Minimally Invasive Cancer Therapies
in Interventional Radiology
Chief, Vascular and Interventional Radiology
Lancaster Radiology Associates
Co-Director, Interventional Vascular Unit
Objectives
• 1- Identify currently available IR procedures
related to cancer care at LGH
• 2- Enhance medical staff knowledge of such
procedures
• 3- Discuss current IR cancer treatments
Palliative and curative therapies
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Diagnosis
Lung
Genitourinary
Gastrointestinal
DIAGNOSIS through Image-Guided
Biopsies
• Often one of the initial procedures used to
obtain a tissue diagnosis
• Multiple modalities including Computed
Tomography, Ultrasound, and Fluoroscopy
• Alone or in combination
• Often correlate with PET scan to identify
“active” sites
Biopsy Technique
• Often coaxial with “outer” introducer needle
and “inner” biopsy needle
• Need a “window”; Want to obtain an
adequate tissue sample for diagnosis but need
to utilize a safe approach
• May use conscious sedation along with local
anesthesia
Solitary pulmonary nodule
PET scan
PET CT fusion
CT guided Lung Biopsy
Lung Biopsy
Ultrasound biopsies
• Require hand-eye coordination
• May be used for random sampling, i.e. for
gross liver biopsy
• For focal lesions, often in difficult to access
locations, if poorly seen on CT scan, or if
lesion is “mobile”
Ultrasound guided biopsy of a focal
liver mass
X-ray guided biopsy
• Especially useful when patient positioning is
limited; can rotate and angle the tube to
obtain an approach for lesion access
• Advantage of real time imaging
Fluoroscopic vertebral body biopsy
Rotational angiography and Xper CT
Technology in new Philips angio equipment that
combines CT and 3D-imaging.
Enhances IR procedures by allowing you to
import previous MRI or CT data and fuse it
with angiographic studies.
Allows the interventionalist to use fluoroscopy
and apply it to a CT image for challenging
access.
Planning images
Progress images
Lung
Palliative
Tunneled pleural catheters
Thermal ablation of destructive chest wall
lesions
Curative
RFA of unresectable lung cancers or lung
metastases
Tunneled pleural catheter
Painful Chest Wall Tumors
RFA
RFA lung cancer
• Early NSCLC or metastases in those deemed
NOT to be surgical candidates
• Could have a poor functional status, abnormal
PFTs’, Octogenarians? etc.
• Relapse in Radiation field
• Painful bone metastasis
• Chest wall invasion
RFA lung cancer
Lung Cancer survival
• If untreated, median survival 9-12 months.
• Surgical resection 5 year 60-70%
• RFA or Radiation 5 year 30-50%
• RFA 1 yr: 83-90%; 2 year 48-83%
LGH statistics
• 20 tumors treated with RFA; 16 patients.
• Treatment goals met in 15/16 patients. All but
one patient was treated for cure.
• 4/16 patients required an additional ablation.
• Stable or without recurrence for up to 26
months.
• 1 unrelated death two days after treatment.
Cardiac arrest.
Genitourinary (GU)
• Palliative
– Percutanous nephrostomy
– Dialysis catheters
– Fistula or hemodialysis access maintenance
• Curative
– Thermal ablation of renal cell cancer
GU procedures
• Percutaneous access to the collecting system
for benign or malignant obstructions, stone
disease, or urosepsis
• Can place internal double J ureteral stents
from percutaneous access
• Can provide access for future stone removal
and/or manipulation
Percutaneous Nephrostomy
PCN
Hemodialysis Catheter
Fistula
Cryoablation of Renal Cancer
CT cryoablation
Cryoablation
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Argon gas for freezing; Helium for thawing.
Multiple probes; RFA just a single probe.
Less risk of damage to collecting system.
Greater risk of bleeding compared with RFA
(coagulative necrosis).
• -20 to -40 degrees Celsius. Cell death.
• Can better identify treated zone.
Survival
• Stage I RCC- surgery with partial nephrectomy
or nephrectomy 80+% 5 year survival
• Difficult to do much better for early disease
• Stage I RCC treated with RFA for 3 cm tumors
or smaller 94% 2 year survival. Decreased
survival as tumor size increases beyond 3 cm.
Is RCC Cryoablation
Effective?
Local Tumor Control After
One Cryoablation Treatment
Efficacy
98%
98%
97%
96%
95%
Littrup
94%
94%
Atwell
93%
92%
Rodriguez
92%
91%
90%
89%
Littrup
19 months
1
Atwell
26 months
Littrup, J Vasc Interv Radiol 2007; Atwell, J Urol 2010;
Rodriguez, Cardiovasc Interv Radiol 2011
Rodriguez
24 months
36
LGH statistics
• 7 tumors treated
• 6/7 Renal cell cancer. 1/7 benign oncocytoma.
• 6/7 no signs of recurrence. 1/7 partially
treated and opted for surveillance.
Gastrointestinal (GI)
• Palliative
– Peritoneal catheters
– Gastric tubes
– Cholecystostomy drains
– Biliary stents
• Locoregional control
– Catheter-based embolization
– Percutaneous thermal ablation
Peritoneal Catheter
Percutaneous Gastrostomy
Acute Cholecystitis
Percutaneous Cholecystostomy
Biliary Obstruction
Biliary Wallstent
Image-Guided Therapy for
Hepatic Malignancies
Unresectable
Liver
Dominant
Definitions
• Liver-dominant neoplasm: malignancy in
which the hepatic component is the only site
of disease or the dominant site most likely to
lead to patient morbidity or mortality
What’s so good about embolization or
chemoembolization?
