Damian E. Dupuy

Image-guided Radiofrequency Tumor Ablation: Challenges and Opportunities—Part I

PERCUTANEOUS image-guided ablation with use of radiofrequency (RF) or other thermal energy sources such as microwave, high-intensity focused ultrasonography (US), cryotherapy, and laser have recently received much attention as minimally invasive strategies for the local treatment of solid malignancies (1–4). In the first part of this review, we provided a brief synopsis of current RF techniques and reviewed the basic principles of RF ablation and challenges facing the successful implementation of this technology (5). In the second part of this review, we will describe some of the many opportunities that RF ablation affords in an overview of potential clinical applications. The organ systems discussed, such as the liver, bone, lung, and kidney, are those currently receiving the greatest amount of attention from interventional radiologists. However, many additional applications are likely to emerge over the course of the next several years. CLINICAL OPPORTUNITIES FOR RF TUMOR ABLATION

Thermal ablation of tumours: biological mechanisms and advances in therapy

Minimally invasive thermal ablation of tumours has become common since the advent of modern imaging. From the ablation of small, unresectable tumours to experimental therapies, percutaneous radiofrequency ablation, microwave ablation, cryoablation and irreversible electroporation have an increasing role in the treatment of solid neoplasms. This Opinion article examines the mechanisms of tumour cell death that are induced by the most common thermoablative techniques and discusses the rapidly developing areas of research in the field, including combinatorial ablation and immunotherapy, synergy with conventional chemotherapy and radiation, and the development of a new ablation modality in irreversible electroporation.

Image-guided Tumor Ablation: Standardization of Terminology and Reporting Criteria—A 10-Year Update

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes. Online supplemental material is available for this article .

Image-guided tumor ablation: standardization of terminology and reporting criteria.

The field of interventional oncology with use of image-guided tumor ablation requires standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison between treatments that use different technologies, such as chemical (ethanol or acetic acid) ablation, and thermal therapies, such as radiofrequency (RF), laser, microwave, ultrasound, and cryoablation. This document provides a framework that will hopefully facilitate the clearest communication between investigators and will provide the greatest flexibility in comparison between the many new, exciting, and emerging technologies. An appropriate vehicle for reporting the various aspects of image-guided ablation therapy, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings, are outlined. Methods for standardizing the reporting of follow-up findings and complications and other important aspects that require attention when reporting clinical results are addressed. It is the groups intention that adherence to the recommendations will facilitate achievement of the groups main objective: improved precision and communication in this field that lead to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes. The intent of this standardization of terminology is to provide an appropriate vehicle for reporting the various aspects of image-guided ablation therapy.

Microwave Ablation of Lung Malignancies: Effectiveness, CT Findings, and Safety in 50 Patients

PURPOSE To retrospectively evaluate effectiveness, follow-up imaging features, and safety of microwave ablation in 50 patients with intraparenchymal pulmonary malignancies. MATERIALS AND METHODS This HIPAA-compliant study was approved by the institutional review board; informed consent was waived. From November 10, 2003, to August 28, 2006, 82 masses (mean, 1.42 per patient) in 50 patients (28 men, 22 women; mean age, 70 years) were percutaneously treated in 66 microwave ablation sessions. Each tumor was ablated with computed tomographic (CT) guidance. Follow-up contrast material-enhanced CT and positron emission tomographic (PET) scans were reviewed. Mixed linear modeling and logistic regression were performed. Time-event data were analyzed (Kaplan-Meier survival estimates and log-rank statistic). All event times were the time to a patients first event (alpha level = .05, all analyses). RESULTS At follow-up (mean, 10 months), 26% (13 of 50) of patients had residual disease at the ablation site, predicted by using index size of larger than 3 cm (P = .01). Another 22% (11 of 50) of patients had recurrent disease resulting in a 1-year local control rate of 67%, with mean time to first recurrence of 16.2 months. Kaplan-Meier analysis yielded an actuarial survival of 65% at 1 year, 55% at 2 years, and 45% at 3 years from ablation. Cancer-specific mortality yielded a 1-year survival of 83%, a 2-year survival of 73%, and a 3-year survival of 61%; these values were not significantly affected by index size of larger than 3 cm or 3 cm or smaller or presence of residual disease. Cavitation (43% [35 of 82] of treated tumors) was associated with reduced cancer-specific mortality (P = .02). Immediate complications included pneumothorax (Common Terminology Criteria for Adverse Events [CTCAE] grades 1 [18 of 66 patients] and 2 [eight of 66 patients]), hemoptysis (four of 66 patients), and skin burns (CTCAE grades 2 [one of 66 patients] and 3 [one of 66 patients]). CONCLUSION Microwave ablation is effective and may be safely applied to lung tumors. (c) RSNA, 2008.

