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 • Reliance on post-ablation imaging • No assessment of nodes • Higher patient impact • Pathology available for margins • 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)

* * N

o significant difference between the 3 groups Zemlyak et al., J Am Coll Surg, 2010

RFA vs External Beam Radiation

Image-guided Ablation

• Local therapy with less “collateral damage” • Single session, but repeatable • Potential for procedural complications

Radiation Therapy

• Effects on adjacent lung tissue & dosage limitations • Multiple visits • Fewer complications

Surgical resection (LR, sub LR, VATS) Radiation therapy (conventional EB) No difference in DFS

Ablation ?

OS at 5 years: 40-55% 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 survival 1,2

1 yr

70% 92%

2 yr

48% 73%

3 yr

- 50% 1. Lencioni R et al. Lancet-Oncol, 2008; 9:621-628 2. Zemlyak et al., J Am Coll Surg, 2010

What about RFA and pulmonary metastases?

Study

Gillams ‘13 CVIR Chua ‘10 Ann. Oncol 122 148 Yan ‘07 J Surg Oncol 30 Hiraki ‘07 JVIR 27

n

RFA of lung metastases

Mean size

1.7 cm (.5 – 4) 4 cm (+/- 1.0)

1-yr OS

95%

2-yr OS

75% - - - - - - 75% 63%

3-yr OS

57%

5-yr OS

- - 60% 45% 45% Variety of histologies (~65% CRC) Hepatic dz at time of RFA 1.5 cm (.3 – 3.5) 96% 54% 48%

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 !