Transcript Slide 1

Long term follow-up after
pulmonary radiofrequency ablation
T. de Baère,
Institut Gustave Roussy - Villejuif - France
Lung tumors
•
Cancer
- 80% of cancer cured = suregry ± other therapies (radiation/chemo)
- Others surgical like techniques ? ablative therapies?
•
Primary lung cancer
- Second cause of death in man in France
- Leading cause of cancer death in the world
- 20% of patients are surgical candidates
•
Lung metastases
- 25/30% of cancer patients at autopsy
- 50% of renal cell carcinoma
- Sarcoma (42%), Colon (14%), Breast (9%), Renal (8%),
(7%), Melanoma (6%), ENT (5%)
Testicula
Lung Surgery
•
Surgical resection of metastases
- 1882 : Incidental resection of chest wall sarcoma and 2 metastases
- 1947 : First series of 24 resections, including a repeated thoracotomy
- 2000 : First report of RF ablation in the lung
•
Criteria for resection metastases (The goal is to cure and to not harm)
– Patient must be able to tolerate
– Sufficient pulmonary reserve
– Primary tumor controlled / controlable
– No extra-pulmponary disease
– No better therapy
Lung Radiofrequency
•
Surgical resection of metastases
- 1882 : Incidental resection of chest wall sarcoma and 2 metastases
- 1947 : First series of 24 resections, including a repeated thoracotomy
- 2000 : First report of RF ablation in the lung
•
Criteria for RF Ablation metastases (The goal is to cure and to not harm)
– Patient must be able to tolerate
– Sufficient pulmonary reserve
– Primary tumor controlled / controlable
– No extra-pulmponary disease
– No better therapy
Lung Radiofrequency
•
Surgical resection of metastases
- 1882 : Incidental resection of chest wall sarcoma and 2 metastases
- 1947 : First series of 24 resections, including a repeated thoracotomy
- 2000 : First report of RF ablation in the lung
•
Criteria for RF Ablation metastases (The goal is to cure and to not harm)
– Patient must be able to tolerate
RF can be possible
– Sufficient pulmonary reserve
– Primary tumor controlled / controlable
– No extra-pulmponary disease
– No better therapy
Lung Radiofrequency
•
Surgical resection of metastases
- 1882 : Incidental resection of chest wall sarcoma and 2 metastases
- 1947 : First series of 24 resections, including a repeated thoracotomy
- 2000 : First report of RF ablation in the lung
•
Criteria for RF Ablation metastases (The goal is to cure and to not harm)
– Patient must be able to tolerate
RF can be possible
– Sufficient pulmonary reserve
– Primary tumor controlled / controlable
– No extra-pulmponary disease >> Two sites in a single RF session
– No better therapy
Lung Radiofrequency
•
Surgical resection of metastases
- 1882 : Incidental resection of chest wall sarcoma and 2 metastases
- 1947 : First series of 24 resections, including a repeated thoracotomy
- 2000 : First report of RF ablation in the lung
•
Criteria for RF Ablation metastases (The goal is to cure and to not harm)
– Patient must be able to tolerate
RF can be possible
– Sufficient pulmonary reserve
– Primary tumor controlled / controlable
– No extra-pulmponary disease >> Two sites in a single RF session
– No better therapy
– Limited to small size tumors
Principle of radiofreqiency
420 – 500 kHz sinusoidal current
QuickTime™ et un
décompresseur Cinepak
sont requis pour visionner cette image.
 ionic agitatin
 friction
 tissues heating
Temperature > 60°C : immediate cellular death
Principle of radiofreqiency
420 – 500 kHz sinusoidal current
 ionic agitatin
 friction
 tissues heating
Temperature > 60°C : immediate cellular death
Methods (treatment)
•
•
Accurate needle placement
CT guidance
– Needle placement
• Real time CT or Fluoro CT
QuickTime™ et un
décompresseur codec YUV420
sont requis pour visionner cette image.
