Radiofrequency ablation combined with conventional radiotherapy: a treatment option for patients with medically inoperable lung cancer

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1 Radiofrequency ablation combined with conventional radiotherapy: a treatment option for patients with medically inoperable lung cancer Poster No.: C-0654 Congress: ECR 2011 Type: Scientific Paper Authors: P. ARGUIS, F. Casas, M. Sanchez, R. Marrades, E. Carrero, F. Lomeña, R. J. Perea, T. M. de caralt; Barcelona/ES Keywords: DOI: Interventional non-vascular, Lung, Oncology, CT, Percutaneous, Ablation procedures, Radiation therapy / Oncology, Neoplasia /ecr2011/C-0654 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Purpose The purpose of this communication is to evaluate the effectiveness of lung radiofrequency ablation (RFA) followed by conventional radiotherapy in medically inoperable stage I non-small cell lung cancer and the extent of treatment-related morbidity. For patients with stage I NSCLC surgical resection is the best treatment option. However, due to coexistent morbid medical conditions, occasionally these patients are not suitable for surgery. Patients who are not surgical candidates are usually treated with radical radiotherapy. In a meta-analysis determining the effectiveness of radical radiotherapy for stage I/II medically inoperable NSCLC patients, overall 5-year survival ranged from 0 to 42%, with complete response rates of 33 to 61% and local failure rates ranging from 6 to 70%. One of the reasons for radiotherapy failure is poor local control. The reason for combining RFA with Radiotherapy is the different action mechanism. RFA is more effective in central areas of the tumour and Radiotherapy in the periphery. Images for this section: Page 2 of 17

3 Fig. 1: NSCLC. Radiofrequency + Radiotherapy. Page 3 of 17

4 Methods and Materials Between June 2003 and July 2010 we treated a series of 10 patients with medically unresectable stage I (T1-T2aN0M0) lung cancer: 9 male and 1 female, with a mean age of 75.8 (range: 65-89). The mean tumour size was 3.2 cm (range ). The mean follow-up period was 22.8 months (range: 6 to 77). Patients were considered non-surgical candidates by an interdisciplinary group because of age, insufficient respiratory reserve and comorbidity (mainly cardiovascular disease). Patient data are summarized in Table 1 Proof of malignancy was obtained in all patients (see inclusion criteria). RFA was performed under conscious sedation using CT fluoroscopy guide (Fig 1 on page 5). A CT study was performed at the end of the RF procedure (Fig 2 on page 6), and 24 hours after (fig 3 on page 7) to assess technical success and to detect any complications. Beginning within 4-5 weeks after completion of RFA, patients underwent external-beam radiotherapy. Radiation was performed with 25 fractions of 2.5 Gy per fraction for a total of 62.5 Gy (Fig 4 on page 8). Evaluation of the therapeutic effects was determined using contrast enhanced CT scans taken every 6 months (Fig 5 on page 9) and MRI (Fig 6 on page 10) and dual point PET/CT (Fig 7 on page 11) in some cases. TABLE 1. PATIENTS SEX AGE SICE (stage) NON SURGERY (cause) FOLLOW- UP (month) RELAPSE Male 71 4 (T2a) Pulmonary months (adrenal metastasis) CAUSE OF DEATH Respiratory failure Male (T1b) Pulmonary 21 No neck cancer- Page 4 of 17

5 + cardiopathy Male (T2a) Age 35 No - Male (T1b) Pulmonary 21 6 months (pulmonary metastasis) Male (T2a) Age + 25 No - pulmonary + cardiopathy Male (T1b) Pulmonary 18 No - + cardiopathy Female (T2a) Pulmonary 12 No - Male (T1b) Pulmonary 7 No - Male (T1b) Age + 6 No - pulmonary Male (T2a) Pulmonary 6 No - related bleeding Respiratory failure * Inclusion Criteria: 1. Patients with cytology or biopsy-proven NSCLC stage I (T1-T2a N0 M0). 2. Lung tumour accessible by percutaneous route. 3. Clinical staging with positron emission tomography (PET). 4. Medically inoperable due to comorbid conditions 5. Approved by an interdisciplinary group consisting of pulmonologists, thoracic surgeons, medical oncologists, radiation oncologists and radiologists. 6. Signed informed consent for radiofrequency ablation 7. Coagulation test Images for this section: Page 5 of 17

