Percutaneous imaging-guided cryoablation for lung cancer

Safety and Effectiveness of Track Cauterization for Lung Cryoablation

PURPOSE

To evaluate the safety and effectiveness of track cauterization for lung cryoablation through comparison of postprocedural adverse event (AE) rates.

MATERIALS AND METHODS

Fifty-nine patients who underwent 164 percutaneous lung cryoablation procedures between 2013 and 2018 were included in this retrospective study. The study cohort was subdivided by whether track cauterization was conducted or not at the end of the procedure. The study cohort was also subdivided by the number of probes (1-2 probes vs 3-4 probes). Postablation AE rates were assessed by immediate and delayed (at 1 month or later) AEs, pneumothorax, hemothorax, pleural effusion, and whether intervention was required. Univariate and multivariate logistic regression analyses were used to compare differences in AE rates.

RESULTS

Patients who underwent procedures with track cautery were 2.6 times less likely to exhibit pleural effusion (P = .017). Patients who underwent procedures conducted with a higher number of probes were 3.8 times more likely to receive interventions (P < .001), 1.6 times more likely to experience pneumothorax (P = .037), and 2.1 times more likely to experience pleural effusion (P = .003). History of lung surgery, increased number of probes, size of the probe, and absence of track cautery were noted to be significant predictors of AEs and need for interventions (all P < .05).

CONCLUSIONS

Track cauterization in lung cryoablation was proven to reduce pleural effusion, but no difference in pneumothorax or delayed AEs was noted. The use of fewer probes was associated with a lower rate of AEs.

2024 multidisciplinary consensus on image-guided lung tumor ablation from the Taiwan Academy of Tumor Ablation

In this article, the multidisciplinary team of the Taiwan Academy of Tumor Ablation, who have expertise in treating lung cancer, present their perspectives on percutaneous image-guided thermal ablation (IGTA) of lung tumors. The modified Delphi technique was applied to reach a consensus on clinical practice guidelines concerning ablation procedures, including a comprehensive literature review, selection of panelists, creation of a rating form and survey, and arrangement of an in-person meeting where panelists agreed or disagreed on various points. The conclusion was a final rating and written summary of the agreement. The multidisciplinary expert team agreed on 10 recommendations for the use of IGTA in the lungs. These recommendations include terms and definitions, line of treatment planning, modality, facility rooms, patient anesthesia settings, indications, margin determination, post-ablation image surveillance, qualified centers, and complication ranges. In summary, IGTA is a safe and feasible approach for treating primary and metastatic lung tumors, with a relatively low complication rate. However, decisions regarding the ablation technique should consider each patient's specific tumor characteristics.

Investigation of Lung Cancer Cell Response to Cryoablation and Adjunctive Gemcitabine-Based Cryo-Chemotherapy Using the A549 Cell Line

Due to the rising annual incidence of lung cancer (LC), new treatment strategies are needed. While various options exist, many, if not all, remain suboptimal. Several studies have shown cryoablation to be a promising approach. Yet, a lack of basic information pertaining to LC response to freezing and requirement for percutaneous access has limited clinical use. In this study, we investigated the A549 lung carcinoma cell line response to freezing. The data show that a single 5 min freeze to -15 °C did not affect cell viability, whereas -20 °C and -25 °C result in a significant reduction in viability 1 day post freeze to <10%. These populations, however, were able to recover in culture. Application of a repeat (double) freeze resulted in complete cell death at -25 °C. Studies investigating the impact of adjunctive gemcitabine (75 nM) pretreatment in combination with freezing were then conducted. Exposure to gemcitabine alone resulted in minimal cell death. The combination of gemcitabine pretreatment and a -20 °C single freeze as well as combination treatment with a -15 °C repeat freeze both resulted in complete cell death. This suggests that gemcitabine pretreatment may be synergistically effective when combined with freezing. Studies into the modes of cell death associated with the increased cell death revealed the increased involvement of necroptosis in combination treatment. In summary, these results suggest that repeat freezing to -20 °C to -25 °C results in a high degree of LC destruction. Further, the data suggest that the combination of gemcitabine pretreatment and freezing resulted in a shift of the minimum lethal temperature for LC from -25 °C to -15 °C. These findings, in combination with previous reports, suggest that cryoablation alone or in combination with chemotherapy may provide an improved path for the treatment of LC.

