1. Living Longer: Colon Cancer Patients Gain Time With Radiofrequency Ablation Treatment CT Sofocleous, EN Petre, M Gonen, KT Brown, RH Thornton, AM Covey, LA Brody, W Alago, M D'Angelica, SB Solomon, Y Fong, NE Kemeny. Memorial Sloan-Kettering Cancer Center, New York, NY Abstract 107: “Radiofrequency Ablation of Recurrent Colorectal Cancer Hepatic Metastases After Hepatectomy” @ www.SIRmeeting. 35th Annual Scientific Meeting March 13–18, 2010, Tampa, FL.

2. Facts about Colon Cancer Second leading cause of cancer-related death in the United States. 150,000 new patients diagnosed each year. Half of these patients will have cancer spread to their liver (liver metastases) at some point during the course of their disease. Surgery is considered the best treatment for liver metastases but the majority of the patients are not candidates for surgery. “In those (<25%) who undergo surgery, recurrence (a new spot of cancer coming back) is a serious problem. Traditionally chemotherapy has been the only therapy.

3. sofoclec@mskcc.org Treatment for Colon Cancer Liver Metastases Surgery (10-25%) Chemotherapy: systemic / Local IR Treatment -Ablation -RFA, Cryo, other - Radioembolization - Chemoembolization

4. Interventional Treatment NO CUTS Minimally Invasive: Needles, Catheters Imaging Guidance FEWER complications/ Side effects Fast Recovery. GO HOME SAME DAY!

6. Radiofrequency Ablation A special Needle (electrode is placed and destroys the tumor locally in the liver with minimal effect on the surrounding normal tissue.

7. Pt becomes electrical circuit. Generator produces AC at 300-500 kHz (RF range). Ionic agitation. Frictional heating. Protein denaturation, desiccation, coagulation necrosis. Impedance rises. How does RF work?

8. Thermal Ablation Cooking with Heat Heat induced cell death: –48 o C: in 45 min. –50-52 o C: after 4-6 min. –> 60 o C: Instantaneous cell death. –100-110 o C: Vaporization, carbonization, charring.

9. sofoclec@mskcc.org Ablation Needle/Electrode: Shape of Burn Ablation Needle/Electrode: Shape of Burn

10. sofoclec@mskcc.org Ablation Changes under the Microscope

11. Who is a Good Patient For Ablation Small Number of Tumors Small Size of Tumor Treatment of new tumors or enlarging Tumors after surgery or chemotherapy Traditionally Ablation has been offered to Patients that cannot have Surgery Ideal: Solitary Tumor < 3 cm

12. 2010: Surgery vs. Ablation for CLM SurgeryRFA Mortality0-6%<0.5% Morbidity17-56%8-10% LOS13 days2 days LTP3.8-44%2-60 (10.7) % OS 5 year 31-58 %14-55 %* unresectable patients *

13. Patients that have tumor recurrence in their liver after surgery have limited therapy options. Those with less than 3 tumors under 5 cm each may benefit from ablation. “ “Radiofrequency Ablation of Recurrent Colorectal Cancer Hepatic Metastases After Hepatectomy.”

14. “Radiofrequency Ablation of Recurrent Colorectal Cancer Hepatic Metastases After Hepatectomy.” We ablated 71 CLM that developed after liver surgery in 56 patients. We calculated: Successful ablation: Burn size covering the entire tumor on 4-6 week post-treatment CT Complications Cancer coming back at the site of ablation: local tumor progression (LTP) and Overall patient survival

15. Risk Factors: Modified clinical risk score (CRS) Risk Factors: Modified clinical risk score (CRS) Tumor Size (>3 cm). Disease Free Interval (<12 months). Number of tumors > 1. LN + primary. CRS2 year survival 1 year No Tumor 0-274%66% 3-442%22%

16. Follow-up Imaging: Success /No LTP PRE 4 weeks 24 months 47 months

17. Repeat Ablation Treats Tumor Coming Back LTP-free survival Median (months) 1-year rate Primary After 1 RF 1050% *Assisted Repeated RF 2564% (*includes all the ablations performed for the same target tumor

18. p<0.01 Tumor-free Interval by CRS CRSMedian1-2-3-years 0-216 mos66%48% 3-45 mos22%00

19. Overall Patients Survival after RF Median1-2-3-yr 31 mos91%66%41% Additional Length of Life after Failure of Surgery

20. Overall Survival by CRS p=0.03 CRSMedian1-2-3-year 0-235 mos98%73%45% 3-421 mos69%42%28%

21. Median survivalHAICNo HAICp Overall SurvivalNot reached25 months LTP-free Survival14 months10 months0.19 Ablation with local chemotherapy

22. Conclusion: RF ablation can treat colon cancer liver metastases that come back after surgery. This can significantly prolong life of patients with limited treatment options. The combination of a low clinical risk score, surveillance with imaging and repeat ablation to treat LTP are associated with better outcomes

23. SIR 2005 New Orleans