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Chapter24:Image-guided ablation in thethorax
ABC
DE
Figure 24.2 Microwave ablation (MWA) for a pleural-based, ovarian cancer metastasis. A 69-year-old woman who was originally diagnosed with stage III ovarian
cancer, who is status post total abdominal hysterectomy, radiation therapy to the groin, and multiple courses of chemotherapy. (A) Pretreatment computed
tomography (CT) image shows a 2.4-cm right paravertebral mass abutting the aorta (arrow). (B) CT-fluoroscopic image shows a single MW applicator centered
within the mass. (C) T2-weighted magnetic resonance imaging with gadolinium 16 days posttreatment shows that the treated lesion has decreased in size to
1.8 cm and is hypointense (arrow). (D) Positron emission tomography (PET)/CT image 14 months posttreatment shows stable postablation changes, including
stable photopenia and tumor shrinkage (arrow). (E) PET/CT image 25 months posttreatment shows no increased fluorodeoxyglucose activity corresponding to the
treated tumor (arrow).
ABC
Figure 24.3 Cryoablation (CA) for palliative treatment of metastatic squamous cell carcinoma to the right middle lobe and the chest wall.
(A) A fluorodeoxyglucose positron emission tomography/computed tomography (CT) fusion, axial image of a 59-year-old man with a 7.7-cm pleural-based
metastasis in the right lung that is attached to and abuts the pericardium (arrow) and a 5.5-cm right chest wall mass, who presented for palliative CA. (B) Six CA
probes were positioned in the large right middle-lobe mass; several repositionings and activations were required to provide coverage of the entire tumor. CA was
used to image the “ice ball” during treatment to determine the ablation zone–heart interface (arrows). (C) CT image 1 month after ablation shows a hypodense
response at the treatment site with near-complete necrosis of the lesion (arrow). Given the palliative nature of this patient’s treatment, there is an expected residual
enhancing tumor at the margins of the treated lesion.
stereotactic body radiotherapy. Only mortality information
was available for comparison between all three modalities. One
treatment-related death occurred in the RFA cohort (2.0%;
1/51), no deaths occurred in the stereotactic body radiotherapy cohort (0%; 0/55), and ve deaths occurred in the sublobar
resection cohort (2.4%; 5/211).
47
disease, chest wall masses, and painful bony metastases. Since
it was rst reported,48 the goal of thermal ablation has been to
ll a void in the treatment of lung cancer for patients who are
unable to tolerate surgical resection; who require palliation for
pain, cough, dyspnea, and hemoptysis; who require treatment
for recurrence (particularly recurrences in an irradiated eld);
who require cytoreduction; and for those who refuse surgery.
Applications and outcomes for thoracic ablation
Ablation can be used to treat any thoracic malignancy: primary lung cancers, recurrent primary lung cancers, metastatic
Worldwide experience with image-guided ablation of thoracic
malignancies has grown rapidly (Table24.1).
52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81
26,27,30,38,41,42,47,49,50,51,
e literature regarding ablation therapy is diverse;
patient groups are heterogeneous and there is great variance
229
230
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Table 24.1 Worldwide experience with image-guided ablation of thoracic malignancies in series with ≥ 50 patients
Ablation
Author Title Journal Study group
Radiofrequency ablation (RFA)
Bonichon F,
Palussiere J,
Godbert Y, et al.
Garetto I, Busso
M, Sardo D, et al.
Galbis Caravajal
JM, Jornet Fayos
J, Cuenca Torres
M, et al.
Crabtree T, Puri
V, Timmerman R,
et al.
Ambrogi MC,
Fanucchi O, Cioni
R, et al.
Kashima M,
Yamakado K,
Takaki H, et al.
