Efficacy and safety of radiofrequency ablation for lung cancers: A systematic review and meta-analysis

Image-guided Ablative Procedures

Various image-guided ablative procedures include chemical and thermal ablation techniques and irreversible electroporation. These have been used for curative intent for small tumours and palliative intent for debulking, immunogenicity and pain control. Understanding these techniques is critical to avoiding complications and achieving superior clinical outcomes. Additionally, combination with immunotherapy and chemotherapies is rapidly evolving. There are numerous opportunities in interventional radiology to advance ablation techniques and seamlessly integrate into current treatment regimens for both benign and malignant tumours.

Cone-beam computed tomography image-guided percutaneous microwave ablation for lung nodules in a hybrid operating room: an initial experience

OBJECTIVES

The experience of thermal ablation of lung lesions is limited, especially performing the procedure under localisation by cone-beam CT in the hybrid operation room (HOR). Here, we present the experience of microwave ablation (MWA) of lung nodules in the HOR.

METHODS

We reviewed patients who underwent image-guide percutaneous MWA for lung nodules in the HOR under general anaesthesia between July 2020 and July 2022. The workflow in the HOR including the pre-procedure preparation, anaesthesia consideration, operation methods, and postoperative care was clearly described.

RESULTS

Forty lesions in 33 patients who underwent MWA under general anaesthesia (GA) in the HOR were analysed. Twenty-seven patients had a single pulmonary nodule, and the remaining six patients had multiple nodules. The median procedure time was 41.0 min, and the median ablation time per lesion was 6.75 min. The median global operation room time was 115.0 min. The median total dose area product was 14881 μGym2. The median ablation volume was 111.6 cm3. All patients were discharged from the hospital with a median postoperative stay of 1 day. Four patients had pneumothorax, two patients had pleural effusion during the first month of outpatient follow-up, and one patient reported intercostal neuralgia during the 3-month follow-up.

CONCLUSIONS

Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if we follow the workflow provided. The procedure provides an alternative to managing pulmonary nodules in patients.

CLINICAL RELEVANCE STATEMENT

Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if the provided workflow is followed.

KEY POINTS

• We tested the feasibility of microwave ablation of lung lesions performed in a hybrid operating room. • To this end, we provide a description of microwave ablation of the lung under cone-beam CT localisation. • We describe a workflow by which ablation of the pulmonary nodule can be performed safely under general anaesthesia.

Enhancing the therapeutic impact of sublethal radiofrequency hyperthermia in malignant solid tumor treatment

Radiofrequency ablation (RFA) is an effective alternative to surgery for managing some malignant solid tumors. However, for medium-to-large tumors (>3 cm), tumors adjacent to large blood vessels, and certain irregular tumors, sublethal radiofrequency hyperthermia (RFH) often produces a margin of ablated tumor owing to the "heat-sink" effect. This effect typically leaves behind viable residual tumors at the margin. Several studies have reported that a sublethal RFH can significantly enhance the efficacy of chemotherapy, radiotherapy, immunotherapy, and gene therapy for malignant solid tumors. The possible mechanisms by which RFH enhances these therapies include heat-induced tissue fracturing, increased permeability of the cytoplasmic membrane, exaggerated cellular metabolism, blockade of the repair pathways of radiation-damaged tumor cells, and activation of the heat shock protein pathways. Therefore, RFA in combination with chemotherapy, radiotherapy, immunotherapy, or gene therapy may help reduce the rates of residual and recurrent tumors after RFA of malignant solid tumors.

Transbronchial Microwave Ablation of Peripheral Lung Tumors: The NAVABLATE Study

BACKGROUND

Image-guided thermal ablation is a minimally invasive local therapy for lung malignancies. NAVABLATE characterized the safety and performance of transbronchial microwave ablation (MWA) in the lung.

METHODS

The prospective, single-arm, 2-center NAVABLATE study (NCT03569111) evaluated transbronchial MWA in patients with histologically confirmed lung malignancies ≤30 mm in maximum diameter who were not candidates for, or who declined, both surgery and stereotactic body radiation therapy. Ablation of 1 nodule was allowed per subject. The nodule was reached with electromagnetic navigation bronchoscopy. Cone-beam computed tomography was used to verify the ablation catheter position and to evaluate the ablation zone postprocedure. The primary end point was composite adverse events related to the transbronchial MWA device through 1-month follow-up. Secondary end points included technical success (nodule reached and ablated according to the study protocol) and technique efficacy (satisfactory ablation based on 1-month follow-up imaging).

RESULTS

Thirty subjects (30 nodules; 66.7% primary lung, 33.3% oligometastatic) were enrolled from February 2019 to September 2020. The pre-procedure median nodule size was 12.5 mm (range 5 to 27 mm). Procedure-day technical success was 100% (30/30), with a mean ablative margin of 9.9±2.7 mm. One-month imaging showed 100% (30/30) technique efficacy. The composite adverse event rate related to the transbronchial MWA device through 1-month follow-up was 3.3% (1 subject, mild hemoptysis). No deaths or pneumothoraces occurred. Four subjects (13.3%) experienced grade 3 complications; none had grade 4 or 5.

CONCLUSION

Transbronchial microwave ablation is an alternative treatment modality for malignant lung nodules ≤30 mm. There were no deaths or pneumothorax. In all, 13.3% of patients developed grade 3 or above complications.

An Interventional Radiologist's Guide to Lung Cancer

Lung cancer continues to be the third leading cause of cancer and the leading cause of cancer deaths. As the field of interventional oncology continues to grow, interventional radiologists are increasingly treating lung cancer patients. Involvement begins with tissue diagnosis for which biomarkers and immunohistochemistry are used to guide selective and advanced medical therapies. An interventional radiologist must be aware of the rationale behind tissue diagnosis and techniques to minimize biopsy complications. Staging is an important part of tumor board conversations and drives treatment pathways. Surgical therapy remains the gold standard for early-stage disease but with an aging population the need for less invasive treatments such as radiation therapy and ablation continue to grow. The interventionalist must be aware of the indications, techniques, and pre- and posttherapy managements for percutaneous ablation. Endovascular therapy is broadly divided into therapeutic treatment of lung cancer, which is gaining traction, and treatment of lung cancer complications such as hemoptysis. This review aims to provide a good basis for interventional radiologists treating lung cancer patients.

A case of recurrent laryngeal nerve paralysis caused by radiofrequency ablation for mediastinal recurrence of lung cancer

Radiofrequency ablation (RFA) has emerged as a potent therapeutic modality for tumor treatment, and offers benefits such as reduced recovery time and minimal damage to nearby tissues. However, RFA is not devoid of complications, notably nerve damage during intrathoracic lesion treatments, which can significantly impact patients' quality of life. This report describes the unique case of a 71-year-old male who experienced hoarseness attributed to injury to the recurrent nerve after RFA for a locally recurrent lung cancer lesion in the mediastinum near the aortic arch. Although RFA has the advantages of a minimally invasive nature and positive outcomes, its risk of nerve injury, specifically in the thoracic region, highlights the need for improved techniques and preventive measures.

