Transcript Radiofrequency Ablation of Lung Cancer

Radiofrequency Ablation
of Lung Cancer
Andrew R. Forauer, MD FSIR
Interventional Radiology
Dartmouth-Hitchcock Medical Center
I have no financial disclosures
(but am willing to entertain offers…)
Modern Cancer Therapy
Chemotherapy
Radiation Therapy
Surgery
• Interventional Radiology is
emerging as a fundamental
discipline involved in cancer
treatment
• Percutaneous ablation
• Embolization techniques
• Intra-arterial drug delivery
Radiofrequency Ablation (RFA)
• Thermal (heat) based tumor ablation system
• Most common clinical applications:
– Liver
– Kidney
– Bone, other soft tissue
Mechanism of action
Thermal energy
damage to cellular proteins,
enzymes, & nucleic acids
Creates a volume of tissue
necrosis & coagulation
Patient selection
• Early stage patients who are good surgical
candidates proceed to surgical resection
• What about those with multiple co-morbidities
and/or poor lung function?
• Up to 50% of their mortality will still be Ca-related
Tumor selection
•
•
•
•
Solitary lesions (usually)
3 cm or less
Non-small cell histology
Location
– Safe & reasonable percutaneous route
– No extension to hilum/mediastinum
– Not contiguous with major vessels or nerves
Surgery
Ablation
Radiation
Therapy
RFA vs Surgical Resection
Image-guided Ablation
Surgical Resection
• Well tolerated, no incision
• Higher patient impact
• Reliance on post-ablation
imaging
• Pathology available for
margins
• No assessment of nodes
• Nodal status determined
Sublobar resection, RFA, &
cryoablation compared
• Overall 3-year survival:
– 87% (SLR), 87% (RFA), 77% (cryo) *
• 3-year disease free survival:
– 61% (SLR), 50% (RFA), 47% (cryo) *
* No significant difference between the 3 groups
Zemlyak et al., J Am Coll Surg, 2010
RFA vs External Beam Radiation
Image-guided Ablation
Radiation Therapy
• Local therapy with less
“collateral damage”
• Effects on adjacent lung
tissue & dosage limitations
• Single session, but
repeatable
• Multiple visits
• Fewer complications
• Potential for procedural
complications
Radiation therapy
(conventional EB)
Surgical resection
(LR, sub LR, VATS)
No difference in DFS
OS at 5 years:
40-55%
Ablation
?
OS at 5 years:
15-30%
SBRT: Better at local dz control;
OS @ 5 yrs ~50%
RFA outcomes
Overall survival data in RFA series tends to
reflect a population with more co-morbidities,
but Ca specific survival is encouraging
Overall survival¹
Ca specific survival1,2
1 yr
70%
92%
2 yr
48%
73%
1. Lencioni R et al. Lancet-Oncol, 2008; 9:621-628
2. Zemlyak et al., J Am Coll Surg, 2010
3 yr
-50%
What about RFA and pulmonary
metastases?
RFA of lung metastases
Study
n
Mean
size
1-yr 2-yr
OS OS
3-yr
OS
5-yr
OS
Gillams ‘13
CVIR
122
1.7 cm
(.5 – 4)
95%
75%
57%
---
Chua ‘10
Ann. Oncol
148
4 cm
(+/- 1.0)
---
---
60%
45%
Yan ‘07
J Surg Oncol
30
- - -
75%
63%
45%
Hiraki ‘07
JVIR
27
1.5 cm
(.3 – 3.5)
96%
54%
48%
Variety of
histologies
(~65%
CRC)
Hepatic dz
at time of
RFA
70 yr old patient w/ colorectal Ca & a LLL metastasis
Pre-ablation CT
Peri-procedural CT during
probe positioning
4 month follow-up PET/CT; CEA now wnl
Summary
• RFA can be used to treat both primary &
metastatic tumors
• Doesn’t preclude other complimentary
therapies
• Patient selection is key/critical (not about the
specialty, ego, or absolutes- its about the
PATIENT)
Current areas under investigation in IR
• Chemotherapy delivered via the
pulmonary artery
• Selective chemoembolization
• Combining chemotherapy infusions
with ablation procedures
Thank you for your attention !