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RFA - Radiofrequency Ablation
Interventional Radiology

RFA - Radiofrequency Ablation

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Interventional Radiology

A needle heated to 60 degrees for a few minutes does what a scalpel used to. For a small liver cancer, ten-year survival matched surgery in a randomized trial.

Radiofrequency ablation passes an alternating current through a needle placed inside a tumor, a thyroid nodule, a faulty vein or a patch of abnormal lining, and the heat that builds around the tip destroys the tissue in place. The same technique now serves the liver, the thyroid, the legs, the esophagus, the heart and the spine, and the trials behind each use are set out below, along with the recurrences and the complications they recorded. Send us your scans and reports, and the specialist for your organ will tell you whether ablation fits and what it would replace.

66% vs 66%
Five-year survival, ablation against resection, early liver cancer
75%
Thyroid nodule volume gone at one year
1 day
Median return to normal activity after vein ablation
Free
Specialist review of your scans
Free consultation

Cells die above 60 degrees. Radiofrequency ablation produces that temperature in a controlled sphere around a needle tip without cutting anything open. The needle goes in through the skin, or through an endoscope or a catheter, under ultrasound, CT or X-ray guidance. A generator sends an alternating current at radio frequency down the needle, ions in the tissue vibrate, and friction heats a zone of two to five centimeters across. Heating takes ten to thirty minutes for most targets. The dead tissue stays where it is. Over months it shrinks and turns to scar.

Why the size of the target matters so much
A single needle heats a sphere of limited size, and tissue at the edge of a large tumor cools faster than tissue at the center, especially next to a blood vessel that carries heat away. For liver tumors, the results of ablation fall off sharply above three centimeters, and that threshold, more than any other single fact, decides who is offered ablation and who is offered surgery. Microwave ablation, a sibling technique that heats faster and is less affected by nearby vessels, is used for larger targets in many units and shares the same page in most guidelines.

Where is it used, and what did the trials find?

Liver cancer
The best-studied use. A randomized trial in Hong Kong assigned 218 patients with early hepatocellular carcinoma, a single tumor of five centimeters or less or up to three tumors of three centimeters or less, to surgical removal or to ablation. Ten years later overall survival was 47.6 percent after surgery and 41.8 percent after ablation, a difference that did not reach significance, and five-year survival was identical at 66 percent. Ablation meant a shorter procedure, less blood loss and a shorter stay. Recurrence was frequent in both groups, 71 percent against 82 percent, because the cirrhotic liver that grew the first tumor goes on growing others. Liver metastases from bowel cancer are treated the same way when surgery is not possible.
Thyroid nodules
For benign nodules that press on the windpipe, are visible in the neck or cause discomfort, ablation is an alternative to removing half the gland. A meta-analysis of 12 studies and 1,186 nodules found the nodule volume reduced by 68 percent at six months, 75 percent at one year and 87 percent at three years after radiofrequency ablation, with pressure symptoms and cosmetic concerns reduced in step. Nodules under 30 milliliters did best. The gland keeps working, so thyroid hormone tablets for life are avoided. The nodule has to be proven benign by two needle samples first.
Varicose veins
The faulty saphenous vein is closed from inside with a catheter, under local anesthetic, and the blood reroutes through healthy veins. A Danish randomized trial of 500 patients compared radiofrequency, laser, foam injection and surgical stripping. One year on, the vein had reopened in 4.8 percent after radiofrequency, 5.8 percent after laser, 16.3 percent after foam and 4.8 percent after stripping. Pain scores after the procedure were lowest with radiofrequency, and patients were back to normal activity in a median of one day against four after stripping.
Barrett's esophagus
When the lining of the lower esophagus has changed in response to years of acid and has begun to show precancerous cells, a balloon carrying an electrode is passed down an endoscope and burns the abnormal lining away. In a sham-controlled trial of 127 patients, the precancerous change was eradicated in 81 to 91 percent of treated patients against 19 to 23 percent of controls, progression to worse disease fell from 16.3 to 3.6 percent, and cancers fell from 9.3 to 1.2 percent. Six percent developed a narrowing that needed stretching.
Heart rhythm
Cardiologists use the same current through catheters inside the heart to isolate the pulmonary veins in atrial fibrillation. The CABANA trial randomized 2,204 patients across ten countries to ablation or to drug treatment. Ablation halved the recurrence of fibrillation, 49.9 against 69.5 percent, and reduced death or cardiovascular hospital admission, without significantly reducing the combined rate of death, disabling stroke, serious bleeding and cardiac arrest. A heart rhythm enquiry is answered by the cardiology team.
Bone, nerves and pain
Painful bone metastases, benign bone tumors in young people, the small nerves that carry pain from arthritic facet joints in the spine, and the nerves to the knee in arthritis are all ablated with the same generators, mainly for pain relief. The evidence is weaker than for the uses above.
  • A liver tumor of more than three centimeters, or more than three tumors, does worse with a single needle. Surgery, microwave ablation, embolization or transplant are weighed instead.
  • A tumor against the main bile ducts, the bowel, the gallbladder or the diaphragm can be ablated only with protective measures, and in some positions not at all.
  • A thyroid nodule that is suspicious or malignant on cytology belongs to surgery in most guidelines, with ablation reserved for selected tiny cancers in patients who cannot have an operation.
  • A varicose vein that is very tortuous or very close to the skin is treated by foam or by removing it through small cuts.
  • Barrett's esophagus with a visible nodule needs the nodule removed endoscopically first, and ablation of the flat lining afterward.

