F. Deschamps

Radiofrequency ablation is a valid treatment option for lung metastases: experience in 566 patients with 1037 metastases

Radiofrequency of lung metastases below 4 cm, demonstrated an overall survival of 62 months, associated with a 4-year local efficacy of 89%. Repeatability of the technique allows a 4-year lung disease control rate of 44.1%, with patient retreated safely up to four times. Radiofrequency is an option for treatment of small size lung metastases, namely the ones below 2 to 3 cm in diameter.

Thermal ablation techniques: a curative treatment of bone metastases in selected patients?

IntroductionThermal ablation techniques (radiofrequency-ablation/cryotherapy) can be indicated with a curative intent. The success rate and prognostic factors for complete treatment were analysed.Material/methodsThe medical records of all patients who had undergone curatively intended thermal ablation of bone metastases between September 2001 and February 2012 were retrospectively analysed. The goal was to achieve complete treatment of all bone metastases in patients with oligometastatic disease (group 1) or only of bone metastases that could potentially lead to skeletal-related events in patients with a long life expectancy (group 2). We report the rate of complete treatment according to patient characteristics, primary tumour site, bone metastasis characteristics, radiofrequency ablation/cryotherapy and the treatment group (group 1/group 2).ResultsEighty-nine consecutive patients had undergone curatively intended thermal ablation of 122 bone metastases. The median follow-up was 22.8xa0months [IQRu2009=u200912.2-44.4]. In the intent-to-treat analysis, the 1-year complete treatment rate was 67xa0% (95%CI: 50xa0%-76xa0%). In the multivariate analysis the favourable prognostic factors for complete local treatment were oligometastatic status (pu2009=u20090.02), metachronous (pu2009=u20090.004) and small-sized (pu2009=u20090.001) bone metastases, without cortical bone erosion (pu2009=u20090.01) or neurological structures in the vicinity (pu2009=u20090.002).ConclusionThermal ablation should be included in the therapeutic arsenal for the cure of bone metastases.Key Points• Thermal ablation techniques are currently performed to palliate pain caused by bone metastases.• In selected patients, thermal ablation can also be indicated with a curative intent.• Oligometastatic and/or metachronous diseases are good prognostic factors for local success.• Small-size (<2xa0cm) bone metastases and no cortical erosion are good prognostic factors.

Evaluating Cryoablation of Metastatic Lung Tumors in Patients—Safety and Efficacy The ECLIPSE Trial—Interim Analysis at 1 Year

Introduction: To assess the feasibility, safety and local tumor control of cryoablation for treatment of pulmonary metastases. Materials and Methods: This Health Insurance Portability and Accountability Act (HIPAA) compliant, IRB-approved, multicenter, prospective, single arm study included 40 patients with 60 lung metastases treated during 48 cryoablation sessions, with currently a minimum of 12 months of follow-up. Patients were enrolled according to the following key inclusion criteria: 1 to 5 metastases from extrapulmonary cancers, with a maximal diameter of 3.5u2009cm. Local tumor control, disease-specific and overall survival rates were estimated using the Kaplan–Meier method. Complications and changes in physical function and quality of life were also evaluated using Karnofsky performance scale, Eastern Cooperative Oncology Group performance status classification, and Short Form-12 health survey. Results: Patients were 62.6u2009±u200913.3 years old (26–83). The most common primary cancers were colon (40%), kidney (23%), and sarcomas (8%). Mean size of metastases was 1.4u2009±u20090.7u2009cm (0.3–3.4), and metastases were bilateral in 20% of patients. Cryoablation was performed under general anesthesia (67%) or conscious sedation (33%). Local tumor control rates were 56 of 58 (96.6%) and 49 of 52 (94.2%) at 6 and 12 months, respectively. Patients quality of life was unchanged over the follow-up period. One-year overall survival rate was 97.5%. The rate of pneumothorax requiring chest tube insertion was 18.8%. There were three Common Terminology Criteria for Adverse Events grade 3 procedural complications during the immediate follow-up period (pneumothorax requiring pleurodesis, noncardiac chest pain, and thrombosis of an arteriovenous fistula), with no grade 4 or 5 complications. Conclusion: Cryoablation is a safe and effective treatment for pulmonary metastases with preserved quality of life following intervention.