Methods (treatment)
•
•
Accurate needle placement
CT guidance
– Needle placement
• Real time CT or Fluoro CT
– Needle/electrode position
• Multiplanar reconstruction
Material
• 244 patients (27-81 years)
- Age : 62±14 years (27-85)
• 397 tumors 4 - 70 mm (m=17 ± 9.5)
– Métastases : 197 patients (81%) - (343 tumors)
– Primary : 47 patients (19%) - (52 tumors)
– Unilateral 187 patients (77%), bilateral 57 patients (23%)
– Number of tumor / Patient
• n = 1 (57%), n = 2 (25%), n = 3 (13%), n = 3 (5%), n = 5 or + (6%)
Results
• 301 RF sessions / 314 lung treated
– Usally one lung at a time / 13 bilateral
• Anesthesia
• General anesthesia
• Conscious sedation
• Local
296
3
2
Side effects and Complications (During treatment)
• Pneumothorax with chest tube
12%
• Alveolar hemorraghe
14%
• Cutaneous burn
1%
• Death
0.5% (ventricular fibrillation)
Side effect (after hospital discharge)
•
No symptom
At least one symptom
Pain
Hemoptysis
Pneumopathy
Respiratory insufficiency
66 %
34 %
23% (mild 4%, moderate19%)
5%
3%
0.5%
Rate of local tumor progression
• Incomplete local ablation
Per tumor : 6.1% (4-9) @1 year, 11.2% (8-15) @ 2 years
tumor ≤ 2cm : 3.7% (2-7) @1 year, 8.2% (5-13) @ 2 years
tumor >2cm : 12.4% (7-21) @1 year, 19.4% (12-30) @ 2 years
Treatment failure according to the tumor size
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
P = 0.002
size <= 2 cm
size > 2 cm
logrank p = 0.0002
0
6
12
18
24
At risk
287
110
263
97
209
64
145
37
110
26
30
36
Months
69
51
9
18
Survival
Survival : med =25 months
88.7% (84-92) @ 1 year, 70.3% (63-76) @ 2 years
Patients without pulmonary evolution (RF site or distant)
Patients
treated
with
radiofrequency
57.5%
(51-64)
@ 1 year,
38.8%
(32-47) @ 2 years
of lung tumors
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
Survival
Interval without pulmonary evolution
0
6
12
18
24
At risk
244
244
224
179
179
105
119
67
89
40
30
36
Months
35
60
26
12
Survival
Survival : med =25 months
88.7% (84-92) @ 1 year, 70.3% (63-76) @ 2 years
Patients without pulmonary evolution (RF site or distant)
57.5% (51-64) @ 1 year, 38.8% (32-47) @ 2 years
Interval without pulmonary evolution
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
66%
52%
54%
35%
Primary lung tumor
Pulmonary metastasis
0
6
12
18
24
At risk
47
195
41
136
22
81
12
53
8
31
30
36
Months
6
3
20
9
Survival
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
90%
72%
54%
35%
Overall survival
Interval without pulmonary evolution
0
6
12
18
24
At risk
195
195
178
136
147
81
98
53
76
31
30
55 CRC mets patients
85%@1year,
64%@2 years,
46% @ 3 years
36
Months
32
52
20
9
(Yan TD, Ann Surg Oncol 2007)
(Simon CJ, Radiology 2007)
71 CRC mets patients
84%@1year,
62%@2 years,
46% @ 3 years
18 CRC mets patients
87%@1year,
78%@2 years
(Yamakado K, JVIR 2007)
Survival
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
90%
72%
54%
35%
Overall survival
Interval without pulmonary evolution
0
6
12
18
24
At risk
195
195
178
136
147
81
98
53
76
31
30
36
Months
32
52
20
9
LONG-TERM RESULTS OF LUNG METASTASECTOMY: PROGNOSTIC ANALYSES
BASED ON 5206 CASES Ugo Pastorino, J Thorac Cardivasc Surg 1997
RF ablation lung metastases
• Minimaly invasive
• High local success rate
• Curative treatment in non surgical patients
Will replace some surgery ?
• Size is the main limitation
> 90 %
≤ 50 %
= 70 %
2.5-3.5 cm
4/5 cm
His own lung radiofrequency procedure
from a painter patient
[email protected] : What is missing in the room ?
Factors for survival
• Size > 2 cm (p=0.0002)
• Rectal origin (p=0,02)
•
•
Number
Location (related to the pleura, medistinum