1. MANAGEMENT OF LUNG TUMORS; IMAGE-GUIDED ABLATION vs. SBRT
Servet Tatli MD
Associate Professor Radiology
Harvard Medical School
Department of Radiology
Brigham and Women’s Hospital

2. Objectives
Review current status of image-guided tumor ablation techniques to treat lung neoplasms
Discuss advantages and disadvantages of image-guided ablation to treat lung neoplasms in comparison to radiation therapy
Nothing to disclose
Akciger Malign Tumorleri: Ablasyon vs Cyberknife
Ctesi, 3/28/17 at 8:20-8:40, 10 min
Salon A 2

3. Image-Guided Ablation
In last decades, a rapid advancement in image-guided tumor ablative methods (i.e., RF ablation)
effective
safe (no late complications)
preserves normal lung parenchyma
successful regardless of tumor histology
minimally invasive
feasible to inoperable patient with other co-morbidities
requires minimal hospital stay; can be performed as outpatient
can be performed under conscious sedation
can be combined with other methods (or when others fail)
serves for various goals (cure, local control, symptom palliation)
Frequently associated with CAD, RAD, carotid arterial disease

4. Image-Guided Ablation
widely available
fast
practical
can be done in a session
requires no prior procedures such as fiducial placement or biopsy
can be done at the time of biopsy
easily tolerated by patients
does not usually require patient cooperation
repeatable
easy to learn
less expensive than other alternatives
4.25 times higher cost of SBRT
Frequently associated with CAD, RAD, carotid arterial disease

5. Patient Selection Early stage (stage I&II) NSCLC
non-surgical candidate
failed other treatments
Solitary or small number of lung metastases
without extrapulmonary disease
Advanced (stage IIIB/IV) NSCLC & lung metastases
local tumor control
symptom palliation (chest pain, cough, dyspnea, hemoptysis) (Wagner TD, Curr Drug Targets 2010)

6. Tumor Selection Size Number Location < 3 cm (ideal), up to 5 cm
<3-5
exceptions (very slow growing tumors such as adenoid cystic carcinoma of salivary glands)
Location
pleural-based
intraparenchymal (surrounded by lung parenchyma)
>1 cm from bronchus, hilum, mediastinum (heart, trachea)
safe access route
Frequently associated with CAD, RAD, carotid arterial disease

7. Complications Pneumothorax: (~30%), majority is mild, and asymptomatic
central tumors, patients with no prior history of surgery
~1/3 requires pig tail catheter insertion; next day removal
Hemoptysis: (~3%), may last 1-2 weeks
no intervention required
Infection: (~2%)
requiring IV antibiotic
Hydro/hemothorax, pulmonary hemorrhage: self-limited
Cavitation and bronchial fistula formation: very rare
ablation of large tumors near large bronchi
Issue related to low lung reserve and other co-morbidities
~2.5 % (4/153) procedure related death (Simon CJ, Radiology 2007)
Frequently associated with CAD, RAD, carotid arterial disease 7

8. Lung Ablation, effectiveness
Variable reported outcome
depending on case selection and the method to measure
heterogeneous populations (~50% NSCLC and ~50% mets)
Over all post ablation complete tumor necrosis rate
(38% to 91% ; ~63.5 %) (Ambrogi MC, E J of Cardiothoracic Surg 2006)
Local recurrence of 43% with median disease free survival of 23 months (Beland MD, Radiology 2010)
Local tumor control at 1year: 88% (Lencioni RR, Clin Oncology 2008)
overall survival: 1 year (92%), 2 years (73%)
Overall survival: (Simon JS, Radiology 2007)
NSCLC at 1, 2, 3, 4, 5 y: 78%, 57%, 36%, 27% & 27%
colorectal mets at 1, 2, 3, 4, 5 y: 87%, 78%, 57%, 57% & 57%
Frequently associated with CAD, RAD, carotid arterial disease 8

9. Lung Ablation, effectiveness
1037 lung metastases in 642 patients,
De Baere T, Annals of Oncology, 2015 9

10. Lung Ablation vs. SBRT External beam XRT SBRT
5-year overall survival rates; 0% to 42% (Rowel NP, Thorax 2001)
SBRT
local control rate at 3 years: ~90 (Onishi H, Cancer 2004)
3 year overall survival: 58% (Timmerman R, JAMA 2010)
5 year lung cancer specific survival rate
XRT: 46%
SBRT:73%
RFA: 77% (Tramontano AC, AJR 2012)
Frequently associated with CAD, RAD, carotid arterial disease 10

11. RFA vs. SBRT Decision should be depend on tumor size location
comorbidities
individual patient preference
availability
Frequently associated with CAD, RAD, carotid arterial disease

12. RFA vs. SBRT
Patients with cardiopulmonary compromise may find it difficult to stay still during SBRT
RFA
require no prior biopsy or fiducial placement
can be done in a single session
repeatable
can be combined with other techniques
Frequently associated with CAD, RAD, carotid arterial disease

13. RFA vs. SBRT RFA is not appropriate:
central tumors
blood vessels (heat sink)
central airways, nerves, esophagus (injury)
large tumors (>3cm), decreased effectiveness
Microwave may be proven more effective
better energy deposition (higher intratumoral heat)
less effected by thermal sink
Cryoablation may be better
central tumor
large tumors
IRE may be better for central tumors
Frequently associated with CAD, RAD, carotid arterial disease

14. Conclusion
Image-guided RF ablation is promising treatment option for selected patients with primary or metastatic neoplasm of lungs that are not amenable to surgery
It is not only safe and minimally invasive but also associated with improve long term survival given the patient population treated
Careful patient selection and appropriate preablation work up and post ablation surveillance are important for satisfactory results
Frequently associated with CAD, RAD, carotid arterial disease

15. Thank you