Diagnostic accuracy of 18F-FDG
PET/CT for assessing response to
radiofrequency ablation treatment
in lung metastases: a multicentre
prospective study
Radiofrequency ablation of thoracic
tumours: lessons learned with
ablation of 100 lesions
Study of survival in patients with
malignant lung lesions treated with
radiofrequency
Treatment of stage I lung cancer
in high-risk and inoperable
patients: comparison of prospective
clinical trials using stereotactic body
radiotherapy (RTOG 0236), sublobar
resection (ACOSOG Z4032), and
radiofrequency ablation (ACOSOG
Z4033)
Long-term results of radiofrequency
ablation treatment of stage 1
non-small cell lung cancer: a
prospective intention-to-treat study
Complications after 1000 lung
radiofrequency ablations in 420
patients: a single center’s experience
Eur J Nucl Med Mol
Imaging 2013; 40
(12): 1817–1827
Radiol Med 2014;
119 (1): 33–40
Clin Transl
Oncol 2013; 15
(10): 830–835
J Thorac
Cardiovasc
Surg 2013; 145
(3): 692–699
J Thorac
Oncol 2011; 6
(12): 2044–2051
AJR Am J
Roentgenol 2011;
197 (4): W576–580
89 patients
115 tumors
Metastatic
n = 115
81 patients
100 tumors
Primary
lung n = 30
Metastatic n = 70
59 patients
Primary
lung n = 36
Metastatic n = 23
55 patients SBRT
211 patients
sublobar
51 patients RFA
57 patients
59 tumors
Primary lung
n = 57
420 patients
1403 tumors
Primary lung
n = 137
Metastatic
n = 283
strategy F/U assessment Signicant ndings
RFA CT, PET-CT PET/CT at 3 months was compared to baseline PET/CT
RFA CT, PET-CT Predictors of complete ablation included mean diameter
RFA Unknown Survival and curative treatment was most effective in
RFA, SBRT,
sublobar
resection
RFA CT with contrast All patients had pathology-proven stage I NSCLC. All
RFA CT (obtained
a
(2 months or less prior to RFA treatment). The specificity
of PET/CT at 3 months was low due to persistent
inflammation, particularly for lesions close to the pleura.
of lesions (20 mm lesions were more successfully ablated
than 38 mm lesions) and the histological type (metastases
were completely treated more often than NSCLC).
Survival at 1-, 2-, and 3-years was 84.5%, 65.4%, and 51.5%.
Predictors of 3-year survival were coexistence of other
metastases and diameter < 20 mm.
stage I primary tumors and metastatic tumors. For lesions
treated with curative intent, the survival in primary
tumors was 30.97±4.57 months and for metastases it was
25.14±4.68 months.
CT, PET This study prospectively evaluated selection criteria
and short-term outcomes among 3 prospective clinical
trials using SBRT, sublobar resection, and RFA. For the
RFA portion of the study, only mortality information was
available for comparison. One treatment-related death
occurred in the RFA cohort (2.0%), no deaths occurred
in the SBRT cohort (0%), and five deaths occurred in the
sublobar resection cohort (2.4%)
procedures were technically successful and no mortality
or major morbidity was associated with treatment. At
mean follow-up of 47 months the complete response rate
was 59.3% (significantly higher for stage Ia than stage Ib).
Cancer-specific actuarial survival at 1 year was 89%.
Complications were assessed in 420 patients treated with
3–7 days after
RFA)
a cool-tip RFA system. Deaths related to RFA occurred in
4 procedures (0.4%). The major complication rate (grade
3 or 4 adverse event) was 9.8% and included aseptic
pleuritis, pneumonia, lung abscess, bleeding requiring
transfusions, pneumothorax requiring pleural sclerosis,
bronchopleural fistula, brachial nerve injury, tumor
seeding, and diaphragm injury.
newgenrtpdf
Palussiere J,
Marcet B, Descat
E, et al.
Okuma T,
Matsuoka T,
Yamamoto A, et al
Singnurkar A,
Solomon SM,
Gonen M, et al.
Chua TC, Sarkir A,
Saxena A, et al.
Chua TC,
Thornbury K,
Saxena A, et al.
Pennathur A,
Abbas G, Gooding
WE, et al.
Lung tumors treated with
percutaneous radiofrequency
ablation: computer tomography
imaging follow-up
Determinants of local progression
after computer tomography-guided
percutaneous radiofrequency
ablation for unresectable lung
tumors: 9 year experience in a single
institution
18
F-FDG PET/CT for the prediction
and detection of local recurrence
after radiofrequency ablation of
malignant lung lesions
Long-term outcome of
image-guided percutaneous
radiofrequency ablation of lung
metastases: an open-labeled
prospective trial of 148 patients
Radiofrequency ablation as an
adjunct to systemic chemotherapy
for colorectal pulmonary metastases
Image-guided radiofrequency
ablation of lung neoplasm in 100
consecutive patients by a thoracic
surgical service
Cardiovasc
Intervent
Radiol 2011; 34
(5): 989–997
Cardiovasc
Intervent Radiol
2010; 33: 787–793
J Nucl Med
2010; 51
(12): 1833–1840
Ann Oncol
2010; 21
(10): 2017–2022
Cancer 2010; 116
(9): 2106–2114
Ann Thorac
Surg 2009; 88
(5): 1601–1606
189 patients
350 tumors
Primary
lung n = 60
Metastatic
n = 290
73 patients
138 tumors
Primary
lung n = 12
Metastatic
n = 126
68 patients
94 tumors
Primary
lung n = 44
Metastatic n = 38
148 patients
Tumors: mean
2 ± 2 per patient
Primary
lung n = 8
Metastatic
n = 140
100 patients
Primary
colon n = 68
Primary rectum
n = 32
100 patients
109 tumors
Primary
lung n = 46
Recurrent
lung n = 25
Metastatic n = 29
RFA CT The most common imaging findings found 1 year after
treatments were fibrosis (generally with tumors < 2 cm)
or nodules. None of the five patterns identified (fibrosis,
cavitation, nodule, atelectasis, and disappearance) were
predictors of absence of local tumor progression on
follow-up.
