CT guided thermal ablation of recurrent lung cancer in patients post radiotherapy. A case series review

Transcription

1 CT guided thermal ablation of recurrent lung cancer in patients post radiotherapy. A case series review Poster No.: R-0106 Congress: 2014 CSM Type: Scientific Exhibit Authors: S. Gray; BRISBANE/AU Keywords: Lung, Interventional non-vascular, CT, PET-CT, Ablation procedures, Cancer DOI: /ranzcr2014/R-0106 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 14

2 Aim Lung cancer is currently the leading cause of cancer related mortality for both men and 1 women worldwide making it an important global health issue. For local non-small cell lung cancer (NSCLC), the standard treatment is surgical resection, which achieves the 2 highest cure rate. However, at least 20% of patients are unable to have surgery due to 3 medical comorbidities. The treatment of choice for non-surgical candidates, or those who refuse surgery with early disease involves external beam radiotherapy, with or without 4,5 chemotherapy. Once local recurrence occurs within the radiation field, there is little scope for further irradiation due to the risk of radiation-induced fibrosis, tumour resistance and increasing cumulative radiation exposure. As a result, there are limited treatment options available consisting of chemotherapy or palliation. Thermal ablation therapy represents a novel salvage therapy for this subset of patients. The aim of this study is to retrospectively evaluate the clinical outcomes of time to local progression (TTLP) and overall survival (OS) for percutaneous computer tomography (CT) guided thermal ablation performed on patients with local tumour recurrence post external beam radiotherapy. The aim of the project is to evaluate and confirm thermal ablation as a viable salvage therapy for patients with recurrent NSCLC post-radiotherapy. Page 2 of 14

3 Methods and materials Patients were selected using a radiology thermal ablation database at a large tertiary hospital. Data was collected retrospectively through systematic review of patient charts and imaging. Inclusion criteria - Patients with biopsy confirmed Non Small Cell Lung Cancer (NSCLC) who underwent percutanteous CT guided thermal ablation between 2008 and 2013, and had received prior external beam radiotherapy. Exclusion Criteria - Patients were excluded if radiotherapy did not precede thermal ablation, the recurrent tumour (target) was outside the radiated lung field or the target was distant from the treated lesion. Both Radio-frequency Ablation (RFA) and Microwave Ablation (MWA) thermal ablation techniques were used under CT guidance. MWA replaced RFA by mid RFA was performed in four tumours. Two RFA ablations were performed using a Valleylab Cool Tip device from Covidien and two ablations were performed using a Starburst-XL device from Angiodynamics. Eight MWA cases were performed with the Acculis MTA from Angiodynamics whilst one case was performed using the Evident MWA system from Covidien. All ablations were performed by an experienced thoracic radiologist with 10 years experience in lung ablation. The choice of conscious sedation or general anaesthesia was determined by the anaesthetist in charge at the time of the procedure. Patient's were generally admitted overnight and discharged the following day Baseline CT was performed 24 hours post Ablation. Generally patients were followed up with 3, 6, 12 month, then 6-monthly CT scans. PET/CT was performed at 3-6 months post ablation. 5 The Modified Recist Criteria were used to determine the response to ablation therapy. The response was classified into one of: Complete Response (CR), Partial Response (PR), Stable Disease (SD) and 5 Progressive Disease (PD). Overall Survival (OS) was defined as the time interval between first ablation and death. The primary clinical outcomes of TTLP and OS were analysed using the Kaplan-Meier method. TTLP was analysed per leison, whilst OS was analysed per patient. The Clinical outcomes (TTLP and OS) were compared for nodule size (<30mm and > 30 mm) and between RFA and MWA modalities. Statlistical significance was considered at a value of p < Page 3 of 14

