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

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

Modern Cancer Therapy Chemotherapy Radiation Therapy Surgery

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

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

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

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

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

Radiation Therapy Surgery Ablation

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

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

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

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; OS @ 5 yrs ~50%

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; 9:621-628 2. Zemlyak et al., J Am Coll Surg, 2010

What about RFA and pulmonary metastases?

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%

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

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

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)

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

Thank you for your attention !