RFA CT Risk factors for local progression were age (≥ 70 years),
tumor size (≥ 2 cm), sex (male), and no achievement
of roll-off during RFA (p < 0.05). Multivariate analysis
indicated that the only independent factor for local tumor
progression was tumor size ≥ 2 cm (p = 0.003).
RFA CT, 18F-FDG PET/
CT
Study evaluated pre- and post-ablation imaging features
associated with recurrence. Pre-therapy predictors of
recurrence-free survival included tumors < 3 cm and SUV
< 8. Treated metastases recurred less often than treated
primary lung cancers. Post-RFA factors that predicted
reduced recurrence-free survival were unfavorable uptake
pattern, post-RFA SUV, and an increase in SUV over time
after ablation.
RFA CT 46% of patients had a complete response to treatment.
The median progression-free survival was 11 months
and the predictors for overall survival included diseasefree interval and response to treatment. Complications
occurred in 45% of patients.
RFA CT with contrast Patients had a wide variety of tumor grade and staging
at diagnosis. Median overall survival after RFA was
36 months and 5-year survival was 30%. On univariate
analysis 7 factors were shown to affect overall survival
after RFA: histopathological grade of primary tumor, time
to RFA treatment, response to treatment, repeat RFA
treatment, presence of extrapulmonary metastases at the
time of RFA, presence of mediastinal lymphadenopathy,
and use of adjuvant chemotherapy.
RFA CT, PET, RECIST Thoracic surgeons performed ablations. The median
survival for patients was 23 months. The 2-year overall
survival for patients with primary lung cancer, recurrent
cancer, and metastatic cancer were 50%, 55%, and 41%.
(Continued)
231
232
Table 24.1 (cont.)
Author Title Journal Study group
Yamakado K,
Inoue Y, Takao M,
et al.
Nour-Eldin NE,
Naguib NN, Saeed
AS, et al.
Yoshimatsu R,
Yamagami T,
Terayama K, et al.
Zhu JC, Yan TD,
Glenn D, et al.
Lencioni R,
Crocetti L, Cioni R
Nomura M,
Yamakado K,
Nomoto Y, et al.
Long-term results of radiofrequency
ablation in colorectal lung
metastases: single center experience
Risk factors involved in the
development of pneumothorax
during radiofrequency ablation of
lung neoplasms
Delayed and recurrent
pneumothorax after radiofrequency
ablation of lung tumors
Radiofrequency ablation of lung
tumors: feasibility and safety
Response to radiofrequency ablation
of pulmonary tumors: a prospective,
intention-to-treat, multicentre clinical
trial (the RAPTURE study)
Complications after lung
radiofrequency ablation: risk factors
for lung inflammation
Oncol Rep 2009;
22 (4): 885–891
AJR Am J
Roentgenol 2009;
193 (1): W43–W48
Chest 2009; 135
(4): 1002–1009
Ann Thorac
Surg 2009; 87
(4): 1023–1028
Lancet Oncol
2008; 9: 621–628
Br J Radiol 2008;
81 (963): 244–249
78 patients
198 tumors
Metastatic
n = 198
82 patients
124 tumors
Primary
lung n = 10
Metastatic
n = 114
68 patients
220 tumors
Primary
lung n = 14
Metastatic n = 54
100 patients
Tumors: mean
no. ablated per
session 2.0 ± 1.4
Primary
lung n = 6
Metastatic n = 94
106 patients
183 tumors
Primary
lung n = 33
Metastatic n = 73
130 patients
Primary
lung n = 17
Metastatic
n = 113
Ablation
strategy F/U assessment Signicant ndings
RFA CT, CEA levels Local tumor progression rates at 1-, 3-, and 5-years were
10.1%, 20.6%, and 20.6%. Median survival time was
38.0 months. Significant predictors of better prognostic
outcome included tumor diameter ≤ 3 cm, single-lung
metastasis, lack of extrapulmonary metastases, and a
normal CEA value.