4 Images for this section: Fig. 1: 76-year-old male with local recurrence of RUL NSCLC treated with 60Gy in 30 fractions. a, b. Axial CT scan at 6 and 9 months post XRT shows increasing fullness of the treated tumour. c. Axial FGD-PET scan demonstrates residual circumferential uptake with non-avid centre, likely indicating necrosis. Royal Brisbane and Womens' Hospital - BRISBANE/AU Page 4 of 14

5 Fig. 2: 76-year-old male with local recurrence of RUL NSCLC treated with 60Gy in 30 fractions. a. Planning scan on the day of MWA shows the tumour to have further increased in size, growing into the mediastinum, the maximum diameter measured at 61.4mm. b, c, d. Three of a total of five overlapping ablation positions shown, targeting the FDG-PET avid tumour margin. Royal Brisbane and Womens' Hospital - BRISBANE/AU Page 5 of 14

6 Fig. 3: 76-year-old male with local recurrence of RUL NSCLC treated with 60Gy in 30 fractions. a, b. Axial and coronal FDG-PET scan 6 months post MWA shows residual FDG-uptake in the lower pole of the ablated tumour (arrow). c, d. Repeat technically successful targeted MWA of the small residual avid focus, the multi-planar reformats confirming the appropriate position of the antenna. Royal Brisbane and Womens' Hospital - BRISBANE/AU Page 6 of 14

7 Results 9 patients were identified who met the inclusion criteria. 4 of these patients underwent a second ablation for local tumour recurrence resulting in a total of 13 ablations. Local tumour recurrence occurred in 5 of 9 patients (56%) of which 4 of 5 patients underwent a second ablation (80%). No recurrence of the target lesion was observed in any patient following a second ablation. Median Time to Local Progression following ablation was 14 months. Cummulative local progression rates at one and two years were 33% and 42% respectively. Mean Overall Survival was 52 months (95% CI, 21,84). There was no statistically significant difference in Time to Local Progression between RFA and MWA techniques. Tumours with small size (<30 mm) had a Time to Local Progression of 15 months compared to 12 months for larger tumours (>30 mm) although this was not statistically significant. Pneumothorax occured in 4 of 13 ablations (33%). Of the patients who experienced pneumothorax 2 required chest drain placement. Page 7 of 14

8 Images for this section: Fig. 4: Subject and Tumour characteristics Royal Brisbane and Womens' Hospital - BRISBANE/AU Page 8 of 14

9 Fig. 5: Treatment Characteristics Royal Brisbane and Womens' Hospital - BRISBANE/AU Fig. 6: Time to Local Progression by modality and lesion size Royal Brisbane and Womens' Hospital - BRISBANE/AU Page 9 of 14

10 Fig. 7: Kaplan-Meier curve of TTLP for recurrent NSCLC treated with thermal ablation in patients previously receiving radiation therapy (n=11). The median TTLP is 14 months (95% CI, 6, 21). TTLP = Time to local progression. NSCLC = Non Small Cell Lung Cancer, CI = Confidence Interval Royal Brisbane and Womens' Hospital - BRISBANE/AU Page 10 of 14

11 Conclusion There are limited treatment options available for patients with recurrent lung cancer post radiotherapy. Our study demonstrates that thermal ablation represents a promising salvage therapy with promising overall survival and time to local progression results. The time to local progression in our study at 14 months was the same as 6 that seen in the study by Schoellnast et al. but considerably longer in a 7 study by Leung et al. of 3 months. Possible differences may be related to a larger mean tumour size in the Leung et al. study of 45mm versus mean tumour diameter of 34 mm in our study and 28 mm in the study by Schoellnast et al. The overall survival in our study was 52 months. This compares to 8 33 months and 21 months in Pennathur et al. and Schoellnast et al. 6 respectively. Possible reasons by this was the relatively high rate of reablation performed in our study (57% compared to 9% in Schoellnast et al.) resulting in greater cummulative thermal energy delivered and more aggressive local control. In our study all patients who were reablated did not develop subsequent tumour recurrence. This is one of the strengths of thermal ablation, whereby treatments can be repeated in the setting of recurrence with little adverse effects. Pneumothoraces occured in 31% of cases, of which 15% required chest 9,10 tube insertion. These rates are similar to those seen in other studies. Our study did not show a statistically significant difference in outcomes between radiofrequency ablation and microwave ablation. This is surprising given the significant theoretical advantages in microwave ablation with more 11,12 rapid heating zone, higher temperature and less heat sink effect. Our result may have been impacted by the relatively small sample size. The most significant limitation of this study is its small sample size and retrospective design. There are promising prospects for thermal ablation to be used in combination with radiotherapy. Possible synergies are thought to occur due to radiotherapy targeting oxygenated cells of the periphery, whilst thermal ablation targets more hypoxic cells in the centre. Thermal ablation is less effective at the periphery due to increasing heat sink effects of blood vessels. 13,14 Page 11 of 14

