- SIR RFS IO Service Line - Created By: Kevin Anton MD, PhD
Date: 9/10/2014
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2 76 year old female with h/o rectal cancer who underwent
coloanal resection 4 yrs prior and several cycles of
chemotherapy
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3 81 year old male with right upper lobe lung mass Dupuy, D.,
et al. Semin Intervent Radiol. 2010 September; 27(3): 268275.
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4 76 year old female with severe COPD and left lower lobe lung
mass Dupuy, D., et al. Chest. 2006; 129:738-745
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Primary lung cancer Adenocarcinoma Small cell Squamous cell
Large cell Lung metastasis Pneumonia Mycobacterial Fungal Rounded
atelectasis 5 Courtesy of the Journal of Respiratory Diseases
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6 (Right Image): Left lower lobe spiculated mass abutting the
major fissure w/ surrounding ground glass opacity (Left Image):
Enhancing rectal mass w/ fat stranding Rectal Cancer diagnosed 4
yrs prior
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7 Metastatic Rectal Cancer Rectal Cancer diagnosed 4 yrs
prior
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8 2.2-cm right upper lobe mass (arrow) with spiculated margins
and small pleural tail
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9 Adenocarcinoma
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10 5-cm, spiculated mass in the left lower lobe abutting the
aorta
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11 Squamous Cell Carcinoma
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12 PET CT Left lower lobe lung mass
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13 CT-guided biopsy of left lower lobe lung mass Chest tube
placement and lung re-expansion Post-biopsy pneumothorax
15 Radiofrequency ablation (RFA) electrode in the mass Follow
up images 3 (top) and 9 months (bottom) post-ablation Dupuy, D., et
al. Semin Intervent Radiol. 2010 September; 27(3): 268275.
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16 Pre-treatment PET Follow up CT images 27 months
post-ablation Dupuy, D., et al. Chest. 2006; 129:738-745 Follow up
PET 23 months post-ablation
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17 American Cancer Society. Global Cancer Facts and Figures 2
nd Edition. Atlanta: American Cancer Society; 2011.
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18 American Cancer Society. Global Cancer Facts and Figures 2
nd Edition. Atlanta: American Cancer Society; 2011.
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19
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Exposure to carcinogens (smoking) Genetic Susceptibility
Environmental exposure to pollutants (asbestos) 20 Wong, E.
Copyright 2012-2013 McMaster Pathophysiology Review (MPR).
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Chronic, non-resolving coughing Persistent chest pain Shortness
of breath, wheezing Hemoptysis Hoarseness Swelling of the face and
neck Loss of appetite Loss of weight Fatigue Recurrent pneumonia or
bronchitis 21 2013 Digital News Agency. DNA is powered by The
Television Consultancy Limited.The Television Consultancy
Limited
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24 Cancer Type CharacteristicsLocationPETCalcifications
Adenocarcinoma (40%) Irregular, lobulated, or spiculated border
Peripheral / Sub- pleural SUV 0.4 11.6 (non- BAC) Adenocarcinoma
In- Situ (previously bronchoalveolar) Bubble-like areas of low
attenuation within mass (pseudocavitation) PeripheralSUV 0.4 5.9
Squamous Cell (25- 30%) Cavitary (82%) Commonly cause bronchial
obstruction (segmental or lobar lung collapse) Central (2/3) or
Peripheral (1/3) SUV 1.6 32.6 Small Cell (10-15%) Locally invasive
Bulky mediastinal/hilar lymphadenopathy Central (Hilar /
Mediastinal) SUV 2.1 24.1 Carcinoid (
26 Stage T1b: Stage T1b: 2.9 cm RUL nodule (>2 cm but 3cm)
2.9 cm RUL nodule (>2 cm but 3cm) Stage T2: Stage T2: Nodule in
the bronchus intermedius, 4 cm from the carina (endobronchial
lesion > 2 cm from the carina) Nodule in the bronchus
intermedius, 4 cm from the carina (endobronchial lesion > 2 cm
from the carina) UyBico S. et al. Radiographics. 2010; 30:
1163-1181. Stage T3: Stage T3: Primary mass with satellite nodules
Primary mass with satellite nodules Stage T4: Stage T4: Primary RUL
tumor with smaller separate nodule in the RLL Primary RUL tumor
with smaller separate nodule in the RLL
Deliver direct treatments to lung cancer without significant
side effects or damage to nearby normal tissue. Radiofrequency
Ablation Microwave Ablation Cryoablation Chemoembolization 28 Radio
Frequency Ablation Therapy in a patient with lung cancer with
SOMATOM Definition AS+ (health.siemens.com).
