To report on a case of a 4.7 × 4.5 × 3.5 cm unresectable HCC at the hepatic hilum adjacent to the major vessels and the bile duct that was successfully treated using percutaneous Electrochemotherapy in combination with stereotactic navigation.

Stereotactic percutaneous Electrochemotherapy has the potential to be used as a curative treatment method for HCC with diameters of more than 4 cm, even in close proximity to critical structures like major blood vessels and central bile ducts.

Luerken, L., Doppler, M., Brunner, S.M. et al. Stereotactic Percutaneous Electrochemotherapy as Primary Approach for Unresectable Large HCC at the Hepatic Hilum. Cardiovasc Intervent Radiol (2021) Read paper


To introduce a standardized approach for evaluation of ablation completeness after CT-guided thermal ablation of liver tumors, using volumetric quantitative ablation margins (QAM).

The proposed volumetric approach for QAM computation enables precision and reproducibility in the assessment of ablation margins. The quantitative feedback on ablation completeness opens possibilities for intra-operative decision making and for refined analyses on predictability and consistency of local tumor control after thermal ablation of liver tumors.

Sandu R-M, Paolucci I, Ruiter SJS, Sznitman R, de Jong KP, Freedman J, Weber S and Tinguely P (2021) Volumetric Quantitative Ablation Margins for Assessment of Ablation Completeness in Thermal Ablation of Liver Tumors. Front. Oncol. 11:623098. doi: 10.3389/fonc.2021.623098 Read paper


To compare the primary efficacy of computed tomography-navigated stereotactic guidance to that of manual guidance for percutaneous microwave ablation of liver malignancies

In total, 221 patients with 423 treated liver lesions underwent microwave ablation (MWA). Manual guidance and stereotactic guidance were used for 136 and 287 lesions. Percutaneous microwave ablation under stereotactic guidance exhibited significantly greater primary efficacy than conventional manual guidance

Schaible, J., Lürken, L., Wiggermann, P. et al. Primary efficacy of percutaneous microwave ablation of malignant liver tumors: comparison of stereotactic and conventional manual guidance. Sci Rep 10,18835 (2020) Read paper


To assess the technical feasibility of MRI/CT image fusion and completeness of ablation treatment for primary or metastatic liver lesions invisible on contrastenhanced CT planning scans and outcome in patients
treated with stereotactic microwave ablation (SMWA).

Technical success of MRI/CT image fusion was given in all 24 lesions in all 15 patients. Treatment success directly after ablation was 91.6% as full coverage was identified in 22 of 24 lesions. The first follow-up MRI examination showed complete ablation for 22 lesions (91.7%) in 13 patients.

M. Cathomas et al., "Value of MRI/CT Image Fusion for Targeting ‘‘invisible’’ Lesions in Stereotactic Microwave Ablation (SMWA) of Malignant Liver Lesions: A Retrospective Analysis”, Cardiovasc Intervent Radiol 10.1007 Read paper


Retrospective analysis of 153 patients with malignant liver tumors (301 lesions) treated with stereotactic image-guided microwave ablation over a 3-year period to assess factors influencing targeting accuracy and treatment efficacy

The median target positioning error per ablation probe was 2.9 ± 2.3 mm. Factors influencing ablation site recurrence were lesion size and target positioning error but not location of the lesion.

P. Tinguely et al., "Stereotactic Image-Guided Microwave Ablation for Malignant Liver Tumors – A Mulitvariable Accuracy and Efficacy Analysis”, Front. Oncol. 10:842 Read paper


Analysis of 23 Patients with 40 non-HCC and non-CRLM tumors treated with microwave ablation between 2015 and 2017

The success rate wa 97,5% with 1 incomplete ablation. 74% of the interventions were done with biopsy and microwave ablation. No major complications occured. There was a disease progression in 74% of the patients. The median time to progression was 7 months.

S. Perrodin et al., “Percutaneous stereotactic image-guided microwave ablation for malignant liver lesions”, Nature, Scientific Reports 9, Art. no. 13836, Sep. 2019 Read paper


Retrospective analysis of 88 patients with HCC treated with Microwave Ablation. The analysis includes technical and clinical parameters of 119 interventions and 174 ablations

All 88 patients were treated with the CAS-One procedure. The approach led to an efficacy rate of 96.3% and a local recurrence rate of 6.3% after 12 months. Intra-operative image fusion detected the need for immediate re-ablation in 15% of the ablations

A. Lachenmayer et al., “Stereotactic Image‐Guided Microwave Ablation of Hepatocellular Carcinoma using a computer‐assisted navigation system”, Liver Int., p. liv.14187, Jul. 2019. Read paper


Irreversible electroporation (IRE) has the possibility to treat tumors near larger bile ducts that are sensitive to thermal injury without harming the bile tree.

The method has been proven to be feasible and safe with promising oncological results. 81% of the treatments were performed with initial success. All patients with missed ablations were re-treated. Local recurrence rate at 3 months was 3% and 37% at one year.

