- lesions number less than or no more than four; of which each is 5 cm
or smaller, be they primary or secondary hepatic tumours with not extrahepatic
- those patients with a background of liver cirrhosis are classified via
the Child-Pugh class system. Only lesions in category A or B would be accepted
for RFA .
If the target tumour is larger than the ablation
periphery, overlapping regions must be performed in order to be sure that the
entire tumour has been ablated .
A successful ablation should achieve 100oC
within tissue of a 2 cm to 5 cm radius around the needle tip and is
held there between 8 minutes to 20 minutes per session . Ablation
is required not only for the entire lesion but also a 2 cm cuff of tumour
free margin so that any microscopic tumour invasion at the periphery may also
be eradicated. The edge of the ablative region can be observed sonographically
by echogenic micro bubbles that occur when the tissue is heated by the radio
frequency field .
Ideally, tumours should be at least 2 cm away from
large portal or hepatic vessels to reduce cooling effects and be at least 1 cm
away from liver capsule as this can affect adjacent anatomy and be extremely
painful. For optimal results, a tumour should be 3 cm in radius or less .
This is because the lesion may require overlapping ablations unless it is less
than 2 cm in diameter.
The following patients are contraindicated for RFA therapy
- Pacemakers (As patients become part of a closed loop electrical circuit,
this may adversely affect pacemaker functioning)
- Close proximity to gallbladder
- Close proximity to major bile ducts
- Haemodynamically compromised patients
- Hip replacements (need to put grounding pads elsewhere)
- Child-Pugh Class C Cirrhosis
- Pregnancy 
Radio frequency (RF) generators operate at 460 kHz
with a power setting of between 50 W to 200 W. Once the desired
temperature is reached in target tissue, the power is automatically adjusted to
a cool down setting as the Watts required to maintain the desired tissue
necrotising temperature is reduced. The patient is part of a closed loop
circuit including an:
- RF generation
- An electrode needle
- A large dispersive electrode (ground pads)
An alternating current (AC) field in radiofrequency range
is thus created within the patient.
Due to the high resistance of tissue when compared with
metal electrodes, those ions in target tissue which surround the electrode are
highly agitated while they attempt to follow the direction of the alternating
current . This agitation causes frictional heat which acts to cause
coagulative necrosis when local tissue temperature is between 50oC
to 100oC. The difference between the small surface area of the
needle electrode and the large area of the ground pads causes the generated
heat to be focussed and concentrated around the needle electrode .
Heating the tissue around the needle tip above 100oC
causes carbonisation or vaporisation of the tissue. The gas then provides
insulation against the ablative field that the physician is attempting to
establish. The needle tips are internally cooled to avoid tissue vaporisation.
Patients are given a suitable appointment time allowing
for a procedural time of about 2-3 hours duration. The procedure is considered
a day procedure and can proceed in one of two ways;
- conscious sedation (ultrasound or CT machines required)
- Full GA if lesion is located peripherally or if patient co-operation is
in question, (equipment and anaesthetics team required).
The procedure is usually scheduled as a morning procedure.
This is so that the day unit can perform 4 hour post procedure observation
and the patient can be discharged on the same day. The patient arrives at least
2 hours before the procedure, to be admitted on time and have any blood
product if required. A provisional overnight bed is usually considered should
complications arise which may require surgical intervention.
Regardless of which pain management technique is used, a
full blood (including platelet count) work up is performed the week prior to
the procedure. This will allow ample time to order fresh frozen platelets or
other blood corrective products and ensure that the patient has ample time on
the morning before the procedure to absorb them.
If the patient has had external imaging performed to
identify the lesion, those images are made available to the department in the
week leading up to the appointment. This is so that the most appropriate
preparation can be made. Body habitus may be a factor to determine if CT
combined with ultrasound may be required (e.g. hypersthenic patients where the
hepatic flexure of the bowel may make it difficult to see lesions even using an
intercostal approach with only ultrasound). A cirrhotic liver may make it
difficult for ultrasound to resolve posteriorly located lesions and so a
combination of ultrasound with CT may be required.
External imaging can be scanned into PACS (Picture
Archiving and Communications System) and original images returned to the patient.
This allows portability of imaging such that wherever the procedure takes place
(ultrasound department with conscious sedation or CT with ultrasound machine
combined, angiography or interventional room with ultrasound machine if full GA
required) the images can be displayed at a momentís notice, and the image
manipulated as required (e.g. change zoom factor, brightness / contrast etc).