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Indications: Early stage non-small cell lung cancer Lung
metastasis Chest wall invasion Relapse in XRT field Painful bone
metastasis Patient Selection: Stage 1 disease Non-operative
candidate (co-morbidities) Likely to suffer or die from disease if
untreated 29 Adapted from D. Dupuys Lung CA Ablation. WCIO May
2013.
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Many patients are non-operable candidates Systemic and regional
treatments are frequently inadequate, toxic, or costly Stage 1
disease less likely to have lymphatic spread Regional/systemic
spread can be defined by non- invasive imaging (PET-CT) 30 Adapted
from D. Dupuys Lung CA Ablation. WCIO May 2013.
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31 Adapted from D. Dupuys Lung CA Ablation. WCIO May 2013.Simon
et al. Eur J Radiol. 2012; 81:4167-72. Survival same as no
treatment if CCI high 90% 3-year survival if CCI low CCI = Charlson
Comorbidity Index
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Pre-procedure management/work-up Biopsy Confirm malignancy
Focused history and routine physical examination Laboratory tests
INR 35-50k (Institution-specific) Lung function tests FEV1 > 400
mL Imaging studies (staging, tumor location) Evaluation for lesion
diameter, disease extension (lesion number and extrapulmonary
lesions) and the adjacency to major vessels (>3-10 mm), heart or
trachea. In cases of curative intent, lesions 3-5cm should be
carefully considered due to the increased rate of recurrence.
Lesions > 5cm should be excluded from treatment. However, other
ablation techniques such as microwave and irreversible
electroporation may overcome some of the limitations of RFA, namely
for large tumors or tumors close to large vessels*
Multi-disciplinary team review Evaluation for candidacy Informed
Consent Indications & contraindications Risks and benefits 32
*de Baere T. Lung Cancer Ablation: What Is the Evidence? Semin
Intervent Radiol. 2013 Jun;30(2):151-156.
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33 What potential complications should this patient have been
consented for? Infection: Pneumonia Lung abscess Injury to adjacent
structures: Pneumothorax Bronchopleural fistula Nerve injury
Diaphragmatic Injury Bleeding Aseptic pleuritis Other: Tumor
seeding Death M Kashima, et al. American Journal of Roentgenology
2011 197:4, W576-W580. S Rose, et al. J Vasc Interv Radiol
2006;17:927951
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Post-procedure management / IO Clinic follow-up: Things to
watch for Immediate/Delayed complications Length of hospitalization
dependent on complications Average length of stay = 1-2 days
Symptom management Pain control Imaging No standard imaging
protocol for post-RFA ablation Contrast-enhanced CT, PET, and
PET-CT for follow-up Monitor for local recurrence Metabolic imaging
can detect early local recurrence Average follow up in IR clinic:
3-4 weeks post-procedure 34
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Early Phase (Immediately to 1 wk post-RFA) Ablation zone >
original tumor size Most common: Cone-shaped or rim of hyperemia
(ground glass opacity) surrounding target Intralesional bubbles
Intermediate Phase (>1 wk to 2 months post-RFA) Ablation zone
> original tumor size, but smaller than early phase Regressing
parenchymal edema, inflammation & hemorrhage Late Phase (>2
months after RFA) 3 months ablation zone size > baseline tumor 6
months ablation zone size < baseline tumor 35 Fereidoun et al.
Radiographics. 2012; 32:4, 947-969.
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Post-ablation imaging features include CT appearance, size,
enhancement, and metabolic activity on PET-CT. Initial staging PET-
CT Whole-body CT with CT nodule densitometry through the ablation
zone PET-CT at 3 months and thereafter every 6 months alternating
with CT alone. Abtin, F et al. Radiographics 2012; 32:
947-969.
