Radiofrequency Ablation in India and UAE | Complete Patient Guide

ELIGIBLE CANDIDATES:

• Hepatocellular carcinoma (HCC): BCLC Stage 0 (very early) or Stage A (early); single lesion ≤5 cm or up to 3 lesions each ≤3 cm; Child-Pugh Class A or B (score ≤7 preferred)

• Colorectal liver metastases (CRLM): ≤5 lesions, each ≤4 cm, in the absence of extrahepatic disease or with well-controlled extrahepatic disease; patient not eligible for curative resection due to anatomical or functional constraints

• Renal cell carcinoma (RCC): T1a tumours ≤4 cm, peripheral location, solitary or bilateral kidneys, or patients with von Hippel-Lindau disease requiring nephron-sparing approaches

• Non-small cell lung cancer (NSCLC): Stage I (T1–T2a, N0, M0) in patients with compromised pulmonary reserve (FEV1 <40% predicted) precluding lobectomy; also used for pulmonary oligometastases

• Osteoid osteoma: Symptomatic lesions ≤1.5 cm confirmed on thin-slice CT, unresponsive to NSAIDs, with nidus accessible to percutaneous electrode placement

• Benign thyroid nodules: Solid or predominantly solid autonomously functioning thyroid nodules (AFTN) causing compressive symptoms or hyperthyroidism, evaluated per Korean Society of Thyroid Radiology (KSThR) guidelines

• Adrenal metastases: Isolated adrenal oligometastasis ≤5 cm in patients with controlled primary disease

REQUIRED DIAGNOSTIC WORKUP PRIOR TO RFA:

• Triphasic contrast-enhanced CT (liver protocol) or gadoxetate disodium MRI (hepatobiliary phase) for hepatic lesion characterisation

• PET-CT (18F-FDG) to exclude extrahepatic metastatic disease in CRLM candidates

• Complete liver function panel: serum bilirubin, ALT, AST, albumin, prothrombin time/INR, AFP (for HCC), CEA and CA 19-9 (for CRLM)

• Child-Pugh and MELD scores; ICG retention rate at 15 minutes (R15) in cirrhotic patients — R15 >20% is a relative contraindication

• Chest CT for staging; bone scan or PSMA PET in prostate cancer metastasis candidates

• Renal function: eGFR, serum creatinine, DMSA scan for split renal function in renal RFA candidates

• Cardiac risk stratification: 12-lead ECG, echocardiogram (ECHO) if general anaesthesia or moderate sedation is planned

• Coagulation profile: platelet count ≥50,000/µL and INR ≤1.5 required for percutaneous approach; correction with FFP or platelet transfusion if needed

• Multidisciplinary tumour board review with surgeon, medical oncologist, interventional radiologist, and hepatologist

CONTRAINDICATIONS:

• Uncorrectable coagulopathy (INR >2.0, platelets <30,000/µL despite correction)

• Child-Pugh Class C cirrhosis (absolute contraindication for hepatic RFA)

• Lesion size >5 cm as monotherapy (relative; may combine with TACE as bridge therapy — TACE-RFA hybrid)

• Lesions abutting central bile ducts (within 1 cm of common hepatic duct or right/left hepatic duct bifurcation) — high risk of biliary stricture

• Presence of biliary-enteric anastomosis (increased infection risk due to reflux aerobilia — consider alternative ablative modalities)

• Implanted cardiac pacemaker or defibrillator (monopolar RFA systems may interfere with device function; requires cardiology clearance and reprogramming; bipolar systems preferred)

• Uncontrolled extrahepatic disease burden in patients with CRLM

• Pregnancy

• Active systemic infection or sepsis

PERCUTANEOUS RFA (Standard Minimally Invasive Approach):

The most widely performed approach, conducted under ultrasound (US), CT fluoroscopy, or CT-US fusion guidance with moderate sedation or general anaesthesia depending on lesion location and patient tolerance. A single 17-gauge internally cooled or multi-tined electrode (eg, Covidien Cool-tip, RITA StarBurst, Boston Scientific LeVeen) is advanced through the skin and into the target lesion under real-time imaging. Impedance-controlled or temperature-controlled energy delivery protocols are applied for 10–30 minutes per ablation cycle. Multiple overlapping spherical ablation zones (clustering technique) are used for lesions >2.5 cm to ensure complete coverage. CEUS with SonoVue or Lumason contrast agent is used intra-procedurally at many high-volume centres to confirm ablation completeness before electrode withdrawal. Applicable to: hepatic HCC, CRLM, RCC, adrenal metastases, osteoid osteoma, thyroid nodules.

