Download Understanding ______ Cancer and Basic Management - SIR

- SIR RFS IO Service Line Created By: Kevin Anton MD, PhD
Date: 9/10/2014
 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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 81 year old male with right upper lobe lung
mass
Dupuy, D., et al. Semin Intervent Radiol. 2010 September; 27(3): 268–275.
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 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
Courtesy of the Journal of Respiratory Diseases
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 (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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 Metastatic Rectal
Cancer
Rectal Cancer diagnosed 4 yrs prior
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 2.2-cm right upper
lobe mass (arrow)
with spiculated
margins and small
pleural tail
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 Adenocarcinoma
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 5-cm, spiculated mass
in the left lower lobe
abutting the aorta
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 Squamous Cell
Carcinoma
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PET CT – Left lower lobe lung mass
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Post-biopsy pneumothorax
CT-guided biopsy of left lower lobe
lung mass
Chest tube placement and
lung re-expansion
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Radiofrequency ablation
Immediately post-ablation
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Radiofrequency ablation (RFA)
electrode in the mass
Dupuy, D., et al. Semin Intervent Radiol. 2010 September;
27(3): 268–275.
Follow up images 3 (top) and 9
months (bottom) post-ablation
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Follow up PET 23 months
post-ablation
Pre-treatment PET
Follow up CT images 27
months post-ablation
Dupuy, D., et al. Chest. 2006; 129:738-745
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American Cancer Society. Global Cancer Facts and Figures 2nd Edition. Atlanta: American Cancer
Society; 2011.
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American Cancer Society. Global Cancer Facts and Figures 2nd Edition. Atlanta: American Cancer
Society; 2011.
18
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 Exposure to carcinogens
(smoking)
 Genetic Susceptibility
 Environmental
exposure to pollutants
(asbestos)
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Wong, E. Copyright © 2012-2013 McMaster Pathophysiology Review (MPR).
 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
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Television Consultancy Limited.
 Recurrent pneumonia or bronchitis
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Characteristics
Cancer Type
Location
PET
Adenocarcinoma (40%)
•
Irregular, lobulated, or spiculated
border
Peripheral / Subpleural
SUV 0.4 –
11.6 (nonBAC)
Adenocarcinoma InSitu (previously
bronchoalveolar)
•
Bubble-like areas of low attenuation
within mass (pseudocavitation)
Peripheral
SUV 0.4 –
5.9
Squamous Cell (2530%)
•
•
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 (<5%)
•
Central well-marginated nodule/mass
with endoluminal component and
post-obstructive effects
Avid enhancement
Central /
Endobronchial
Frequently
false
negative
Large peripheral mass, solid
attenuation with irregular margin
Peripheral
SUV 2.9 –
19.1
•
Large Cell (10-15%)
•
Calcifications
Yes (26-33%)
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Stage T3:
Stage T1b:
•
Stage T2:
•
Nodule in the
bronchus
intermedius, 4
cm from the
carina
(endobronchial
lesion > 2 cm
from the carina)
• Primary mass
with satellite
nodules
2.9 cm RUL
nodule (>2 cm
but ≤ 3cm)
Stage T4:
• Primary RUL
tumor with
smaller
separate
nodule in the
RLL
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UyBico S. et al. Radiographics. 2010; 30: 1163-1181.
 Medical Management:
 Smoking Cessation
 Chemotherapy
 Targeted Therapies (Anti-angiogenesis agents, molecular
targets, etc.)
 External Beam Radiation Therapy
 Surgical Management:
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 Deliver direct treatments to lung cancer without
significant side effects or damage to nearby normal
tissue.
 Radiofrequency Ablation
 Microwave Ablation
 Cryoablation
 Chemoembolization
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
Adapted from D. Dupuy’s 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)
Adapted from D. Dupuy’s Lung CA Ablation. WCIO May 2013.
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CCI = Charlson
Comorbidity Index
90% 3-year survival
if CCI low
Survival same as no
treatment
if CCI high
Simon et al. Eur J Radiol. 2012; 81:4167-72.
Adapted from D. Dupuy’s Lung CA Ablation. WCIO May 2013.
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
Pre-procedure management/work-up

Biopsy
 Confirm malignancy

Focused history and routine physical examination

Laboratory tests
 INR < 1.5, Platelets > 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
*de Baere T. Lung Cancer Ablation: What Is the Evidence? Semin Intervent Radiol. 2013 Jun;30(2):151-156.
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 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
S Rose, et al. J Vasc Interv Radiol 2006;17:927–951
M Kashima, et al. American Journal of Roentgenology 2011 197:4, W576-W580.
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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
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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
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 PETCT
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.
Abtin, F et al. Radiographics 2012; 32: 947-969.

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)

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
• Immediate – Post-ablation zones
• Intermediate (1 month) – Larger ablation zone than
original tumor but surrounding ground-glass and
hemorrhage have involuted.
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
• 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.
12-months
Abtin, F et al. Radiographics 2012; 32: 947-969.
•
PET findings
suggestive of
recurrence:
•
•
• Metastatic renal cell carcinoma
•
• 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).
Increasing
metabolic activity
after 2 months
Residual activity
centrally or at the
region of the
ablated tumor
Development of
nodular activity
at original tumor
nodule
Abtin, F et al. Radiographics 2012; 32: 947-969.
 Single center experience with 1000
RFA sessions in 420 patients
M Kashima, et al. American Journal of Roentgenology 2011 197:4, W576-W580.
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 Symptoms
 Cough, shortness of breath, hemoptysis, weight loss
 Imaging
 Radiograph: Opacity/Mass
 CT: Characterization/Staging
 PET-CT: Staging/Nodal Involvement/Metastasis
 Management
 Medical: Chemotherapy, targeted therapies
 Surgical: Wedge resection, lobectomy, pneumonectomy
 Radiation Oncology: External beam radiation therapy
 IR: RFA, Microwave ablation, Cryoablation, Chemoembolization
 RFA in Lung Cancer
 Stage 1 disease
 Non-operable candidates
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
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): 268–275.

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.

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 Center’s 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; 17:927–951.

Thierry de Baere, Geoffroy Farouli, et al. Lung Cancer Ablation: What Is the Evidence? Semin
Intervent Radiol. 2013 Jun;30(2):151-156.
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This presentation was adapted from a template created by Don J. Perry, MD
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