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Radiofrequency Ablation of Lung Cancer

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1 Radiofrequency Ablation of Lung Cancer
Andrew R. Forauer, MD FSIR Interventional Radiology Dartmouth-Hitchcock Medical Center

2 I have no financial disclosures
(but am willing to entertain offers…)

3 Modern Cancer Therapy Chemotherapy Radiation Therapy Surgery

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

5 Radiofrequency Ablation (RFA)
Thermal (heat) based tumor ablation system Most common clinical applications: Liver Kidney Bone, other soft tissue

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

7 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

8 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



11 Radiation Therapy Surgery Ablation

12 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

13 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

14 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

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

16 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; 9: 2. Zemlyak et al., J Am Coll Surg, 2010

17 What about RFA and pulmonary metastases?

18 RFA of lung metastases Study n Mean size 1-yr OS 2-yr 3-yr 5-yr
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 63% Hepatic dz at time of RFA Hiraki ‘07 JVIR 27 1.5 cm (.3 – 3.5) 96% 54% 48%

19 70 yr old patient w/ colorectal Ca & a LLL metastasis
Peri-procedural CT during probe positioning Pre-ablation CT

20 4 month follow-up PET/CT; CEA now wnl

21 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)

22 Current areas under investigation in IR
Chemotherapy delivered via the pulmonary artery Selective chemoembolization Combining chemotherapy infusions with ablation procedures

23 Thank you for your attention !

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