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 !