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Indications & Patient Selection
BCLC staging, Milan criteria, contraindications
Ideal Candidates (BCLC 0/A)
- Single HCC ≤3 cm (optimal ≤2 cm — highest complete ablation rates)
- Up to 3 nodules ≤3 cm (Milan criteria compatible)
- Child-Pugh A or B7 (B8+ — hepatology review required)
- ECOG PS 0–1
- Bridging therapy to transplant (downstage or maintain Milan while waiting)
- Recurrent HCC post-resection if anatomically accessible
Relative Indications / Tumor Board
- 3–5 cm HCC: combination ablation + TACE (TACE-ablation); microwave preferred over RFA for larger tumors
- Subphrenic/perivascular HCC (near major bile duct or portal vein): hydrodissection
- Recurrent HCC after TACE: ablation of residual viable tumor confirmed by LI-RADS LR-TR Viable
Contraindications
- Child-Pugh C (unless bridge to transplant — very selective)
- Uncorrectable coagulopathy (INR >1.5 — correct with FFP; platelets <50K — transfuse)
- Tumors adjacent to common bile duct/hepatic duct confluence: risk of biliary stricture — surgical or combined approach preferred
- Extrahepatic disease (curative intent contraindicated)
- Poor acoustic/CT window or inaccessible lesion (rare with CT guidance)
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Pre-Procedure Planning
Imaging review, labs, modality selection, anesthesia
Imaging Review
- Diagnostic MRI liver (LI-RADS LR-4 or LR-5 preferred — confirm arterial phase enhancement + washout)
- CT or PET-CT to exclude extrahepatic disease
- Review prior TACE lipiodol deposition: viable tumor = arterial enhancement BEYOND lipiodol zone
- Measure tumor diameter in 3 planes; plan probe trajectory to achieve 1 cm circumferential margin
Labs
- CBC, CMP, PT/INR, type and screen
- AFP (baseline; 50% HCCs are AFP-producing — useful for response tracking)
- HBV/HCV viral load (active HBV: prophylactic entecavir pre-procedure)
Modality Selection
| Ablation Type | Best For | Limitation |
|---|---|---|
| Microwave (MWA) | Most HCC <5 cm; near vasculature (less heat-sink) | Tip artifact; larger ablation zone harder to predict |
| RFA | Well-circumscribed HCC <3 cm, away from vessels | Heat-sink near portal/hepatic veins; slower |
| Cryoablation | Subphrenic, perivascular, near bile ducts (visible iceball) | Longer procedure; cryoshock risk (rare) |
Anesthesia plan confirmed. MAC preferred for breath-hold compliance and pain management. General anesthesia for subphrenic or difficult lesions requiring controlled apnea.
Recent cross-sectional imaging reviewed. Lesion size, location, proximity to bile ducts, bowel, diaphragm, and major vessels documented.
Coagulopathy corrected. INR ≤1.5, platelets ≥50K before procedure.
HBV status confirmed. Active HBV replication → entecavir prophylaxis ordered pre-procedure.
Ablation probe and energy system confirmed available. Verify probe size and manufacturer protocol for planned tumor diameter.
D5W available for hydrodissection if lesion near bile duct, diaphragm, or bowel (<1 cm clearance).
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Consent / Risks
Risks to discuss with patient
Procedure-Specific Risks
- Incomplete ablation / local tumor recurrence (10–30% depending on tumor size and location)
- Hepatic abscess (1–2%; higher with bilioenteric anatomy — Whipple, biliary stents)
- Biliary injury / biloma (duct proximity — bile duct ≥5 mm distance recommended)
- Post-ablation syndrome (fever, malaise, RUQ pain — self-limited 3–7 days)
- Tumor seeding (rare, <1% — risk with biopsy at time of ablation)
- Hepatic decompensation (Child-Pugh B — bilirubin rise, ascites worsening)
General Risks
- Hemorrhage / hematoma requiring transfusion or embolization (<2%)
- Pneumothorax (subphrenic approach, crossing pleural space)
- Skin burn (grounding pad burns — RFA; probe insertion site)
- Anesthesia risks (MAC / general)
- Contrast reaction (if IV contrast used for confirmation)
- Infection / sepsis
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Supplies
CT guidance, ablation probes, medications
Imaging & Guidance
- CT fluoroscopy suite (wide-bore 70 cm preferred)
- Preprocedure CT arterial/portal phase for lesion targeting
- IV contrast (lesion confirmation at start if planning phase)
Ablation Probes
- MWA: Neuwave Certus, Covidien Emprint, or Medtronic Solero — 13–17G antenna; 45–60W, 10–15 min/zone
- RFA: Cool-Tip (Medtronic) or VIVA RF (AngioDynamics) — 17G internally cooled; grounding pads ×2
- Cryo: Varian, Boston Scientific 17–18G; freeze-thaw-freeze cycle
Access & Hydrodissection
- 21G Chiba/coaxial needle
- D5W 200–500 mL (hydrodissection — NOT saline; saline conducts electricity)
- Extension tubing for continuous D5W drip
- Grounding pads ×2 (RFA only) — thighs, lateral placement
- Standard procedural tray: sterile drapes, syringes, 25G/22G needles, lidocaine 1%
Medications
- MAC sedation: propofol infusion, fentanyl, versed per anesthesia
- Lidocaine 1% — skin and subcutaneous down to liver capsule
- Toradol 30 mg IV (post-procedure pain; hold if renal insufficiency)
- Ondansetron 4 mg IV (anti-emetic)
- Tylenol 975 mg PO q8h (post-ablation fever)
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Procedure Steps
CT-guided microwave / RFA / cryoablation
1
Patient Positioning & Setup
Supine (most HCC) or left lateral decubitus (posterior right lobe lesions). Arms above head. Apply grounding pads to bilateral thighs if using RFA. Establish IV access ×2.
