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Achieving Curative Ablation Outcomes: It Is All about the Imaging

2020; Radiological Society of North America; Volume: 298; Issue: 1 Linguagem: Inglês

10.1148/radiol.2020203930

1527-1315

Michael C. Soulen, Constantinos T. Sofocleous,

Lung Cancer Diagnosis and Treatment

HomeRadiologyVol. 298, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialAchieving Curative Ablation Outcomes: It Is All about the ImagingMichael C. Soulen , Constantinos T. SofocleousMichael C. Soulen , Constantinos T. SofocleousAuthor AffiliationsFrom the Abramson Cancer Center, Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (M.C.S.); and Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY (C.T.S.).Address correspondence to M.C.S. (e-mail: [email protected]).Michael C. Soulen Constantinos T. SofocleousPublished Online:Nov 10 2020https://doi.org/10.1148/radiol.2020203930MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Han et al in this issue.Michael C. Soulen, MD, is director of interventional oncology at the Abramson Cancer Center at the University of Pennsylvania. His research interest is clinical trials for image-guided therapies. He is co-chair of the RSNA Clinical Trials Methodology Workshop. He serves on the Board of Directors of the Society of Interventional Oncology and the North American Neuroendocrine Tumor Society. In 2020 he was awarded the Gold Medal by the Society of Interventional Radiology.Download as PowerPointOpen in Image Viewer Constantinos T. Sofocleous, MD, PhD, is professor of interventional radiology at Weill-Cornell Medical College, practicing interventional oncology at Memorial Sloan Kettering Cancer Center. He is an expert in image-guided interventions in the liver and lung with focus in colorectal cancer metastatic disease. His research involves the creation, assessment, and validation of imaging and tissue biomarkers to optimize image-guided liver-directed therapies in the treatment of colorectal cancer liver metastases.Download as PowerPointOpen in Image Viewer Every 3.5 minutes, someone is diagnosed with colorectal cancer; every 9 minutes, someone dies of this disease (1). Liver metastases are the leading determinant of death in this population and 38% of patients dying of metastatic colorectal cancer have liver-only metastasis. Thus, curative therapies directed at the liver are essential.Surgical resection is a well-established curative-intent therapy that provides a 10-year survival rate of up to 40% when it is combined with repeat resection for recurrence (2). Image-guided ablative therapies are an attractive and minimally invasive outpatient alternative for select patients with no more than a few small metastases in accessible locations. The National Comprehensive Cancer Network guidelines recommend ablation as a stand-alone treatment or in combination with resection as long as all visible disease can be eradicated (3). Nevertheless, liver resection remains the preferred treatment for colorectal liver metastasis (CLM) because of better local tumor control rates. In propensity-weighted comparisons, the hepatic recurrence rate for radiofrequency ablation is two to three times higher than resection except for small metastases, with proposed threshold sizes of less than 3 cm and less than 2 cm (4). For ablation to become an accepted alternative to a surgical procedure, it needs to achieve ablation with clear margins (A0). This requires choosing the right lesions, in the right patients, with real-time imaging confirmation of margins and, ideally, with the use of three-dimensional software technology (5).In 2016, Memorial Sloan-Kettering reported a 10-year experience ablating 233 CLMs (6). Of those, 201 of 233 (86.3%) were smaller than 3 cm. Initial failure to achieve A0 ablation occurred in 15 of 233 (6.4%) and local tumor progression occurred in 113 of 233 (48.5%), the vast majority within 2 years. Local tumor progression occurred in seven of 28 (15%) metastases ablated with 5–10-mm margins and one of 21 (5%) ablated with margins larger than 10 mm. Independent predictors of failure were tumor size larger than 3 cm (hazard ratio [HR], 2.0; 95% CI: 1.2, 3.3) and ablation margin smaller than 5 mm (HR, 10.2; 95% CI: 5.1, 20.1). Ablation margins were measured on scans performed 4–8 weeks after ablation. There was no difference noted for subcapsular tumors.In this issue of Radiology, Han et al (7) report on the radiofrequency ablation of 512 CLMs, with failure to achieve A0 ablation in 10 of 512 (1.9%) and local tumor progression occurring in 126 of 512 (24.6%). Among the 365 patients, 250 (68%) had no metastasis larger than 2 cm. Multivariable Cox regression analyses showed that tumor size 2 cm or larger in diameter (HR, 3.8; 95% CI: 2.3, 6.2; P < .001), subcapsular tumor location (HR, 1.9; 95% CI: 1.1, 3.1; P = .02), and minimal ablative margin 5 mm or smaller (HR, 11.7; 95% CI: 4.7, 29.2; P < .001) were associated with the local tumor progression rate after radiofrequency ablation. Margins were assessed immediately with intraprocedural contrast agent–enhanced CT with additional ablation performed if needed. This critical step explains the superior local tumor control achieved in this study.These results suggest we are moving toward the goal of ablation as a curative alternative to a surgical procedure. In terms of patient selection, limiting tumor size to 2–2.5 cm rather than 3 cm may be an important aspect, although the key factor remains the ability to completely eradicate the target CLM. The results for the