RFA CT Exclusion criteria included tumors > 5 cm and > 5 lesions.
The incidence of CT detected PTX was 11.3%. Risk factors
for PTX included age over 60 years, emphysema, tumor
diameter ≤ 1.5 cm, lesions in the lower lung, ≥ 2.6 cm of
aerated lung traversed by the electrode, and traversal of
the major pulmonary fissure.
RFA Chest radiograph PTX occurred in 42.3% of sessions; 40.2% of sessions with
PTXs had a delayed or recurrent PTX. The only significant
predictor of delayed or recurrent PTX (versus no PTX or
non-progressive PTX) was contact of the ground-glass
opacity that appeared after treatment with the pleura.
RFA CT Post-procedure morbidity was 43%; PTX was the most
common complication. Significant risk factors for
morbidity included ablating more than 2 lesions per
session, length of probe trajectory > 3 cm, and hilar
location.
RFA CT, RECIST A prospective, intention-to-treat, single arm study
evaluating patients from the US, Europe, and Australia.
Confirmed complete responses to treatment lasting at
least 1 year were shown in 88% (77/85) of assessable
patients. There was no difference in response between
patients with NSCLC or lung metastases.
RFA C-reactive protein
(CRP)
CRP value was measured before treatment and every
1–2 days during the hospital stay after treatment.
The major complication rate was 18.3%, with
inflammation-related complications including interstitial
pneumonia and aseptic pleuritis. Risk factors for severe
lung inflammation included tumor size ≥ 2 cm and
previous XRT.
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newgenrtpdf
Sano Y, Kanazawa
S, Gibara H, et al.
Simon CJ, Dupuy
DE, DiPetrillo TA,
et al.
Hiraki T, Sakurai J,
Tsuda T, et al.
Yan TD, King J,
Sjarif A, et al.
Gadaleta C,
Catino A,
Mattiolo V
Yan T, King J, Sjarif
A, et al.
Feasibility of percutaneous
radiofrequency ablation for
intrathoracic malignancies: a large
single-center experience
Pulmonary RFA: Long-term safety
and efficacy in 153 patients
Risk factors for local progression
after percutaneous radiofrequency
ablation of lung tumors: evaluation
based on a preliminary review of 342
tumors
Learning curve for percutaneous
radiofrequency ablation of
pulmonary metastases from
colorectal carcinoma: a prospective
study of 70 consecutive cases
Radiofrequency thermal ablation in
the treatment of lung malignancies
Percutaneous RFA of pulmonary
metastases from colorectal
carcinoma: Prognostic determinants
for survival
Cancer 2007; 109
(7): 1397–1405
Radiology 2007;
243 (1): 268–275
Cancer 2006; 107
(12): 2873–2880
Ann Surg
Oncol 2006; 13
(12): 1588–1595
In Vivo 2006; 20
(6A): 765–767
Ann Surg
Oncol 2006; 13
(11): 1529–1537
137 patients
366 tumors
153 patients
189 tumors
122 lung
67 metastatic
128 patients
342 tumors
Primary
lung n = 25
Metastatic
n = 317
55 patients
Tumors: mean
no. ablated per
patient 2 ± 1
54 patients
93 tumors
Primary
lung n = 10
Metastatic n = 83
55 patients
Tumors: mean
no. of 2 ± 2
CRC pulmonary
metastases
RFA Chest radiograph Study evaluated minor complications, major
complications, and side effects. No procedure-related
mortality, but two patients died during the study
because of intractable PTX and massive hemoptysis. The
major complication rate was 17.1%; the most common
complication was PTX requiring tube drainage.
RFA CT/PET Initial technical success was 98%. Survival for Stage
I NSCLC patients was reported and did not differ among
patients with tumors less than or greater than 3 cm. For
18 patients with colorectal metastases: 1-, 2-, and 3-year
survival was 86.8%, 77.5%, and 57%, respectively.
RFA CT Local progression occurred in 27% of tumors after the
first ablation session. Independent risk factors for local
progression included larger tumor size and the use of
internally cooled electrode.
RFA CT A diverse patient population, with some patients
receiving adjuvant, systemic chemotherapy. The overall
morbidity was 37%, with the most common complication
being PTX. Risk factors for complications included the
number of metastases ablated and the RFA treatment
period (older vs more recent). The study concludes that
there is a learning curve to RFA; with greater institution
experience, there is less morbidity.
RFA CT, MRI with
gadolinium
Complete necrosis occurred in 95% of treated lesions,
with median follow-up of 18 months. The most
frequent complication was PTX. MRI obtained during
follow-up generally showed central hypointensity, with a
surrounding homogeneous hyperintense ring.