Safety and local efficacy of computed tomography-guided microwave ablation for treating early-stage non-small cell lung cancer adjacent to bronchovascular bundles

OBJECTIVES

To retrospectively evaluate the safety and efficacy of computed tomography (CT)-guided percutaneous microwave ablation in treating early-stage non-small cell lung cancer (NSCLC) adjacent to bronchovascular bundles.

METHODS

Two hundred and thirty-one patients with early-stage NSCLC who underwent CT-guided microwave ablation of the tumor were included for analysis. Among these, 66 lesions were located adjacent to the bronchovascular bundle. Achievement of the specific ablation range (defined as the ablation zone encompassing the tumor and the adjacent vessel) was assessed after ablation. Complications and tumor progression after treatment were examined and compared between the bronchovascular bundle and non-bronchovascular bundle groups.

RESULTS

A total of 231 patients were included. Overall, 1-, 2-, and 3-year local progression-free survival (LPFS) was 77.4%, 70.5%, and 63.8%, respectively. Bronchovascular bundle proximity, pure-solid tumor, tumor size, and ablation margin < 5 mm were independent risk factors for local progression in multivariate analysis. In the bronchovascular bundle group, the 1-, 2- and 3-year LPFS rates were 63.0%, 50.7%, and 43.4%, respectively; vessel proximity and specific ablation range failure were independent risk factors for local progression. Overall survival in the entire cohort was 93.0% at 1 year, 76.1% at 2 years, and 55.0% at 3 years. The incidence of postoperative complications did not significantly differ between the two groups (p > 0.05). The most common complication was pneumothorax. Severe hemoptysis did not occur.

CONCLUSION

Tumor location near the bronchovascular bundles was a significant risk factor for local progression after microwave ablation. Achieving a specific ablation range may increase LPFS for these lesions.

CLINICAL RELEVANCE STATEMENT

Achieving the specific ablation range may improve local efficacy for early-stage non-small cell lung cancer located adjacent to the bronchovascular bundle.

KEY POINTS

• Local efficacy of percutaneous microwave ablation in treating early-stage non-small cell lung cancer was affected by bronchovascular bundle proximity. • Achieving the specific ablation range may improve local efficacy for lesions located adjacent to the bronchovascular bundle.

Special Considerations and Techniques of Interventions in Lung Transplant Recipients

Lung transplant remains an important treatment option for patients with end-stage lung diseases providing improvement in survival rates and quality of life. Specialized considerations should be applied with interventions of lung transplant recipients as they host specific anatomic variations and high risk towards certain complications. In this article, we highlight the role of interventional radiology for lung transplant recipients along with discussion of interventional techniques. Specific emphasis is placed on describing and explaining the techniques pertained to the points of anastomosis, diagnosis and treatment of malignancies, and management of complications in lung transplant recipients.

Efficacy and safety of radiofrequency ablation in the treatment of inoperable patients with pulmonary malignant nodules

BACKGROUND

Radiofrequency ablation (RFA) has been recently applied as an alternative treatment in the patients with pulmonary malignancies. The aim of our study was to assess the incidence of complications and survival rate of RFA for malignant lung nodules, and evaluate the efficacy and safety of RFA in the treatment of inoperable patients with pulmonary malignant nodules.

METHODS

The clinical data of 50 patients with primary and metastatic lung malignant nodules treated with RFA from June 2015 and July 2017 in Hebei General Hospital were considered, and the characteristics and clinical data of these patients were analysed. Complications, progression-free survival and overall survival at 1, 2 and 5 years of these patients were evaluated.

RESULTS

Following the procedure. There were no major complications and deaths during the operation. 26 (52%) patients presented mild-to-moderate chest pain that was easily controlled by analgesic drugs. 8 (16%) patients with pneumothorax, 4 (8%) haemoptysis, 6 (12%) pneumonia, 7 (14%) pleural effusion and 1 (2%) postoperative bronchopleural fistula. Needle-track implantation was observed in 2 (4%) patients. Median progression-free survival (PFS) was 24.6 months. The PFS at 1, 2, 5 years was 76%, 52% and 20%, respectively. Median overall survival (OS) was 35.5 months. The OS at 1, 2 and 5 years was 80%, 58% and 32%, respectively.

CONCLUSION

RFA is a safe and effective alternative treatment for the inoperable patients with primary or metastatic pulmonary malignant nodules. The clinical impact and long-term results of RFA need to be further confirmed in a larger series of patients, and RFA should ideally be compared with surgery.

Robotic versus freehand CT-guided radiofrequency ablation of pulmonary metastases: a comparative cohort study

PURPOSE

Radiofrequency ablation (RFA) is a curative treatment option for small lung metastases, which conventionally involves multiple freehand manipulations until the treating electrode is satisfactorily positioned. Stereotactic and robotic guidance has been gaining popularity for liver ablation, although has not been established in lung ablation. The purpose of this study is to determine the feasibility, safety, and accuracy of robotic RFA for pulmonary metastases, and compare procedures with a conventional freehand cohort.

METHODS

A single center study with prospective robotic cohort, and retrospective freehand cohort. RFA was performed under general anesthesia using high frequency jet ventilation and CT guidance. Main outcomes were (i) feasibility/technical success (ii) safety using Common Terminology Criteria for Adverse Events (iii) targeting accuracy (iv) number of needle manipulations for satisfactory ablation. Robotic and freehand cohorts were compared using Mann-Whitney U tests for continuous variables, and Fisher's exact for categorical variables.

RESULTS

Thirty-nine patients (mean age 65 ± 13 years, 20 men) underwent ablation of 44 pulmonary metastases at single specialist cancer center between July 2019 and August 2022. 20 consecutive participants underwent robotic ablation, and 20 consecutive patients underwent freehand ablation. All 20/20 (100%) robotic procedures were technically successful, and none were converted to freehand procedures. There were 6/20 (30%) adverse events in the robotic cohort, and 15/20 (75%) in the freehand cohort (P = 0.01). Robotic placement was highly accurate with 6 mm tip-to-target distance (range 0-14 mm) despite out-of-plane approaches, with fewer manipulations than freehand placement (median 0 vs. 4.5 manipulations, P < 0.001 and 7/22, 32% vs. 22/22, 100%, P < 0.001).

CONCLUSIONS

Robotic radiofrequency ablation of pulmonary metastases with general anesthesia and high frequency jet ventilation is feasible and safe. Targeting accuracy is high, and fewer needle/electrode manipulations are required to achieve a satisfactory position for ablation than freehand placement, with early indications of reduced complications.