2
MAC / General Anesthesia Initiated
MAC preferred. Confirm adequate IV access. For subphrenic or posterior lesions requiring controlled apnea for probe insertion, general anesthesia with anesthesiologist for held-breath technique.
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Preprocedural CT Planning
Unenhanced CT from diaphragm to pelvis. Confirm lesion position and respiratory motion. Plan probe trajectory: avoid gallbladder, bowel, bile ducts, diaphragm. Note respiratory position at end-expiration for insertion. For tumors >2.5 cm: plan overlapping zones ("tiling") — map multiple probe positions before starting.
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Skin Prep, Drape, and Local Anesthesia
Standard sterile prep over right abdomen/flank. 1% lidocaine down to liver capsule — the peritoneum is exquisitely sensitive; adequate capsular block reduces patient movement during probe advancement.
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Probe Placement
CT scout → target lesion center → choose subcostal or intercostal approach (intercostal: use 11th or 12th space, ABOVE rib to avoid neurovascular bundle). Insert probe tip through skin; advance in increments under apneic conditions with intermittent CT fluoroscopy. Final CT confirms probe tip centered in/at deep margin of tumor. Traverse normal liver parenchyma to reach tumor — reduces capsular bleeding risk for subcapsular lesions.
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Hydrodissection (if Needed)
If bile ducts, bowel, or diaphragm within 1 cm of planned ablation zone: insert 21G Chiba needle into targeted dissection plane. Inject D5W 20–50 mL — confirm separation on CT. Use continuous slow D5W drip during ablation to maintain separation. Use D5W only — saline conducts electricity and can cause injury.
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Ablation
Activate per manufacturer protocol. Monitor for breakthrough pain (inadequate anesthesia or probe repositioning needed) and for arcing (RFA — reduce power, check grounding pads). For tumors >2.5 cm: complete first zone, then shift probe 1.5 cm and ablate again. Two-probe simultaneous MWA technique for 3–5 cm lesions creates larger confluent zone.
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Intraprocedural Assessment
CT after ablation. Ablation zone should be hyperattenuating (MWA/RFA) or hypoattenuating iceball (cryo). Zone must encompass tumor + ≥5 mm margin in ALL directions. If margin inadequate: reposition probe and ablate additional zone before withdrawal.
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Probe Tract Ablation
On withdrawal, activate probe during removal to ablate tract (MWA/RFA) — reduces seeding risk. Not offered with cryoablation.
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Post-Ablation CT
Unenhanced CT to document ablation zone size, check for pneumothorax, hematoma, or subcapsular collection. Document final ablation zone dimensions in 3 planes.
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Recovery
4h observation minimum. Pain control: Toradol + Tylenol scheduled; opioids PRN. Monitor CBC at 4h. Post-ablation fever (>38°C) expected — Tylenol and reassurance.
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Pearls & Pitfalls
Technique refinements and critical errors to avoid
Technique Pearls
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Ablation margin ≥5 mm in ALL planes = local tumor control goal; ≥10 mm strongly preferred for tumors with vascular invasion pattern. Plan 1.5–2× tumor diameter probe zone to achieve adequate margins.
✦
For subcapsular HCC: traverse normal liver before entering tumor. No free needle pass through capsule directly into tumor — reduces capsular bleeding risk.
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Perivascular HCC (touching portal vein ≥3 mm): MWA preferred over RFA (less heat-sink effect). Reposition probe toward the portal side of the tumor to achieve margin despite heat dissipation.
✦
Two-probe simultaneous MWA technique for 3–5 cm lesions: activate both simultaneously for larger confluent zone. Overlapping coagulation is additive, not just additive — the synergy yields a larger zone than sequential ablation.
✦
Cryoablation iceball tracking: clearly seen as hypoattenuating zone on CT in real time. Monitor continuously; stop freeze when iceball extends 1 cm beyond tumor edge in all directions.
✦
Check AFP pre- and 4–6 weeks post-ablation. Rising AFP at follow-up = likely residual/recurrent HCC before imaging shows it — important early signal to act on.
Critical Pitfalls
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DO NOT ablate tumor adjacent to common bile duct/hepatic duct confluence without hepatobiliary surgery backup. Biliary stricture risk is high. Combined surgical/ablation or resection preferred.
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Bilioenteric anastomosis (Whipple, Roux-en-Y) = high abscess risk. Prophylactic antibiotics required. Do not treat without covering antibiotics and close post-procedure surveillance.