LAPAROSCOPIC RFA:

Performed under general anaesthesia via laparoscopic ports, allowing direct ultrasound-guided electrode placement under laparoscopic visualisation. Enables thermal protection of adjacent structures (bowel, diaphragm, gallbladder) using hydrodissection or CO2 gas insufflation techniques. Preferred for subcapsular lesions, lesions in hepatic segments II/III adjacent to the diaphragm, or lesions not clearly visible on percutaneous US. Can be combined with laparoscopic cholecystectomy, peritoneal washings, or limited hepatic resection in a single operative session.

OPEN SURGICAL RFA:

Reserved for cases where RFA is performed as an adjunct to open hepatic surgery — eg, resection of one lobe combined with RFA of contralateral bilobar metastases (resection-plus-ablation strategy). Allows largest electrode arrays and direct hepatic vein occlusion (Pringle manoeuvre) to minimise heat-sink effect. Rarely used as a standalone procedure in the modern era given the superiority of percutaneous and laparoscopic approaches for appropriate candidates.

TACE-RFA COMBINATION (Hybrid Approach):

For HCC lesions 3–5 cm, transcatheter arterial chemoembolisation (TACE) with lipiodol-doxorubicin or drug-eluting beads (DEB-TACE) is performed 2–4 weeks prior to RFA. TACE induces partial tumour necrosis and reduces tumour vascularity, diminishing the heat-sink effect and thereby expanding the effective RFA ablation zone by up to 40%. Multiple randomised controlled trials (eg, TACE-RFA vs RFA alone) have demonstrated superior local control rates and improved 3-year overall survival with the combined approach for intermediate-sized HCC.

MICROWAVE ABLATION (MWA) — RFA Successor Technology:

MWA (eg, Neuwave, Acculis, Emprint systems) operates at 915 MHz or 2.45 GHz, achieving higher intratumoral temperatures (>150°C), larger and more predictable ablation zones independent of tissue impedance, and shorter ablation times (5–10 minutes vs 20–30 minutes for RFA). MWA is increasingly preferred over RFA for lesions >3 cm, perivascular lesions (minimises heat-sink effect), and lung tumours (avoids tissue charring that limits RFA efficacy). At GAF Healthcare partner hospitals in India and the UAE, both RFA and MWA are available; the interventional radiology team will recommend the optimal modality based on lesion-specific characteristics during the pre-treatment multidisciplinary evaluation.

STEREOTACTIC ABLATIVE RADIOTHERAPY (SABR/SBRT) — Alternative for RFA-Ineligible Cases:

For patients whose lesions are percutaneously inaccessible, or who have coagulopathy precluding needle insertion, SBRT with CyberKnife, TrueBeam STx, or Elekta Unity MR-Linac delivers ablative radiation doses (eg, 50–60 Gy in 3–5 fractions for liver; 54–60 Gy in 3 fractions for lung). Local control rates at 2 years are 85–95% for NSCLC and 70–80% for hepatic lesions, comparable to RFA in selected series.

IMAGE GUIDANCE TECHNOLOGIES AVAILABLE AT PARTNER CENTRES:

• CT-fluoroscopy (real-time cone-beam CT for trajectory confirmation)

• Fusion imaging: MRI-US or PET-CT-US co-registration for lesions occult on standard ultrasound

• Robotic needle guidance systems (eg, Maxio by Quantum Surgical) for sub-millimetre electrode placement accuracy

• Intraoperative contrast-enhanced ultrasound (CEUS) for real-time ablation margin assessment

PHASE 1 — PRE-ARRIVAL & REMOTE CONSULTATION (2–4 weeks before travel):

• Patient submits medical records via GAF Healthcare's secure digital portal: all prior imaging (CT/MRI/PET-CT in DICOM format), pathology reports, recent blood work, and comorbidity history

• GAF Healthcare's clinical coordinators route the case to the appropriate interventional radiology and oncology team at the selected partner hospital in India or the UAE

• A formal written second opinion and treatment plan is issued within 48–72 hours, including recommended ablation modality (RFA vs MWA), approach (percutaneous vs laparoscopic), and expected outcomes

• GAF Healthcare initiates e-Medical Visa (India) or UAE entry visa assistance in parallel

