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

2. Objectives Review of image-guided tumor ablation technique to treat lung neoplasms Discuss technical issues that may arise during image-guided ablation of lung neoplasms with some illustrated examples Nothing to disclose

3. NSCLC 2nd most common cancer in both men and women By far the leading cause of cancer related deaths in both gender Surgical resection remains the mainstay for early- stage (stage I/II) NSCLC (Rajdev L, Surg Oncol 2002) –only 30% patients with disease confined to lung (stage I/II) only 1/3 of these are surgical candidates

4. Lung Metastases The second most common organ for metastases ~20% patients with primary site removed are found to have metastases limited to the lungs –colorectal, osteosarcoma, RCC, testis, breast, melanoma (Pastorino U, J Thor Cardiovasc Surg 1997) Resection of pulmonary metastases may result in improved disease-free survival (Saito Y, J Thor Cardiovasc Surg 2002) –not candidates for surgical resection low pulmonary reserve, co-morbid conditions, diseases in both lungs

5. Prognosis High number of poor surgical candidates Unsatisfactory response to conventional treatment methods necessitate alternative treatment methods

6. Alternative Image-guided thermal ablation techniques such as RF ablation may be alternative treatment option for these patients’ groups

7. Patient Selection Stage I/II NSCLC: non surgical candidates Solitary or limited number lung metastasis without extrapulmonary disease Stage III/IV NSCLC and pulmonary metastasis –local tumor control –symptom palliation (chest pain, cough, dyspnea, hemoptysis)

8. Tumor Selection Size –< 3 cm (ideal) –up to 5 cm Number –<3-5 –exceptions (adenoid cystic carcinoma of salivary glands) Location –pleural-based –intraparenchymal (surrounded by lung parenchyma) >1 cm from bronchus, hilum, mediastinum (heart, trachea)

9. Patient Evaluation Evaluation by thoracic oncologist / surgeon Consultation with interventional radiologist –rationale: cure, local tumor control, symptom palliation –feasibility: size, location, access route –risk/benefit –cardiopulmonary status cardiology evaluation pulmonary function test –medications (anticoagulants) –concurrent pulmonary infection

10. Patient Evaluation Percutaneous biopsy for pathological diagnosis –may not need in every case prior path diagnosis, new mass, FDG avidity > 4 SUV Baseline imaging: CECT, MRI, PET/CT –no more than 4 weeks before than RF ablation Anesthesia consult Coagulation workup: PT, PTT, INR, platelet, hct

11. Preparation Discontinue anticoagulants Overnight fasting Prophylactic antibiotics –broad-spectrum: Ancef 1-2mg, IV Pacemaker malfunction; needs temporary deactivation (RF ablation)

12. Guidance US: lack of acoustic penetration due to bones and lungs –may be used for pleural based or chest wall tumors MRI: limited availability –poor visualization of ablation applicator –require MR compatible equipment CT: imaging modality of choice –excellent tumor and ablation probe visualization –multiplanar reformations PET/CT: metabolic information + other advantages of CT

13. Ablation Procedure Anesthesia –GA, double lumen T tube, blocker, continuing inflation Positioning –tumor side down if possible –avoid excessive overhead positioning of the arm Access –over the rib not below –avoid transgressing fissures –avoid ablating pleura, no tract burn Multiple tumors –treat tumors at one side at one session Hinshaw JL, Radiographics 2014

14. Ablation Procedure To achieve adequate tumor necrosis ablation needs to include: –entire tumor & surrounding parenchyma (ablation margin, >6-10mm) adjacent critical structure aerated lung (insulator) heat sink –over lapping ablations to cover large tumors www.onemedplace.com

15. Ablation Procedure Intraprocedural monitoring

16. Ablation Procedure Intraprocedural monitoring

17. Ablation Procedure Parenchymal hemorrhage

18. Ablation Procedure Pneumothorax

19. Ablation Procedure Pneumothorax

20. Ablation Procedure Post-ablation pneumonia and abscess

21. Ablation Procedure Artificial pneumothorax Dupuy DE, Radiology 2011

22. Ablation Procedure 72 yof with a NSCLC who was not a candidate for surgical resection due to severe COPD Severe emphysema

23. Ablation Procedure Large tumors 45 yof with breast Ca and solitary RLL met, which was treated by surgically but showed recurrence.

24. Ablation Procedure Central tumors 30-yof with lung metastases from adenoid cystic ca of salivary gland

25. Ablation Procedure Central tumors 77- year-old woman with non-small cell carcinoma (NSCLC)

26. Ablation Procedure Multiple tumors 60-year-old woman metastatic salivary gland adenoid cystic ca

27. Ablation Procedure Multiple tumors 60-year-old woman metastatic salivary gland adenoid cystic ca

28. Fused Image Monitoring Ablation Procedure Image-registration can be used to visualize the tumor Planning

29. Ablation Procedure Post XRT recurrence

30. Post-procedural care PACU: CXR (2-3 hr), labs (CBC, chem 7, myoglobin) Overnight admission to observe Next day: CXR, labs (CBC), (CT, MR, PET/CT) 1 week follow up clinic visit: analgesia, post ablation syndrome, brown sputum, shortness of breath 3, 6, 9, 12 months follow up imaging (CT, MR, PET/CT)

31. Post ablation, assesment Assessment of adequacy of ablation –difficult to differentiate post-ablation changes from residue –ablated surrounding tissue increases size of treated tumor completely ablated tumor may appear grown in size (RECIST criteria is not helpful) –contrast-enhanced CT is more useful than non-contrast imaging –MR, PET/CT more sensitive than CECT in detection of viable tumor

32. Lung Ablation, surveillance Dupuy D E Radiology 2011

33. Lung Ablation, surveillance T1WI post contrast (subtracted) T2WI T1WIT2WI Pre-ablation MRI Post-ablation MRI

34. Lung Ablation, surveillance Cavity formation, rare 1 year6 months3 months24-hours

35. Lung Ablation, surveillance Recurrence pre-ablation post-ablation (subtracted)

36. 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 tumor control at 1year: 88% (Lencioni RR, Clin Oncology 2008) Overall survival: 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% (Simon JS, Radiology 2007)

37. Lung Ablation, effectiveness De Baere T, Annals of Oncology, 2015

38. 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 Careful patient selection and appropriate pre- ablation work up and post ablation surveillance are important factors for satisfactory results

39. Thank you