Sequential research-related biopsies in phase I trials: acceptance, feasibility and safety

BACKGROUNDnSequential tumour biopsies are of potential interest for the rational development of molecular targeted therapies.nnnPATIENTS AND METHODSnFrom June 2004 to July 2009, 186 patients participated in 14 phase I clinical trials in which sequential tumour biopsies (13 trials) and/or sequential normal skin biopsies (6 trials) were optional. All patients had to sign an independent informed consent for the biopsies.nnnRESULTSnTumour biopsies were proposed to 155 patients and 130 (84%) signed the consent while normal skin biopsies were proposed to 70 patients and 57 (81%) signed the consent. Tumour biopsies could not be carried out in 41 (31%) of the 130 consenting patients. Tumour biopsies were collected at baseline in 33 patients, at baseline and under treatment in 56 patients. Tumour biopsies were obtained using an 18-gauge needle, under ultrasound or computed tomography guidance. Only nine minor complications were recorded. Most tumour biopsy samples collected were intended for ancillary molecular studies including protein or gene expression analysis, comparative genomic hybridization array or DNA sequencing. According to the results available, 70% of the biopsy samples met the quality criteria of each study and were suitable for ancillary studies.nnnCONCLUSIONSnIn our experience, the majority of the patients accepted skin biopsies as well as tumour biopsies. Sequential tumour and skin biopsies are feasible and safe during early-phase clinical trials, even when patients are exposed to anti-angiogenic agents. The real scientific value of such biopsies for dose selection in phase I trials has yet to be established.BACKGROUNDnSequential tumour biopsies are of potential interest for the rational development of molecular targeted therapies.nnnPATIENTS AND METHODSnFrom June 2004 to July 2009, 186 patients participated in 14 phase I clinical trials in which sequential tumour biopsies (13 trials) and/or sequential normal skin biopsies (6 trials) were optional. All patients had to sign an independent informed consent for the biopsies.nnnRESULTSnTumour biopsies were proposed to 155 patients and 130 (84%) signed the consent while normal skin biopsies were proposed to 70 patients and 57 (81%) signed the consent. Tumour biopsies could not be carried out in 41 (31%) of the 130 consenting patients. Tumour biopsies were collected at baseline in 33 patients, at baseline and under treatment in 56 patients. Tumour biopsies were obtained using an 18-gauge needle, under ultrasound or computed tomography guidance. Only nine minor complications were recorded. Most tumour biopsy samples collected were intended for ancillary molecular studies including protein or gene expression analysis, comparative genomic hybridizartion array or DNA sequencing. According to the results available, 70% of the biopsy samples met the quality criteria of each study and were suitable for ancillary studies.nnnCONCLUSIONSnIn our experience, the majority of the patients accepted skin biopsies as well as tumour biopsies. Sequential tumour and skin biopsies are feasible and safe during early-phase clinical trials, even when patients are exposed to anti-angiogenic agents. The real scientific value of such biopsies for dose selection in phase I trials has yet to be established.

Intra-Arterial Hepatic Chemotherapy: A Comparison of Percutaneous Versus Surgical Implantation of Port-Catheters

PurposeTo compare retrospectively the safety and efficacy of percutaneous and surgical implantations of port-catheters for intra-arterial hepatic chemotherapy (IAHC).Materials and MethodsBetween January 2004 and December 2008, 126 consecutive patients (mean age 58xa0years) suffering from liver colorectal metastases were referred for intra-arterial hepatic chemotherapy (IAHC). Port-catheters were percutaneously implanted (P) through femoral access with the patient under conscious sedation when no other surgery was planned or were surgically implanted (S) when laparotomy was performed for another purpose. We report the implantation success rate, primary functionality, functionality after revision, and complications of IAHC.ResultsThe success rates of implantation were 97% (nxa0=xa065 of 67) for P and 98% (nxa0=xa058 of 59) for S. One hundred eleven patients received IAHC in our institution (nxa0=xa056P and nxa0=xa055S). Primary functionality was the same for P and S (4.80 vs. 4.82 courses), but functionality after revision was significantly higher for P (9.18 vs. 5.95 courses, pxa0=xa00.004) than for S. Forty-five complications occurred during 516 courses for P and 28 complications occurred during 331 courses for S. The rates of discontinuation of IAHC linked to complications of the port-catheters were 21% (nxa0=xa012 of 56) for P and 34% (nxa0=xa019 of 55) for S.ConclusionOverall, significantly better functionality and similar complication rates occurred after P versus S port-catheters.

Percutaneous ablation of bone tumors

Percutaneous ablation (radiofrequency or cryotherapy) of bone tumors is most often performed for palliative purposes. Many studies have shown that percutaneous ablation of a painful bone metastasis can significantly and sustainably reduce symptoms. It is therefore an alternative to radiotherapy and to long-term opiates. Percutaneous ablation can also be performed for curative purposes. In this situation, its efficacy has however only been studied to a very small extent (apart from radiofrequency ablation of osteoid osteomas in which the success rate is almost 100%). In our experience, the success rate after radiofrequency ablation of a bone metastasis is 75% if it is less than 3cm in diameter and fall significantly over this (to 40%, P=0.04). This treatment can therefore be justified in oligometastatic patients whose disease is progressing slowly. Its benefit on survival has however not been assessed in this selected population. Whether it is performed for palliative or curative reasons, percutaneous ablation should ideally be followed by an injection of cement if the metastasis being treated is lytic and located in a bone, which is subject to mechanical forces. The aim of consolidating cementoplasty is to counterbalance the additional risk of fracture due to destruction of the percutaneously ablated bone.

