UPDATE on I n t er v ent ional Radio logy

J GARNON,

RL CAZZATO,

J CAUDRELIER,

E BOATTA,

P RAO,

M NOURI-NEUVILLE,

G KOCH,

P AULOGE,

A GANGI

Department of Interventional Radiology

University Hospital of Strasbourg, France

Disclosure

I have the following the conflict(s) of interest to declare:

BTG-Galil

Canon

Medtronic

the « interventional » radiologist

Interventional radiology in 2018

Interventional radiology in 2018

MRI ANGIO-CT CBCTUS

Patient

TEP-CT

• Ablation: - RFA- MWA- Cryo- IRE- HIFU

• Cement

• Screws

• Ethanol

• Embolization:- Bland- + chemo- + radiation

• Catheter

• Feeding tubes

diagnostic• percutaneous biopsy = 1st option in the majority of cases

• size limit = 5 mm (lung, liver, kidney, bone) to 10 mm (lymph node, adrenal…)

• nb of samples depend on location and tumor size

• almost all locations are accessible

• quality of biopsy depends on the visibility of the lesion with imaging

diagnostic

curative treatment

84 y.o

Hypertension

Diabetes

Brain stroke X3

Cardiac failure

Lung insufficiency

Renal insufficiency

Parkinson

Prostate cancer

Colon cancer

Dementia

The beginning of ablation…

curative treatment

• Percutaneous ablation can provide complete local destruction of a tumour

• different modalities:

Modality Mechanism of action approach evidences Principal applications

RFA Heat-based percutaneous +++ Liver, lung, kidney

Microwave ablation Heat-based percutaneous +++ Liver, lung

Cryoablation Cold-based percutaneous +++ Kidney, bone

HIFU Heat-based non-invasive +/- bone

Irreversibleelectroporation

Non-thermal percutaneous +/- Pancréas, liver

curative treatment

curative treatment• Kidney:

- Stage T1a RCC

- in non-surgical candidates (but more and more as an alternative to surgery)

- Cryo +++

- Technical success > 98% in recent studies

- 5y cancer-free survival > 95% in most studies

- safe in the elderly population

curative treatment• Kidney:

10,218 patients

Treatment:

4522 RN (44.2%)

2820 PN (27.6%)

899 TA (8.8%)

1978 AS (19.4%)

curative treatment• Kidney:

« Patients who underwent a local treatment had a

statistically significant CSS benefit compared to

those with deferred therapy »

1-year FU

curative treatment

Tanis E, Nordlinger B, Mauer M, Sorbye H, van Coevorden F, Gruenberger T, Schlag PM, Punt CJ, Ledermann J, Ruers TJ. Local recurrence rates after radiofrequency ablation orresection of colorectal liver metastases. Analysis of the European Organisation for Research and Treatment of Cancer #40004 and #40983. Eur J Cancer. 2014 Mar;50(5):912-9. doi:10.1016/j.ejca.2013.12.008.

Park MJ, Kim TH, Lee KM, Cheong JY, Kim JK. Radiofrequency ablation of metastatic liver masses: recurrence patterns and prognostic factors based on radiologic features.Hepatogastroenterology. 2013 May;60(123):563-7.

• Liver:

- early stage HCC (BLCC algorythm)

- colorectal metastasis (ESMO guidelines)

- heat-based: RFA/MWA

- optimal size: <3cm (LR < 3% for lesion < 3cm)

- ideal safety margins: 5 to 10mm

curative treatment• Lung:

- Inoperable NSCLC +

- metastasis +++

- heat-based: RFA

- optimal size: <2cm

Radiofrequency ablation is a valid treatment option for lung metastases:

Experience in 566 patients with 1037 metastases.De Baere et al. Annals of Oncology 2015

1037 metastases (566 patients) – mean size =15 mm – mean number = 1,8

OS: 1 y - 92,4%, 2 y - 79,4%, 3 y - 67,7%, 4 y - 58,9%, 5 y - 51,5%

LR : 8%

palliative treatment

symptoms interventions

denutrition Gastrostomy, jejunostomy, central lines

fractures (iliac, spine) Cementoplasty, screw fixation

pain Cementoplasty, ablation, neurolysis

Bleeding embolisation

Tumour control TACE, radioembolization

palliative treatment

palliative treatment

- significant decrease of the pain

- faster than with RT

- response duration is variable but 6 months duration can be achieved

- As a 1st line ttt or after RT

- very low rate of complication

- Not depending on the histological type of tumour

- cryoablation ++

• Ablation for pain palliation:

MRI ANGIO-CT CBCTUS

Patient

TEP-CT

ReceptionWaiting

room

Consultations

Preparation

Recovery room

Meeting

room

Department of Interventional Oncology

Patient selection and information = it is the role of the interventional radiologist !!

• IR has a role in many situations: diagnostic, palliation, curative treatment

• There are more and more evidences supporting the use of thermal ablation for local control (liver, kidney, lung but many potential other locations)

• The IR should know about the oncological pathologies

• He/she should be part of the multidisciplinary discussion

CONCLUSION

CT-scan

IR surgeon