Transcript Magnetic Resonance Angiography: Applications in the

IMAGE-GUIDED ABLATION OF
LUNG NEOPLASMS
Servet Tatli MD
Associate Professor of Radiology
Harvard Medical School
Department of Radiology
Brigham and Women’s Hospital
Objectives
• Review of image-guided tumor ablation
technique to treat lung neoplasms
• Discuss technical issues that may arise during
image-guided ablation of lung neoplasms with
some illustrated examples
• Nothing to disclose
NSCLC
• 2nd most common cancer in both men and women
• By far the leading cause of cancer related deaths
in both gender
• Surgical resection remains the mainstay for earlystage (stage I/II) NSCLC(Rajdev L, Surg Oncol 2002)
– only 30% patients with disease confined to lung (stage I/II)
• only 1/3 of these are surgical candidates
Lung Metastases
• The second most common organ for metastases
• ~20% patients with primary site removed are found
to have metastases limited to the lungs
– colorectal, osteosarcoma, RCC, testis, breast, melanoma
(Pastorino U, J Thor Cardiovasc Surg 1997)
• Resection of pulmonary metastases may result in
improved disease-free survival (Saito Y, J Thor Cardiovasc Surg 2002)
– not candidates for surgical resection
• low pulmonary reserve, co-morbid conditions, diseases in both lungs
Prognosis
• High number of poor surgical
candidates
• Unsatisfactory response to
conventional treatment
methods
necessitate
alternative
treatment
methods
Alternative
Image-guided thermal ablation techniques
such as RF ablation
may be alternative treatment option
for these patients’ groups
Patient Selection
• Stage I/II NSCLC: non surgical candidates
• Solitary or limited number lung metastasis without
extrapulmonary disease
• Stage III/IV NSCLC and pulmonary metastasis
– local tumor control
– symptom palliation (chest pain, cough, dyspnea,
hemoptysis)
Tumor Selection
• Size
– < 3 cm (ideal)
– up to 5 cm
• Number
– <3-5
– exceptions (adenoid cystic carcinoma of salivary glands)
• Location
– pleural-based
– intraparenchymal (surrounded by lung parenchyma)
• >1 cm from bronchus, hilum, mediastinum (heart, trachea)
Patient Evaluation
• Evaluation by thoracic oncologist / surgeon
• Consultation with interventional radiologist
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rationale: cure, local tumor control, symptom palliation
feasibility: size, location, access route
risk/benefit
cardiopulmonary status
• cardiology evaluation
• pulmonary function test
– medications (anticoagulants)
– concurrent pulmonary infection
Patient Evaluation
• Percutaneous biopsy for pathological diagnosis
– may not need in every case
• prior path diagnosis, new mass, FDG avidity > 4 SUV
• Baseline imaging: CECT, MRI, PET/CT
– no more than 4 weeks before than RF ablation
• Anesthesia consult
• Coagulation workup: PT, PTT, INR, platelet, hct
Preparation
• Discontinue anticoagulants
• Overnight fasting
• Prophylactic antibiotics
– broad-spectrum: Ancef 1-2mg, IV
• Pacemaker malfunction; needs temporary
deactivation (RF ablation)
Guidance
• US: lack of acoustic penetration due to bones and lungs
– may be used for pleural based or chest wall tumors
• MRI: limited availability
– poor visualization of ablation applicator
– require MR compatible equipment
• CT: imaging modality of choice
– excellent tumor and ablation probe visualization
– multiplanar reformations
• PET/CT: metabolic information + other advantages of CT
Ablation Procedure
• Anesthesia
– GA, double lumen T tube, blocker, continuing inflation
• Positioning
– tumor side down if possible
– avoid excessive overhead positioning of the arm
• Access
– over the rib not below
– avoid transgressing fissures
– avoid ablating pleura, no tract burn
• Multiple tumors
– treat tumors at one side at one sessionHinshaw JL, Radiographics 2014
Ablation Procedure
• To achieve adequate tumor
necrosis ablation needs to
include:
– entire tumor &
surrounding parenchyma
(ablation margin, >6-10mm)
• adjacent critical structure
• aerated lung (insulator)
• heat sink
– over lapping ablations
to cover large tumors
www.onemedplace.com
Ablation Procedure
• Intraprocedural monitoring
Ablation Procedure
• Intraprocedural monitoring
Ablation Procedure
• Parenchymal hemorrhage
Ablation Procedure
• Pneumothorax
Ablation Procedure
• Pneumothorax
Ablation Procedure
• Post-ablation pneumonia and abscess
Ablation Procedure
• Artificial pneumothorax
Dupuy DE, Radiology 2011
Ablation Procedure
• Severe emphysema
72 yof with a NSCLC who was not a candidate for surgical resection
due to severe COPD
Ablation Procedure
• Large tumors
45 yof with breast Ca and solitary RLL met, which was treated by
surgically but showed recurrence.