Percutaneous thermal ablation of primary lung cancer

Percutaneous ablation of small-size non-small-cell lung cancer (NSCLC) has demonstrated feasibility and safety in nonsurgical candidates. Radiofrequency ablation (RFA), the most commonly used technique, has an 80-90% reported rate of complete ablation, with the best results obtained in tumors less than 2-3cm in diameter. The highest one-, three-, and five-year overall survival rates reported in NSCLC following RFA are 97.7%, 72.9%, and 55.7% respectively. Tumor size, tumor stage, and underlying comorbidities are the main predictors of survival. Other ablation techniques such as microwave or cryoablation may help overcome the limitations of RFA in the future, particularly for large tumors or those close to large vessels. Stereotactic ablative radiotherapy (SABR) has its own complications and carries the risk of fiducial placement requiring multiple lung punctures. SABR has also demonstrated significant efficacy in treating small-size lung tumors and should be compared to percutaneous ablation.

Lung ablation: Best practice/results/response assessment/role alongside other ablative therapies

Today, in addition to surgery, other local therapies are available for patients with small-size non-small-cell lung cancer (NSCLC) and oligometastatic disease from various cancers. Local therapies include stereotactic ablation radiotherapy (SABR) and thermal ablative therapies through percutaneously inserted applicators. Although radiofrequency ablation (RFA) has been explored in series with several hundreds of patients with pulmonary tumours, investigation of the potential of other ablation technologies including microwave ablation, cryoablation, and irreversible electroporation is ongoing. There are no randomised studies available to compare surgery, SABR, and thermal ablation. In small-size lung metastases, RFA seems to produce results very close to surgical series with >90% local control and 5-year overall survival of 50%. In primary lung cancer, the technique is reserved for non-surgical candidates. In future, the low invasiveness of thermal ablative therapies will allow for a combination of ablation and systemic therapies in order to improve the outcomes of ablation alone. Another major advantage of thermal ablation is the possibility to treat several metastases in close proximity to one another and retreatment in the same location in case of failure, which is not possible with SABR.

Liver, lung and peritoneal metastases in colorectal cancers: Is the patient still curable? What should the radiologist know

Regardless of the advances in chemotherapy, the only curative treatment for colorectal metastases is surgery, which must be complete and excise all of the metastatic sites of disease. Thanks to advances in neoadjuvant chemotherapy and also to alternative techniques, such as radiofrequency ablation, however, surgical treatments have become available to a larger number of patients and have improved patient survival. The aim of this article is to describe the different treatment strategies for colorectal metastases and to examine the role of imaging in defining the resect ability of these metastases. The key factors in the radiological report in the initial and post-chemotherapy assessments are described.

Percutaneous thermal ablation: A new treatment line in the multidisciplinary management of metastatic leiomyosarcoma?

BACKGROUNDnThe role of percutaneous thermal ablation (PTA) in the multidisciplinary management of metastatic leiomyosarcoma (LMS) has not been thoroughly evaluated.nnnMATERIALS AND METHODSnSingle institution retrospective review of all patients with LMS metastases treated with PTA from June 2004 to December 2014. Iterative PTAs were performed as a multifocal treatment for all recurrent or residual macroscopic metastases discovered on imaging after completion of systemic treatment, or alternatively as a targeted treatment of selective metastases found to be progressive on systemic treatment. The primary endpoint was the time to untreatable progression (TTUP), recorded as the time elapsed between the first PTA and the re-initiation of systemic chemotherapy to treat disease progression. Secondary endpoints were overall survival, the 1, 3 and 5-year survival rates, and local control rate.nnnRESULTSnA total of 93 LMS metastases (average diameter 18.2xa0mm, range 3-45xa0mm) were successfully treated in 30 patients over 50 treatment sessions with a median follow-up of 34.6 months. The median TTUP was 14.2 months (range 2.4-122.8). The median overall survival after PTA was 48.3 months and the 1, 3 and 5-year overall survival rates were 96.7% (95%CI 84.3-100.0%), 62.0% (95%CI 45.8-84.0%), and 28.3% (95%CI 13.5-59.1%) respectively. Local control rate at 1 year was 95.2% and at 3 years was 89.4%.nnnCONCLUSIONnIterative PTA is an effective treatment line option for appropriately selected patients with metastatic LMS that can delay re-initiation of systemic chemotherapy.