High risk lung nodule: A multidisciplinary approach to diagnosis and management

Pulmonary nodules are often discovered incidentally during CT scans performed for other reasons. While the vast majority of nodules are benign, a small percentage may represent early-stage lung cancer with the potential for curative treatments. With the growing use of CT for both clinical purposes and lung cancer screening, the number of pulmonary nodules detected is expected to increase substantially. Despite well-established guidelines, many nodules do not receive proper evaluation due to a variety of factors, including inadequate coordination of care and financial and social barriers. To address this quality gap, novel approaches such as multidisciplinary nodule clinics and multidisciplinary boards may be necessary. As pulmonary nodules may indicate early-stage lung cancer, it is crucial to adopt a risk-stratified approach to identify potential lung cancers at an early stage, while minimizing the risk of harm and expense associated with over investigation of low-risk nodules. This article, authored by multiple specialists involved in nodule management, delves into the diagnostic approach to lung nodules. It covers the process of determining whether a patient requires tissue sampling or continued surveillance. Additionally, the article provides an in-depth examination of the various biopsy and therapeutic options available for malignant lung nodules. The article also emphasizes the significance of early detection in reducing lung cancer mortality, especially among high-risk populations. Furthermore, it addresses the creation of a comprehensive lung nodule program, which involves smoking cessation, lung cancer screening, and systematic evaluation and follow-up of both incidental and screen-detected nodules.

Innovative Invasive Loco-Regional Techniques for the Treatment of Lung Cancer

Surgical resection is still the standard treatment for early-stage lung cancer. A multimodal treatment consisting of chemotherapy, radiotherapy and/or immunotherapy is advised for more advanced disease stages (stages IIb, III and IV). The role of surgery in these stages is limited to very specific indications. Regional treatment techniques are being introduced at a high speed because of improved technology and their possible advantages over traditional surgery. This review includes an overview of established and promising innovative invasive loco-regional techniques stratified based on the route of administration, including endobronchial, endovascular and transthoracic routes, a discussion of the results for each method, and an overview of their implementation and effectiveness.

A CT-Based Radiomics Nomogram to Predict Complete Ablation of Pulmonary Malignancy: A Multicenter Study

Objective

Thermal ablation is a minimally invasive procedure for the treatment of pulmonary malignancy, but the intraoperative measure of complete ablation of the tumor is mainly based on the subjective judgment of clinicians without quantitative criteria. This study aimed to develop and validate an intraoperative computed tomography (CT)-based radiomic nomogram to predict complete ablation of pulmonary malignancy.

Methods

This study enrolled 104 individual lesions from 92 patients with primary or metastatic pulmonary malignancies, which were randomly divided into training cohort (n=74) and verification cohort (n=30). Radiomics features were extracted from the original CT images when the study clinicians determined the completion of the ablation surgery. Minimum redundancy maximum relevance (mRMR) and least absolute shrinkage and selection operator (LASSO) were adopted for the dimensionality reduction of high-dimensional data and feature selection. The prediction model was developed based on the radiomics signature combined with the independent clinical predictors by multiple logistic regression analysis. The area under the curve (AUC), accuracy, sensitivity, and specificity were calculated. Receiver operating characteristic (ROC) curves and calibration curves were used to evaluate the predictive performance of the model. Decision curve analysis (DCA) was applied to estimate the clinical usefulness and net benefit of the nomogram for decision making.

Results

Thirteen CT features were selected to construct radiomics prediction model, which exhibits good predictive performance for determination of complete ablation of pulmonary malignancy. The AUCs of a CT-based radiomics nomogram that integrated the radiomics signature and the clinical predictors were 0.88 (95% CI 0.80-0.96) in the training cohort and 0.87 (95% CI: 0.71–1.00) in the validation cohort, respectively. The radiomics nomogram was well calibrated in both the training and validation cohorts, and it was highly consistent with complete tumor ablation. DCA indicated that the nomogram was clinically useful.

Conclusion

A CT-based radiomics nomogram has good predictive value for determination of complete ablation of pulmonary malignancy intraoperatively, which can assist in decision-making.

Effect of Hashimoto's thyroiditis on the extent of the ablation zone in early stages of ultrasound-guided radiofrequency ablation for papillary thyroid microcarcinoma: a large cohort study of 772 patients

PURPOSE

To evaluate the effect of Hashimoto's thyroiditis (HT) on the extent of ablation zone in ultrasound (US)-guided radiofrequency ablation (RFA) for early stages of papillary thyroid microcarcinoma (PTMC).

METHOD

We selected 772 patients with 797 PTMCs who underwent with RFA from August 2017 to August 2020. They were subdivided into two groups as follows: (i) 216 patients (224 PTMCs) with HT in the 'HT + PTMC' group and (ii) 556 patients (573 PTMCs) with healthy thyroid in the 'PTMC' group. We assessed the extent (maximum diameter and volume) of the ablation zone by contrast-enhanced ultrasound (CEUS) immediately, one day, and 1 week following RFA.

RESULTS

The ablation zone of the 'HT + PTMC' group was smaller than that of the 'PTMC' group at 1 week of RFA (maximum diameter: 14.6 ± 3.1 mm vs. 15.2 ± 3.2 mm and volume: 0.932 ± 0.498 mL vs. 1.028 ± 0.540 mL, respectively, p < .05). However, there were no differences before, immediately, and one day post-RFA (p > .05). Life-threatening complications did not develop in any of the patients.

CONCLUSION

RFA-treated PTMCs were smaller in size in patients with HT than in those with a healthy thyroid at 1 week of RFA. However, the exact mechanism underlying this phenomenon and its clinical significance warrant further investigation.

Availability of Interventional Oncology in Germany in the Years 2018 and 2019 - Results from a Nationwide Database (DeGIR Registry Data)

OBJECTIVE

 Over the past few decades, radiology has established itself in tumor therapy through interventional oncology including innovative and efficient procedures for minimalinvasive treatment of various tumor entities besides the "classic" therapeutic options such as surgery, chemotherapy and radiotherapy.Aim of this study was to evaluate the extent to which interventional oncology can provide nationwide care using the data from the register of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR registry), which records radiological interventions as part of quality assurance.

METHODS

 The numbers of interventions of participating clinics, which were recorded as part of module D (oncological procedures including TACE or other tumor-specific embolization, ablation, percutaneous tumor therapy) and identified by the DeGIR registry between 2018 and 2019, were analyzed retrospectively. The collected intervention data were evaluated regarding federal states and 40 smaller regions (administrative districts and former administrative districts).

RESULTS

 In 2018, 11 653 oncological interventions in 187 clinics were recorded by the DeGIR registry. In 2019, the number of participating clinics rose to 216 and the number of oncological interventions increased by 6 % to 12 323. The average number of oncological interventions per clinic decreased slightly from 62.5 (2018) to 57.1 (2019). The DeGIR requirement for being certified as a training center was met by 116 clinics in 2018 including 31 clinics with more than 100 interventions and 129 clinics in 2019 including 36 with more than 100 interventions. Oncological interventions have been performed in each of the 40 regions. An average of 599 interventions per region (standard deviation of 414) was recorded in the period between 2018 and 2019.

