Radiofrequency Ablation of Lung Metastases Close to Large Vessels during Vascular Occlusion: Preliminary Experience

doi:10.1016/j.jvir.2011.02.028

Journal of Vascular and Interventional Radiology

Volume 22, Issue 6, June 2011, Pages 749-754

https://doi.org/10.1016/j.jvir.2011.02.028 Get rights and content

Abstract

Purpose

To report an initial prospective evaluation of the technical feasibility, efficacy, and safety of combining percutaneous temporary balloon occlusion (PBO) of a large pulmonary artery adjacent to a metastatic lung tumor treated with percutaneous radiofrequency (RF) ablation.

Materials and Methods

In six patients, lung RF ablation with a multitined, expandable electrode with simultaneous PBO via femoral access was attempted with the use of digital angiography and multidetector computed tomography (CT). Follow-up imaging was obtained immediately after treatment, at 1–2 days, and at 2, 6, 9, and 12 months; positron emission tomography/CT was performed at 4 months.

Results

Metastases targeted measured 17–37 mm (22 ± 8) and were in contact with a pulmonary artery 3–5 mm. Temporary occlusion of the pulmonary arterial branch in contact with the tumor was technically possible in five of six patients. Postablation CT scans obtained within 2 days of the procedure showed ablation zones measuring 37–57 mm (47 ± 8) in their shortest diameter. Three patients developed lung infarction within 1 month after RF ablation, and two had to be readmitted. At 3 months after the procedure, four patients had persistent occlusion of the balloon-occluded vessel. No uptake was demonstrated 4 months after ablation; at 12 months, all tumors showed complete ablation on CT.

Conclusions

RF ablation of lung tumors with PBO is a feasible technique, but it induces atelectasia and long-lasting vascular occlusion responsible for a high rate of readmission. The results of this small study warrant careful further exploration of the benefits of the technique, compared with RF ablation without PBO or other methods of ablative therapy.

Section snippets

Materials and Methods

Institutional review board approval was obtained for RF combined with PBO for lung metastases 4 cm or smaller in contact with a pulmonary artery 3 mm or larger. Contact was defined by a lack of lung parenchyma seen between the tumor and vessel on a computed tomography (CT) acquisition, in the axial plane, of 3 mm or thinner (Figure 1, Figure 2). All patients who participated in the study provided informed consent. All patients were referred after discussion in a multidisciplinary tumor board.

Results

During the period of the study, nine patients with metastases 4 cm or smaller in contact with a pulmonary artery 3 mm or larger were seen in consultation. Six were deemed eligible to receive RF ablation during PBO, and three were not because the metastases were located too posterior in the lung parenchyma to allow for safe anterolateral or lateral puncture of the tumor in a dorsal or slightly oblique decubitus position. RF ablation was preferred over surgery by the tumor board in three patients

Discussion

It is difficult to fully ablate tissue in contact with large vessels; in animal experiments, the shapes of ablation areas close to large vessels are reported to be irregular with notches (1). In clinical practice in the liver, the proximity of large hepatic vessels is a strong independent predictor of incomplete ablation, with reported incomplete ablation rates of 53% (by Lu et al [4]) and 23% (by Elias et al [3]) for tumors abutting such vessels. Incomplete ablation was found in only 7% (4)

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Contact between the targeted tumour and a vessel or bronchi >3 mm in diameter have been reported by several authors as a predictive factor of incomplete local treatment.20,27 Percutaneous balloon occlusion of the segmental pulmonary artery involved during lung RFA has been reported in five patients with 100% local efficacy at 12 months using combined positron-emission tomography (PET) with CT for follow-up; however, tolerance was poor.28 MWA, by working at higher temperatures,29 has been demonstrated to lower convective cooling close to large vessels in animal studies,30,31 but the benefit in lowering incomplete ablation has not been demonstrated in clinical practice.
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.
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: None of the authors have identified a conflict of interest.

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Clinical studyRadiofrequency Ablation of Lung Metastases Close to Large Vessels during Vascular Occlusion: Preliminary Experience

Abstract

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

J Vasc Interv Radiol

J Vasc Interv Radiol

Eur J Radiol

J Vasc Interv Radiol

Radiofrequency liver ablation: experimental comparative study of water-cooled versus expandable systems

AJR Am J Roentgenol

Radiofrequency tissue ablation of the liver: in vivo and ex vivo experiments with four different systems

Eur Radiol

Local recurrences after intraoperative radiofrequency ablation of liver metastases: a comparative study with anatomic and wedge resections

Ann Surg Oncol

Clinical study
Radiofrequency Ablation of Lung Metastases Close to Large Vessels during Vascular Occlusion: Preliminary Experience