RFA CT Even though 30 of 55 patients had previously resected
liver metastases, overall median survival was 33 months.
1-, 2-, and 3-year actuarial survival was 85%, 64%, and
46%. In univariate analysis lesion size, location, and need
for repeat RFA were predictive of survival. In a multivariate
model only lesion size remained predictive.
233
(Continued)
234
Table 24.1 (cont.)
Author Title Journal Study group
Hiraki T, Tajiri N,
Mimura H, et al.
de Baere T,
Palussiere J,
Auperin A, et al.
Ambrogi MC,
Lucchi M, Dini P,
et al
Kang S, Luo R,
Liao W, et al.
Pneumothorax, pleural effusion,
and chest tube placement after
radiofrequency ablation of lung
tumors: incidence and risk factors
Midterm local efficacy and
survival after RFA of lung tumors
with minimum follow-up of
1 year: prospective evaluation
Percutaneous RFA of lung
tumors: results in the midterm
Single group study to evaluate the
feasibility and complications of RFA
and usefulness of post-treatment
positron emission tomography in
lung tumors
Radiology 2006;
241 (1): 275–283
Radiology 2006;
240 (2): 587–589
Eur J Cardiothorac
Surg 2006; 30
(1): 177–183
World J Surg Oncol
2004; 2: 30
142 patients
392 tumors
60 patients
100 tumors
Primary
lung n = 9
Metastatic n = 51
54 patients
64 tumors
Primary
lung n = 40
Metastatic n = 24
50 patients
120 tumors
Primary
lung n = 23
Metastatic n = 27
newgenrtpdf
Ablation
strategy F/U assessment Signicant ndings
RFA CT PTX occurred in 52% of sessions; risk factors included
male sex, no previous lung surgery, greater number of
tumors ablated, involvement of middle or lower lobes,
and increased length of lung traversed by the electrode.
Pleural effusion occurred in 19% of sessions; risk factors
included use of a cluster electrode, decreased distance to
nearest pleural, and decreased length of lung traversed
by electrode. Chest tube placement for PTX occurred in
21% of sessions; risk factors included no history of lung
surgery, the use of cluster electrode, and involvement of
upper lobe.
RFA CT All patients had tumors 4 cm or smaller. RFA local
treatment success was 93% per tumor and 88% per
patient. An ablation area at least 4 times larger than
the initial tumor was predictive of complete ablation
treatment.
RFA CT/PET At a mean follow-up of 2 years, there were 62% complete
responses with higher response rates for metastatic
lesions (71%) and those smaller than 3 cm (70%).
RFA CT, PET Tumors smaller than 3.5 cm were completely killed after
RFA. In tumors larger than 3.5 cm, the part within 3.5 cm
was killed. While CT showed that tumors became larger 1
to 2 weeks after RFA procedure, PET demonstrated tumor
destruction in 70% cases, compared with 38% in CT.
Microwave ablation (MWA)
Vogl TJ, Worst TS,
Naguib NN, et al.
Belfiore G, Ronza
F, Belfiore MP,
et al.
Factors influencing local tumor
control in patients with neoplastic
pulmonary nodules treated with
microwave ablation: a risk-factor
analysis
Patient’s survival in lung
malignancies treated by microwave
ablation: our experience on 56
patients
AJR Am J
Roentgenol 2013;
200 (3): 665–672
Eur J Radiol 2013;
82 (1): 177–181
57 patients
91 tumors
56 patients
69 tumors
Primary
lung n = 44
Metastatic n = 25
MWA Unknown 33% of tumors underwent local progression with mean
time to tumor progression being 8.3 ± 5.5 months.
Significant risk factors for local tumor progression
included maximum tumor diameter > 15.5 mm, irregular
shape of the tumor, pleural contact, and < 26.7 J/mm
applied to the tumor.
MWA CT Follow-up CT revealed a decrease in diameter of 64%
and 71% of lesions at 3- and 6-months. One year
cancer-specific mortality was 69% and the estimate for
mean survival time was 27.8 months.
newgenrtpdf
Lu Q, Cao W,
Huang L, et al.
Wolf FJ, Grand DJ,
Machan JT, et al.
Cryoablation
Yashiro H,
Nakatsuka S,
Inoue M, et al.
Ito N, Nakatsuka
A, Inoue M, et al.
Wang H, Littrup
PJ, Duan Y, et al.