CONCLUSION

 Based on the distribution of the documented oncological interventions at federal state level as well as the district level, the supply of interventional tumor therapy depends on the geographical location. Therefore, the demand of oncological interventions might not be sufficiently covered in some regions.

KEY POINTS

· Interventional-oncological tumor therapies are performed throughout Germany. · Looking at the notable geographical differences, the need for interventional oncological procedures does not seem to be sufficiently met.. · In order to improve the comprehensive provision of oncological interventions, the training of interventional radiologists should be promoted further..

CITATION FORMAT

· Radosa CG, Nadjiri J, Mahnken AH et al. Availability of Interventional Oncology in Germany in the Years 2018 and 2019 - Results from a Nationwide Database (DeGIR Registry Data). Fortschr Röntgenstr 2022; DOI: 10.1055/a-1729-0951.

Factors Associated with Pulmonary Function Changes in Patients Undergoing Microwave Ablation for Pulmonary Ground-Glass Nodules

Purpose: Microwave ablation has become an alternative treatment for pulmonary ground-glass nodules (GGN) and is widely accepted by clinicians. However, its effect on lung function remains unknown. Therefore, this retrospective study aimed to explore pulmonary function changes and associated risk factors in patients undergoing computed tomography (CT)-guided microwave ablation (MWA) for treating pulmonary GGN. Materials and Methods: Thirty-five patients diagnosed with pulmonary GGN on thin-layer chest CT and enhanced CT were examined. Patients unable or unwilling to undergo thoracoscopic surgery underwent CT-guided simultaneous percutaneous core needle biopsy and MWA. Pulmonary function tests (PFT) were performed before ablation and 3 days and 6 months post-ablation. Forced expiratory volume in one second (FEV1), FEV1%, forced vital capacity (FVC), maximal voluntary ventilation (MVV), and peak expiratory flow (PEF) values pre- and post-MWA were analysed. Linear regression analysis was used to examine the correlation between ablation volume and changes in PFT findings 3 days post-ablation. Associations between patient characteristics, rates of postoperative complications, and PFT findings were analysed. Results: Forty-eight lesions were completely ablated and examined intraoperatively. There were significant differences in pre- and post-operative PFT findings on day 3 but not at 6 months. The mean ablation volume after 3 days of 11.4 ± 6.3 cm³ was positively correlated with changes in FEV1, MVV, and PEF values. Patients' age (mean, 59.4 ± 13.0 years) positively correlated with changes in PEF values. The rates of change in FVC and MVV values were significantly higher with multiple pulmonary nodules than with isolated pulmonary nodule. PFT findings were similar between patients who experienced or did not experience complications (eg, pneumothorax and pleural effusion). Conclusions: Pulmonary function could be impaired shortly after MWA. PFT findings may correlate with age, ablation volume, and number of ablated lesions. In most patients, pulmonary function returned to the preoperative state after 6 months.

Advances and controversies in the management of early stage non-small cell lung cancer

Complete resection continues to be the gold standard for the treatment of early-stage lung cancer. The landmark Lung Cancer Study Group trial in 1995 established lobectomy as the minimum intervention necessary for the management of early-stage non-small cell lung cancer, as it was associated with lower recurrence and metastasis rates than sublobar resection and lower postoperative morbidity and mortality than pneumonectomy. There is a growing tendency to perform sublobar resection in selected cases, as, depending on factors such as tumor size, histologic subtype, lymph node involvement, and resection margins, it can produce similar oncological results to lobectomy. Alternative treatments such as stereotactic body radiotherapy and radiofrequency ablation can also produce good outcomes in inoperable patients or patients who refuse surgery.

Hsp70 Promotes SUMO of HIF-1α and Promotes Lung Cancer Invasion and Metastasis

Objective

This study aims to investigate the effect of heat shock protein-70 (Hsp70) on epithelial-mesenchymal transition (EMT) of lung cancer cells under heat stimulation and to explore its possible molecular mechanism.

Methods

qRT-PCR and immunohistochemistry assay were used to detect the expression of Hsp70 in lung cancer tissues and adjacent tissues. EdU assay was used to detect the cell activity. The effect of Hsp70 on the migration and invasion of A549 and NCI-H446 cells was detected by the wound-healing assay and Transwell assay. A tumor transplantation animal model was established to detect the effect of overexpression of Hsp70 on proliferation and metastasis of lung cancer cells. Western blot assay was used to detect the effect of thermal stimulation and overexpression of Hsp70 on SUMO modification of HIF-1α.

Results

The wound-healing rate of A549 and NCI-H446 cells under Hsp70 stimulation was significantly higher than blank control group. At the same time, the number of cells passing through the membrane increased significantly. Hypodermic tumor transplantation in nude mice proved that knockout Hsp70 can inhibit proliferation and metastasis of lung cancer cells. Thermal stimulation upregulated the expression of Hsp70 and promoted SUMO modification of HIF-1α, ultimately promoting the proliferation and metastasis of lung cancer. Inhibition of Hsp70 reverses the effect of thermal stimulation on lung cancer by reducing the SUMO modification of HIF-1α.

Conclusion

Thermal stimulation can promote EMT in A549 and NCI-H446 cells and promote cell migration and invasion in vitro and in vivo by upregulation of Hsp70. This process is associated with the promotion of SUMO modification of HIF-1α.

Image-guided combined ablation and resection in thoracic surgery for the treatment of multiple pulmonary metastases: A preliminary case series

Objectives

To demonstrate the feasibility and preliminary outcomes of a novel hybrid technique combining percutaneous microwave ablation and wire-assisted wedge resection for patients with multiple pulmonary metastases using intraoperative imaging.

Methods

We describe our technique and present a retrospective case series of 4 patients undergoing iCART at our institution between August 2018 and January 2020. Procedures were performed in a hybrid operating suite using the ARTIS Pheno cone beam computerized tomography scanner (Siemens Healthineers, Erlangen, German). Patient information included past history of malignancy as well as lesion size, depth, location, and histology result. Surgical complications and length of stay were also recorded.

Results

Five procedures were performed on 4 patients during the study period. One patient underwent bilateral procedures 4 weeks apart. All patients underwent at least 1 ablation and 1 wedge resection during the combined procedure. Patient ages ranged from 40 to 66 years and the majority (75%) were men. All had a past history of cancer. Lesions were treated in every lobe. Size and depth ranged from 6 to 24 mm and 21 to 33 mm, respectively, for ablated nodules and 5 to 27 mm and 0 to 22 mm, respectively, for the wedge resected nodules. Three procedures were completed uniportal and operative time ranged from 51 to 210 minutes. All cases sustained <10 mL blood loss. There were 2 intraoperative pneumothorax, 1 prevented successful completion of the ablation. One patient required a prolonged period of postoperative physiotherapy and was discharged on day 6. The other patients were discharged on postoperative day 2 or 3. All 5 histology specimens confirmed metastatic disease.