Day of procedure
On the day of the booked procedure, the sonographer liases
with day unit nursing staff in the early morning. As sonographers, we ensure
that full blood profile (namely International Normalised Ratio [INR], Partial
Thromboplastin Time [PTT], Prothrombin Time [PT] and platelet count) are
available and documented and to be within normal limits. Patients who have a
background of liver disease may require platelets or other blood corrective
factors before the procedure. To ensure the patient meets these criteria we
discuss the patientís preparation needs with nursing staff from day procedure
unit. The preparation in addition to blood counts includes ensuring that the
patient has a day bed, the patient has been fasting for 6 hours prior to
the examination (we recommend nil orally from midnight the night before), the
patient has been admitted and all paperwork is in order, the patient has been
changed into a hospital gown and is lying on a trolley. We prefer the patient
on a trolley as the mattress is firmer (and so there is less of a concavity of
the supine position, whereas the softer bed mattresses allow the middle of the
patient to be in a slightly kyphotic position). Ease of portability of the
trolley is another factor. Once the patient has had the RFA, the patient must
remain in supine position for at least 4 hours to minimise any potential
If blood products are required for the patient, discussion
with the patientís primary nurse ensures that the product will have been
administered and be effective by the time we send for the patient. If possible,
the patient should be cannulated with a suitable line for analgesic drug
therapy during the procedure.
Once everything is ready we organise a porter to bring the
patient on their trolley with their history and full drug chart.
Once in our department, the patient is identified and the
sonographer introduces themselves and the patient is reminded in brief of the
procedure. We stress that the patient will be bed bound for the procedure and
also for 4 hours post procedure. If they need use of toilet facilities before
we begin, it is offered.
Ultrasound machines with the option of compound imaging
are ideal to better delineate the lesion(s) within the liver. Harmonics may be
useful if the lesion to be ablated is not deep; as tumours deep within the
liver will not be observed due to the principles of harmonics. Most often, we
use a curved 3 MHz to 5 MHz curved array transducer appropriately
covered with a sterile cover using aseptic techniques. Standard gel is used for
the initial scan but sterile gel is used on the sterile side of the cover
during the procedure. In this facility we used either the Phillips IU22 or the
ATL 5000. Sometimes due to the heterogenous or fatty nature of the liver to be
treated, it was necessary to use the phased array 2 MHz to 5 MHz
transducer. All factors are optimised, depth and focal zone set appropriately
at or just deep to the area to be investigated. Standard power and contrast
settings are used as per typical abdominal set up (1.1 Mechanical Index
and approximately 60 decibels respectively). Gain is set adequately to
observe the entire liver parenchyma with the Time Gain Compensation (TGC) at a
mildly increasing curve toward the posterior edge of liver.
After observation of previous imaging to identify target
lesion, we scan the liver to ensure no further hepatic lesions or biliary
pathology are present. The lesion is measured, the liver segment identified and
colour Doppler is applied to the B mode image to check vascularity of tumour.
In addition, the presence of any major hepatic or portal vessels in the
immediate area are identified. If the patient has had recent prior ultrasound
imaging in our department we will target our examination to the region of
interest. If previous imaging is from an external source or prior imaging is
more than a few weeks old, we will perform a full assessment of the liver and
observe the gallbladder and bile ducts (figure 1).
Also, as we are scanning we attempt to surmise the method
of best approach of needle insertion. Ultimately the radiologist will determine
the needle track. However, discussion with the patient may reveal information
which will prove valuable in ensuring the success of the procedure. For
instance, although a right posterior oblique position Ė with the patient lying
on their left side Ė using an intercostal approach from lateral side may seem
ideal; but if the patient has excruciating left hip pain and cannot lie still
regardless of the level of analgesic help, then a more anterior approach could
be considered in order to obtain full patient co-operation.
Such information gathered by the sonographer can
streamline the preparation and allow the radiologist maximum time for ablation.
Also while scanning, the patient is instructed on breathing technique and its
importance to the success of the procedure.
Nursing staff are then called in to assemble monitoring
devices. A blood pressure cuff and oxygen saturation monitor are attached to
the patient. On the opposite arm a needle is inserted (if not already done by
day unit nurse) and checked with saline for patency. This line will remain
insitu for the duration of the patientís stay in the hospital for drug
Midazolam and fentanyl are the drugs of choice for
sedation and analgesic unless contra-indicated. Oxygen is provided via nasal prongs
or mask. The two grounding pads are placed on the patientís thighs (shaved if
necessary). Once an adequate baseline blood pressure and oxygen saturation
(finger pulse oxymeter) have been established, the patient is ready to be
formally consented in writing by the radiologist. Information gathered by the
sonographer is discussed with the radiologist and then the RFA proceeds. The
sonographer writes the report and awaits the end of the therapy to finalise the
procedure. The radiologist also scans to conclude the best method of approach
and practise breathing techniques with the patient.