CT-guided percutaneous
microwave ablation of pulmonary
malignancies: results in 69 cases
Microwave ablation of lung
malignancies: effectiveness, CT
findings, and safety in 50 patients
Factors affecting local progression
after percutaneous cryoablation of
lung tumors
Computer tomographic appearance
of lung tumors treated with
percutaneous cryoablation
Thoracic masses treated with
percutaneous cryotherapy: initial
experience with more than 200
procedures
World J Surg Oncol
2012; 7 (10): 80
Radiology 2008;
247 (3): 871–879
J Vasc Interv
Radiol 2013; 24
(6): 813–821
J Vasc Interv
Radiol 2012; 23
(8): 1043–1052
Radiology 2005;
235 (1): 289–298
69 patients
93 tumors
Primary
lung n = 26
Metastatic n = 21
Recurrent lung
n = 22
50 patients
82 tumors
Primary
lung n = 30
Metastatic n = 20
71 patients
210 tumors
Primary
lung n = 11
Metastatic
n = 199
56 patients
79 tumors
Primary
lung n = 12
Metastatic n = 67
187 patients
234 tumors
Primary lung
n = 196
Metastatic n =38
Stage I n = 5
Stage II n = 17
Stage IIIA n = 20
Stage IIIB n = 60
Stage IV n = 63
MWA CT Patients had a wide variety of tumor histology, sizes, and
burdens. Complications occurred with 24.64% of patients,
with the most common being pneumothorax (18.84%).
Overall survival rate at 1 year was 66.7%; the overall
survival rate for NSCLC patients at 1 year was 75.0%; and
the overall survival rate for lung metastases at 1 year was
47.6%.
MWA CT Upon follow-up, 26% of patients had residual disease at
the ablation site. Predictors of residual disease included
tumor size larger than 3 cm. Kaplan–Meier yielded
actuarial survival of 65% at 1-year and cancer-specific
mortality of 83% at 1-year.
CA CT Median follow-up was 454 days, with local tumor
progression occurring in 23.8% of tumors. Risk factors for
local progression included existence of a thick vessel ≥
3 mm within 3 mm from the edge of tumor.
CA CT 78% of ablation zones showed the following
transformations: consolidation or nodular pattern seen
within 1-week follow-up; involution and “stripe” seen at
1 month or later; and eventually zones became indistinct.
80% of cases of local progression arose from the “stripe”
pattern.
CA CT A landmark technical report documenting the safety and
feasibility of CA. Although ice coverage for peripheral
lesions less than 4 cm was nearly complete, only 80%
coverage was achieved for central masses larger than
4 cm. The Karnofsky Performance Scale improved
significantly for those with advanced stage disease.
235
Irreversible electroporation (IRE)
Usman M, Moore
W, Talati R, et al.
Irreversible electroporation of lung
neoplasm: a case series
Med Sci Monit
2012; 18
(6): CS43–CS47
2 patients
2 tumors
Primary
lung n = 1
Metastatic n = 1
IRE CT with contrast This small case series evaluates two patients who were
not candidates for surgery of traditional thermal ablation
due to tumor location. Both lesions showed progression
within 6 months of treatment.
(Continued)
236
Table 24.1 (cont.)
Ablation
Author Title Journal Study group
Thomson KR,
Cheung W, Ellis
SJ, et al.
Multiple ablation modalities
Alexander ES,
Hankins CA,
Machan JT, et al.
Nour-Eldin NE,
Naguib NN, Tawfik
AM, et al.
Grieco CA, Simon
CJ, Mayo-Smith
WW, et al.
a
Given the limited study sizes of those patients treated with IRE, these studies were included in spite of having < 50 patients.
SBRT = stereotactic body radiotherapy; CRC = colorectal cancer; CA = cryoablation; PTX = pneumothorax.
Investigation of the safety of
irreversible electroporation in
humans
Rib fractures after percutaneous
radiofrequency and microwave
ablation of lung tumors: incidence
and relevance
Outcomes of an algorithmic
approach to management of
pneumothorax complicating thermal
ablation of pulmonary neoplasms
Percutaneous thermoablation as a
palliative treatment for chest wall
masses
J Vasc Interv
Radiol 2011; 22
(5): 611–621
Radiology 2013;
266 (3): 971–978
J Vasc Interv
Radiol 2011; 22
(9): 1279–1286
J Vasc Interv Radiol
2006; 17: S61
Abstract 168
38 patients
69 tumors
4 patients with
lung lesions
Primary
lung n = 1
Metastatic n = 3
163 patients
195 tumors
Primary lung
n = 131
Metastatic n = 32
164 patients
248 tumors
Primary
lung n = 20
Metastatic
n = 228
52 patients
58 thoracic wall
masses
strategy F/U assessment Signicant ndings
IRE CT with biopsy in
RFA n = 113
MWA n = 74
Both n = 8
RFA n = 200
MWA n = 48
RFA n = 51
MWA n = 5
CA n = 2
This study evaluated IRE for various tumor pathologies
1 patient
and treatment locations. Those patients with lesions in
the lungs and kidneys had the worst outcome. All of the
lung IRE ablations were incomplete; one lung patient was
lost to follow-up.