Ablation Procedure
• Central tumors
30-yof with lung metastases from adenoid cystic ca of salivary gland
Ablation Procedure
• Central tumors
77- year-old woman with non-small cell carcinoma (NSCLC)
Ablation Procedure
• Multiple tumors
60-year-old woman metastatic salivary gland adenoid cystic ca
Ablation Procedure
• Multiple tumors
60-year-old woman metastatic salivary gland adenoid cystic ca
Ablation Procedure
• Image-registration can be used to visualize the
tumor
Planning
Monitoring
Fused Image
Ablation Procedure
• Post XRT recurrence
Post-procedural care
• PACU: CXR (2-3 hr), labs (CBC, chem 7, myoglobin)
• Overnight admission to observe
• Next day: CXR, labs (CBC), (CT, MR, PET/CT)
• 1 week follow up clinic visit: analgesia, post ablation
syndrome, brown sputum, shortness of breath
• 3, 6, 9, 12 months follow up imaging (CT, MR, PET/CT)
Post ablation, assesment
• Assessment of adequacy of ablation
– difficult to differentiate post-ablation changes from residue
– ablated surrounding tissue increases size of treated tumor
• completely ablated tumor may appear grown in size (RECIST
criteria is not helpful)
– contrast-enhanced CT is more useful than non-contrast
imaging
– MR, PET/CT more sensitive than CECT in detection of
viable tumor
Lung Ablation, surveillance
Dupuy D E Radiology 2011
Lung Ablation, surveillance
T2WI
T1WI
post contrast
T2WI
T1WI
post contrast
(subtracted)
Pre-ablation
MRI
Post-ablation
MRI
Lung Ablation, surveillance
• Cavity formation, rare
1 year
6 months
3 months
24-hours
Lung Ablation, surveillance
• Recurrence
post-ablation
(subtracted)
pre-ablation
post-ablation
Lung Ablation, effectiveness
• Variable reported outcome
– depending on case selection and the method to measure
– heterogeneous populations (~50% NSCLC and ~50% mets)
• Over all post-ablation complete tumor necrosis rate
– (38% to 91% ; ~63.5 %) (Ambrogi MC, E J of Cardiothoracic Surg 2006)
• Local tumor control at 1year: 88% (Lencioni RR, Clin Oncology 2008)
• Overall survival:
• NSCLC at 1, 2, 3, 4, 5 y: 78%, 57%, 36%, 27% & 27%
• colorectal mets at 1, 2, 3, 4, 5 y: 87%, 78%, 57%, 57% & 57%
Lung Ablation, effectiveness
De Baere T, Annals of Oncology, 2015
Conclusion
• Image-guided RF ablation is promising
treatment option for selected patients with
primary or metastatic neoplasm of lungs that
are not amenable to surgery
• Careful patient selection and appropriate preablation work up and post ablation
surveillance are important factors for
satisfactory results
Thank you