Minimally Invasive Cancer Therapies in Interventional Radiology Chief, Vascular and Interventional Radiology Lancaster Radiology Associates Co-Director, Interventional Vascular Unit

Objectives 1- Identify currently available IR procedures related to cancer care at LGH 2- Enhance medical staff knowledge of such procedures 3- Discuss current IR cancer treatments

Palliative and curative therapies Diagnosis Lung Genitourinary Gastrointestinal

DIAGNOSIS through Image-Guided Biopsies Often one of the initial procedures used to obtain a tissue diagnosis Multiple modalities including Computed Tomography, Ultrasound, and Fluoroscopy Alone or in combination Often correlate with PET scan to identify “active” sites

Biopsy Technique Often coaxial with “outer” introducer needle and “inner” biopsy needle Need a “window”; Want to obtain an adequate tissue sample for diagnosis but need to utilize a safe approach May use conscious sedation along with local anesthesia

Solitary pulmonary nodule

PET scan

PET CT fusion

CT guided Lung Biopsy

Lung Biopsy

Ultrasound biopsies Require hand-eye coordination May be used for random sampling, i.e. for gross liver biopsy For focal lesions, often in difficult to access locations, if poorly seen on CT scan, or if lesion is “mobile”

Ultrasound guided biopsy of a focal liver mass

X-ray guided biopsy Especially useful when patient positioning is limited; can rotate and angle the tube to obtain an approach for lesion access Advantage of real time imaging

Fluoroscopic vertebral body biopsy

Rotational angiography and Xper CT Technology in new Philips angio equipment that combines CT and 3D-imaging. Enhances IR procedures by allowing you to import previous MRI or CT data and fuse it with angiographic studies. Allows the interventionalist to use fluoroscopy and apply it to a CT image for challenging access.

Planning images

Progress images

Lung Palliative Tunneled pleural catheters Thermal ablation of destructive chest wall lesions Curative RFA of unresectable lung cancers or lung metastases

Tunneled pleural catheter

Painful Chest Wall Tumors

RFA

RFA lung cancer Early NSCLC or metastases in those deemed NOT to be surgical candidates Could have a poor functional status, abnormal PFTs’, Octogenarians? etc. Relapse in Radiation field Painful bone metastasis Chest wall invasion

RFA lung cancer

Lung Cancer survival If untreated, median survival 9-12 months. Surgical resection 5 year 60-70% RFA or Radiation 5 year 30-50% RFA 1 yr: 83-90%; 2 year 48-83%

LGH statistics 20 tumors treated with RFA; 16 patients. Treatment goals met in 15/16 patients. All but one patient was treated for cure. 4/16 patients required an additional ablation. Stable or without recurrence for up to 26 months. 1 unrelated death two days after treatment. Cardiac arrest.

Genitourinary (GU) Palliative – Percutanous nephrostomy – Dialysis catheters – Fistula or hemodialysis access maintenance Curative – Thermal ablation of renal cell cancer

GU procedures Percutaneous access to the collecting system for benign or malignant obstructions, stone disease, or urosepsis Can place internal double J ureteral stents from percutaneous access Can provide access for future stone removal and/or manipulation

Percutaneous Nephrostomy

PCN

Hemodialysis Catheter

Fistula

Cryoablation of Renal Cancer

CT cryoablation

Cryoablation Argon gas for freezing; Helium for thawing. Multiple probes; RFA just a single probe. Less risk of damage to collecting system. Greater risk of bleeding compared with RFA (coagulative necrosis). -20 to -40 degrees Celsius. Cell death. Can better identify treated zone.

Survival Stage I RCC- surgery with partial nephrectomy or nephrectomy 80+% 5 year survival Difficult to do much better for early disease Stage I RCC treated with RFA for 3 cm tumors or smaller 94% 2 year survival. Decreased survival as tumor size increases beyond 3 cm.

36 Is RCC Cryoablation Effective? 1 Littrup, J Vasc Interv Radiol 2007; Atwell, J Urol 2010; Rodriguez, Cardiovasc Interv Radiol months 26 months 24 months

LGH statistics 7 tumors treated 6/7 Renal cell cancer. 1/7 benign oncocytoma. 6/7 no signs of recurrence. 1/7 partially treated and opted for surveillance.