subcapsular location are discordant and requires further investigation. The dominant factor in both the Han and Memorial Sloan-Kettering series is the ablation margin, with hazard ratios above 10 dwarfing all other variables in multivariable analysis. Recent work indicates that margins 10 mm or larger are associated with no local tumor progression, regardless of the use of radiofrequency or microwave ablation of small colorectal liver metastases (8). This is where real-time ablation confirmation imaging software is critical. Trying to eyeball margins around an irregular volume on axial images is fraught with error and operator bias. The use of three-dimensional software has shown an improved discrimination value in measuring the ablation margins and identifying the patients at risk for local tumor progression (5). The use of such technology intraoperatively is key for the evolution of ablation as a cure for CLM.Reliable ablation planning and confirmation software that functions within clinical workflow is the most important short-term goal in making percutaneous ablation standard of care for eligible patients. Other considerations include ablation technology. Most of our data are for radiofrequency ablation, which is obsolete. Microwave ablation can achieve higher tumoricidal temperatures in shorter times than radiofrequency ablation and is effective in perivascular tumors, whereas radiofrequency ablation is limited by the heat sink phenomena. Microwave ablation may expand the size limits for successful A0 ablation. Tumor biology and genetics also impact the ability to treat CLM with success. Several investigators have reported that Kirsten rat sarcoma viral oncogene homolog (KRAS) mutant tumors appear more likely to progress even with optimal margins (9). Preclinical research is investigating the ablation zone microenvironment and biologic pathways that lead to local recurrence.A recent meta-analysis indicates that outcomes of microwave ablation for CLM are similar to hepatectomy (10). The only question is for which patients and lesions could ablation replace a surgical procedure. For this question, proper patient selection and imaging confirmation of complete eradication of the target tumor with sufficient margins is mandatory.Disclosures of Conflicts of Interest: M.C.S. disclosed no relevant relationships. C.T.S. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed money to author for board membership from Scientific Publication Board; money paid to author for consultancy from Sirtex, Ethicon, BTG, Terumo; grants/grants pending from BTG, Sirtex, Ethicon; payment for lectures from Ethicon; payment for development of educational presentations from Terumo, Ethicon; travel/accommodations/meeting expenses from Terumo, Ethicon, BTG. Other relationships: disclosed no relevant relationships.References1. Benson AB 3rd. Epidemiology, disease progression, and economic burden of colorectal cancer. J Manag Care Pharm 2007;13(6 Suppl C):S5–S18. Medline, Google Scholar2. Creasy JM, Sadot E, Koerkamp BG, et al. Actual 10-year survival after hepatic resection of colorectal liver metastases: what factors preclude cure? Surgery 2018;163(6):1238–1244. Crossref, Medline, Google Scholar3. National Comprehensive Cancer Network Web site. https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf. Accessed October 23, 2020. Google Scholar4. Wang LJ, Zhang ZY, Yan XL, Yang W, Yan K, Xing BC. Radiofrequency ablation versus resection for technically resectable colorectal liver metastasis: a propensity score analysis. World J Surg Oncol 2018;16(1):207. Crossref, Medline, Google Scholar5. Kaye EA, Cornelis FH, Petre EN, et al. Volumetric 3D assessment of ablation zones after thermal ablation of colorectal liver metastases to improve prediction of local tumor progression. Eur Radiol 2019;29(5):2698–2705. Crossref, Medline, Google Scholar6. Shady W, Petre EN, Gonen M, et al. Percutaneous Radiofrequency Ablation of Colorectal Cancer Liver Metastases: Factors Affecting Outcomes—A 10-year Experience at a Single Center. Radiology 2016;278(2):601–611. https://doi.org/10.1148/radiol.2015142489. Link, Google Scholar7. Han K, Kim JH, Yang SG, et al. A Single-Center Retrospective Analysis of Periprocedural Variables Affecting Local Tumor Progression after Radiofrequency Ablation of Colorectal Cancer Liver Metastases. Radiology 2021;298:212–218. Link, Google Scholar8. Shady W, Petre EN, Do KG, et al. Percutaneous Microwave versus Radiofrequency Ablation of Colorectal Liver Metastases: Ablation with Clear Margins (A0) Provides the Best Local Tumor Control. J Vasc Interv Radiol 2018;29(2):268–275.e1. Crossref, Medline, Google Scholar9. Calandri M, Yamashita S, Gazzera C, et al. Ablation of colorectal liver metastasis: Interaction of ablation margins and RAS mutation profiling on local tumour progression-free survival. Eur Radiol 2018;28(7):2727–2734. Crossref, Medline, Google Scholar10. Meijerink MR, Puijk RS, van Tilborg AAJM, et al. Radiofrequency and Microwave Ablation Compared to Systemic Chemotherapy and to Partial Hepatectomy in the Treatment of Colorectal Liver Metastases: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2018;41(8):1189–1204. Crossref, Medline, Google ScholarArticle HistoryReceived: Sept 30 2020Revision requested: Oct 9 2020Revision received: Oct 13 2020Accepted: Oct 14 2020Published online: Nov 10 2020Published in print: Jan 2021 FiguresReferencesRelatedDetailsCited ByInterventional Oncology: 2043 and BeyondMohammad Elsayed, Stephen B. 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