Radiofrequency Ablation of Lung Cancer

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Radiofrequency Ablationof Lung Cancer

• Andrew R. Forauer, MD FSIR
• Interventional Radiology
• Dartmouth-Hitchcock Medical Center

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I have no financial disclosures

• (but am willing to entertain offers)

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Modern Cancer Therapy

• Chemotherapy

Radiation Therapy
Surgery
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• Interventional Radiology is emerging as a
  fundamental discipline involved in cancer
  treatment
• Percutaneous ablation
• Embolization techniques
• Intra-arterial drug delivery

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Radiofrequency Ablation (RFA)

• Thermal (heat) based tumor ablation system
• Most common clinical applications
• Liver
• Kidney
• Bone, other soft tissue

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Mechanism of action
Thermal energy
damage to cellular proteins, enzymes, nucleic
acids
Creates a volume of tissue necrosis coagulation
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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

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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

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Radiation Therapy
Surgery
Ablation
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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

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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
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RFA vs External Beam Radiation

• Image-guided Ablation

• Radiation Therapy

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

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

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Radiation therapy (conventional EB)
Surgical resection (LR, sub LR, VATS)
No difference in DFS
Ablation ?
OS at 5 years 15-30
OS at 5 years 40-55
SBRT Better at local dz control OS _at_ 5 yrs 50
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RFA outcomes

• Overall survival data in RFA series tends to
  reflect a population with more co-morbidities,
  but Ca specific survival is encouraging

1 yr 2 yr 3 yr
Overall survival¹ 70 48 - -
Ca specific survival1,2 92 73 50
1. Lencioni R et al. Lancet-Oncol, 2008
9621-628
2. Zemlyak et al., J Am Coll Surg, 2010
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What about RFA and pulmonary metastases?
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RFA of lung metastases
Study n Mean size 1-yr OS 2-yr 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 Variety of histologies (65 CRC)
Yan 07 J Surg Oncol 30 - - - 75 63 45 Hepatic dz at time of RFA
Hiraki 07 JVIR 27 1.5 cm (.3 3.5) 96 54 48
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70 yr old patient w/ colorectal Ca a LLL
metastasis
Peri-procedural CT during probe positioning
Pre-ablation CT
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4 month follow-up PET/CT CEA now wnl
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Summary

• RFA can be used to treat both primary
  metastatic tumors
• Doesnt preclude other complimentary therapies
• Patient selection is key/critical (not about the
  specialty, ego, or absolutes- its about the
  PATIENT)

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Current areas under investigation in IR

• Chemotherapy delivered via the pulmonary artery
• Selective chemoembolization
• Combining chemotherapy infusions with ablation
  procedures

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Thank you for your attention !