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The trials behind each use
Use Trial Compared Result
Early liver cancer Randomized, 218 patients, British Journal of Surgery 2017 Ablation against surgical removal Five-year survival 66.4 against 66.5 percent. Ten-year 41.8 against 47.6, within chance. Shorter stay and less blood loss with ablation.
Benign thyroid nodules Meta-analysis, 12 studies, 1,186 nodules, Endocrine 2020 Volume before and after Volume down 68 percent at six months, 75 at one year, 87 at three years. Symptoms and appearance improved.
Varicose veins Randomized, 500 patients, British Journal of Surgery 2011 Radiofrequency, laser, foam, stripping Vein reopened at one year in 4.8, 5.8, 16.3 and 4.8 percent. Least pain and fastest recovery with radiofrequency and foam.
Barrett's esophagus with precancerous change Randomized, sham-controlled, 127 patients, New England Journal of Medicine 2009 Ablation against a sham procedure Precancerous change eradicated in 81 to 91 percent against 19 to 23. Cancers 1.2 against 9.3 percent. Stricture in 6 percent.
Atrial fibrillation Randomized, 2,204 patients, JAMA 2019 Catheter ablation against drugs Recurrence 49.9 against 69.5 percent. Death or cardiovascular admission reduced. Hard outcomes not significantly different.

Who is a candidate?

  • A target the imaging can see clearly and a needle can reach without crossing a vital structure.
  • For the liver, one tumor of three centimeters or less, or up to three small ones, in a patient whose liver function and clotting allow a needle, with or without cirrhosis.
  • For the thyroid, a benign nodule, confirmed twice, that causes pressure, swallowing difficulty, a visible swelling or anxiety, in a patient who would rather not lose half the gland.
  • For the legs, reflux in the saphenous vein on ultrasound, with symptoms or skin changes.
  • For the esophagus, Barrett's change with dysplasia confirmed by two pathologists.
  • Anyone turned down for surgery because of age, heart or lung disease, or a liver too damaged to lose a segment, since ablation asks far less of the body.

Most referrals from abroad come under the last point. Ablation began as a treatment for patients who could not have an operation, and it remains the treatment that the frail, the elderly and the cirrhotic can have when nothing else is on offer. For a fit patient with a small tumor the choice against surgery is closer. The trial above is the fairest guide to it.

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Ablation or its alternatives, organ by organ
Organ Ablation suits The alternative suits
Liver One tumor of three centimeters or less, or up to three, in a patient unfit for surgery or who chooses to avoid it Larger or more numerous tumors, tumors against the hilum or the bowel, patients fit for resection who prefer the lower recurrence of removal
Thyroid A benign nodule with symptoms, a patient who wants to keep the gland working Suspicious or malignant nodules, very large multinodular goiters, nodules behind the breastbone
Veins A straight saphenous trunk with reflux Tortuous veins, recurrent veins after previous surgery, very superficial veins close to the skin
Esophagus Flat Barrett's lining with confirmed dysplasia A visible nodule, which is removed endoscopically first
Kidney A small mass in a patient with one kidney, poor kidney function or a high surgical risk Larger masses and fit patients, where partial removal is standard

How do I prepare, and what does the day involve?