CT, PET-CT Rib fractures near the ablation zone occurred in 13.5% of
patients. Risk factors for fracture included being female,
tumors close to the chest wall, and having an ablation
zone involving the visceral pleura. No adverse events
were associated with fracture; 2 patients (9.1%) reported
mild pain.
CT PTXs occurred in 18.1% of sessions (8.9% occurred
during MWA and 91.1% occurred during RFA). Mild PTXs
were closely observed; moderate PTXs were manually
evacuated; severe and progressive PTXs required
intercostal chest tubes.
CT Improvement in pain symptoms occurred in 70.5%.
There was no change in 18.2% and worsening of pain
symptoms in 11.4%. None of the patients with more than
1 tumor showed improvement. Ablations done within
90 days of XRT yielded a 100% response, versus 57.7%
in those who received XRT greater than 90 days prior to
ablation.
newgenrtpdf
Chapter24:Image-guided ablation in thethorax
in follow-up periods, reporting, and evaluations. Success can
be veried using the “gold-standard” biopsy; however, this is
too invasive and impractical to standardize.
82,83
e RECIST
protocol is also an ineective measure of success because even
completely ablated tumors may not shrink.84 While it is impossible to compare studies due to variances in patient populations
and methods used to measure outcomes, certain conclusions
from the literature can be drawn:(1)the adequacy of tumor
ablation depends on size
of tumor ablation predicts survival
to CT for long-term follow-up
23,31,81,83
tive
vant therapy
; (5)ablation may potentiate the response of adju-
57,85
; and (6)RFA successfully palliates colorectal
cancer metastases to the lung.
29,31,49,54,55,59,67,73,74,83
49,51
; (3)PET/CT is superior
38,39,40,73
; (4) palliation is eec-
49,57,59,66,70
; (2)the adequacy
worsening of pulmonary function, which makes it a particularly appealing option for those patients with impaired lung
function.
In a study of 50 patients treated with MWA, Kaplan–Meier
analysis yielded an actuarial survival at 1, 2, and 3years of 65%,
55%, and 45%, respectively. Cancer-specic mortality yielded
a 1-, 2-, and 3-year survival of 83%, 73%, and 61%. Of note,
cancer-specic mortality was not signicantly aected by
tumor size or the presence of residual disease. Cavitation was,
however, associated with a lower cancer-specic mortality; the
authors hypothesized that this imaging nding was indicative of a more thoroughly ablated lesion.41 Several studies have
revealed that tumor size is a signicant risk factor for tumor
progression or recurrence aer microwave treatment.
71,74
Several large studies evaluating CA for the treatment of
Ablation of primary and metastatic
thoracictumors
In 2016 there will be an estimated 224,390 new cases of lung
cancer and 158,080 lung cancer deaths in the United States.86
While the death rate related to lung cancer has steadily declined
over the past two decades, lung cancer still remains the leading
cause of cancer-related mortality. e lung is also a common
site for metastatic disease with common primaries, including
sarcomas, colorectal cancer, breast cancer, renal cancer, melanoma, and head and neck cancer.87 Surgery is regarded as the
best treatment option for the minority of patients with localized disease; however, optimizing non-operative treatments for
the many patients whose tumors remain unresectable remains
the most compelling application for image-guided thermal
ablation.
Our institution retrospectively evaluated the use of RFA
treatment for pulmonary malignancies in 153 patients with
189 inoperable primary and metastatic lung tumors. For
those patients with stage INSCLC, median survival time was
29months. Kaplan–Meier analysis of those patients with stage
INSCLC yielded predicted survival estimates at 1, 2, 3, 4, and
5 years of 78%, 57%, 36%, 27%, and 27%, respectively. e corresponding survival rates for those patients with colorectal
metastases to the lungs were 87%, 78%, 57%, 57%, and 57%.66
Many of the patients in the latter group received adjuvant
chemotherapy, making the eects of ablation dicult to assess.
However, one can surmise that RFA and chemotherapy may
provide a synergistic advantage for those patients with colorectal pulmonary metastases.