• Pre-admission instructions provided: medication holds (anticoagulants — warfarin stopped 5 days prior, DOACs stopped 24–48 hours prior per bridging protocol; NSAIDs stopped 7 days prior), fasting instructions (6 hours solid food, 2 hours clear liquids), and pre-procedure bowel preparation if applicable

PHASE 2 — ARRIVAL & PRE-PROCEDURE WORKUP (Days 1–2):

• Airport pick-up by GAF Healthcare's dedicated ground team; transfer to partner hotel or hospital guest house

• Day 1: Outpatient clinic review with interventional radiologist and hepatologist/oncologist; confirmatory imaging (repeat triphasic CT or contrast MRI if >4 weeks since prior study); anaesthesia pre-assessment; baseline labs including CBC, coagulation screen, LFTs, renal function, serum AFP/CEA

• Day 2 (morning of procedure): Hospital admission; IV access established; anaesthesia team review; patient positioned on CT or US fluoroscopy table; pre-procedure timeout conducted per WHO Surgical Safety Checklist

PHASE 3 — THE RFA PROCEDURE (Day 2, duration 1–3 hours):

• Moderate conscious sedation (midazolam + fentanyl ± propofol) or general endotracheal anaesthesia administered depending on lesion location, expected procedure duration, and patient cooperation

• Real-time imaging guidance (CT fluoroscopy, fusion US, or laparoscopic US) used to confirm electrode trajectory before advancement

• Electrode deployed within tumour; ablation initiated — typically 2–4 overlapping ablation cycles of 10–15 minutes each for lesions 2–5 cm

• CEUS or contrast CT performed at end of procedure to assess ablation zone coverage and identify any residual enhancement indicating viable tumour

• Electrode tract ablated on withdrawal to minimise bleeding and tumour seeding risk

• Patient transferred to post-anaesthesia care unit (PACU) for 2–4 hours of monitoring

PHASE 4 — IN-HOSPITAL RECOVERY (Days 2–4):

• Vital signs, oxygen saturation, pain scores monitored every 2 hours for the first 12 hours

• IV analgesia (paracetamol + ketorolac ± opioid PRN); transition to oral analgesia by Day 2

• Post-ablation syndrome (low-grade fever 37.5–38.5°C, fatigue, right upper quadrant discomfort) is an expected and self-limiting response to tissue necrosis, managed with antipyretics and hydration

• Day 2 post-procedure: Repeat LFTs, CBC, CRP; physician review; ambulation commenced

• Day 3: Discharge for percutaneous cases; Days 4–5: Discharge for laparoscopic cases

PHASE 5 — OUT-OF-HOSPITAL RECOVERY IN DESTINATION COUNTRY (Days 4–14):

• Patient stays at GAF Healthcare partner accommodation (serviced apartment or hotel) near the hospital for observation period

• Day 7 (± 2 days): First post-ablation contrast-enhanced CT or MRI (modified RECIST criteria applied to ablation zone assessment); review with treating radiologist

• Wound check (1–2 cm puncture site); suture or Steri-Strip removal if applicable

• Activity guidance: no strenuous exercise, heavy lifting (>5 kg), or swimming for 2 weeks; walking and light daily activities permitted from Day 3

• Anti-emetics, oral analgesia, and proton pump inhibitor (PPI) prescribed for the out-of-hospital period

• GAF Healthcare coordinator available 24/7 for any clinical concerns; telemedicine access to treating physician

PHASE 6 — FIT-TO-FLY ASSESSMENT & DEPARTURE (Weeks 2–3):

• Physician clearance for international flight issued based on: absence of fever, haemodynamic stability, satisfactory post-ablation imaging, and acceptable inflammatory markers

• Short-haul flights (<4 hours): typically cleared at Day 10–14

• Long-haul flights (>6 hours): clearance recommended at Day 14–21; compression stockings and ambulation every 2 hours in-flight advised to reduce DVT risk

• Complete discharge summary, CD of all imaging, histopathology, and follow-up protocol sent digitally to patient and home oncologist

PHASE 7 — LONG-TERM FOLLOW-UP PROTOCOL (Months 1–24):

• Month 1: Contrast CT or MRI (assess for residual tumour, early local recurrence, or procedure-related complications)

• Month 3: Repeat imaging + AFP (for HCC) or CEA/CA19-9 (for CRLM)

• Month 6 and 12: Cross-sectional imaging + tumour markers + clinical review

• GAF Healthcare facilitates remote multidisciplinary review sessions between the patient's home oncologist and the treating team for all follow-up imaging interpretation