  1. The scans that show the target, as images, since a report alone cannot show a path. For the liver a recent contrast CT or MRI, for the thyroid the ultrasound and both cytology reports. For the veins, the duplex ultrasound. For the esophagus, the endoscopy and pathology reports.
  2. Blood tests, including clotting, platelets, liver and kidney function, and for the thyroid the hormone levels.
  3. A full list of medicines, with blood thinners marked, and any allergy to local anesthetic or contrast.
  4. Earlier treatments to the same organ, including surgery, embolization, radiotherapy and previous ablation.
Sedation or general anesthetic
Thyroid and vein ablation are done under local anesthetic, with a mild sedative if you want one, and you talk to the team throughout. Liver and kidney ablation are done under deep sedation or general anesthetic, because the needle passes through the capsule of the organ and the heating is felt, and because the patient must not move. Esophageal ablation is done under sedation like any endoscopy. An anesthesiologist is present for the deep sedation and general anesthetic cases.

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The day, organ by organ
Organ Guidance Anesthetic Time Stay
Liver Ultrasound or CT, through the skin General anesthetic or deep sedation One to two hours One night, two after a large or awkward tumor
Thyroid Ultrasound, through the skin Local, with sedation optional 30 to 60 minutes Home the same day after two hours
Veins Ultrasound, catheter through a puncture Local 45 to 60 minutes per leg Home the same day, walking within the hour
Esophagus Endoscope Sedation 30 to 45 minutes Home the same day
Kidney CT or ultrasound General anesthetic One to two hours One night
Tell the team before the procedure
Blood thinners and when you last took them. A pacemaker or defibrillator, since radiofrequency current can interfere with it and a cardiology plan is needed. Pregnancy. Allergy to contrast, local anesthetic or antibiotics. Metal implants near the target. Diabetes and its treatment. For the liver, any history of encephalopathy or ascites.
Planning
On the day, the radiologist scans the target again and plans the path, the number of needle positions and the protective measures, such as fluid injected between the liver and the bowel, or between the thyroid and the nerve to the voice box.
Ablation
The needle is placed under continuous imaging, the generator runs for the planned minutes, and for a larger target the needle is repositioned once or twice so that the heated zones overlap. Contrast imaging at the end confirms that the whole target and a margin around it have been treated.
Recovery
Observation for two hours after a thyroid or vein procedure, and overnight after the liver or kidney, with a check of the blood count in the morning. Pain at the site for a few days answers to paracetamol. A low fever for a day or two after liver ablation is expected as the dead tissue is absorbed.
Follow-up imaging
A contrast CT or MRI of the liver at one month and then every three months in the first year, since a rim of surviving tumor is treated by a second session while it is small. An ultrasound of the thyroid at three, six and twelve months. A duplex scan of the vein at one week and one month.

What are the risks?

Liver
Bleeding from the needle track, in a few percent. Poor clotting raises it. Bile duct injury when the tumor lies near the ducts, with a bile collection or a narrowing weeks later, and burns to the bowel or diaphragm when a tumor sits against them, which injecting fluid to push them away prevents. Abscess in the dead tissue, in a small minority. Seeding along the track, rare, and prevented by heating the track on the way out. The trial above recorded the same mortality and complication rates for ablation and surgery.
Thyroid
Pain during and after, a bruise, and a temporary change in voice in a few percent from heat near the nerve to the voice box, which recovers within weeks in nearly all cases. Permanent voice change is rare. Rupture of the nodule through the capsule weeks later, rare, with a swelling that settles with antibiotics.
Veins
Bruising and tightness along the vein for a week or two. A patch of numbness where a skin nerve runs beside the vein, which fades over months. Clot extending into the deep vein, in under one percent, checked for on the follow-up scan. Skin burns, rare, prevented by the fluid injected around the vein.
Esophagus
Chest pain for a few days, treated with liquid painkillers and a soft diet. Narrowing of the esophagus needing stretching in six percent of patients in the trial above. Bleeding, rare.
Among 109 patients treated by ablation and 109 by surgery for early liver cancer, mortality and complication rates were similar, while treatment time, blood loss and hospital stay were all lower with ablation.
Randomized trial, British Journal of Surgery, 2017

Warning signs after you leave

Some symptoms cannot wait.

Go to a local emergency department the same day for severe or worsening pain, a swelling that grows, fever above 38 degrees, faintness, vomiting blood or black stools, yellowing of the eyes after a liver procedure, a hot swollen calf after a vein procedure, or difficulty swallowing that worsens after an esophageal one. Take the procedure report with you.

How many days do I need, and what decides the cost?