• Minimally-invasive loco-regional treatment
• Spares the patient the morbidity of surgery,
radiation, or systemic therapy
• Achieves tumor necrosis
• Increases drug concentration delivered and
dwell time of agent(s)
• Decreases systemic toxicity
Definitions
• Embolization: refers to blocking arteries by
particles alone
• Oily Chemoembolization: infusion of
chemotherapeutic agents with Ethiodized oil
followed by embolic agents
• Drug-eluting beads: chemoembolization with
calibrated microspheres that release drug over
time
Definitions
• Tumor Ablation: direct application of thermal
or chemical therapies to tumor(s) to eradicate
or substantially destroy it
– Chemical: ethanol or acetic acid
– Thermal: application of energy to cause tumor
necrosis. Examples include radiofrequency
ablation (RFA), microwave, cryotherapy, highintensity focused ultrasound (HIFU)
Why consider tumor ablation?
• Patients are living longer and presenting later in
life with cancer.
• Co-morbid conditions are a major factor in
considering patients for surgical resection.
• Minimally invasive therapies are in demand.
• Tumor ablation offers a chance for cure without
surgery.
• Important psychological benefits to patients
instead of just waiting and seeing what happens.
Hepatocellular Carcinoma
• Fewer than 20% of patients are candidates for
resection due to cirrhosis.
• Transplantation only curative option for those
with limited disease (one tumor < 5 cm, or
three tumors < 3 cm).
• Choice of therapy depends on overall size,
number, and location of tumors.
Chemoembolization of HCC:
Randomized Trials
1) Lo et al., Hepatology 2002
80 Patients, 80% hep. B +, 7 cm tumors (60% multifocal)
TACE
Supportive care
57, 31, 26%
32, 11, 3% (1, 2, 3 year survival)
2) Llovet et al., Lancet 2002
112 Patients, 80-90% hep. C +, 5 cm tumors (70% multifocal)
TACE
82, 63%
Supportive care
63, 27% (1, 2 year survival)
Hepatoma
Hepatoma
resectable
surgery
OLT candidate
1 tumor ² 5cm
2-3 tumors ²3cm
<2cm
image q3 months
>2cm
embo/ablate
image q3 months
Not Surgical Candidate
Childs A/B
BCLC A-C
PS 0-2
Labs OK
Childs C
Okuda 3
PS 3-4
bad labs
<3 cm ablate
3-8 cm embo/ablate
>8cm embo
sorafenib?
death talk
sorafenib?
Colorectal Metastases
• Median Survival for untreated 6-13 months
• Survival for most effective chemotherapy is 20
months
• Resecting metastases increases 5-year survival
from 0-1% to 31-58%, perhaps even higher,
more recent studies suggest.
• Only 5-20% eligible for surgical resection.
COLON CANCER
Chemoembolization: Phase II Trials
BCLC
#PTS
NWU
U Penn1 Frankfurt2
40
30
120463
Disease Control 63%
63%
43% 63%
Med. Surv. 24 mo. 29 mo. 27 mo. 38 mo.iology
2009
Colorectal mets and RF ablation
• RF ablation useful in patients not eligible for
surgical resection, however, multiple
independent studies showed that survival
rates approach those of surgical resection.
• Local control best achieved in tumors 3.5 cm
in size or smaller; goal of RFA is achieve a 1-cm
ablation zone.
• RFA mortality is < 0.5% compared with 17-37%
for surgical resection.
Colorectal Metastases
Colon Mets
Resectable
liver dominant
unresectable
labs and PS OK
not liver dominant
OR
contraindication to embo
[3-6 months chemo]
resect
<3 cm ablate
3-6 cm embo/ablate
>6 cm embo
systemic
systemic
Neuroendocrine Tumors
• Only 5% of carcinoid tumors
• Up to 90% of gastrinomas
• Patients can be plagued by unregulated
hormonal secretions of their tumors.
• Control with somatostatin agents.
• Those with hormonal production often have
bulk liver disease, a contraindication to
surgery.
NET
NET
Liver dominant
No sx on Sandostain-LAR
LFTs normal
tumor burden <50%
clinic/labs/imaging
q 3-6 months
Not liver dominant
Sx despite Sandostatin
OR abnl LFTs
OR tumor burden 50%
resectable
surgery
unresectable
embo
[ablate]
systemic rx
palliative embo
Summary
• Interventional Radiology has a critical role in the care of
cancer patients and offers both palliative and curative
therapies.
• Although many of these therapies are not first line
treatment, they should not be considered rescue therapy
either. Rather, these interventions should be considered
routinely during the evaluation and management of the
cancer patient.
• There is increasing evidence to support improved survival
and improved quality of life with combination therapies;
for example, ablation with adjuvant chemotherapy, or
chemoembolization with adjuvant radiation therapy.
Thank you
• Lancaster Radiology Associates 299-4173
• Interventional Radiology 544-4929
• Consultations through Centralized Scheduling
at 544-5941.