Is cryoablation still suitable for advanced non-small cell lung cancer after failure of first-line chemotherapy? A multicenter, prospective, randomized-controlled trial of eighty-seven patients

The aim of this study was to investigate the therapeutic effect of cryoablation treatment in advanced NSCLC patients who had failed first-line chemotherapy. Eighty-seven patients from ten hospitals in China were enrolled into the study, forty-four patients received cryoablation treatment plus basic treatment (experimental group), and forty-three patients had basic treatment alone (control group). Follow-up was performed once every three months until the end of the study or the death of the patient. The primary endpoints were overall and post-intervention survival; secondary endpoints included tumor markers, solid tumor efficacy, and symptom changes before and after treatment. There was no significant difference in median OS between the two groups of patients (9.0 months vs 11.2 months, P = 0.583). The disease control rate (DCR) and living quality of the experimental group was higher than that of the control group. In terms of OS, indiscriminate use of cryoablation for such patients was not beneficial, though it could improve symptoms of patients. Cryoablation had a significant effect on selected advanced NSCLC patients after the failure of first-line chemotherapy.

Cryoablation is superior to radiofrequency ablation for the treatment of non-small cell lung cancer: A meta-analysis

This meta-analytical study compared the efficacy of cryoablation and radiofrequency ablation (RFA) in treating non-small cell lung cancer (NSCLC). We searched PubMed, Cochrane, Embase, and Web of Science™ for all relevant articles published until April 2022 that compared the efficacy of RFA and cryoablation in treating NSCLC. We used the Cochrane evaluation tool to assess the risk of bias. The fixed- or random-effects models were used, when appropriate. The primary outcome was a 3-year disease-free survival, whereas recurrence rate and complication rates were secondary outcomes. There were 340 patients divided across the seven studies we included in our meta-analysis. Based on the continuous-type variable analysis, cryoablation was superior to RFA in terms of 3-year disease-free survival (P = 0.003) and complication (P ＜ 0.00001) rates. Similarly, significant reductions in cryoablation were found for recurrence rates (P = 0.05) compared with RFA. Overall, cryoablation was superior to RFA in terms of prognosis and lifespan, regardless of whether systemic metastases occurred in non-small cell lung cancer.

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.

Robotic bronchoscopy: potential in diagnosing and treating lung cancer

INTRODUCTION

Lung cancer remains the deadliest form of cancer in the world. Screening through low-dose CT scans has shown improved detection of pulmonary nodules; however, with the introduction of robotic bronchoscopy, accessing and biopsying peripheral pulmonary nodules from the airway has expanded. Improved diagnostic yield through enhanced navigation has made robotic bronchoscopy an ideal diagnostic technology for many proceduralists. Studies have demonstrated that robotic bronchoscopes can reach further with improved maneuverability into the distal airways compared to conventional bronchoscopes.

AREAS COVERED

This review paper highlights the literature on the technological advancements associated with robotic bronchoscopy and the future directions the field of interventional pulmonary may utilize this modality for in the treatment of lung cancer. Referenced articles were included at the discretion of the authors after a database search of the particular technology discussed.

EXPERT OPINION

As the localization of target lesions continues to improve, robotic platforms that provide reach, stability, and accuracy paves the way for future research in endoluminal treatment for lung cancer. Future studies with intratumoral injection of chemotherapy and immunotherapy and ablation modalities are likely to come in the coming years.

Thermal ablation for primary and metastatic lung tumors: Single-center analysis of peri-procedural and intermediate-term clinical outcomes

PURPOSE

To evaluate the peri-procedural and intermediate-term clinical outcomes of thermal ablation of primary and metastatic lung cancer through analysis of a 5-year institutional experience.

METHODS

In this retrospective, IRB-approved study, 55 consecutive lung ablation interventions (33 cryoablation and 22 microwave ablations) performed at an academic medical center from 2017 to 2022 were evaluated. Cryoablation was performed utilizing multiple 14-guage probes using a triple freeze/thaw protocol. Microwave ablation required a single 14-guage probe, set to 60-80 watts for 5-10 min. Lung disease distribution was 58.2 % bilateral with largest lesion size of 5.5 cm. Periprocedural outcomes including technical success and complications as well as long-term outcomes including radiographic response, objective response ratio (ORR), disease control rate (DCR), progression free survival (PFS), overall survival (OS), and functional status were elucidated.

RESULTS

Technical success rate was 100 %. The most common complication was pneumothorax which occurred in 36 (65.5 %) patients, with 27 (49.1 %) requiring chest tube placement. At 6 months, 52 (98.2 %) of the patients demonstrated a complete response and 1 patient exhibited a partial response, yielding an ORR and a DCR of 100 %. The PFS was 26 ± 19 months, and the OS was 90.9 %, 83.6 %, and 74.5 % at 1, 3, and 5 years, respectively. Additionally, 92.7 % (51) of patients maintained or improved their functional status (ECOG) at 6 months.

CONCLUSION

Percutaneous thermal ablation techniques are evolving and promising treatments for both primary and metastatic lung tumors. Our 5-year institutional experience demonstrated their safety and efficacy with preservation of functional performance.