Conclusions

Our hybrid approach provides a minimally invasive and comprehensive personalized therapy for patients with multiple pulmonary metastases under a single general anesthetic. It provides histology-based diagnosis whilst minimizing lung tissue loss and eliminating the need for transfer from radiology to operating theatre. Emergence of ablation as a treatment for stage 1 non–small cell lung cancer and the expansion of lung cancer screening may widen the application of iCART in the future.

Feasibility and Safety of Radiofrequency Ablation Guided by Bronchoscopic Transparenchymal Nodule Access in Canines

BACKGROUND

The treatment of pulmonary malignancies remains a challenge. The efficacy and safety of bronchoscopic radiofrequency ablation (RFA) for the treatment of lung cancer are not well elucidated.

OBJECTIVE

This study aimed to evaluate the feasibility and safety of RFA guided by bronchoscopic transparenchymal nodule access (BTPNA) in vivo.

METHODS

In an attempt to determine the parameters of RFA, we first performed RFA in conjunction with automatic saline microperfusion in the lung in vitro with various ablation energy (10, 15, 20, 25, and 30 W) and ablation times (3, 5, 8, and 10 min). The correlation between ablated area and RFA parameter was recorded and analyzed. Further, we conducted a canine study with RFA by BTPNA in vivo, observing the ablation effect and morphological changes in the lung assessed by chest CT and histopathologic examination at various follow-up time points (1 day, n = 3; 30 days, n = 4; 90 days, n = 4). The related complications were also observed and recorded.

RESULTS

More ablation energy, but not ablation time, induced a greater range of ablation area in the lung. Ablation energy applied with 15 W for 3 min served as the appropriate setting for pulmonary lesions ≤1 cm. RFA guided by BTPNA was performed in 11 canines with 100% success rate. Inflammation, congestion, and coagulation necrosis were observed after ablation, which could be repaired within 7 days; subsequently, granulation and fibrotic scar tissue developed after 30 days. No procedure-related complication occurred during the operation or in the follow-up periods.

CONCLUSION

The novel RFA system and catheter in conjunction with automatic saline microperfusion present a safe and feasible modality in pulmonary parenchyma. RFA guided by BTPNA appears to be well established with an acceptable tolerance; it might further provide therapeutic benefit in pulmonary malignancies.

[Interventional Radiology in Oncology - Update 2021]

Interventional radiology plays a crucial role in oncology. The most common interventional treatments are transarterial embolisation as well as percutaneous thermal ablations. Transarterial embolisation, such as transarterial chemoembolization (TACE) or selective internal radiation therapy (SIRT) are well established, usually palliatively intended treatment options for primary and secondary hepatic malignancies. Embolisation is usually well tolerated under conscious sedation and can be repeated several times. Percutaneous thermoablation is a local ablative, usually curatively intended treatment for hepatic, renal and pulmonary tumors. As a minimally invasive technique, it competes against surgery and radiation therapy. There are different types of thermoablation, most commonly used are radiofrequency ablation (RFA), microwave ablation (MWA) and cryo-ablation. Ablation is usually performed in general anesthesia, less common in conscious sedation. New interventional treatments are high intensity focused ultrasound (HIFU) and irreversible electroporation (IRE). HIFU allows a non-invasive, imaging-guided thermoablation that is currently certified for uterine myoma, prostate cancer and bone tumors. IRE is a minimal invasive non-thermal ablation that is especially established for locally advanced tumors that show a close relationship to large vessels, for example pancreatic cancer.

Society of Interventional Radiology Multidisciplinary Position Statement on Percutaneous Ablation of Non-small Cell Lung Cancer and Metastatic Disease to the Lungs: Endorsed by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology

PURPOSE

To state the Society of Interventional Radiology's position on the use of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease to the lung.

MATERIALS AND METHODS

A multidisciplinary writing group, with expertise in treating lung cancer, conducted a comprehensive literature search to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.

RESULTS

A total of 63 studies, including existing systematic reviews and meta-analysis, retrospective cohort studies, and single-arm trials were identified. The expert writing group developed and agreed on 7 recommendations on the use of image-guided thermal ablation in the lung.

CONCLUSION

SIR considers image-guided thermal ablation to be an acceptable treatment option for patients with inoperable Stage I NSCLC, those with recurrent NSCLC, as well as patients with metastatic lung disease.

Survival prediction for non-small cell lung cancer patients treated with CT-guided microwave ablation: development of a prognostic nomogram

OBJECTIVES

To explore the outcomes of CT-guided percutaneous microwave ablation (MWA) in non-small cell lung cancer (NSCLC) patients, and then develop an effective nomogram to predict the survival.

METHODS

NSCLC patients treated with MWA were randomly allocated to either the training cohort or the validation cohort (3:1). The primary outcome measurement was overall survival (OS), whose predictors were identified by univariate and multivariate analyses in the training cohort. Then, a predictive nomogram was developed to predict the OS, with the predictive accuracy evaluated by C-statistic and receiver operating characteristic in both the training and validation cohorts.

RESULTS

A total of 234 patients (training cohort: n = 176; validation cohort: n = 58) and 271 tumors with a median OS of 17.0 ± 12.2 months were included. The predictors selected into the nomogram included tumor diameter (hazard ratio [HR], 2.12; 95% confidence interval [CI], 1.37-3.30; p < 0.001), extrapulmonary metastases (HR, 1.77; 95% CI, 1.06-2.95; p = 0.030), tumor stage (HR, 1.38; 95% CI, 1.07-1.79; p = 0.013), tumor type (HR, 2.00; 95% CI, 1.48-2.72; p < 0.001) and post-MWA TKIs (HR, 0.55; 95% CI, 0.34-0.89; p < 0.001), based on the results of univariate and multivariate analyses. The C-statistic showed good predictive performance, with a C-statistic of 0.838 (95% CI, 0.779-0.897) internally and 0.808 (95% CI, 0.695-0.920) externally (training cohort and validation cohort, respectively).

CONCLUSIONS

The nomogram was effective in predicting the OS in NSCLC patients treated with MWA, and could be applied to identify patients who may benefit most from MWA and be helpful for clinical decision making.

Stage I non-small cell lung cancer: Treatment modalities, Dutch daily practice and future perspectives

OBJECTIVES

Several treatment modalities are available for patients with stage I non-small cell lung cancer (NSCLC). Over the past decade, these treatment modalities have been further investigated and might have changed current treatment regimens. In this review we present an overview of the treatment options, developments and future perspectives for stage I NSCLC. Furthermore, we describe the current use of these treatment modalities in the Netherlands.

