Evidence of the added clinical value of modern ablation techniques continues to emerge, yet many doctors remain unaware of the massive potential of interventional oncology to destroy tumours and treat pain. This afternoon’s Special Focus Session will attempt to bridge the gap.
When Prof. Afshin Gangi, President of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), was a medical student, he only learned of three techniques for tackling bone metastasis: analgesics, radiotherapy, and hormone treatment.
“The role of interventional radiology, curating and cementing – I didn’t even know it existed,” he told ECR Today.
Ablation and consolidation in bone cancers is now one of the fastest-growing areas in many oncology centres. It is particularly useful to increase the comfort of terminally ill patients, where clinicians have no other options to tackle pain except to increase doses of analgesics. Often, this leads to the patient becoming emaciated and losing contact with family and friends due to the side effects of the medication.
“Dying in pain is not a gift,” explained Gangi, professor of radiology and nuclear medicine at the University Hospital of Strasbourg, France. “You can see interventional radiologists as snipers – we can’t stop a full army, but we can stop a group of aggressive tumours and, by doing so, can do a lot to improve quality of life.”
Palliative care patients are among the largest group seen by interventional radiologists for ablation or embolisation of hyper-vascular tumours, he added. Where a patient only has five or six metastases, techniques such as cryotherapy or thermal ablation can destroy the tumour completely – and shut down the patient’s pain.
A smaller group of patients are those with two or three metastases whose disease is not responding to systemic therapy. In this case, ablation can kill the tumour – not just to remove pain, but to cure the patient.
“It’s more technically demanding, more difficult, and there are more ways to have complications,” Gangi said. “But the survival time of the patient depends on the results, and the symptoms are treated at the same time.”
In the case of bone tumours, the patient will often need consolidation work after the initial ablation. Thermal ablation weakens the bone by necrosing it, for example, and it needs to be pinned or treated with cement before the patients can go about their daily lives.
In other cancers, such as liver cancer, an important factor to consider is the size of the tumour, according to Prof. Dr. Philippe Pereira, director of the Clinic of Radiology, Minimally Invasive Therapies and Nuclear Medicine at the Academic Hospital of Heilbronn from the Ruprecht Karl University of Heidelberg, Germany. The maximum size of liver tumour typically treated with a curative intent using interventional radiology is 3–5cm, although it does depend on the type of tumour. As a result, he argues that no single discipline has the solution to cancer care.
“More and more, oncology is interdisciplinary, and combines treatment with other disciplines,” said Pereira. “The new kid on the block, for example, is the immune impact of interventional oncology, which is very exciting at this time.”
Several studies show, for example, that liver tumours with a diameter of up to 5cm can be treated by combining thermal ablation with local chemoembolisation or with systemic therapies. On the immune side, a treatment targeted to the liver tumour can be combined with a systemic immune treatment for maximum effect.
Another exciting development is where a targeted interventional oncology treatment has been shown to induce a systemic immune system response in the patient. He gives the example of where treating a kidney cancer stimulated the immune system to destroy lymph node metastases elsewhere.
Both Gangi and Pereira agree that working across disciplines, with other oncology professionals, is essential. It is important for interventional radiologists to know where the patient is reporting pain to ensure that it matches the location of tumours on images, Gangi added. Furthermore, when palliative patients report pain, they should be seeing an interventional radiologist for treatment within 7–10 days.
According to Pereira, a major challenge is to understand the success rates of interventional oncology compared to, say, conventional surgery. With limited clinical trials being run, he highlights the importance of large registries containing details of all therapies received by patients, along with follow-ups of outcomes after one, two and three years, thereby obtaining real-world data.
Please note that, for organisational reasons, both Professor Gangi and Professor Pereira had to be replaced for the live session during the highlight week. Their interviews and statements, however, have certainly not lost any significance.
LIVE
Special Focus Session, Tuesday, November 3, 17:00–18:00
SF 4 Interventional radiology in oncology
- Chairperson’s introduction
Julien Garnon; Strasbourg/FR - Ablation techniques in the lung
Carole A. Ridge; Dublin/IE - Ablation and embolisation techniques in the liver
Teik Chon See; Cambridge/UK - Ablation techniques in the bone
Roberto Luigi Cazzato; Strasbourg/FR - Live Q&A: The role of the interventional radiologist in the treatment of lung, liver and bone lesions
FURTHER READING
Minami Y, Nishida N, Kudo M (2019) Radiofrequency ablation of liver metastasis: potential impact on immune checkpoint inhibitor therapy. Eur Radol. 9(9):5045-5051: european-radiology.org/6189
Wei Z, Ye X, Yang X (2017) Advanced non small cell lung cancer: response to microwave ablation and EGFR Status. Eur Radiol. 27(4):1685-1694: european-radiology.org/4474
Oñate Miranda M, Moser TP (2018) A practical guide for planning pelvic bone percutaneous interventions (biopsy, tumour ablation and cementoplasty). Insights Imaging. 9(3):275-285: i3-journal.org/600
Dulnik Bucka D, Esteban Cuesta H, Bueno Horcajadas A, Kassarjian A, Chen Xu S, Martel Villagrán J (2019) Osteoid osteoma treated by percutaneous radiofrequency ablation procedure: a case series. ECR 2019 / C-2306: myESR.org/192306
Seidel R, Massmann A, Fries P, Schneider G, Buecker A (2016) Local hepatic tumour control in patients with HCC undergoing transarterial lipiodol embolisation followed by microwave ablation. ECR 2016 / B-1002: myESR.org/161002