Cancer image liver

Radiofrequency ablation: Putting the heat on liver cancer

Learn how this short procedure is used to manage hepatocellular carcinoma, a deadly complication of cirrhosis.

Since Joe Biggins, 63, was diagnosed with liver cirrhosis 2 years ago, he's visited the hepatology clinic every 6 months and had an abdominal ultrasound and a blood test for alpha fetoprotein (AFP). These studies are done regularly in patients with cirrhosis to rule out hepatocellular carcinoma (HCC), which affects 8% of these patients and is a common cause of death among them. Detecting the tumor when it's small and localized provides a good chance of eliminating the cancer and improving survival.

Today, Mr. Biggins' ultrasound shows an area that's highly suspicious for a liver tumor, and his AFP result is elevated at 125 ng/ml (normal, 0 to 10 ng/ml). The primary care provider orders a computed tomography (CT) scan, which shows a 1.5-cm lesion in the right lobe of his liver. A subsequent biopsy confirms the diagnosis.

Exploring the options

Discussing HCC with Mr. Biggins and his wife, the hepatologist details the following treatment options:

* Radiofrequency ablation is a thermal technique that can be done percutaneously laparoscopically, or during open surgery. An electrode placed in the tumor generates heat from 80?¡ã C to 110?¡ã C (176?¡ã F to 230?¡ã F) to destroy the tumor cells. The heat also closes small blood vessels and decreases the risk of bleeding. The least invasive percutaneous approach poses fewest risks. It can be done on an outpatient basis with the patient receiving intravenous (I.V) sedation and analgesia rather than general anesthesia.

* Complete resection of the tumor offers the best chance of long-term survival, but cirrhosis can limit the amount of resection the patient can tolerate and increases his risk of postoperative liver failure and death.

* Systemic chemotherapy is rarely used. It significantly reduces the patient's quality of life during treatment, and its effectiveness is questionable.

* Liver transplantation may be considered if the patient has a small tumor confined to the liver without metastasis; the risk of cancer recurrence is high with more extensive tumors.

* Intrahepatic arterial chemoembolization or chemoinfusion may be used to treat an unresectable tumor. Because HCC is hypervascular, chemotherapy can be directed through the vessels into the tumor.

The hepatologist and interventional radiologist review Mr. Biggins' diagnostic test results. Because he has a single, small lesion, no ascites or encephalopathy, adequate liver function, and good nutritional status, the physicians recommend radiofrequency ablation.

Close to the time of the procedure, Mr. Biggins will have preadmission lab work and a history and physical with special attention to allergies because he'll receive an antibiotic and other medications. The physicians may order additional imaging studies to evaluate the size and status of his lesion.

Preparing your patient

Teach Mr. and Mrs. Biggins what to expect when he's admitted for radiofrequency ablation of his tumor. Explain that he'll have to start fasting the night before the procedure. When he arrives at the hospital, he'll go to a special room in the X-ray department. A nurse will place an I.V device in his arm to provide medication that'll control discomfort and help him relax during the procedure. He'll also receive I.V antibiotics to prevent infection. His vital signs, heart rhythm, and oxygen saturation will be monitored, and he'll receive oxygen via nasal cannula. Grounding pads for the radiofrequency generator will be applied to his legs, so hair from the top of his thighs to just above his knees may be clipped to help the pads adhere.

Tell Mr. Biggins that the physician will inject a local anesthetic into his abdominal wall and make a quarter-inch incision there. Using ultrasound, CT, or magnetic resonance imaging, he'll guide a needle-electrode into the lesion to destroy it with heat. (See A Probing Look at the Needle-Electrode for details.) He'll monitor the area with imaging throughout the procedure. Explain that over time his liver will reabsorb the destroyed cells.

Remind Mr. Biggins and his wife that someone will have to drive him home after the procedure because he won't be able to drive safely after receiving sedation. Give them a written guide to reinforce what you've taught them.

On the day of ablation

When Mr. Biggins arrives at the hospital, make sure that he's fasting and that his history, physical examination, lab work, and signed consent form are in his chart. If his platelet count is less than 40,000/mm^sup 3^ or his prothrombin time is more than 1?? times longer than normal, he may receive a platelet transfusion or fresh frozen plasma before the procedure to prevent bleeding.

After reviewing Mr. Biggins' ultrasound and CT films, the interventional radiologist orders sedation and analgesia for the patient and begins the procedure. At one point in treatment, Mr. Biggins experiences diaphoresis and intense burning at the site of the lesion and receives additional analgesia. (The burning sensation means the procedure is going as expected.) He tolerates the rest of the procedure well, and the ultrasound image shows the lesion is gone. He's transferred to the recovery area for observation and monitoring.

Mr. Biggins is scheduled for a follow-up CT scan in 3 to 4 weeks. Before he and his wife leave the hospital, teach them how to recognize signs of complications, including hemorrhage, damage to adjacent organs (especially the bowel), liver abscess, and biliary strictures. Give them phone numbers to call if a problem develops and prescriptions for an oral antibiotic and acetaminophen with oxycodone (Percocet) to manage pain.

Back in a routine

The morning after Mr. Biggins' procedure, you call his home and his wife reports that he's taken two Percocet since his discharge and he slept all night. His temperature is normal and the puncture site isn't red or draining. You instruct her to call if they have any questions or problems.

Six months later, Mr. Biggins comes to the hepatology clinic for a routine visit. His AFP result is normal, and his abdominal ultrasound and CT scan show no tumor recurrence. Radiofrequency ablation has eliminated his liver tumor, and your nursing interventions helped prevent complications.

SELECTED REFERENCES

Chong, W: "Radiofrequency Ablation of Liver Tumors," Journal of Clinical Gastroenterology. 32(5):372-374, May/June 2001.

Curley, S.: "Radiofrequency Ablation of Malignant Liver Tumors," Annals of Surgical Oncology. 10(4):338-347, May 2003.

Rhim, H., and Dodd, G.: "Radiofrequency Thermal Ablation of Liver Tumors," Journal of Clinical Ultrasound. 27(5):221-229, June 1999.

Watkins, K., and Curley, S.: "Liver and Bile Ducts," in Clinical Oncology, 2nd edition, M. Abeloff, et al. (eds). New York, N.Y., Churchill Livingstone, 2000.

By Martha C. Shea, RN, BSN

Martha C. Shea is nurse-manager of the hepatitis C resource center in the Digestive Diseases Section of the Connecticut VA Healthcare System in West Haven.