Long term follow-up after pulmonary radiofrequency ablation

T. de Baère,

Institut Gustave Roussy - Villejuif - France

Lung tumorsLung tumors

• Cancer- 80% of cancer cured = suregry ± other therapies (radiation/chemo)

- Others surgical like techniques ? ablative therapies?

• Primary lung cancer- Second cause of death in man in France- Leading cause of cancer death in the world- 20% of patients are surgical candidates

• Lung metastases- 25/30% of cancer patients at autopsy- 50% of renal cell carcinoma- Sarcoma (42%), Colon (14%), Breast (9%), Renal (8%),

Testicular (7%), Melanoma (6%), ENT (5%)

Lung SurgeryLung Surgery

• Surgical resection of metastases- 1882 : Incidental resection of chest wall sarcoma and 2 metastases- 1947 : First series of 24 resections, including a repeated thoracotomy- 2000 : First report of RF ablation in the lung

• Criteria for resection metastases (The goal is to cure and to not harm)– Patient must be able to tolerate– Sufficient pulmonary reserve– Primary tumor controlled / controlable– No extra-pulmponary disease– No better therapy

Lung RadiofrequencyLung Radiofrequency

• Surgical resection of metastases- 1882 : Incidental resection of chest wall sarcoma and 2 metastases- 1947 : First series of 24 resections, including a repeated thoracotomy- 2000 : First report of RF ablation in the lung

• Criteria for RF Ablation metastases (The goal is to cure and to not harm)– Patient must be able to tolerate– Sufficient pulmonary reserve– Primary tumor controlled / controlable– No extra-pulmponary disease– No better therapy

Lung RadiofrequencyLung Radiofrequency

• Surgical resection of metastases- 1882 : Incidental resection of chest wall sarcoma and 2 metastases- 1947 : First series of 24 resections, including a repeated thoracotomy- 2000 : First report of RF ablation in the lung

• Criteria for RF Ablation metastases (The goal is to cure and to not harm)– Patient must be able to tolerate– Sufficient pulmonary reserve– Primary tumor controlled / controlable– No extra-pulmponary disease– No better therapy

RF can be possible

Lung RadiofrequencyLung Radiofrequency

• Surgical resection of metastases- 1882 : Incidental resection of chest wall sarcoma and 2 metastases- 1947 : First series of 24 resections, including a repeated thoracotomy- 2000 : First report of RF ablation in the lung

• Criteria for RF Ablation metastases (The goal is to cure and to not harm)– Patient must be able to tolerate– Sufficient pulmonary reserve– Primary tumor controlled / controlable– No extra-pulmponary disease >> Two sites in a single RF session

– No better therapy

RF can be possible

Lung RadiofrequencyLung Radiofrequency

• Surgical resection of metastases- 1882 : Incidental resection of chest wall sarcoma and 2 metastases- 1947 : First series of 24 resections, including a repeated thoracotomy- 2000 : First report of RF ablation in the lung

• Criteria for RF Ablation metastases (The goal is to cure and to not harm)– Patient must be able to tolerate– Sufficient pulmonary reserve– Primary tumor controlled / controlable– No extra-pulmponary disease >> Two sites in a single RF session

– No better therapy– Limited to small size tumors

RF can be possible

420 – 500 kHz sinusoidal current

ionic agitatin

friction

tissues heating

Principle of radiofreqiencyPrinciple of radiofreqiency

TemperatureTemperature > 60°C : immediate cellular death > 60°C : immediate cellular death

QuickTime™ et undécompresseur Cinepak

sont requis pour visionner cette image.

420 – 500 kHz sinusoidal current

ionic agitatin

friction

tissues heating

Principle of radiofreqiencyPrinciple of radiofreqiency

TemperatureTemperature > 60°C : immediate cellular death > 60°C : immediate cellular death

Methods (treatment)Methods (treatment)

• Accurate needle placement• CT guidance

– Needle placement• Real time CT or Fluoro CT

QuickTime™ et undécompresseur codec YUV420

sont requis pour visionner cette image.