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Segment VIII (near right hepatic vein/IVC junction): cryoablation preferred — visible iceball avoids inadvertent IVC thermal injury that is not visible with MWA/RFA.
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Do NOT biopsy before ablation. Tissue confirmation is acceptable post-ablation or can await LI-RADS response. Pre-ablation biopsy significantly increases seeding risk.
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Child-Pugh B8+: risk of decompensation increases substantially. Keep ablation zone as small as clinically appropriate (preserve functional liver volume). Discuss with hepatology; bridging to transplant listing preferred over repeated ablation.
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Post-Procedure Care
Recovery, surveillance imaging, LI-RADS TR response
Day 0 Recovery
- 4h bedrest, vitals q30min ×4h
- CBC at 4h (hematocrit drop >6 = significant hemorrhage — repeat CT)
- Pain management: Toradol + Tylenol scheduled; opioids PRN
- Post-ablation fever (>38°C) expected — Tylenol, reassurance; persistent >72h = CT to r/o abscess
- Nausea: ondansetron PRN
- Discharge if stable (most patients same-day for single-lesion; overnight for Child-Pugh B or complex cases)
Days 1–3: Post-Ablation Syndrome
- RUQ pain, fever, fatigue, malaise — self-limiting and expected
- Continue scheduled Tylenol; avoid NSAIDs if renal dysfunction
- Patient education: call if rigors, temp >39°C, jaundice worsening, or increasing pain not controlled with oral medications
Imaging Follow-up Schedule
| Timepoint | Study | What to Assess |
|---|---|---|
| 4–6 weeks | MRI liver with gadolinium | LI-RADS TR-1 (no enhancement) = complete response; LI-RADS TR-Viable = residual/recurrence |
| 3 months | MRI liver | Early recurrence detection; AFP trend |
| 6 months | MRI liver | Continued surveillance; new lesions |
| 12 months | MRI liver + AFP | Annual thereafter; transplant candidacy reassessment |
LI-RADS Treatment Response (TR) Categories
| Category | Finding | Action |
|---|---|---|
| LI-RADS TR-1 (No viable) | No arterial enhancement in ablation zone | Routine surveillance per schedule above |
| LI-RADS TR-2 (Probably no viable) | Minimal equivocal enhancement | Repeat MRI at 3 months |
| LI-RADS TR-3 (Equivocal) | Enhancement present, unclear viability | Repeat imaging or biopsy; tumor board discussion |
| LI-RADS TR-Viable | Nodular/thick rim arterial enhancement | Re-ablation or TACE; urgent tumor board |
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Emergency Escalation
Hemorrhage, pneumothorax, abscess, decompensation
Hemorrhage
Subcapsular Hematoma / Active Bleeding
Subcapsular hematoma: most self-limit; serial CT if expanding; transfuse if Hgb <8.
Active arterial extravasation: emergent hepatic arteriography + embolization. Call surgery if hemodynamically unstable or pericapsular blood with ongoing bleeding (hepatic artery pseudoaneurysm post-ablation).
Pneumothorax
Post-Ablation Pneumothorax (Subphrenic Access)
Identified on post-ablation CT after intercostal approach. Small (<20%, asymptomatic): observation and supplemental oxygen.
Moderate-large or symptomatic: chest tube — IR or CT-guided 8–12F pigtail catheter. Monitor with serial CXR.
Hepatic Abscess
Fever + Leukocytosis at 1–2 Weeks Post-Ablation
CT abdomen with contrast. Thick-walled, gas-containing, or fluid collection in ablation zone = abscess until proven otherwise.
Management: CT-guided drain placement (8–12F pigtail); aspirate for culture and Gram stain. Broad-spectrum antibiotics: pip-tazo 3.375g IV q6h; narrow based on culture results. Bilioenteric anatomy patients: higher threshold for ERCP to decompress bile ducts.
Biliary Injury
Rising Bilirubin + Biloma on Follow-up Imaging
Biliary injury may manifest days to weeks post-ablation. Infected biloma requires drainage.
Management: ERCP ± biliary stent for bile leak; CT-guided drain if biloma infected. Bile duct stricture at hepatic hilum (late finding): hepatobiliary surgery consultation urgently.
Hepatic Decompensation
Child-Pugh B: Rising Bilirubin, Worsening Ascites, Encephalopathy
Most likely to occur 3–14 days post-ablation in Child-Pugh B8+ patients or those with prior large ablation zones.
Management: Hepatology consult immediately. Lactulose for encephalopathy; diuresis for ascites. Consider TIPS evaluation if refractory ascites. Expedite transplant listing — decompensation post-ablation may improve transplant priority (MELD increase).
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Related Resources
Internal links and external guidelines
External Guidelines
- AASLD HCC Guidelines (2023) — ablation indication thresholds and surveillance protocol
- ESMO Clinical Practice Guidelines HCC — European consensus on BCLC staging and treatment allocation
- LI-RADS v2018 Treatment Response Algorithm — TR category definitions and imaging criteria
- Barcelona Clinic Liver Cancer (BCLC) staging system — treatment allocation by stage