MATERIALS AND METHODS

A bibliographical search was performed in PubMed and the Cochrane Library for publications concerning treatment modalities for stage I NSCLC. In addition, evidence-based guidelines of the European Society for Medical Oncology (ESMO) and the National Comprehensive Cancer Network (NCCN) were studied.

RESULTS

The guideline-recommended treatment for operable stage I NSCLC patients is a lobectomy with systematic lymph node dissection. Inoperable patients or those refusing surgery are offered stereotactic ablative radiotherapy (SABR). Percutaneous ablation, such as radiofrequency ablation, is a non-surgical minimally invasive technique offered to those who are ineligible for surgery or SABR. The role of systemic therapy is currently limited. However, the efficacy of immunotherapy is being investigated in clinical trials. In the Netherlands, an increasing use of SABR and a relative decrease in resection rates have been observed.

CONCLUSION

Surgery and SABR are currently the prevailing treatment modalities for stage I NSCLC patients. Despite optimization of treatment regimens, survival of patients with stage I NSCLC remains to be improved. Future studies are required to optimize treatment strategies, but also to investigate factors influencing treatment decision-making for patients with stage I NSCLC.

Image-guided percutaneous ablation for the treatment of lung malignancies: current state of the art

Image-guided percutaneous lung ablation has proven to be a valid treatment alternative in patients with early-stage non-small cell lung carcinoma or oligometastatic lung disease. Available ablative modalities include radiofrequency ablation, microwave ablation, and cryoablation. Currently, there are no sufficiently representative studies to determine significant differences between the results of these techniques. However, a common feature among them is their excellent tolerance with very few complications. For optimal treatment, radiologists must carefully select the patients to be treated, perform a refined ablative technique, and have a detailed knowledge of the radiological features following lung ablation. Although no randomized studies comparing image-guided percutaneous lung ablation with surgery or stereotactic radiation therapy are available, the current literature demonstrates equivalent survival rates. This review will discuss image-guided percutaneous lung ablation features, including available modalities, approved indications, possible complications, published results, and future applications.

Advances in study of the sequence of lung tumor biopsy and thermal ablation

Percutaneous thermal ablation is an important treatment for lung cancer and is widely used in hospitals. Puncture biopsy is generally required for pathological diagnosis before or after thermal ablation. Pathological diagnosis provides both evidence of benign and malignant lesions for ablation therapy and is of important significance for the next step in disease management. Furthermore, the sequence of ablation and biopsy affects the accuracy of pathological diagnosis, the complete ablation rate of thermal ablation, and incidence of surgery‐related complications. Ultimately, it may affect the patient's benefit from local treatment. This article reviews the research progress of traditional asynchronous biopsy followed by ablation, the emerging methods of synchronous biopsy followed by ablation, and synchronous ablation followed by biopsy in the last decade.

Key points

The sequence of ablation and biopsy affects the accuracy of pathological diagnosis, the complete ablation rate of thermal ablation, and the incidence of surgical‐related complications.

This article reviewed the recent 10 years' literature on the surgical sequence of biopsy and ablation for lung tumors, the advantages, disadvantages and indications of different orders were analyzed.

The evolution of interventional oncology in the 21st century

Interventional oncology (IO) has proven to be highly efficient in the local therapy of numerous malignant tumors in addition to surgery, chemotherapy, and radiotherapy. Due to the advent of immune-oncology with the possibility of tumor control at the molecular and cellular levels, a system change is currently emerging. This will significantly rule oncology in the coming decades. Therefore, one cannot think about IO in the 21st century without considering immunology. For IO, this means paying much more attention to the immunomodulatory effects of the interventional techniques, which have so far been neglected, and to explore the synergistic possibilities with immuno-oncology. It can be expected that the combined use of IO and immuno-oncology will help to overcome the limitations of the latter, such as limited local effects and a high rate of side-effects. To do this, however, sectoral boundaries must be removed and interdisciplinary research efforts must be strengthened. In case of success, IO will face an exciting future.

Bronchoscopic treatments for early-stage peripheral lung cancer: Are we ready for prime time?

Lung cancer is the leading cause of cancer-related death worldwide and surgical lobectomy remains the preferred therapy for patients with early-stage NSCLC. Medical comorbidities and advanced age preclude resection in many patients and minimally invasive ablative therapies are needed for treatment. Stereotactic ablative radiation is established as an effective modality in this patient group, although may be contraindicated in some patients with prior radiation exposure, comorbidities or centrally positioned tumours. Percutaneous ablative methods are available, although are frequently associated with significant complications. Numerous endoscopic ablative techniques are under evaluation. With a more favourable safety profile and the ability to provide diagnosis and staging information potentially within a single procedure, there is a strong rationale for development of bronchoscopic ablative modalities. In the following article, the authors aim to explore the role bronchoscopic ablation may play in treatment of peripheral lung tumours, and to describe a pathway to establishing these modalities as part of routine care. The current status of several bronchoscopic ablative options is discussed in detail.

Synchronous core-needle biopsy and microwave ablation for highly suspicious malignant pulmonary nodule via a coaxial cannula

Aims

This study aimed to evaluate the safety and feasibility of computed tomography (CT)-guided synchronous percutaneous core-needle biopsy and microwave ablation (MWA) for highly suspicious malignant pulmonary nodules.

Materials and Methods

This retrospective study evaluated medical records of 54 consecutive patients (mean age, 65.5 ± 11.2 years) with 62 highly suspicious malignant pulmonary nodules who synchronously underwent percutaneous core-needle biopsy and MWA via a coaxial cannula (Group A) or sequentially underwent these procedures (Group B) from September 2016 to November 2017. All patients were followed up for at least 6 months after MWA. The safety and feasibility of synchronous core-needle biopsy and MWA were analyzed by comparing clinical data, technical success rate, complication, and curative effect per nodule with those of sequential procedures.

Results

Technical success rates were 100% in both groups. The pneumothorax rate was 29.6% (8/27) in Group A and 57.1% (20/35) in Group B, which was statistically different (P = 0.031). In Group A, hemoptysis and pleural effusion rates were 22.2% (6/27), and in Group B, the corresponding rates were 28.6% (10/35) and 20.0% (7/35), respectively. No postprocedural pulmonary artery pseudoaneurysm, bronchopleural fistula, or needle-tract tumor seeding developed in both groups. After 6 months' follow-up, the effective rates (complete + partial response) in both groups were 100%.

Conclusions

Synchronous core-needle biopsy and MWA via a coaxial cannula is technically safe and feasible in the management of highly suspicious malignant pulmonary nodules, and this procedure has lesser complications and similar effects (both 100% effective treatment) compared with sequential procedures.