Progress in the cryoablation and cryoimmunotherapy for tumor

With the rapid advancement of imaging equipment and minimally invasive technology, cryoablation technology is being used more frequently in minimally invasive treatment of tumors, primarily for patients with early tumors who voluntarily consent to ablation as well as those with advanced tumors that cannot be surgically removed or cannot be tolerated. Cryoablation is more effective and secure for target lesions than other thermal ablation methods like microwave and radiofrequency ablation (RFA). The study also discovered that cryoablation, in addition to causing tumor tissue necrosis and apoptosis, can facilitate the release of tumor-derived autoantigens into the bloodstream and activate the host immune system to elicit beneficial anti-tumor immunological responses against primary. This may result in regression of the primary tumor and distant metastasis. The additional effect called " Accompanying effects ". It is the basis of combined ablation and immunotherapy for tumor. At present, there is a lot of research on the mechanism of immune response induced by cryoablation. Trying to solve the question: how positively induce immune response. In this review, we focus on: 1. the immune effects induced by cryoablation. 2. the effect and mechanism of tumor immunotherapy combined with cryoablation. 3.The clinical research of this combination therapy in the treatment of tumors.

Image-guided percutaneous ablation for lung malignancies

Image-guided percutaneous lung ablation has proven to be an alternative and effective strategy in the treatment of lung cancer and other lung malignancies. Radiofrequency ablation, microwave ablation, and cryoablation are widely used ablation modalities in clinical practice that can be performed along or combined with other treatment modalities. In this context, this article will review the application of different ablation strategies in lung malignancies.

Therapeutic Bronchoscopy for Lung Nodules: Where Are We Now?

Lobar resection has been the established standard of care for peripheral early-stage non-small cell lung cancer (NSCLC). Over the last few years, surgical lung sparing approach (sublobar resection [SLR]) has been compared with lobar resection in T1N0 NSCLC. Three nonsurgical options are available in those patients who have a prohibitive surgical risk, and those who refuse surgery: stereotactic body radiotherapy (SBRT), percutaneous ablation, and bronchoscopic ablation. Local ablation involves placement of a probe into a tumor, and subsequent application of either heat or cold energy, pulsing electrical fields, or placement of radioactive source under an image guidance to create a zone of cell death that encompasses the targeted lesion and an ablation margin. Despite being in their infancy, the bronchoscopic ablative techniques are undergoing rapid research, as they extrapolate a significant knowledge-base from the percutaneous techniques that have been in the radiologist's armamentarium since 2000. Here, we discuss selected endoscopic and percutaneous thermal and non-thermal therapies with the focus on their efficacy and safety.

Advanced bronchoscopic techniques for the diagnosis and treatment of peripheral lung cancer

Lung cancer is the leading cause of cancer related deaths worldwide. As a result of the increasing use of chest CT scans and lung cancer screening initiatives, there is a rapidly increasing need for lung lesion analysis and - in case of confirmed cancer - treatment. A desirable future concept is the one-stop outpatient bronchoscopic approach including navigation to the tumor, malignancy confirmation and immediate treatment. Several novel bronchoscopic diagnostic and treatment concepts are currently under evaluation contributing to this concept. As the majority of suspected malignant lung lesions develop in the periphery of the lungs, improved bronchoscopic navigation to the target lesion is of key importance. Fortunately, the field of interventional pulmonology is evolving rapidly and several advanced bronchoscopic navigation techniques are clinically available, allowing an increasingly accurate tissue diagnosis of peripheral lung lesions. Additionally, multiple bronchoscopic treatment modalities are currently under investigation. This review will provide a concise overview of advanced bronchoscopic techniques to diagnose and treat peripheral lung cancer by describing their working mechanisms, strengths and weaknesses, identifying knowledge gaps and indicating future developments. The desired one-step concept of bronchoscopic 'diagnose and treat' peripheral lung cancer is on the horizon.

The clinical efficacy of argon-helium knife cryoablation combined with nivolumab in the treatment of advanced non-small cell lung cancer

To investigate the clinical safety and efficacy of argon-helium knife cryoablation combined with nivolumab in the treatment of advanced non-small cell lung cancer (NSCLC), 64 patients with advanced NSCLC were retrospectively reviewed. From July 2019 to December 2019, all patients received argon-helium knife cryoablation combined with nivolumab (cryo-nivolumab group, n = 32) or cryoablation alone (cryoablation group, n = 32) at Guangzhou Fuda Cancer Hospital. Short-term efficacy, adverse effects, immune function, tumor markers cytokeratin 21-1 (CYFRA21-1), carcinoembryonic antigen (CEA), neuron-specific enolase (NSE) and circulating tumor cells (CTCs) levels were compared between the two groups. Baseline characteristics were balanced between the two groups. All adverse effects were manageable and no significant difference was noted between the two groups (P > 0.05). Patients in cryo-nivolumab group had a significant improvement in immune function and short-term efficacy (P < 0.05). The levels of CTCs and tumor markers CYFRA21-1 and NSE in cryo-nivolumab group were reduced significantly (P < 0.05). Argon-helium knife cryoablation combined with nivolumab was well tolerated and safe and was superior to cryoablation alone in improving clinical efficacy in patients with advanced NSCLC.