12 Personal information Simon Gray, Mathew Cheng, Karin Steinke, Michael Fay 1 Department of Medical Imaging, Royal Brisbane & Womens' Hospital, Queensland, Australia. 2 Department of Medicine, Princess Alexandra Hospital, Queensland, Australia, Queensland, Australia. 3 Department of Radiation Oncology, Royal Brisbane & Womens' Hospital, Queensland, Australia. Page 12 of 14

13 References 1. Ferlay J, Soerjomataram I, Ervik M, et al: Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11, GLOBOCAN 2012 v1.0. Lyon, France, International Agency for Research on Cancer, Van Schil PE: Surgery for non-small cell lung cancer. Lung Cancer 34 Suppl 2:S127-32, El-Sherif A, Gooding WE, Santos R, et al: Outcomes of sublobar resection versus lobectomy for stage I non-small cell lung cancer: a 13-year analysis. Ann Thorac Surg 82:408-15; discussion 415-6, O'Rourke N, Roque IFM, Farre Bernado N, et al: Concurrent chemoradiotherapy in non-small cell lung cancer. Cochrane Database Syst Rev:CD002140, Abbas G, Schuchert MJ, Pennathur A, et al: Ablative treatments for lung tumors: radiofrequency ablation, stereotactic radiosurgery, and microwave ablation. Thorac Surg Clin 17:261-71, Schoellnast H, Deodhar A, Hsu M, et al: Recurrent non-small cell lung cancer: evaluation of CT-guided radiofrequency ablation as salvage therapy. Acta Radiol 53:893-9, Leung VA, DiPetrillo TA, Dupuy DE: Image-guided tumor ablation for the treatment of recurrent non-small cell lung cancer within the radiation field. Eur J Radiol 80:e491-9, Pennathur A, Luketich JD, Abbas G, et al: Radiofrequency ablation for the treatment of stage I non-small cell lung cancer in high-risk patients. J Thorac Cardiovasc Surg 134:857-64, Simon CJ, Dupuy DE, DiPetrillo TA, et al: Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients. Radiology 243:268-75, Choe YH, Kim SR, Lee KS, et al: The use of PTC and RFA as treatment alternatives with low procedural morbidity in non-small cell lung cancer. Eur J Cancer 45:1773-9, Simon CJ, Dupuy DE, Mayo-Smith WW: Microwave ablation: principles and applications. Radiographics 25 Suppl 1:S69-83, Yu NC, Raman SS, Kim YJ, et al: Microwave liver ablation: influence of hepatic vein size on heat-sink effect in a porcine model. J Vasc Interv Radiol 19: , 2008 Page 13 of 14

14 13. Wachsberger P, Burd R, Dicker AP: Tumor response to ionizing radiation combined with antiangiogenesis or vascular targeting agents: exploring mechanisms of interaction. Clin Cancer Res 9: , Jain SK, Dupuy DE, Cardarelli GA, et al: Percutaneous radiofrequency ablation of pulmonary malignancies: combined treatment with brachytherapy. AJR Am J Roentgenol 181:711-5, 2003 Page 14 of 14