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Percutaneous Treatment of Thoracic Malignancy William Moore, M.D. Associate Professor of Radiology Stony Brook University Medical Center Union University.

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Presentation on theme: "Percutaneous Treatment of Thoracic Malignancy William Moore, M.D. Associate Professor of Radiology Stony Brook University Medical Center Union University."— Presentation transcript:

1 Percutaneous Treatment of Thoracic Malignancy William Moore, M.D. Associate Professor of Radiology Stony Brook University Medical Center Union University 10/19/2012

2 Objectives: Epidemiology of Lung Cancer. Epidemiology of Lung Cancer. Technique of Percutaneous Ablation. Technique of Percutaneous Ablation. Radiofrequency Biology of Cell Death. Radiofrequency Biology of Cell Death. Cryobiology of Cell Death. Cryobiology of Cell Death. Imaging Follow–up. Imaging Follow–up. Preliminary Data. Preliminary Data.

3 Epidemiology of lung cancer. Lung cancer is the leading cause of cancer related death for both men and women in the United States. Lung cancer is the leading cause of cancer related death for both men and women in the United States. In 2009: In 2009: estimated 219,440 cases of lung cancer diagnosed in the US and 1.3 million cases worldwide. estimated 219,440 cases of lung cancer diagnosed in the US and 1.3 million cases worldwide. 159,000 deaths from lung cancer were estimated in the United States in ,000 deaths from lung cancer were estimated in the United States in 2009

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6 So how do we find a lung cancer?

7 Chest x-ray Chest x-ray CT CT

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15 So how do we find a lung cancer? Chest x-ray Chest x-ray CT CT Bronchoscopy Bronchoscopy Findings metastatic disease elsewhere Findings metastatic disease elsewhere

16 Standard Therapy for Lung Cancer: Lobectomy is the standard therapy for stage I non-small cell lung cancer (NSCLC). Lobectomy is the standard therapy for stage I non-small cell lung cancer (NSCLC). 5-year survivals as great as 80-90% and local recurrence rates of 5%. 5-year survivals as great as 80-90% and local recurrence rates of 5%. Unfortunately, only 30% of cases are resectable at the time of diagnosis. Unfortunately, only 30% of cases are resectable at the time of diagnosis. Secondary other medical conditions (PFT) Secondary other medical conditions (PFT)

17 Limited Resection: For the moderately compromised patient, sublobar resection is an option. For the moderately compromised patient, sublobar resection is an option. The main concern with sublobar resection is the increased local recurrence relative to lobectomy. The main concern with sublobar resection is the increased local recurrence relative to lobectomy. For patients who are unable to tolerate pulmonary resection, external beam radiation (XRT) has traditionally been used. For patients who are unable to tolerate pulmonary resection, external beam radiation (XRT) has traditionally been used.

18 Treatment results are inferior to those of resection. Treatment results are inferior to those of resection. In a study of Stage 1 Lung cancers who received XRT of at least 60 Gy. In a study of Stage 1 Lung cancers who received XRT of at least 60 Gy. 3 year survival 19%.* 3 year survival 19%.* 5-year survivals 12%.* 5-year survivals 12%.* Median survival is estimated at 19.9 months.** Median survival is estimated at 19.9 months.** *Kupelian PA, Komaki R, Allen P. Int J Radiat Oncol Biol Phys. 1996;36: ** Chest: 2002;121; External Beam Radiation:

19 Chest: 2002;121; Chest: 2007; 123; XRT No Rx Surgical Resection

20 So what else could we do?

21 Local therapy has been tried What is the goal? What is the goal? Cure Cure What could we use? What could we use? Microwave Microwave Laser Laser Radiofrequency Radiofrequency Freezing Freezing Heating Heating IRE IRE

22 General Ablation Technique: CT guidance is used for ALL lung applications CT guidance is used for ALL lung applications We use general Anesthesia for all procedures. We use general Anesthesia for all procedures. Total anesthesia time is about hours. Total anesthesia time is about hours.

23 Start RFA

24 RF Generator Patient return/grounding pads RFA Electrode RFA technique:

25 RFA technique: RITA/Angiodynamics Starburst Probes Starburst Probes We use the Starburst Talon 4 cm probe. We use the Starburst Talon 4 cm probe. This has a flexible handle which is 20 cm long. Perfect for CT applications. This has a flexible handle which is 20 cm long. Perfect for CT applications. Sterile saline infusion pump system Sterile saline infusion pump system Saline goes into the patient and diffuses among the lung propagating the RF signal (0.1cc/min) Saline goes into the patient and diffuses among the lung propagating the RF signal (0.1cc/min)

26 Cool-Tip Electrode

27 RFA technique: Valley-labs The single probe: The single probe: This is for smaller lesions. This is for smaller lesions. There is a 3 cm exposed tip. There is a 3 cm exposed tip.

