肺癌热消融适应症_杨宁肿瘤介入医学网

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%

Mery et al. Similar Long-term Survival of Elderly Patients With Non-small Cell Lung Cancer Treated With Lobectomy or Wedge Resection Within the Surveillance, Epidemiology, and End Results Database Chest 2005; 128:237-245

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）

Kyasa et al.Characteristics and outcomes of patients with unresected early-stage non-small cell lung cancer. South Med J 2002; 95:1149-1152

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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