[Expert Consensus for Thermal Ablation of Pulmonary Subsolid Nodules (2021 Edition)]

局部热消融技术在肺部结节治疗领域正处在起步与发展阶段，为了肺结节热消融治疗的临床实践和规范发展，由“中国医师协会肿瘤消融治疗技术专家组”“中国医师协会介入医师分会肿瘤消融专业委员会”“中国抗癌协会肿瘤消融治疗专业委员会”“中国临床肿瘤学会消融专家委员会”组织多学科国内有关专家，讨论制定了“热消融治疗肺部亚实性结节专家共识（2021年版）”。主要内容包括：①肺部亚实性结节的临床评估；②热消融治疗肺部亚实性结节技术操作规程、适应证、禁忌证、疗效评价和相关并发症；③存在的问题和未来发展方向。

Catastrophic complications following cryoablation of lung cancer

Image-guided cryoablation has low procedure-related morbidity and mortality rates, with the complications usually being self-limiting. The most common complications include pneumothorax, hemoptysis, pleural effusion, cough, phrenic nerve injury, and tumor implantation. Bronchopleural or bronchocutaneous fistula formation is a rare but severe complication of lung cancer ablation. We report a patient with non-small cell lung cancer who developed a bronchocutaneous fistula, persistent empyema, and chest wall abscess a month after cryoablation. With this case report, we aim to sensitize physicians to such complications.

[Minimally Invasive Therapies for Early Stage Non-small Cell Lung Cancer]

肺癌是目前全球最常见的癌症和癌症死亡的主要原因，其中非小细胞肺癌（non-small-cell lung cancer, NSCLC）约占肺癌总数的85%。随着计算机断层扫描（computed tomography, CT）等影像学筛查手段得到不断普及，肺癌的病理类型从以往以晚期中央型肺鳞癌为主，转变为现在的以早期周围型磨玻璃样结节等为表现的肺腺癌为主。肺癌的早诊早治有着重要意义，而微创介入技术的不断发展完善，使得肺癌治疗有了更多的选择，例如立体定向放射、经皮穿刺消融、支气管介入等。本文将就目前临床常见的这些微创介入治疗的作用原理、优势、不足及展望做一评述。

Radiofrequency Ablation for Stage I Non-Small Cell Lung Cancer: An Updated Review of Literature from the Last Decade

This review summarizes the current findings on radiofrequency ablation (RFA) for stage I non-small cell lung cancer (NSCLC) from relevant literature published in the last decade. While most earlier studies included small populations and had short follow-up periods, more robust data have become available owing to prospective or large cohort studies. The reported overall survival rates after RFA for stage I NSCLC were 83-96%, 40-74%, and 23-61% at 1, 3, and 5 years, respectively, in recent studies. Furthermore, many comparative studies on the outcomes of RFA and stereotactic body radiotherapy have been performed. Most of these studies report no significant difference in survival outcomes between the therapies. Currently, major guidelines define RFA as a reasonable alternative treatment for stage I NSCLC in non-surgical candidates.

Percutaneous image-guided ablation: From techniques to treatments

Image-guided ablation is performed by percutaneously introducing ablation probes to deliver energy into a tumor to destroy it in a controlled and localized fashion. Ablation modalities can be broadly classified as thermal or non-thermal based on the mechanism of tumor destruction and are performed using different types of image guidance for planning, delivering and follow-up of the treatment. Ablation is performed in a minimally invasive fashion, providing greater residual organ preservation with minimal morbidity to the patient. Image-guided ablation is being used in the clinic for the treatment of primary and metastatic tumors, and this article reviews state of the art for the treatment of malignancies in the liver, lung, kidney and musculoskeletal tissue.

Endobronchial treatment of peripheral tumors: ongoing development and perspectives

The expanded possibilities to explore the lung deeper with new tools such as electromagnetic navigation bronchoscopy (ENB) or radial probe endobronchial ultrasonography (radial EBUS), combined with miniaturization of traditional local therapies such as radiofrequency ablation (RFA), radiotherapy, cryotherapy or photodynamic therapy, let the bronchoscopists hope for new ways of endoscopic treatments. This challenge could change the practice in the upcoming decades but raise some physical and technical issues. Safety and efficacy need to be solidly established to face the serious concurrence of stereotactic radiotherapy (SBRT) or percutaneous RFA. Here we describe ongoing development and perspectives for endobronchial treatment of peripheral lung tumors.