28 Cluster tip probe. Three separate tips are on this single shaft probe. This has a 3 cm tip exposure. With a 5-6 cm spherical kill zone Three separate tips are on this single shaft probe. This has a 3 cm tip exposure. With a 5-6 cm spherical kill zone minute total burn minute total burn

29 RFA Mechanisms of Cell Destruction

30 Tumor Biology with RFA: At 45 °C cellular swelling begins. The minimal acceptable tissue temperature for cell death is 60 ° C. Cellular proteins are denatured enzymes are deactivated and cellular death results.

31 Tumor Biology with RFA: At °C charring of tissue can occur. Cavitation or gas formation also occur at this temperature. The impedance (tissue resistance to energy flow) increases dramatically. This is a problem in the lung because of possible air emboli to the brain. Stroke is a known risk with RFA.

32 Cryoablation This is a freezing procedure. This is a freezing procedure. Just like the RFA we place a needle into the lesion and rather then heat it up we freeze it. Just like the RFA we place a needle into the lesion and rather then heat it up we freeze it.

33 Isotherm forms a 2.4 mm Right Angle CryoProbe DIAMETER(MM)LENGTH(MM) 0 o C 0 o C o C o C

34 PCT Technique: Depends on the size of the lesion. Depends on the size of the lesion. Small lesions (1-2 cm) Small lesions (1-2 cm) Single Needle; place the needle in the center of the lesion. Single Needle; place the needle in the center of the lesion.

35 PCT Technique: Larger Lesions (> cm) Larger Lesions (> cm) Cluster technique Cluster technique Several needles clustered around the lesion. Several needles clustered around the lesion.

36 Ablation Protocol We perform a freeze- thaw-freeze cycle on all tumors. We perform a freeze- thaw-freeze cycle on all tumors. 10 minute freeze 10 minute freeze (-140°C) (-140°C) 8 minute thaw 8 minute thaw (Never go above 0° C) (Never go above 0° C) 10 minute freeze 10 minute freeze 3 minute thaw to remove the needle from the ice block. 3 minute thaw to remove the needle from the ice block. Total Ablation time 28 minutes

37 1996 Argon Based Joule-Thompson Cryoprobes

38 Ice Ball Formation Different gases have different Joule–Thomson (Kelvin) coefficient Helium is warmer at 1 atmosphere while most other gases aka Argon get colder.

39 Cryobiology Mechanisms of Cell Destruction

40 Freezing tissue damages cells in two ways: 1. Direct damage (to the cells) at the time of cryoablation Slow cooling injury Slow cooling injury Fast cooling injury Fast cooling injury 2. Indirect damage (to the tissue) following cryoablation Ischemia Ischemia Apoptosis Apoptosis Freezing Damage Mechanisms

41 When cells are frozen quickly: Water is trapped inside the cell because of how fast the temperature decrease Water is trapped inside the cell because of how fast the temperature decrease This results in Intracellular Ice Formation (IIF) This results in Intracellular Ice Formation (IIF) The cytoplasm becomes supercooled The cytoplasm becomes supercooled This damages the cell membrane. This damages the cell membrane. Holding the freeze causes recrystallization increasing cell damage. Holding the freeze causes recrystallization increasing cell damage. Direct Damage

42 When cells are frozen slowly: Ice forms in the extracellular matrix Ice forms in the extracellular matrix The cell dehydrate but now has more concentrated cytoplasm The cell dehydrate but now has more concentrated cytoplasm Upon thawing cell rehydrates and expands beyond the membrane resulting in lysis Upon thawing cell rehydrates and expands beyond the membrane resulting in lysis

43 Indirect Damage Two theories Two theories Blood vessel engorgement Blood vessel engorgement Ice formation causes vessel wall engorgement and distention resulting in stasis. Ice formation causes vessel wall engorgement and distention resulting in stasis. Damage to the endothelial cells Damage to the endothelial cells Much like direct causes but this results in decreased blood flow to the tumor. Much like direct causes but this results in decreased blood flow to the tumor. Final result necrosis Final result necrosis

44 Complications: for RFA and PCT

45 Immediate complications: Pneumothorax Pneumothorax Small: 30% of our cases Up to 50% in literature Small: 30% of our cases Up to 50% in literature Large: 20%; all required chest tubes Large: 20%; all required chest tubes Three required prolonged hospitalization. Three required prolonged hospitalization. Pulmonary Hemorrhage: Pulmonary Hemorrhage: Minor degrees in almost all cases. Minor degrees in almost all cases. Hemoptysis: Hemoptysis: Moderate (200 cc) in 1 of cases. Moderate (200 cc) in 1 of cases.