D. Stillström, M. Beermann, J. Engstrand, J. Freedman, H. Nillson, «Initial experience with irreversible electroporation of liver tumors”, European Journal of Radiology Open, Jan. 2019. Read paper


The purpose of this paper is to present the benefits of going into computer assisted targeting techniques and microwave technology; pitfalls and overview of outcomes. The main target organ was the liver and the main
indications were ablation of hepatocellular carcinomas and colorectal liver metastases

With the aid of effective energy delivery in the form of microwaves and irreversible electroporation, and with the assistance of navigated targeting, ablative therapy of soft tissue tumours has come of age and within reach of all interventionists. Local ablative treatments may also in the near future be an integral part of boosted immunotherapy regime

M. Beermann, J. Lindeberg, J. Engstrand, K Galmén, S. Karlgren, D. Stillström, H. Nilsson, P. Harbut, J. Freedman, "1000 consecutive ablation sessions in the era of computer assisted image guidance – Lessons learned", European Journal of Radiology Open, Jan. 2019. Read paper


Case report describing a microwave ablation of a tumour located in hard-to-reach location in the liver.

The efficient and successful ablation of the breast cancer metastasis in liver segment I shows that the CAS-One procedure enables and facilitates ablations in complex locations

T. Fischer, A. Lachenmayer, M. Maurer, «CT-guided navigated microwave ablation (MWA) of an unfavorable located breast cancer metastasis in liver segment I”, Radiol. Case Reports, vol. 14, no. 2, pp. 146–150, Feb. 2019. Read paper


This retrospective study was performed to evaluate the efficacy of 3D‐navigated multi‐probe radiofrequency ablation (RFA) with intraprocedural image fusion for the treatment of hepatocellular carcinoma (HCC) by histopathologic examination

Multi‐probe SRFA with intraprocedural image fusion represents an efficient minimal invasive therapy for HCC, even with tumor sizes larger than 3cm, and without the need of a combination with additional treatments. The results seem to justify the additional efforts related to the stereotactic approach

R. Bale, P. Schullian, G. Eberle, D. Putzer, H. Zoller, S. Schneeberger, C. Manzl, P. Moser, G. Oberhuber, "Stereotactic radiofrequency ablation of hepatucellular carcinoma - A histopathological study in explanted livers", American Association for the Study of Liver Diseases, Dec. 2018. Read paper


Case report on the navigated treatment of lymph node metastases from gastric cancer with a combination of irreversible electroporation and electrochemotherapy

Treatment was well tolerated with no major adverse effects.  At 6-week and 8-month follow-up there was no indication of tumor recurrence

N. Klein, S. Zapf, E. Gunther, and M. Stehling, “Treatment of lymph node metastases from gastric cancer with a combination of Irreversible Electroporation and Electrochemotherapy: a case report,” Clin. Case Reports, vol. 5, no. 8, pp. 1389–1394, Aug. 2017. Read paper

  The aim of this review was to create a summary of
the current evidence concerning the clinical use of high frequency jet ventilation (HFJV) for ablative


HFJV during ablation procedures supports the effect of less tissue movement, resulting
in better surgical precision and outcome; such as shorter procedural
time, fewer shock waves (ESWL) and less recurrence of atrial fibrillation.

K. Galmen, P. Harbut, J. Freedman, JG Jakobsson. High frequency jet ventilation for motion management during ablation procedures, a
narrative review. Acta Anaesthesiologica Scandinavica 2017. Read paper


Discussion on 3D navigation in liver ablation

Stereotactic thermal ablation procedures are reliable and reproducible and challenge surgical resection as the first line treatment in primary and secondary liver tumors

R. Bale, “3D Navigation: do we need it?,” CIRSE, 2017. Read paper


Case report on the use of CAS-One IR in a procedure on an inoperable lung metastasis of a Wilms tumor

The paediatric patient was successfully treated with percutaneous navigated microwave ablation under high- frequency jet ventilation. The case demonstrates the clinical applicability of new-generation targeting technologies 

J. Freedman and P. Harbut, “Navigated Percutaneous Lung Ablation under High-Frequency Jet Ventilation of a Metastasis from a Wilms’ Tumour: A Paediatric Case Report.,” Case Rep. Oncol., vol. 9, no. 2, pp. 400–404, 2016. Read paper


Evaluation of the accuracy and safety of antenna placement with the use of a CT-guided stereotactic navigation system for percutaneous ablation

Percutaneous microwave ablation performed with CT-guide stereotactic navigation provides sufficient accuracy and requires almost no repositioning of the needle. Therefore, it is technically feasible for safe treatments

Engstrand J, Toporek G, Harbut P, Jonas E, Nilsson H, Freedman J. Stereotactic CT-Guided Percutaneous Microwave Ablation of Liver Tumors With the Use of High-Frequency Jet Ventilation: An Accuracy and Procedural Safety Study. Am J Roentgenol. 2017 Jan;208(1):193–200. Read paper


Comparison of needle placement between CT-navigated stereotactic IRE (SIRE) and non-navigated conventional IRE (CIRE) for percutaneous ablation of liver malignancies

