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肺癌热消融适应症

时间:2020-03-03 21:12来源:未知 作者:admin 点击:
Patient Selection Criteria Clinical indications Lung Cancer Patient Characteristics High Risk Limited Recurrence Cyto-reduction Local Control Refractory Patient Refusal Patient Characteristics ACOSOG z4033 High Risk Limited Recurrence Cyto
NSCLC 热消融的目标
  • -Ablation provides only local control of cancer  非治愈性治疗的局部控制(非治愈治疗的局部控制的意义?)
  • -Stage I NSCLC: ablation alone may be used with curative intent(试图治愈,结果如何?)
  • -Stages II-IV: ablation should be combined with other therapies(和什么方法联合?)
  • -Locally recurrent cancer
  • -Limited or low volume metastases
 
Patient Selection Criteria

Clinical indications
Lung Cancer
  • Patient Characteristics
  • High Risk
  • Limited Recurrence
  • Cyto-reduction
  • Local Control
  • Refractory
  • Patient Refusal

Patient Characteristics
ACOSOG – z4033
High Risk

Limited Recurrence

Cyto-reduction

Local Control

Refractory

Patient Refusal
Major criteria (1)
FEV1 ≤ 50%
DLCO ≤ 50%
Minor criteria (2)
FEV1 51-60%
DLCO 51-60%
Age ≥ 75 years
Pulmonary hypertension
Left ventricular function (EF ≤ 40%)
Resting or exercise arterial pO2 < 55 mmHg
pCO2 > 45 mmHg

基本概念 Key concept 
理由之一:年龄大的患者治愈性手术切除不获益
Similar Long-term Survival of Elderly Patients w/ NSCLC Treated with Lobectomy or Wedge Resection within the SEER Database

   - SEER database; 14,555 stage I /II NSCLC
   - No curative (lobar or sublobar) resection
 

Age-groups No resection rate
All  15.7%
< 65 years 7.7%
65-74 years 14.1%
> 75 years 30.4%

理由之二:早期或不可切除肺癌,仅仅观察处理预后差
治疗方式(例数) 中位生存期(M)
Surgery (43)  46.2
Radiation (36) 19.2
No treatment (49)  14.2 
No treatment group:14 refused treatment  
Cause of death =
cancer in 53% patients (compared to 43% after radiation)
McGarry et al.Observation-Only Management of Early Stage, Medically Inoperable Lung Cancer Poor Outcome Chest 2002; 121:1155-1158
理由之三:不可切除早期NSCLC病人的结果和特征
97 patients stage I/II NSCLC(早期)
Cancer-specific therapy (rad/chemo) used in only 27
Median survival 22 months for treated group
Median survival 11 months for untreated group(97-27=70)
 

根据以上三个理由:选择热消融
1. >70岁,可治愈性外科切除的,(可切除的I/II期)- 
2. 不可切除的早期(I/II期)肿瘤,(包括年轻患者,需要和放疗对比吗?)
3. 不可切除肿瘤(应该有大小之分,大的不可切除的肺癌,需要射频局部控制吗?)
 
临床上在选择热消融患者的时候有三种场景:定义治疗;补充治疗和姑息治疗三种
1. 定义治疗包括
  • Stages I or II with clinical comorbidities
  • Stages I or II when the patient refuses  Surgery
  • Limited number of metastases
 
Vogl TJ, Eur J Radiol 2011;77(2):346-57.
Abbas G, et al. Surg Oncol 2009;100(8):645-50.  
Matsuoka T, et al.Int J Clin Oncol 2007;12(2):71-8. 
Casal RF, et al. Clin Chest Med 2010;31:151-163.
De Baère T,  et al. Cardiovasc Intervent  Radiol 2010;34(2):241-51.


Definitive Therapy:NSCLC
     

2. Complementary  to Other  Therapies
Persistent, solitary, peripheral focus after  definitive radiation, surgery and chemotherapy


化疗后残余癌,射频消融(Olympus)

3. 姑息治疗
- Chest wall pain
- Plexus Involvement
- Hemoptysis
- Dyspnea

Lee JM, et al. Radiology 2004;230(1):125-34. 
Belfiore G, et al. AJR Am J Roentgenol 2004;183(4):1003-1. 
Simon CJ, et al. Radiology 2007;243(1):268-75.
VanSonnenberg E, et al. AJR Am L Roentgenol 2005;184(2):381-90.

