Image-guided percutaneous thermal ablation of metastatic pelvic tumor from gynecologic malignancies

Radiofrequency and microwave ablation for treatment of recurrent gynecologic malignancies

OBJECTIVE

Radiofrequency ablation and microwave ablation are used to vaporize tumors not amenable to surgical resection. We sought to evaluate the safety and efficacy of radiofrequency and microwave ablation for the treatment of isolated lesions in patients with recurrent gynecologic malignancy.

METHODS

Patients with gynecologic malignancies treated with radiofrequency or microwave ablation at a university-affiliated cancer center from April 2007 to January 2020 were evaluated. Clinical records were reviewed for number of prior chemotherapy regimens, response to ablation, time to progression, and location of progression.

RESULTS

Thirty-two patients received ablative therapy for treatment of isolated recurrences. Seventeen (53%) patients had ovarian cancer, seven (22%) had endometrial cancer, and eight (25%) had cervical cancer. Thirteen (41%) patients received radiofrequency ablation and 19 (59%) received microwave ablation. Patients had a median of 2 (range 1-12) prior lines of chemotherapy. Sixteen (50%) patients achieved a partial or complete response with two patients experiencing no progression at time of submission. Six (19%) patients had stable disease and 10 (31%) patients had progression at time of initial follow-up imaging. Median progression-free survival for the cohort was 7.3 months (range 1.4-64.7). No significant improvement in median progression-free survival was seen with the addition of adjuvant systemic therapy to radiofrequency or microwave ablation (6.9 vs 7.7 months; HR 0.7, 95% CI 0.3 to 1.7). Clinical benefit, defined as absence of definitive progression at the site of ablation or new target lesions at 4 months, was seen in 22 (68.8%) patients. No major complications occurred, with two patients reporting pain or weakness at the site of ablation.

CONCLUSION

Radiofrequency and microwave ablation demonstrated that 68.8% (n=22) of patients experienced clinical benefit at 4 months. Ablative therapy may be considered for the treatment of isolated lesions in patients with recurrent gynecologic malignancies.

Selection of Treatment Regimens for Recurrent Cervical Cancer

OBJECTIVE

The selection of individualized treatment for recurrent cervical cancer is challenging. This study aimed to investigate the impact of various therapies on survival outcomes after recurrence.

METHODS

Eligible patients were diagnosed with recurrent cervical cancer between March 2012 and April 2018. Postrecurrence progression-free survival (PFS) and overall survival (OS) were investigated in the whole cohort and in subgroups, categorized by recurrence site and prior radiotherapy history, using a multivariate model that incorporated treatment for primary and recurrent tumors, histological pathology, and FIGO staging.

RESULTS

Two hundred and sixty recurrent cervical cancer patients were included. As of March 1, 2020, the median postrecurrence PFS and OS were 7.0 (range 0-94) and 24.0 (1.8-149.1) months, respectively. In a multivariate model measured by PFS, radiotherapy was superior to other therapies for the whole cohort (p=0.029) and recurrence only within the pelvic cavity (p=0.005), but the advantages of radiotherapy disappeared in patients with a history of radiotherapy (p values >0.05). For recurrence only beyond the pelvic cavity, combination therapy resulted in improved PFS (p=0.028). For recurrence both within and beyond the pelvic cavity, no therapy regimen provided additional PFS benefits (p values >0.05). Radiotherapy and combination therapy were also associated with improved postrecurrence OS for recurrence within the pelvic cavity (p=0.034) and only beyond the pelvic cavity (p=0.017), respectively.

CONCLUSIONS

In cervical cancer patients, postrecurrence radiotherapy can improve PFS and OS for patients with recurrence within the pelvic cavity and without prior radiotherapy. For recurrence beyond the pelvic cavity or cases with a history of radiotherapy, combination or individualized therapy may provide potential survival benefits.

