Percutaneous Ablation of Lung Cancer (NSCLC)

Background

  • Lung cancer is the most frequent cause of cancer death: Incidence of 2.1 million patients and mortality of 1.7 million patients per year1
  • Resection is standard of care for early tumours but only 15-30% of patients are eligible2
  • Increased detection rates for early lung cancer due to screening programs
  • Lung is a frequent site of metastatic disease: 1/3 of cancer patients develop lung metastasis3

Indications for Ablation

  • Primary lung cancer: Small-size (<3 cm), non-small cell lung carcinoma (NSCLC) in non-surgical patients4
  • Lung metastasis: Small-size (<3 cm) slow-evolving metastatic lung tumours, oligometastatic disease, recurrences after surgery or radiation tumours.5
  • Patients with limited functional reserve of the lung

Ablation Technique

  • RFA, MWA, Cryo5
  • Multiplanar, CT-based confirmation of needle position required6
  • Margins of 5 mm are predictive of effective ablation7
  • Avoid ablation zones at organ borders (risk of pleural fistula and skin burns) through longer trajectories8

Guidelines

  • European Society for Medical Oncology (ESMO): Ablation for lung-only or oligometastases of the lung9
  • National Comprehensive Cancer Network (NCCN): Ablation as definitive local therapy for inoperable patients10
  • American College of Chest Physicians (ACCP): Percutaneous ablation as a therapeutic option in inoperable patients11
Treatment comparison IR Ablation SBRT Resection
Local efficacy ++ + ++
Tissue and function preservation ++ + --
Short recovery time ++ ++ --
Number of sessions 1 1-5 1
Applicability for future tumours ++ - --
Treatment cost $ $$ $$

Stereotactic Lung Cancer Ablation with CAS-One

  • Multiplanar planning and validation avoid inaccurate needle placement
  • Off-plane needle guidance enables access to all locations in the lung
  • Accurate needle placement in one attempt reduces the risk of pneumothorax
  • Fusion-based margin validation supports reliable and complete ablation

Relevant Studies

Primary lung cancer 
  • One-, three-, and five-year overall survival up to 97%, 72%, 55% reported for ablation12
  • No difference in overall survival between surgery, RFA, and Cryoablation for stage I lesions13
Metastatic lung cancer
  • Ablation can treat several tumours and bilobar disease and induce complete necrosis14
  • Number of tumours and bilobal disease do not affect survival15
Quality of life for the patient
  • Lower morbidity and mortality compared to surgery4, 5
  • Shorter treatment and faster recovery in comparison to surgery4, 16
  • Only one treatment session for ablation whereas SBRT requires several sessions4
Keeping all treatment options (especially for future metastasis)
  • Ablation is the most tissue-saving treatment
  • Surgery requires wedge resections (=large volume loss and reduced lung function)
  • SBRT leads to radiation-induced toxicity which prevents further treatments after 2 tumours and also increases risk for pathological rib fractures with severe pain consequences

References

  1. Bray, F. et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA. Cancer J. Clin. 68, 394–424 (2018).
  2. Walters S. et al. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007
  3. Stella GM, Kolling S, Benvenuti S, Bortolotto C. Lung-Seeking Metastases. Cancers (Basel). 2019 Jul 19;11(7)
  4. de Baere, T. et al. Percutaneous thermal ablation of primary lung cancer. Diagn. Interv. Imaging 97, 1019–1024 (2016).
  5. Palussière, J., Catena, V. & Buy, X. Percutaneous thermal ablation of lung tumors – Radiofrequency, microwave and cryotherapy: Where are we going? Diagn. Interv. Imaging 98, 619–625 (2017).
  6. Antoch, G., Kuehl, H., Vogt, F. M., Debatin, J. F. & Stattaus, J. Value of CT Volume Imaging for Optimal Placement of Radiofrequency Ablation Probes in Liver Lesions. J. Vasc. Interv. Radiol. 13, 1155–1161 (2002).
  7. Anderson, E. M., Lees, W. R. & Gillams, A. R. Early Indicators of Treatment Success After Percutaneous Radiofrequency of Pulmonary Tumors. Cardiovasc. Intervent. Radiol. 32, 478–483 (2009).
  8. Hinshaw, J. L., Lubner, M. G., Ziemlewicz, T. J., Lee, F. T. & Brace, C. L. Percutaneous Tumor Ablation Tools: Microwave, Radiofrequency, or Cryoablation—What Should You Use and Why? RadioGraphics 34, 1344–1362 (2014).
  9. Postmus, P. E. et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. 28, iv1–iv21 (2017).
  10. Ettinger, D. S. et al. , version 5.2018 featured updates to the NCCN guidelines. JNCCN Journal of the National Comprehensive Cancer Network vol. 16 807–821 (2018).
  11. Detterbeck, F. C., Lewis, S. Z., Diekemper, R., Addrizzo-Harris, D. & Alberts, W. M. Executive Summary: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 143, 7S-37S (2013).
  12. Kodama, H. et al. Lung radiofrequency ablation for the treatment of unresectable recurrent non-small-cell lung cancer after surgical intervention. Cardiovasc. Intervent. Radiol. 35, 563–569 (2012).
  13. Zemlyak, A., Moore, W. H. & Bilfinger, T. V. Comparison of Survival after Sublobar Resections and Ablative Therapies for Stage I Non-Small Cell Lung Cancer. J. Am. Coll. Surg. 211, 68–72 (2010).
  14. Jaskolka, J. D. et al. Pathologic assessment of radiofrequency ablation of pulmonary metastases. J. Vasc. Interv. Radiol. 21, 1689–1696 (2010).
  15. Gillams, A., Khan, Z., Osborn, P. & Lees, W. Survival after Radiofrequency Ablation in 122 Patients with Inoperable Colorectal Lung Metastases. Cardiovasc. Intervent. Radiol. 36, 724–730 (2013).
  16. Kim, S. R. et al. Comparison between surgery and radiofrequency ablation for stage i non-small cell lung cancer. Eur. J. Radiol. 81, 395–399 (2012).