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Most common post-RFA imaging findings include: Cone-shaped
sectorial hyperemia (a) or rim of hyperemia characterized by
ground-glass opacity, which may circumferentially or partially
envelop the target lesion Intralesional bubbles (b)
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Abtin, F et al. Radiographics 2012; 32: 947-969. In the
intermediate phase: Ablation zone will continue to be larger,
compared with the original tumor, but should be smaller relative to
the early phase as a result of regressing parenchymal edema,
inflammation, and hemorrhage. Initial scan Pulmonary metastatic
lesion Initial scan Pulmonary metastatic lesion Immediate
Post-ablation zones Immediate Post-ablation zones Intermediate (1
month) Larger ablation zone than original tumor but surrounding
ground-glass and hemorrhage have involuted. Intermediate (1 month)
Larger ablation zone than original tumor but surrounding
ground-glass and hemorrhage have involuted.
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Abtin, F et al. Radiographics 2012; 32: 947-969. In the late
phase: At 3 months, in general, the size of the ablation zone
should be the baseline tumor. By 6 months, ablation zone size
should be the baseline tumor. 6-months 9-months 12-months Nodule
continues to regress in size, measuring smaller than the original
tumor with eventual scarring and remodeling of the lung parenchyma.
There is resolution of the pleural thickening and effusion. Nodule
continues to regress in size, measuring smaller than the original
tumor with eventual scarring and remodeling of the lung parenchyma.
There is resolution of the pleural thickening and effusion.
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Abtin, F et al. Radiographics 2012; 32: 947-969. PET findings
suggestive of recurrence: PET findings suggestive of recurrence:
Increasing metabolic activity after 2 months Increasing metabolic
activity after 2 months Residual activity centrally or at the
region of the ablated tumor Residual activity centrally or at the
region of the ablated tumor Development of nodular activity at
original tumor nodule Development of nodular activity at original
tumor nodule Metastatic renal cell carcinoma Metastatic renal cell
carcinoma CT (left) medial nodular edge of metastasis (arrow) too
close to the bronchus and subject to heat sink effect. CT (left)
medial nodular edge of metastasis (arrow) too close to the bronchus
and subject to heat sink effect. 3-month surveillance PET-CT
(right) shows focal area of recurrence (arrowhead). 3-month
surveillance PET-CT (right) shows focal area of recurrence
(arrowhead).
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Single center experience with 1000 RFA sessions in 420 patients
42 M Kashima, et al. American Journal of Roentgenology 2011 197:4,
W576-W580.
Caroline Simon, Damian Dupuy, et al. Pulmonary Radiofrequency
Ablation: Long-term Safety and Efficacy in 153 Patients. Radiology
2007; 243:1, 268-275. Damian Dupuy, Maria Shulman. Current Status
of Thermal Ablation Treatments for Lung Malignancies. Semin
Intervent Radiol. 2010 September; 27(3): 268275. Damian Dupuy,
Ronald Zagoria, et al. Percutaneous Radiofrequency Ablation of
Malignancies in the Lung. American Journal of Roentgenology 2000;
174:1, 57-59. Damian Dupuy, Thomas DiPetrillo, et al.
Radiofrequency Ablation Followed by Conventional Radiotherapy for
Medically Inoperable Stage I Non-small Cell Lung Cancer. Chest
2006; 129: 738-745. Fereidoun Abtin, Jilbert Eradat, et al.
Radiofrequency Ablation of Lung Tumors: Imaging Features of the
Postablation Zone. Radiographics 2012; 32:4, 947-969.
Interventional Radiology Treatment for Lung Cancer. Society of
Interventional Radiology.
http://www.sirweb.org/patients/lung-cancer/. 2014.
http://www.sirweb.org/patients/lung-cancer/ Irene Bargellini, Elena
Bozzi, et al. Radiofrequency ablation of lung tumours. Insights
Imaging 2011; 2(5): 567-576. Masataka Kashima, Koichiro Yamakado,
et al. Complications After 1000 Lung Radiofrequency Ablation
Sessions in 420 Patients: A Single Centers Experiences. American
Journal of Roentgenology 2011 197:4, W576-W580. Steven Rose,
Patricia Thistlethwaite, et al. Lung Cancer and Radiofrequency
Ablation. J Vasc Interv Radiol 2006; 17:927951. Thierry de Baere,
Geoffroy Farouli, et al. Lung Cancer Ablation: What Is the
Evidence? Semin Intervent Radiol. 2013 Jun;30(2):151-156. 44
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45 This presentation was adapted from a template created by Don
J. Perry, MD