The skin is prepared after consent and the RFA machine
positioned adequately. The grounding pads are also applied.
The skin is cleansed with either chlorhexidine or iodine
standard solutions using a sterile technique. Ultrasound transducers are
covered with sterile covers and sterile gel is used. Using ultrasound guidance
the RFA needle is advanced to the target lesion. A plunger at the proximal end
of the 15 g needle is advanced  to deploy electrodes into the centre of
the target lesion (figure 2).
A multi-pronged umbrella of curved electrodes is lodged
within the tumour and the generator is switched on. Different types of
electrodes (available from a variety of manufacturers) can be used depending on
the intended application, lesion size and lesion location.
The temperature at the tips of the electrodes is
controlled to achieve 100oC for about 8 minutes to 10 minutes.
Once the target temperature is achieved, the system will reduce its output
power. The electrodes can then be adjusted (e.g further deployed). The power
required to maintain target temperature at the electrode tips is decreased
Once the lesion has been ablated, the generator performs a
cool down cycle . The electrodes are then retracted and the needle track is
also ablated using a lesser temperature of about 70-80oC  to
ensure no seeding of tumour occurs and to coagulate the track to reduce
bleeding. Throughout the procedure, the patientís vital signs are constantly
monitored and recorded at various time intervals.
Once the procedure has finished, the day unit nurse is
contacted by the radiology nurse for handover to the day unit for observation. The
patient is made as comfortable as possible. A suitable dressing is applied to
the needle entry site on the skin and the equipment is cleaned and packed away.
The role of CT and MRI in RFA
Ultrasound and CT are the two major imaging modalities
used to assess liver lesions prior to RFA and CT has been the predominate tool
used to assess post RFA treatment success and lesion follow-up [5,8-10].
The real-time capabilities of ultrasound make it the most
practical modality to incorporate electrode guidance and intra-procedure
assessment . However, both CT and MRI play a role in improving the candidate
selection process for RFA and pre-procedure planning [4,11]; such as
determining the most appropriate percutaneous pathway .
The added advantage of these imaging modalities is that
they both provide the benefit of multi-planar imaging Ė CT via the software
reformation process and MRI by direct imaging. Such multi-planar imaging helps
to ascertain the appropriate percutaneous pathway. In addition, MRI has the
added advantage of superior image contrast capabilities .
Traditionally and currently, post procedure follow-up and
assessment of tumour ablation success is commonly performed with contrast
enhanced CT. However, there is an emerging trend to incorporate MRI into the post-procedure
assessment of tumour response to RFA . Some studies are demonstrating that
with dedicated open architecture MRI systems, MRI can be used to improve RFA
success intra-procedurally .The improved intra-procedure success rate and
post-procedure monitoring provided with MRI can be attributed to the
understanding of the characteristic signal intensity demonstrated by liver
tumours and also their contrast media enhancement characteristics. This has
been confirmed with histological assessment in one particular study .
The MRI signal characteristics can be summarised as
- On non-enhanced images, ablated necrotic tissue is demonstrated as a
reduced signal pattern [13-17]. For example, when imaged with MRI, immediately
following RF energy application, it is demonstrated as being hypo-intense on a
T2 weighted sequence. (CT demonstrates the same ablated necrotic tissue as
hypo-dense and ultrasound will display it as hyper-echoic). A relatively
hyper-intense rim of 1 to 2 millimetres is also demonstrated. These
imaging appearances are in relation to the normal healthy liver parenchyma. The
reduced signal intensity is presumed to result from dehydration; that is, water
molecules displaced to the periphery of ablation and coagulation zone.
- The zone of reduced signal as described above, should also appear as
hypo-intense on a Short Tau Inversion Recovery (STIR) sequence .
- Following the administration of intravascular contrast media, a rim or
ring enhancement pattern encompassing the ablated necrotic tissue is displayed
on a T1 weighted sequence. The necrotic tissue itself should not demonstrate
any signal enhancement. This should correspond to the hypo-intense zone
demonstrated on the T2 weighted sequence [13-16].