In a large multicenter prospective clinical trial evaluating
the response of pulmonary tumors to RFA, researchers saw
no signicant dierence in response to treatment between
patients with NSCLC versus pulmonary metastases. Overall
survival at 1 and 2years for patients with NSCLC was 70% and
48%, respectively; for those patients with colorectal metastases
1- and 2-year survival was 89% and 66%; and for patients with
other metastases 1- and 2-year survival was 93% and 67%.63
e study prospectively revealed that RFA could be successfully used to treat a high percentage of patients with small
pulmonary tumors and that treatments had an acceptably
low morbidity. Of importance, RFA was not associated with a
intrathoracic lesions have revealed that the treatment is an
eective and safe option.
43,77,78
e largest study evaluating CA
for thoracic masses demonstrated that location and size were
predictive of increased tumor ice coverage.78 Yashiro and colleagues recently evaluated predictors of progression aer CA
treatment in 71 patients with 210 tumors (11 primary and
199 metastatic neoplasms). Mean follow-up aer CA was
571 days, and local progression was observed in 50 tumors.
Local progression-free rates at 1, 2, and 3years were 80.4%,
69.0%, and 67.7%, respectively. According to multivariate
analy sis, independent risk factors for local progression aer
CA included tumor size greater than 20mm and the presence
of a vessel with at least a 3-mm diameter located within 3mm
of the tumor.
77
Palliation
For patients with inoperable lung cancer or large tumor burdens, there have historically been limited treatment options.
e cytoreductive eect of ablative therapy has had a useful
role in symptom palliation, which is a critical part of the medical management of cancer patients with inoperable lung cancers or with tumors that extend into the osseous structures.
Most lung cancer patients die from their disease; patients’
most common clinical symptoms are cough, dyspnea, hemoptysis, and pain.88 e three main causes of malignancy-related
pain in lung cancer are osseous metastatic disease (34%),
Pancoast tumor (31%), and chest wall disease (21%).89 For palliation of symptoms related to a focal lesion, the ablation size
or coverage is less important than directing attention to the
tumor–bone interface.
Current studies conrm the palliative results of RFA in
treating musculoskeletal, gastrointestinal, pulmonary, and
neurologic-associated lesions; pain relief is presumably a
result of cytoreduction, destruction of adjacent sensory nerve
bers, and decreased neural stimulation following debulk-
90,91,92,93,94
ing.
ablation of thoracic lesions, Grieco and colleagues evaluated
the treatment of 39 patients with 44 chest wall masses. Patients
were treated with RFA, MWA, and CA; 70.5% of procedures
resulted in signicant pain relief. All patients treated with
adjuvant external-beam radiation therapy within 90 days of
RFA reported improvement; this suggests that there may be a
In the largest study to date evaluating palliative
237
Section VII:Chest
synergistic benet to this dual therapy. Interestingly, RT done
more than 90days before ablation showed markedly lower palliative benets.
95
CA has also emerged as an eective treatment option of
osseous lesions. While RFA is a poor treatment choice for sclerotic or intact bone, crotherapy is better able to deliver energy
to these structures.96 Additionally, CA allows for the use of
multiple applicators simultaneously, creating larger lesions in
a single session thanRFA.
97
It is important to note that pleural-based masses can be
quite painful during RF heating. e somatic innervation of
the parietal pleura via the intercostal and phrenic nerves may
incite pain felt either on the body wall or in the corresponding
dermatomes. Multiple doses of sedation or general anesthesia
during the procedure may be needed to overcome this discomfort. It is our experience that pleural-based lesions treated with
CA tend to result in less pain; this is likely due to the “cryoanalgesia eect” on nerves.
43
Conclusion
Given the high incidence and mortality of primary lung malignancies and thoracic metastases, the emergence of ecacious
treatment options is a critical part of oncological care. Presently,
thermal ablation is best used for patients with early-stage lung
cancers who are not surgical candidates, patients with small
and favorably located pulmonary metastases, and patients in
whom palliation of tumor-related symptoms is thegoal.
Research evaluating the ideal tumor size, histology, morphology, and location for thermal ablation is being performed
and further elucidating which patients may be best served by
ablative therapy. Although there has been an inux of studies
evaluating imaging follow-up, there has yet to be a consensus
for which imaging modality or follow-up timing is best to detect
treatment success or early recurrence. As the eld of tumor
ablation progresses, we must delineate which ablation therapies
are best suited for various disease presentations. Additionally,
investigators must work to develop systems that provide larger
and faster ablations with fewer treatment restrictions.
ermal tumor ablation is an evolving and exciting science
with over a decade of clinical experience supporting its use.
Now that the safety and ecacy of these procedures have been
validated, carefully designed multi-institutional studies and
advances in engineering and biological technologies will allow
us to successfully treat and manage lung cancer and pulmonary
metastatic disease.
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