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Hiran Fernando



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    PC 01 - 1-1. Surgery vs Non-Surgical Local Treatment for Small-Sized NSCLC (ID 581)

    • Event: WCLC 2017
    • Type: Pros & Cons
    • Track: Early Stage NSCLC
    • Presentations: 1
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      PC 01.03 - Other First Line Treatment Options (ID 7824)

      15:45 - 16:45  |  Presenting Author(s): Hiran Fernando

      • Abstract
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      Abstract:
      The approach that has most commonly been reported as an alternative to surgery or SBRT for non-small lung cancer (NSCLC) is thermal ablation. There are also different ablative modalities, of which radiofrequency ablation (RFA) has been the most widely reported. RFA was reported for human lung tumors in 2000 [1]. RFA has been shown to be feasible and safe in several studies[2,3]. However, many studies have involved heterogeneous patient populations that included patients with metastatic tumors and NSCLC. Additionally, in those series focusing on NSCLC, patients with different stages. Have been included. Another consideration is that in several centers, these procedures have been performed by interventional radiologists, who are not traditionally part of the multidisciplinary oncology team, and rarely have follow-up clinics, so accurate reporting of recurrence and survival rates has not been optimal. Lastly, other modalities such as microwave or cryoablation, are gaining in popularity [4],[5] Despite some perceived improvements in technology, there is no clinical data that supports one ablative modality over another with respect to cancer outcomes[6] . Currently thermal ablation is reserved for medically inoperable patients with NSCLC. In those series that have reported outcomes specifically for stage I NSCLC outcomes have been good, and comparable with studies of SBRT, when looking at survival rates. One study included 56 patients with stage I NSCLC[7]. Median survival was 29 months. A prospective multi-center phase II trial involving 54 patients was recently reported[8]. Overall survival was 87.3% at 1-year, and 69.8% at two-years. Two-year survival was superior in patients with tumors <2cm (83%). There were only two grade 4, and one grade 5 event within 90 days (not attributable to the RFA). Our group has also treated 21 patients with stage Ia NSCLC (submitted for publication). Three-year survival in our series was 52%. One issue when comparing results of trials using different modalities is how comparable are patient groups. The medically inoperable group in this prospective phase II trial were compared to a medically group in an RTOG phase II trial of SBRT[9]. Although both groups were labelled medically inoperable, lung function was significantly better in patients treated with SBRT. This argues for the need for prospective studies comparing these modalities for medically inoperable patients. The main issue with thermal ablation has been higher rates of local recurrence in most studies. Tumor size is important, and results are better for tumors <2cm[7,8]. This certainly would be an argument for SBRT over RFA. However how recurrence is measured and defined may impact on reporting of local control, and there are differences in how these have been identified in different studies. In the absence of a prospective trial using similar end-point recording, overall survival is the cleanest endpoint with which to make comparisons. In summary, thermal ablation remains a viable option for small stage I NSCLC patients who are deemed medically inoperable. Future innovations include developments in energy source and, also in bronchoscopic delivery to peripheral tumors[10]. References 1. Dupuy DE, Zagoria RJ, Akerley W, et al: Percutaneous radiofrequency ablation of malignancies in the lung. AJR Am J Roentgenol 174:57-9, 2000 2. Ambrogi MC, Fanucchi O, Cioni R, et al: Long-term results of radiofrequency ablation treatment of stage I non-small cell lung cancer: a prospective intention-to-treat study. J Thorac Oncol 6:2044-51, 2011 3. Lencioni R, Crocetti L, Cioni R, et al: Response to radiofrequency ablation of pulmonary tumours: a prospective, intention-to-treat, multicentre clinical trial (the RAPTURE study). Lancet Oncol 9:621-8, 2008 4. Zhong L, Sun S, Shi J, et al: Clinical analysis on 113 patients with lung cancer treated by percutaneous CT-guided microwave ablation. J Thorac Dis 9:590-597, 2017 5. Ahrar K, Littrup PJ: Is cryotherapy the optimal technology for ablation of lung tumors? J Vasc Interv Radiol 23:303-5, 2012 6. Vogl TJ, Nour-Eldin NA, Albrecht M, et al: Thermal Ablation of Lung Tumors: Focus on Microwave Ablation. Rofo, 2017 7. Simon CJ, Dupuy DE, DiPetrillo TA, et al: Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients. Radiology 243:268-75, 2007 8. Dupuy DE, Fernando HC, Hillman S, et al: Radiofrequency ablation of stage IA non-small cell lung cancer in medically inoperable patients: Results from the American College of Surgeons Oncology Group Z4033 (Alliance) trial. Cancer 121:3491-8, 2015 9. Crabtree T, Puri V, Timmerman R, et al: Treatment of stage I lung cancer in high-risk and inoperable patients: comparison of prospective clinical trials using stereotactic body radiotherapy (RTOG 0236), sublobar resection (ACOSOG Z4032), and radiofrequency ablation (ACOSOG Z4033). J Thorac Cardiovasc Surg 145:692-9, 2013 10. Koizumi T, Tsushima K, Tanabe T, et al: Bronchoscopy-Guided Cooled Radiofrequency Ablation as a Novel Intervention Therapy for Peripheral Lung Cancer. Respiration 90:47-55, 2015

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