Ablation Therapy for Advanced Stage Non-Small Cell Lung Cancer: A National Cancer Database Study

PURPOSE

To compare overall survival (OS) of ablation with no treatment for patients with advanced stage non-small cell lung cancer.

METHODS

Patients with clinical stage IIIB (T_1-4N₃M₀, T₄N₂M₀) and stage IV (T_1-4N_0-3M₁) non-small cell lung cancer, in accordance with the American Joint Committee on Cancer, 7th edition, who did not receive treatment or who received ablation as their sole primary treatment besides chemotherapy from 2004 to 2014, were identified from the National Cancer Data Base. OS was estimated using the Kaplan-Meier method and evaluated by log-rank test, univariate and multivariate Cox proportional hazard regression, and propensity score-matched analysis. Relative survival analyses comparing age- and sex-matched United States populations were performed.

RESULTS

A total of 140,819 patients were included. The 1-, 2-, 3- and 5-year survival rates relative to age- and sex-matched United States population were 28%, 18%, 12%, and 10%, respectively, for ablation (n = 249); and 30%, 15%, 9%, and 5%, respectively for no treatment (n = 140,570). Propensity score matching resulted in 249 patients in the ablation group versus 498 patients in the no-treatment group. After matching, ablation was associated with longer OS than that in the no-treatment group (median, 5.9 vs 4.7 months, respectively; hazard ratio, 0.844; 95% confidence interval, 0.719-0.990; P = .037). These results persisted in patients with an initial tumor size of ≤3 cm.

CONCLUSIONS

Preliminary results suggest ablation may be associated with longer OS in patients with late-stage non-small cell lung cancer than survival in those who received no treatment.

Endobronchial Ultrasound-Guided Radiofrequency Ablation of Lung Tumors and Mediastinal Lymph Nodes: A Preclinical Study in Animal Lung Tumor and Mediastinal Adenopathy Models

Radiofrequency ablation (RFA) can be a therapeutic option in medically inoperable lung cancer patients. In this study, we evaluated a prototype bipolar RFA device applicator that can be deployed from a standard endobronchial ultrasound (EBUS) bronchoscope to determine feasibility and histopathological analysis in animal models. Rabbit lung cancers were created by transbronchial injection of VX2 rabbit cancer cells. Once the tumors were developed, they were ablated transpleurally, under EBUS guidance using the prototype RFA device. The animals were then sacrificed for specimen resection. Pig inflammatory lung pseudo-tumors and lymphadenopathy were created by transbronchial injection of a talc paste and ablated transbronchially under EBUS guidance. Pigs were evaluated at 5 days, 2 weeks, and 4 weeks following ablation by bronchoscopy and cone beam computed tomography before necropsy. Nicotinamide adenine dinucleotide hydrogen diaphorase staining was employed to measure the ablation area. Twenty-four VX2 rabbit tumors were ablated. The total ablated area ranged from 0.6 to 3.0 cm² (mean: 1.8 cm²), corresponding to a total energy range of 1 to 6 kJ. Six pig lung pseudo-tumors and 5 mediastinal lymph nodes were ablated. Adjacent airway ulceration was observed in 3 ablations of lymph nodes. These airway complications resolved within 4 weeks of RFA without any treatment. There was no hemoptysis, air embolism, respiratory distress, or other serious complication noted. In these 2 animal models, we provide evidence that EBUS-guided bipolar RFA is feasible and histopathology shows that can ablate lung tumors and mediastinal lymph nodes under real-time ultrasound guidance.

Independent prognostic value of HIF-1α expression in radiofrequency ablation of lung cancer

Radiofrequency ablation (RFA) is widely used in the treatment of lung cancer. Hypoxia-inducible factor-1α (HIF-1α) is a crucial transcription factor regulating oxygen homeostasis that is involved in tumor cell metastasis. The present study investigated the impact of HIF-1α expression and other factors, such as postoperative blood CD4⁺/CD8⁺ ratio, on the prognosis of patients with lung cancer who had received RFA treatment. A total of 80 patients with lung cancer were recruited between January 2011 and October 2016 at The Shenzhen People's Hospital. Lung cancer was confirmed following pathological or histological examination. All patients underwent RFA treatment. Patients were followed up for 6–66 months. HIF-1α expression in lung cancer tissues was assessed by immunohistochemistry. Multivariate survival analysis was performed using Cox proportional hazards model. The results demonstrated that HIF-1α level was low in 36 patients and overexpressed in 44 patients with lung cancer. Kaplan-Meier (KM) curve analysis demonstrated that the overall survival time of patients with high HIF-1α expression was significantly shorter compared with patients with low HIF-1α expression (P<0.05). Furthermore, the results from the KM model and log-rank test revealed that age, Union for International Cancer Control stage, primary or metastatic cancer, chemotherapy, postoperative blood CD4⁺/CD8⁺ ratio, Eastern Cooperative Oncology Group performance status and HIF-1α expression had significant effects on overall survival of patients with lung cancer. The results from Cox analysis demonstrated that high HIF-1α expression, advanced age, clinical staging and chemotherapy were independent risk factors for the prognosis of lung cancer following RFA treatment, and that high HIF-1α expression was associated with the increased risk (5.91-fold) of mortality. In conclusion, the present study demonstrated that HIF-1α expression was increased in lung cancer tissues and was associated with the prognosis of patients with lung cancer who were treated with RFA. These findings suggest that HIF-1α expression may be considered as a marker for evaluating the prognosis of these patients.

Lung Ablation: Indications and Techniques

Lung ablation is ever more recognized since its initial report and use almost two decades ago. With technological advancements in thermal modalities, particularly microwave ablation and cryoablation, better identification of the cohort of patients who best benefit from ablation, and understanding the role of imaging after ablation, image-guided thermal ablation for primary and secondary pulmonary malignancies is increasingly recognized and accepted as a cogent form of local therapy.

Safety and efficacy of thermal ablation for subpleural lung cancers

BACKGROUND

The study was conducted to assess the safety and efficacy of thermal ablation for the treatment of subpleural lung cancer.

METHODS

Eighty-nine patients with 101 subpleural lung cancers were identified between January 2012 and July 2018 in our database and included in this study. Tumors were classified as adhering to cervical, costal, diaphragmatic, and mediastinal pleurae. Lesions were categorized based on their relationship to the pleura: close to the pleura, causing pleural indentation, and involving the pleura. The complete ablation rate, local progression-free survival, complications, and associated factors were analyzed.

RESULTS

Subpleural lung cancers included lesions located under costal (n = 69), mediastinal (n = 17), cervical (n = 8), and diaphragmatic (n = 7) pleurae. The rate of complete ablation was 87.1% and the local progression-free survival rates at 3, 6, 12, and 24 months were 86%, 77%, 75%, and 64%, respectively. Tumor size was the most important factor influencing technique efficacy (P < 0.05), with a complete ablation rate of only 55.6% in lung cancers measuring > 30 mm. There were nine (10.11%) major complications, including one chest abscess, five cases of pneumothorax, and three cases of hemothorax. The occurrence of major complications was associated with increased levels of pain within 48 hours post-procedure (P < 0.05).