46 Follow-up? We follow patient with CT with contrast And Positron Emission Tomography (PET) imaging.

47 Contrast CT CT works by stopping the beam of radiation as it passes through a structure. CT works by stopping the beam of radiation as it passes through a structure. The radiation is collected by the detector and then depending on the density of the structure it will give a specific level of gray. The radiation is collected by the detector and then depending on the density of the structure it will give a specific level of gray. When we add contrast (aka Iodine) structures that are vascular have more iodine in them When we add contrast (aka Iodine) structures that are vascular have more iodine in them More iodine means more attenuation of x-ray beams. More iodine means more attenuation of x-ray beams.

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49 PET Works by given a high energy particle; Works by given a high energy particle; 1.22 MeV particle to the patient which is coupled to FDG-a glucose analog MeV particle to the patient which is coupled to FDG-a glucose analog. This particle is radioactive and breaks down with time. T1/2 3 hours. This particle is radioactive and breaks down with time. T1/2 3 hours. We inject a standard amount mCu and image 1 hour later. We inject a standard amount mCu and image 1 hour later.

50 PET The particle decays by annihilation. The particle decays by annihilation. This means that the particle breaks in half and goes in opposite directions. This means that the particle breaks in half and goes in opposite directions. 511 keV at 180 degrees to each other. 511 keV at 180 degrees to each other.

51 PET The detector will only image the particles that hit the detectors at the same time at 180 degrees. The detector will only image the particles that hit the detectors at the same time at 180 degrees. The glucose is held in the metabolically active cells because of the fluoride which is added to the glucose. The glucose is held in the metabolically active cells because of the fluoride which is added to the glucose.

52 6 month SUV 1 12 month SUV 3.8

53 1 month post Pre-treatment 3 month post6 month post

54 Aorta

55 Pre-treatment1 year post-treatment

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57 Conclusions: RFA and Cryoablation are safe alternatives to standard non-surgical therapy for lung cancer and pulmonary metastatic disease. RFA and Cryoablation are safe alternatives to standard non-surgical therapy for lung cancer and pulmonary metastatic disease. Long term data in the lung is starting to surface for RFA but not PCT. Long term data in the lung is starting to surface for RFA but not PCT. Carefully, performed clinical trials are necessary to determine the exact role of these interventions in patients with lung cancer. Carefully, performed clinical trials are necessary to determine the exact role of these interventions in patients with lung cancer.

58 References: Wang H, Littrup P, Duan Y, et al. Thoracic Masses Treated with Percutaneous Cryotherapy: Initial Experience with More than 200 Procedures. Radiology 2005; 235:289–298 Swensen SJ, Viggiano RW, Midthun DE, et al Lung nodule enhancement at CT: multicenter study. Radiology 2000; 214:73–80 Swensen SJ, Viggiano RW, Midthun DE, et al Lung nodule enhancement at CT: multicenter study. Radiology 2000; 214:73–80 Shankar LK, Hoffman JM, Bacharach S, etal. Consensus recommendations for the use of 18F-FDG PET as an indicator of therapeutic response in patients in National Cancer Institute Trials. J Nucl Med. 2006;47: Hoffman NE, Bischof JC. The Cryobiology of Cryosurgical Injury. Urology 2002 (Suppl 2A): de Baere T, Palussiere J, Auperin A, et al Midterm local efficacy and survival after radiofrequency ablation of lung tumors with minimum follow-up of 1 year: prospective evaluation. Radiology Aug;240(2): de Baere T, Palussiere J, Auperin A, et al Midterm local efficacy and survival after radiofrequency ablation of lung tumors with minimum follow-up of 1 year: prospective evaluation. Radiology Aug;240(2): Zemlyak A, Moore WH, and Bilfinger TV. Comparison of survival after sublobar resections and ablative therapies for stage I non-small cell lung cancer. Journal of the American College of Surgeons 211(1):68-72, 2010 Zemlyak A, Moore WH, and Bilfinger TV. Comparison of survival after sublobar resections and ablative therapies for stage I non-small cell lung cancer. Journal of the American College of Surgeons 211(1):68-72, 2010 Zemlyak AMoore WHBilfinger TVComparison of survival after sublobar resections and ablative therapies for stage I non-small cell lung cancer. Zemlyak AMoore WHBilfinger TVComparison of survival after sublobar resections and ablative therapies for stage I non-small cell lung cancer.


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