Three nights covers the thyroid, the veins and the esophagus, with the procedure on the second day and a check on the third. Liver and kidney ablation need five to seven, because the night in hospital is followed by a few days nearby before flying and a blood count before you go. A second session for a rim of surviving tumor is planned at the one-month scan, on a return visit or, for patients who stay, within the same trip.

Then the flight.

Fly two days after a thyroid, vein or esophageal procedure. After the liver or kidney, wait four to five days, until the blood count is stable and the pain is controlled, because delayed bleeding from the liver, rare as it is, shows itself in that window and is far easier to deal with in a hospital that knows what was done than in a cabin over the sea. On any long flight after vein ablation, walk every hour and wear the compression stocking you were given.

The needle sets the base of the price. Single-use, priced by size. Anesthesia adds an anesthesiologist for the liver and kidney and not for the thyroid or veins. Imaging before, during and after is charged by the scan. The contrast CT at one month belongs to the treatment. Nights in hospital, protective measures such as fluid injection, a second session, and treatment of any complication are separate lines, and combined procedures, above all ablation with chemoembolization for the liver, are quoted together and cost far more than ablation alone. Your own condition moves the figure. Cirrhosis, poor clotting, a pacemaker and diabetes each add checks and sometimes a longer stay.

Packages differ more than procedures do.

Packages published by hospitals in Istanbul for liver ablation range from a day-case procedure with a week in the city to a bundle with chemoembolization and three nights in hospital, and the two are different treatments for different patients. Find out which is proposed for you, and why. Thyroid packages list the procedure, the consultation and transfers, and little else, because the procedure itself is the whole of the treatment. Your own figure follows the free review of your scans.

One coordinator from the international patients team is assigned from your first message and stays with you until you fly. The team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and arranges interpreting in other languages on request, and an interpreter attends the consultation and consent. An invitation letter naming the hospital and the treating physician is sent about ten days before travel. The international patients office arranges the airport transfer, the hotel for you and a companion, and the rides to the hospital, and a companion is needed on the day of any procedure done under sedation. Rooms for patients admitted overnight have a companion bed. Halal, vegetarian and diabetic meals are available, a prayer room is on site, and a request for a female doctor is passed to the department and met wherever the rota allows. Back home, the coordinator stays reachable on the same WhatsApp number, and the follow-up scans can be sent to the treating physician for comment, with the images and not only the reports.

Radiofrequency ablation FAQ

Is radiofrequency ablation as good as surgery for liver cancer?
For a single tumor of three centimeters or less, or up to three small ones, a randomized trial of 218 patients found the same five-year survival, 66 percent, and no significant difference at ten years. Recurrence was somewhat higher after ablation. Above three centimeters, surgery does better.
Does RFA hurt?
Thyroid and vein ablation are done under local anesthetic, and patients describe pressure and warmth. Liver and kidney ablation are done asleep. Soreness for a few days follows any of them.
How much does a thyroid nodule shrink after RFA?
By 68 percent at six months, 75 percent at one year and 87 percent at three years in a meta-analysis of 1,186 nodules. Nodules under 30 milliliters shrink the most.
How long do I need to stay in Istanbul?
Three nights for a thyroid, vein or esophageal procedure and five to seven for the liver or kidney, including the night in hospital and a blood count before flying.
Can RFA be repeated?
Yes. A rim of surviving tumor found on the one-month scan is treated in a second session, and a thyroid nodule that regrows can be treated again. Repeat treatment is planned from the follow-up imaging.
Can my family come with me?
Yes. The international patients office arranges a hotel for you and a companion, and rooms for patients admitted overnight have a companion bed.

References

  1. Ng KKC, Chok KSH, Chan ACY, et al. Randomized clinical trial of hepatic resection versus radiofrequency ablation for early-stage hepatocellular carcinoma. British Journal of Surgery. 2017;104(13):1775-1784.
  2. Trimboli P, Castellana M, Sconfienza LM, et al. Efficacy of thermal ablation in benign non-functioning solid thyroid nodule: A systematic review and meta-analysis. Endocrine. 2020;67(1):35-43.
  3. Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. British Journal of Surgery. 2011;98(8):1079-1087.
  4. Shaheen NJ, Sharma P, Overholt BF, et al. Radiofrequency ablation in Barrett's esophagus with dysplasia. New England Journal of Medicine. 2009;360(22):2277-2288.
  5. Packer DL, Mark DB, Robb RA, et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019;321(13):1261-1274.

Editor's note

Written by the Biruni Hospital medical editorial team. Reviewed by Assistant Professor Yunus Emre AKPINAR, Radiology.

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