Radiofrequency ablation and percutaneous ethanol injection treatment for recurrent local and distant well-differentiated thyroid carcinoma.

Objective:To assess the long-term efficacy of radiofrequency ablation (RFA) and percutaneous ethanol (EtOH) injection treatment of local recurrence or focal distant metastases of well-differentiated thyroid cancer (WTC). Background:RFA and EtOH injection techniques are new minimally invasive surgical alternatives for treatment of recurrent WTC. We report our experience and long-term follow-up results using RFA or EtOH ablation in treating local recurrence and distant focal metastases from WTC. Methods:Twenty patients underwent treatment of biopsy-proven recurrent WTC in the neck. Sixteen of these patients had lesions treated by ultrasound-guided RFA (mean size, 17.0 mm; range, 8–40 mm), while 6 had ultrasound-guided EtOH injection treatment (mean size, 11.4 mm; range, 6–15 mm). Four patients underwent RFA treatment of focal distant metastases from WTC. Three of these patients had CT-guided RFA of bone metastases (mean size, 40.0 mm; range, 30–60 mm), and 1 patient underwent RFA for a solitary lung metastasis (size, 27 mm). Patients were then followed with routine ultrasound, 131I whole body scan, and/or serum thyroglobulin levels for recurrence at the treatment site. Results:No recurrent disease was detected at the treatment site in 14 of the 16 patients treated with RFA and in all 6 patients treated with EtOH injection at a mean follow-up of 40.7 and 18.7 months, respectively. Two of the 3 patients treated for bone metastases are free of disease at the treatment site at 44 and 53 months of follow-up, respectively. The patient who underwent RFA for a solitary lung metastasis is free of disease at the treatment site at 10 months of follow-up. No complications were experienced in the group treated by EtOH injection, while 1 minor skin burn and 1 permanent vocal cord paralysis occurred in the RFA treatment group. Conclusions:RFA and EtOH ablation show promise as alternatives to surgical treatment of recurrent WTC in patients with difficult reoperations. Further long-term follow-up studies are necessary to determine the precise role these therapies should play in the treatment of recurrent WTC.

Percutaneous radiofrequency ablation of painful osseous metastases: A multicenter American College of Radiology Imaging Network trial

The study was conducted to determine whether radiofrequency ablation (RFA) can safely reduce pain from osseous metastatic disease.

Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update.

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes.

Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial.

This study sought to describe the results of a single‐arm multicenter clinical trial using image‐guided percutaneous cryoablation for the palliation of painful metastatic tumors involving bone.

Local surgical, ablative, and radiation treatment of metastases.

Because local therapies directed toward a specific tumor mass are known to be effective for treating early‐stage cancers, it should be no surprise that there has been considerable historical experience using local therapies for metastatic disease. In more recent years, increasing interest in the use of local therapy for metastases likely has arisen from improvements in systemic therapy. In the absence of effective systemic therapies, such local treatments were often considered futile given both the difficulty in eliminating all sites of identifiable metastatic disease as well as realities regarding the rapid natural history of uncontrolled tumor dissemination. However, with a higher likelihood of patients surviving longer after effective systemic therapy, even if not cured, the goal of the eradication of residual metastases via potent local therapies can be rationalized. However, this rationalization should be evidence‐based so as to avoid harming patients for no established benefit. Although surgical metastectomy remains the most common and first‐line standard among local therapies, nonsurgical alternatives, including thermal ablation and stereotactic body radiotherapy, have become increasingly popular because they are generally less invasive than surgery and have demonstrated considerable promise in eradicating macroscopic tumor. Rather than eliminating the need for local therapies, improvements in systemic therapies appear to be increasing the prudent utilization of modern local therapies in patients presenting with more advanced cancer. CA Cancer J Clin 2009;59:145–170.