- Histologic assessment of the hyper-intense rim or ring reveals that it
is comprised of haemmorhagic components, deteriorating hepatocytes and
interstitial oedema [13,14]. This reflects the imaging characteristic of an
- The dimensions of induced thermal coagulation, and therefore ultimately
tumour necrosis, has been found to have a variable representation across a
number of imaging sequences [13,14,16]. Non-enhanced T1 weighted images
underestimate this by up to 5 millimetres. STIR images may overestimate
this by up to 3 millimetres. T2 weighted images may overestimate by up to
2 millimetres. Contrast enhanced T1 weighted images may overestimate this
by up to 4 millimetres.
Intra procedure MRI is not without its own inherent
challenges . It adds a further layer to the patient selection process as
certain implanted devices are contra-indicated to the MRI environment. Careful
attention needs to be paid to the application and placement RF grounding pads
and the RFA equipment may induce imaging artefacts which need to be minimised
Even though MRI guided ablation adds cost and increased
overall procedure time, the benefits of MRI such as direct multi-planar
imaging, superior contrast resolution, characteristic signal pattern, ability
to better ascertain intra-procedure success, no ionising radiation and accurate
post procedure assessment are the factors that render MRI as a very powerful
modality to improve patient outcomes and medical management.
A sonographerís expertise is critical in ensuring the
success of RFA procedure. However, the sonographer also assumes an important
role in the overseeing of staff and equipment coordination with the aim of
ensuring the best use of hospital resources. These responsibilities include the
coordination of the patient preparation from booking, through to ensuring that
blood analysis are performed and if necessary corrected on time, to patient
arrival and ensuring the appropriate imaging are available.
An Example Case Study
The following movie clips (movies 1-3) are taken from the
same patient examination. This case is perhaps one of the more difficult types
that may be encountered in the clinical setting. It is considered difficult for
the following reasons:
- the size of the lesion to be ablated is very small;
- this patientís liver demonstrates ultrasound image characteristics of
advanced cirrhosis, including a heterogeneous texture and irregular contour;
- the patient has a large body habitus and the lesion under investigation
is deep within the liver; and therefore a phased array transducer was used to
optimise lesion detection.
Figure 1 Identification of liver segment and measurement of lesion (prior to RFA).
Figure 2 Needle tip (echogenic focus) in centre of lesion to be ablated.
Figure 3 Needle position confirmed immediately prior to ablation.
Figure 4 Ablation in progress. Tumour and surrounding tissue are going through tissue necrosis and coagulation. As the tissue is undergoing severe heat conditions, the bleeding vessels are seared and microbubble formation appears as a hyperechoic cloud around the needle tip.
Figure 5 Microbubble formation as tissue necroses. As the ablation continues the microbubbles identify the periphery of the tissue necrosed. This should ideally be an extra 2cm cuff around the visible periphery of the original tumour. The first centimetre to treat non visible spread throughout liver tissue, the next centimetre to treat any microscopic growth outside the original perceived boundary. The hyperechoic cloud recedes and is replaced by a heterogenous, echogenic mass of tissue.
Figure 6 On immediate completion of ablation. With time this lesion will appear less echogenic and shrink in size minimally. Follow up imaging with a triphasic CT or MRI is needed to ensure no tumour was left behind.
Movie 1 Pre-RFA: Real-time ultrasound imaging is used to guide the RFA needle to the lesion. Please note the arrow pointing to the needle tip. It appears as a hyper-echoic focus deep within the liver. This is a transverse sector image of the fourth liver segment.
Movie 2 RFA procedure in progress: This movie clip demonstrates the RFA process taking place. Note the hyper-echoic foci appearing around the needle tip, indicative of the ablation process.
Movie 3 Post RFA: Take note of the hyper-echoic cloud in the region of the ablation. Ultrasound imaging is performed immediately post-RFA to determine that there is no bleeding and that the surrounding blood vessels have not been damaged.
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|Received 1 April 2008; received in revised form 29 May 2008;
accepted 11 September 2008
Correspondence: RMIT University, Medical Radiations, School of Medical Sciences, PO Box 71, Bundoora, VIC 3083, Australia. Tel.: +613 9925 7786; Fax: +613 9925 7466; E-mail: firstname.lastname@example.org (Jenny Sim).
Please cite as: Mandarano S, Mandarano G, Sim JH,
The sonographerís role in RFA therapy of liver lesions, Biomed Imaging Interv J 2009; 5(1):e8