6 Fig. 1: Prone CT image shows radiofrequency electrode within the mass. Page 6 of 17

7 Fig. 2: CT scan obtained at the end of the RFA shows a small located pneumothorax and a ground-glass opacity surrounding the nodule consistent with successful ablation Page 7 of 17

8 Fig. 3: CT perfusion obtained 24 hours after the RFA. Image consistent with complete necrosis. Page 8 of 17

9 Fig. 4: NSCLC. Radiofrequency + Radiotherapy. Page 9 of 17

10 Fig. 5: CT scan obtained 18 months after the ablation shows mild pleural thickening without evidence of local recurrence. Page 10 of 17

11 Fig. 6: Contrast-enhanced MRI with subtraction 8 months after the ablation. We can see the nodule treated with contrast enhanced peripheral ring consistent with reactive inflammatory changes. There are also inflammatory changes in the lung parenchyma due to radiotherapy. There is no evidence of contrast enhanced nodular areas suggesting recurrence Page 11 of 17

12 Fig. 7: Image shows the normal aspect of the ablated area 14 months after RF ablation at FDG PET/CT. There is no evidence of recurrence. Page 12 of 17

13 Results There were minor complications after RFA as pneumothorax (3), hemothorax (1) and pleural effusion (3) without requiring chest tube (Fig 8 on page 13). There were no cases of symptomatic pulmonary toxicity secondary to radiotherapy. There were no lung cancer-related deaths. Two patients died of respiratory failure secondary to COPD exacerbation and one case due to neck cancer-related bleeding. There was no evidence of local recurrence. Two patients developed metastases in lung (1) and adrenal glands (1) treated with chemotherapy. * Patient data are summarized in Table 1 Images for this section: Page 13 of 17

14 Fig. 1: Self-limited hemothorax during the ablation. Page 14 of 17

15 Fig. 2: Image shows the normal aspect of the ablated area 14 months after RF ablation at FDG PET/CT. There is no evidence of recurrence. Page 15 of 17

16 Conclusion Combined CT-guided RFA and conventional radiotherapy in medically inoperable patients is a safe modality for the local control of stage I lung cancer better than radiotherapy alone. Randomized studies are needed to know if there is a survival improvement. Images for this section: Fig. 1: Prone CT image shows radiofrequency electrode within the mass. Page 16 of 17

17 References - Lencioni R, Crocetti L, Cioni R, et al. Response to radiofrequency ablation of pulmonary tumours: a prospective, intention-to-treat, multicentre clinical trial (the RAPTURE study). Lancet Oncol 2008; 9: Damian E. Dupuy, Thomas DiPetrillo, Sachin Gandhi, et al. Radiofrequency Ablation Followed by Conventional Radiotherapy for Medically Inoperable Stage I Non-small Cell Lung Cancer. Chest 2006;129; Hiran C. Fernando. Radiofrequency Ablation to Treat Non-Small Cell Lung Cancer and Pulmonary Metastases. Ann Thorac Surg 2008;85:S Fernando HC, De Hoyos A, Landreneau RJ, et al. Radiofrequency ablation for the treatment of non-small cell lung cancer in marginal surgical candidates. J Thorac Cardiovasc Surg 2005; 129: Rowell NP, Williams CJ. Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable): a systematic review. Thorax 2001; 56: Personal Information Dr. Pedro Arguis (parguis@clinic.ub.es) Department of Radiology. Hospital Clinic. Barcelona. Spain. Page 17 of 17