Gastrointestinal (GI) Palliative – Peritoneal catheters – Gastric tubes – Cholecystostomy drains – Biliary stents Locoregional control – Catheter-based embolization – Percutaneous thermal ablation

Peritoneal Catheter

Percutaneous Gastrostomy

Acute Cholecystitis

Percutaneous Cholecystostomy

Biliary Obstruction

Biliary Wallstent

Unresectable LiverDominant Image-Guided Therapy for Hepatic Malignancies

Definitions Liver-dominant neoplasm: malignancy in which the hepatic component is the only site of disease or the dominant site most likely to lead to patient morbidity or mortality

What’s so good about embolization or chemoembolization? Minimally-invasive loco-regional treatment Spares the patient the morbidity of surgery, radiation, or systemic therapy Achieves tumor necrosis Increases drug concentration delivered and dwell time of agent(s) Decreases systemic toxicity

Definitions Embolization: refers to blocking arteries by particles alone Oily Chemoembolization: infusion of chemotherapeutic agents with Ethiodized oil followed by embolic agents Drug-eluting beads: chemoembolization with calibrated microspheres that release drug over time

Definitions Tumor Ablation: direct application of thermal or chemical therapies to tumor(s) to eradicate or substantially destroy it – Chemical: ethanol or acetic acid – Thermal: application of energy to cause tumor necrosis. Examples include radiofrequency ablation (RFA), microwave, cryotherapy, high- intensity focused ultrasound (HIFU)

Why consider tumor ablation? Patients are living longer and presenting later in life with cancer. Co-morbid conditions are a major factor in considering patients for surgical resection. Minimally invasive therapies are in demand. Tumor ablation offers a chance for cure without surgery. Important psychological benefits to patients instead of just waiting and seeing what happens.

Hepatocellular Carcinoma Fewer than 20% of patients are candidates for resection due to cirrhosis. Transplantation only curative option for those with limited disease (one tumor < 5 cm, or three tumors < 3 cm). Choice of therapy depends on overall size, number, and location of tumors.

Chemoembolization of HCC: Randomized Trials 1)Lo et al., Hepatology Patients, 80% hep. B +, 7 cm tumors (60% multifocal) TACE Supportive care 57, 31, 26% 32, 11, 3% (1, 2, 3 year survival) 2) Llovet et al., Lancet Patients, 80-90% hep. C +, 5 cm tumors (70% multifocal) 112 Patients, 80-90% hep. C +, 5 cm tumors (70% multifocal) TACE Supportive care 82, 63%63, 27% (1, 2 year survival)

Hepatoma

Colorectal Metastases Median Survival for untreated 6-13 months Survival for most effective chemotherapy is 20 months Resecting metastases increases 5-year survival from 0-1% to 31-58%, perhaps even higher, more recent studies suggest. Only 5-20% eligible for surgical resection.

COLON CANCER Chemoembolization: Phase II Trials BCLCNWUU Penn 1 Frankfurt 2 #PTS Disease Control 63%63%43%63% Med. Surv.24 mo.29 mo.27 mo.38 mo. iology 2009

Colorectal mets and RF ablation RF ablation useful in patients not eligible for surgical resection, however, multiple independent studies showed that survival rates approach those of surgical resection. Local control best achieved in tumors 3.5 cm in size or smaller; goal of RFA is achieve a 1-cm ablation zone. RFA mortality is < 0.5% compared with 17-37% for surgical resection.

Colorectal Metastases

Neuroendocrine Tumors Only 5% of carcinoid tumors Up to 90% of gastrinomas Patients can be plagued by unregulated hormonal secretions of their tumors. Control with somatostatin agents. Those with hormonal production often have bulk liver disease, a contraindication to surgery.

NET

Summary Interventional Radiology has a critical role in the care of cancer patients and offers both palliative and curative therapies. Although many of these therapies are not first line treatment, they should not be considered rescue therapy either. Rather, these interventions should be considered routinely during the evaluation and management of the cancer patient. There is increasing evidence to support improved survival and improved quality of life with combination therapies; for example, ablation with adjuvant chemotherapy, or chemoembolization with adjuvant radiation therapy.

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