Methods (treatment)Methods (treatment)

• Accurate needle placement• CT guidance

– Needle placement• Real time CT or Fluoro CT

– Needle/electrode position• Multiplanar reconstruction

MaterialMaterial• 244 patients (27-81 years)

- Age : 62±14 years (27-85)

• 397 tumors 4 - 70 mm (m=17 ± 9.5)– Métastases : 197 patients (81%) - (343 tumors)– Primary : 47 patients (19%) - (52 tumors)

– Unilateral 187 patients (77%), bilateral 57 patients (23%)

– Number of tumor / Patient• n = 1 (57%), n = 2 (25%), n = 3 (13%), n = 3 (5%), n = 5 or + (6%)

ResultsResults

• 301 RF sessions / 314 lung treated– Usally one lung at a time / 13 bilateral

• Anesthesia• General anesthesia 296

• Conscious sedation 3

• Local 2

• Pneumothorax with chest tube 12%

• Alveolar hemorraghe 14%

• Cutaneous burn 1%

• Death 0.5% (ventricular fibrillation)

Side effects and Complications (During treatment)Side effects and Complications (During treatment)

• No symptom 66 %At least one symptom 34 %Pain 23% (mild 4%, moderate19%)Hemoptysis 5%Pneumopathy 3%Respiratory insufficiency 0.5%

Side effect (after hospital discharge)Side effect (after hospital discharge)

Rate of local tumor progressionRate of local tumor progression

• Incomplete local ablationIncomplete local ablationPer tumor : 6.1% (4-9) @1 year, 11.2% (8-15) @ 2 years

tumor ≤ 2cm : 3.7% (2-7) @1 year, 8.2% (5-13) @ 2 yearstumor >2cm : 12.4% (7-21) @1 year, 19.4% (12-30) @ 2 years

P = 0.002

SurvivalSurvival

Survival : med =25 months88.7% (84-92) @ 1 year, 70.3% (63-76) @ 2 years

Patients without pulmonary evolution (RF site or distant) 57.5% (51-64) @ 1 year, 38.8% (32-47) @ 2 years    

Interval without pulmonary evolution

36812224147920315381136195

0.000.10

0.200.300.40

0.500.600.700.80

0.901.00

0 6 12 18 24 30 36Months

Primary lung tumorPulmonary metastasis

At risk

66%

52%

54% 35%

SurvivalSurvival

Survival : med =25 months88.7% (84-92) @ 1 year, 70.3% (63-76) @ 2 years

Patients without pulmonary evolution (RF site or distant) 57.5% (51-64) @ 1 year, 38.8% (32-47) @ 2 years    

(Simon CJ, Radiology 2007)

18 CRC mets patients87%@1year,78%@2 years

SurvivalSurvival

Patients with lung metastasis treated by radiofrequency ablation

32527698147178195920315381136195

0.000.10

0.200.300.40

0.500.600.700.80

0.901.00

0 6 12 18 24 30 36Months

Overall survivalInterval without pulmonary evolution

At risk

54%

90%

72%

35%

(Yan TD, Ann Surg Oncol 2007)

55 CRC mets patients85%@1year, 64%@2 years, 46% @ 3 years

71 CRC mets patients84%@1year, 62%@2 years, 46% @ 3 years

(Yamakado K, JVIR 2007)

SurvivalSurvival

LONG-TERM RESULTS OF LUNG METASTASECTOMY: PROGNOSTIC ANALYSES BASED ON 5206 CASES Ugo Pastorino, J Thorac Cardivasc Surg 1997

Patients with lung metastasis treated by radiofrequency ablation

32527698147178195920315381136195

0.000.10

0.200.300.40

0.500.600.700.80

0.901.00

0 6 12 18 24 30 36Months

Overall survivalInterval without pulmonary evolution

At risk

54%

90%

72%

35%

RF ablation lung metastasesRF ablation lung metastases

• Minimaly invasive• High local success rate• Curative treatment in non surgical patients

Will replace some surgery ?• Size is the main limitation

2.5-3.5 cm

> 90 % = 70 % ≤ 50 %

4/5 cm

His own lung His own lung radiofrequency procedure radiofrequency procedure from a painter patientfrom a painter patient

debaere@igr.fr : What is missing in the room ?

• Size > 2 cm (p=0.0002)

• Rectal origin (p=0,02)

• Number• Location (related to the pleura, medistinum

Factors for survivalFactors for survival