CT-navigated stereotactic IRE (SIRE) showed a significant reduction in procedure length and higher accuracy vs the conventional (CIRE) approach.  Radiation dose as measured by DLP was significantly lower in the SIRE group

Beyer LP, Pregler B, Nießen C, Schicho A, Haimerl M, Jung EM, et al. Stereotactically-navigated percutaneous Irreversible Electroporation (IRE) compared to conventional IRE: a prospective trial. PeerJ. PeerJ, Inc; 2016;4:e2277. Read paper


Case report on navigated IRE as a non-thermic method to perform ablation on malignant liver tumors

Procedure was successful. Set-up of navigation device and planning was 23 minutes, and needles (5 electrodes) were placed within 18 minutes, no repositioning was necessary

L. Beyer, P. Wiggermann, and C. Stroszczynski, “Stereotaktisch gestützte perkutane irreversible Elektroporation einer malignen Leberläsion unter Verwendung eines computergestützten Navigationssystems,” IROS Poster Present., 2016.


Evaluation of the targeting accuracy of a stereotactic navigation system for CT-guided interventions using an intra-interventional image fusion and needle placement verification module

Navigated percutaneous microwave ablation (MWA) has a sufficient level of lateral targeting accuracy (4.1 ± 2.6 mm),suggesting that navigated percutaneous application of MWA is accurate and efficacious. Target positioning error reported by intra-interventional image fusion and treatment verification module might be beneficial for the interventionalist for correcting the depth (longitudinal component) or before making a decision of repositioning the needle (lateral component)

Toporek G, Engstrand J, Nilsson H, Michos A, Harbut P, Freedman J, et al. Intra-interventional image fusion and needle placement verification for percutaneous CT-guided interventions. Int J Comput Assist Radiol Surg,. 2015;10(Suppl. 1):37–8.


Overview of ablation modalities used for treatment of hepato­ cellular carcinoma (HCC) and the indications for ablative treatment in common practice

Ablative therapies for HCC are becoming more efficient with advances in energy delivery and targeting, and are poised to become first line treatment for tumors < 30 mm in diameter with the benefits of sparing of liver parenchyma, shorter hospitalization time, fewer complications and shorter recovery times for patients

Freedman J, Nilsson H, Jonas E. New horizons in ablation therapy for hepatocellular carcinoma. Hepatic Oncol. 2015 Oct;2(4):349–58. Read paper


Safety and feasibility assessment of a multiple microwave ablation strategy in patients with initially unresectable colorectal cancer liver metastases

The MWA group showed a 4-year overall survival of 41%, compared to 70% for a historic cohort of primarily resected patients and 4% for patients with palliative treatment, therefore suggesting a survival benefit compared to chemotherapy in the multiple ablation strategy

J. Engstrand, H. Nilsson, A. Jansson, B. Isaksson, J. Freedman, L. Lundell, and E. Jonas, “A multiple microwave ablation strategy in patients with initially unresectable colorectal cancer liver metastases - A safety and feasibility study of a new concept.,” Eur. J. Surg. Oncol., vol. 40, no. 11, pp. 1488–93, Nov. 2014.


Comparison of three guiding methods of needle placement for an optical-based navigation system: : freehand, using a stereotactic aiming device and active depth control, and using a stereotactic aiming device and passive depth control

Using an aiming device may increase the lateral accuracy of navigated needle insertion. Time requirements were reduced using the aiming device and passive depth control. The lateral component was significantly lower when an aiming device was used (2.31.3–2.81.6 mm with an aiming device vs 4.22.0 mm without)

D. Wallach, G. Toporek, S. Weber, R. Bale, and G. Widmann, “Comparison of freehand-navigated and aiming device-navigated targeting of liver lesions,” Int. J. Med. Robot. Comput. Assist. Surg., vol. 10, no. 1, pp. 35–43, Mar. 2014.


Evaluation of the accuracy of navigated Cone Beam CT (CBCT)-guided needle punctures, controlled with CT scans

Stereotactic needle punctures might be planned and performed on volumetric CBCT images and controlled with multidetector CT with positioning accuracy higher or similar to those performed using CT scanners

G. Toporek, D. Wallach, S. Weber, R. Bale, and G. Widmann, “Cone-beam Computed Tomography-guided Stereotactic Liver Punctures: A Phantom Study,” Cardiovasc. Intervent. Radiol., vol. 36, no. 6, pp. 1629–1637, Dec. 2013.







Evaluation of MWA and CAS-One IR navigation versus resection in patients with 1-5 resectable metastases ≤ 30mm where both resection and ablation is possible

100 patients will be included and propensity scored matched with resected patients from the Swedish liver registry with the aim of proving non-inferiority in treating colorectal liver metastases with an ablative approach

J. Freedman, H. Nilsson, E. Jonas, K. de Jong, D. Candinas, and P. Tinguely, Microwave Ablation Versus Resection for Resectable Colorectal liver metastases (MAVERRIC). 2017.