Image-guided tumor ablation in gynecologic oncology: Review of interventional oncology techniques and case examples highlighting a collaborative, multidisciplinary program

As interventional oncology services within radiology mature, image-guided ablation techniques are increasingly applied to recurrent gynecologic malignancies. Ablation may be performed using thermal techniques like cryoablation, microwave ablation, or radiofrequency ablation, as well as non-thermal ones, such as focused ultrasound or irreversible electroporation. Feasibility and approach depend on tumor type, size, number, anatomic location, proximity of critical structures, and goals of therapy. Current indications include local control of limited metastatic disease or palliation of painful bone metastases refractory or unsuitable to conventional therapies. Technical aspects of these procedures, including methods to protect nearby critical structures are presented through illustrative examples. Cases amenable to image-guided ablation include, but are not limited to, hepatic or pulmonary metastases, musculoskeletal metastases, retroperitoneal nodal metastases, pelvic side wall disease, abdominal wall disease, and vaginal or vulvar tumors. Protective maneuvers, such as hydro-displacement of bowel, neuromonitoring, and retrograde pyeloperfusion through ureteral stents, permit safe ablation despite close proximity to vulnerable nerves or organs. Image-guided ablation offers an alternative modality to achieve local tumor control without the risks associated with surgery or systemic treatment in appropriately selected patients. A multidisciplinary approach to use of image-guided ablation includes collaboration between gynecologic oncology, interventional radiology, anesthesia, urology and radiation oncology teams allowing for appropriate patient-centered case selection. Long-term follow up and additional studies are needed to determine the oncologic benefits of such techniques.

A role of eosinophils in mediating the anti-tumour effect of cryo-thermal treatment

Previous, we established a novel therapeutic approach to tumour of cryo-thermal therapy, which can induce durable anti-tumour memory immunity mediated by CD4⁺ T cell, and contribute to prolonged survival in B16F10 murine melanoma model and 4T1 murine mammary carcinoma. It has become apparent that innate immune cells are involved in the regulation of adaptive T cell immunity. Our previous studies revealed that cryo-thermal therapy induced M1 macrophage polarization and DCs maturation were required for the shaping of systemic long-lived T cell mediated anti-tumour memory immunity. Eosinophils are multifunctional innate effector cells and there is lack of knowledge on the role of eosinophils in cryo-thermal-induced anti-tumour immunity. This study revealed that cryo-thermal therapy activated eosinophils in spleen at early stage following the treatment. Furthermore, cryo-thermal-activated eosinophils exerted versatile immunologic regulation from innate immunity to anti-tumour adaptive immunity, such as M1 macrophage polarization, DCs maturation, differentiation of CD4-CTL subtypes and enhanced cytotoxicity of CD8⁺ T cells. Our study indicated that the cryo-thermal-activated eosinophils was essential for the shaping of durable anti-tumour memory immunity. Thus, our results present a new concept for eosinophils mediated anti-tumour immunity after cryo-thermal therapy.

Radiation Dose and Risk Estimates of CT-Guided Percutaneous Liver Ablations and Factors Associated with Dose Reduction

PURPOSE

To determine the radiation dose associated with CT-guided percutaneous liver ablations and identify potential risk factors that result in higher radiation doses.

MATERIALS AND METHODS

Between June 2011 and June 2015, 245 consecutive patients underwent 304 CT-guided liver ablation treatments. Patient demographics, tumor characteristics and procedural parameters were identified and analyzed. The peak skin dose and effective dose were assessed for each procedure. Excess relative risk related to radiation effects was calculated. A logistic regression model was prepared by means of stepwise logistic regression to identify variables predictive of increased radiation exposure.

RESULTS

Tumor ablations were performed with microwave (n = 220), radiofrequency (n = 74) or irreversible electroporation (IRE) (n = 10). The mean peak skin dose for ablations was 239.2 ± 136.4 mGy, and the mean effective dose was 36.6 ± 22.3 mSv. Of the patient and procedural parameters that were analyzed, increasing weight, use of intravenous contrast and/or hydrodissection during the procedure, together with treatment of multiple lesions in the same sitting were all associated with higher radiation exposure. The mean increase in the absolute risk of fatal malignancy from a single procedure was 0.18% (range 0.02-0.9%). No deterministic skin changes were identified in the patient cohort.

CONCLUSION

The overall risk of stochastic and deterministic effects from radiation associated with CT-guided ablations is low compared with other inherent procedural complications. This study identifies several factors that are associated with higher radiation dose in percutaneous liver ablation procedures.

Unusual tumour ablations: report of difficult and interesting cases

Image-guided ablations are nowadays applied in the treatment of a wide group of diseases and in different organs and regions, and every day interventional radiologists have to face more difficult and unusual cases of tumour ablation. In the present case review, we report four difficult and unusual cases, reporting some tips and tricks for a successful image-guided treatment.