CONCLUSION

Local thermal ablation is a safe and effective treatment for subpleural lung cancers. Tumor size was the most significant factor affecting technique efficacy. Post-procedure pain indicated the possibility of major complications.

Localized RNA interference therapy to eliminate residual lung cancer after incomplete microwave ablation

Background

This study evaluated the safety and efficacy of localized injection of polyethylene glycol (PEG)‐hyperbranched polyethyleneimine (PEI)‐EGFR‐small interfering RNA (siRNA) nanocomposites as a treatment for residual lung cancer after incomplete microwave ablation (MWA).

Methods

Human lung cancer cell lines with high and low EGFR expression were selected for the study. The effects of PEG‐PEI‐EGFR‐siRNA nanocomposite transfection on the proliferation, migration, and apoptosis of lung cancer cells were verified. Sixteen healthy ICR mice were injected into the lung to test the biological safety of the nanocomposites. In addition, 24 subcutaneous xenograft BALB/C nude mice with high EGFR expression were separated into four groups and then treated with an intratumoral injection of PEG‐PEI‐EGFR‐siRNA, PEG‐PEI‐normal control (NC)‐siRNA, PEG‐PEI‐EGFR‐siRNA after MWA, or PEG‐PEI‐NC‐siRNA after MWA. Tumor growth, pathological changes, and EGFR expression in each group were observed.

Results

PEG‐PEI‐EGFR‐siRNA nanocomposites were transfected to HCC 827 cells showing high EGFR expression and to H23 cells showing low EGFR expression. In HCC827 cells, downregulation of EGFR gene expression reduced cell proliferation, invasion, and migration, whereas cell apoptosis increased. In contrast, in H23 cells, no significant differences in those parameters were detected. No acute toxicity occurred in the ICR mice during the biosafety test. Localized injection of PEG‐PEI‐EGFR‐siRNA nanocomposites significantly inhibited the growth of human lung xenografts in mice and the growth of residual tumors after MWA.

Conclusion

PEG‐PEI‐EGFR‐siRNA nanocomposites may be a supplemental therapy strategy to treat residual lung cancer after incomplete MWA.

The value of Cone-Beam CT-guided radiofrequency ablation in the treatment of pulmonary malignancies (≤3 cm)

The aim of this study is to explore the safety and efficacy of Cone-Beam computed tomography (CBCT) guided radiofrequency ablation (RFA) in the treatment of pulmonary malignancies. Thirty-one patients with pulmonary malignant tumors (≤3 cm in diameter) were enrolled to this study. Total 43 CBCT guided RFA treatments were performed, including 7 patients undergoing multiple treatments. The target tumor puncture success rate, tumor remission rate, postoperative cumulative survival rate, tumor-free survival rate and complication rate were analyzed. All 43 CBCT guided RFA procedures successfully punctured the target tumors. Complications included five cases of pneumothorax and three cases of hemoptysis. For the 31 patients who underwent CBCT guided RFA, the 1- and 2-year cumulative survival rates were 80.6 and 54.8%, respectively. The 1- and 2-year disease-free survival rates were 54.8 and 32.3%, respectively. The 1-, 3- and 6-month remission rates were 78.4, 68.7 and 63.3%, respectively. The average cumulative radiation dose and average effective radiation dose were 194.62 ± 105.51 mGy and 5.41 ± 3.45 mSv, respectively. CBCT help to shorten the operation time, reduce the unnecessary interventions and also reduce the incidence of complications. CBCT guided RFA is one safe and efficacious treatment for pulmonary malignancies.

An overview of interventional strategies for the management of oncologic pain

Pain is a ubiquitous part of the cancer experience. Often the presenting symptom of malignancy, pain becomes more prevalent in advanced or metastatic disease and often persists despite curative treatment. Although management of cancer pain improved following publication of the WHO's analgesic ladder, when used in isolation, conservative approaches often fail to control pain and are limited by intolerable side effects. Interventional strategies provide an option for managing cancer pain that remains refractory to pharmacologic therapy. The purpose of this review is to investigate these strategies and discuss the risks and benefits which must be weighed when considering their use. Therapies anticipated to have an increasingly important role in the future of cancer pain management are also discussed.

A case report of remarkable response to association of radiofrequency ablation with subsequent Atezolizumab in stage IV nonsmall cell lung cancer

RATIONALE

Programmed cell death-1 (PD-1) or programmed death-ligand 1 (PD-L1) immune checkpoint inhibitors have demonstrated impressive efficacy in patients with nonsmall cell lung cancer (NSCLC). Radiofrequency ablation (RFA) is an alternative locoregional therapy for patients with inoperable NSCLC. We report the role of RFA in a patient with metastasis from advanced stage NSCLC that was managed with checkpoint inhibitors. Therefore, this combination of RFA with subsequent immunotherapy can control NSCLC better than RFA or immunotherapy on their own.

PATIENT CONCERNS

We report here a 61-year-old Chinese male who presented with postoperative recurrence squamous cell lung cancer following the left upper lobectomy and 4 cycles of postoperative adjuvant chemotherapy 6 months back.

DIAGNOSIS

A newly occurring lesion was detected in the left lower lung. Based on computed tomography (CT) and percutaneous lung biopsy enhancement, the patient was diagnosed with stage IV nonsmall cell lung cancer.

INTERVENTIONS

The patient refused systemic chemotherapy. And there was no basis for using tyrosine kinase inhibitors. RFA was performed for 3 times at the left lower lung lesion, which was under control. Afterward, an enlargement of the lesion at left lower lung with involvement to chest wall, and new nodules in both lungs were revealed. After that, the patient received intravenous PD-L1 immune checkpoint inhibitors Atezolizumab. Follow-up restaging CT scan showed disease progression in both lungs. However, by treated 4 months later, partial response was observed at the left lower lung lesion, and stable response was observed at the right upper lung lesion.

OUTCOMES

The patient displayed a remarkable response to Atezolizumab in one lesion at left lower lung, where he received previous locoregional therapy of RFA. As a comparison, another lesion at right upper lung without RFA history showed little response to Atezolizumab.

LESSONS

Our case suggests a significantly synergistic effect of sequential association of RFA and subsequent immunotherapy. Integrating locoregional therapy such as RFA into anti-PD-1/PD-L1 agent regimens may help to release tumor-associated antigen and mediate T-cell immune enhancement, and on the long run improve the ongoing efficacy of checkpoint inhibitors. The combination of locoregional therapy and immunotherapy represents a potential new treatment option in the management of metastatic NSCLC.