Symptom palliation


Palliation for Hemoptysis RFA 1
 
 
 
NSCLC RFA2
一个月后 咯血停止



Palliation for Pain Reduction NSCLC

姑息治疗:Treating Pulmonary Metastases:三种场景,低外科手术风险;高外科手术风险;复发性肺转移

Metastases are resectable when:
Primary cancer is  controllable/controlled.
Extrapulmonary disease  is controllable/controlled.
 


Zheng Y, et al. Surgical and Nonresectional Therapies for Pulmonary Metastasis Surg Clin N Am 2010;90:1041-51.
 
姑息性治疗 : Recurrence after resection

Metastasis  Recurrence from  Cholangiocarcinoma
     

除了 1. Definitive Therapy;2. Complementary to Other Therapies;3. Palliation
经皮消融还需要影像学的标准
PERCUTANEOUS ABLATIONS
Imaging Criteria:影像学的标准与 Feasibility 和  Predictivity 相关


1. Lesion Size
2. Lesion Localization
3. Maximum number of lesions/lung
1)Size
Lesion maximum diameter
    -   < 3cm – ideal diameter
    -   it’s accepted that is not possible to achieve complete  ablation for lesions > 3,5 cm with RFA, even with mutiple  ablations
        尽管多针射频,公认不可能实现完全消融的>3.5cm的病变
    -   MWA – to prefer for lesions > 3 cm (multiple antennas)

Fernando HC, et al. Ann Thorac Surg 2008;85(2):S780-4. 
Carrafiello G, et al. Int J Surg 2008;6:65-9. 
Vogl TJ, et al. Eur J Radiol 2011;77(2):346-57.
De Baère T, et al. Cardiovasc Intervent Radiol 2010;34(2):241-51. 
Herrera LJ, et al. J Thorac Cardiovasc Surg 2003;125(4):929-37. 
Roy AM. Curr Probl Diagn Radiol 2009;38(1):44-52
Gillams AR. BMJ 2007;334(7602):1056-7.
Gillams AR. Cancer Imaging 2008;8  Spec No A:S1-5.
2)Localization
Should not be treated lesions close to large vessels,  heart or trachea
    - To avoid lesions < 1cm from hilum
    - Iguchi et al. – 42 cases at < 10 mm from heart or
    - aorta without any complications
    - MWA could be better in those cases
 
LeVeen RF. Semin Inter Radiol 1997; 14:313-324. 
Wolf F et al Radiology 2008;247:871-879.
Gómez FM, et al. Clin Transl Oncol 2009;11(1):28-34. 
Lee JM, et al. Eur Radiol 2003;13: 2540-7.
Gillams AR, et al. Cardiovasc Intervent  Radiol 2005;28:476-80
3) Maximum number of  lesions/ lung



Gillams AR. Cancer Imaging 2008;8 Spec No A:S1-5.

Multiple Lesions
Primary Cancer controlled. No extrapulmonary disease.

Metastasis
 
俯卧位,后位进针 复查(仰卧位)

   
 
Literature Review
- 24 thermoablation studies (23 RFA and 1 MWA) with exposure of selection criteria
- 2003 to 2010
- 1.013 Patients, 605 Primitives, 408 Metastases
 

Literature Criteria

N of  studies  (n=24)

Literature Criteria

N of studies  (n=24)

Pretreatment reccomendation

 

Imaging criteria

 

- Biopsy

12

Limit value for lesion’s diameter

11

- Coagulation disorders

9

Extension of local disease

19

- Specialist responsable of the  choice

12

Maximum Diameter

11

Clinical criteria

 

Localization (close to major  vessels, heart, trachea, hilum)

19

- Poor lung function

19

Failure of conventional therapy

17

- Comorbidity

17

Surgery Refusal

18

- Advanced age

4

 

 



Patient selection conclusion

Curation - complete tumor destruction (R0-like)

Inoperability
Visibility of the tumor target
Abscence of remote metastases (staging!)

Palliation - macroscopic cytoreduction

Pain relief
Decompression

 
 
 
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