Why isn't RFA now standard of care?

[ImmunoDude]

I've been reading a lot about RFA and its cousin, IRE, and I'm now wondering why it hasn't completely replaced surgical resection for solid tumor patients (other than brain tumors, because it doesn't relieve mass effect).

Based on what I've been reading in journals, a patient with a tumor > 5 cm could have DEB-TACE or SIRT to shrink the tumor until it's amenable to RFA or IRE, all the while taking sorafenib.

One could take a percutaneous tru-cut biopsy of the ablation margins to confirm success intraoperatively, and follow that up with a PET scan.

Another thing I was reading was about the 5-aminofluorescein-albumin dye neurosurgeons use for contrast while resecting gliomas, since they take up massive amounts of albumin. I wonder why anyone hasn't tried to conjugate Y-90 to albumin, and use that to internally irradiate the glioma? .

Another interesting thing: since oxygen is a radiosensitizer, perhaps mixing the SIRT microspheres with perfluorocarbon polymer would increase their effect, since perfluorocarbons can transport huge amounts of oxygen.

And I was reading a few articles on clostridial oncolysis. Apparently, since tumors are hypoxic, and Clostridium spp. are obligate anaerobes, they can, and have been shown to, specifically lyse tumors. And there is this Clostridium oncolyticum species that doesn't produce the dangerous alpha-toxin, and is essentially apathogenic. So perhaps embolizing a tumor with a mixture of clostridial spores and acrylic microspheres to permanently occlude the feeding vessels, thus making the tumor even more hypoxic, could be useful. Perhaps adding the cytosine deaminase gene to the bacteria, and also giving capecitabine would increase the effect.

Obviously periop allopurinol and IV fluids are a must in IO practice, in case of TLS.

I'm just an undergrad now, but I love reading about medicine, especially radiology, specifically nuclear and interventional. I wish I could become a member of RSNA; I'd love to attend one the annual meetings. I'm already a member of SNM. Hopefully during my senior undergrad immunology project I can contribute in some small way to advancing the field. Maybe make a novel tracer or something. Leeds has a medphys and molecular imaging department, so I could make the antibody, link it to DOTA-chelated Tc-99m, and then test it out in a mouse model.

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[cbtk18]

Finish college there first, bud. It'll make your smattering of all those fancy words sound a little less ridiculous.

Sent from my ADR6300 using SDN Mobile

 

[ImmunoDude]

Finish college there first, bud. It'll make your smattering of all those fancy words sound a little less ridiculous.

Sent from my ADR6300 using SDN Mobile

Don't be a jerk. These are valid questions, and they make sense. Or have you people lost the scientific curiousity that drives medicine forward?

 

[ImmunoDude]

Concepts are great but in reality until you have published data, ideally randomized data comparing techniques in comparable patients, your points are moot. RFA is an interesting technique but the studies to date that I have seen have been pretty poor. The RAPTURE study (lung) in my opinion was a severly flawed study from a methodological standpoint and while RFA is frequently used to treat liver disease, there remains a lack of randomized category 1 evidence to support its use. Until that exists it cannot and should not supplant the standard of care.

Then some academic IR needs to conduct a proper RCT comparing resection to ablation.

Surgery should be the last resort after medical and interventional tx has failed. As a patient, would you rather have a 3-5 hour liver resection and the risks of GA and postop complications, plus the pain, scarring, and recovery time, or a 30-45 minute percutaneous ablation done under sedation and only 24 hours of inpatient observation? Cancer patients have enough to deal with.

John Hunter said that patient management should be done strategically rather than by brute force. If surgery isn't absolutely necessary, it shouldn't be done.

Thanks for the answer. Someday, Lord knows how considering my situation essentially forces me into being an IMG, I will become an IR and research nonoperative cancer treatments that will make surgical oncology equivalent to tuberculosis surgery, done only as a last resort.

 

[Gvataken]

I do think that RFA has a role in certain situations. There is some level I evidence that suggests that in select cases ie certain amount of tumor burden in the setting of hepatocellular carcinoma, that RFA has comparable 1 to 4 year survival data. See below Chen et al article.

It is nice that these patients can go home the same day or in less than 24 hours and the recovery in general is quite rapid.

There is still alot of work to overcome some of its shortcomings (heat sinks/incomplete ablations/local recurrences), but I do think that the various ablative therapies (RFA, cryoablation, IRE, microwave, PEI etc) along with the numerous transcatheter therapies (TACE/bland embolization/drug eluting beads/internal beam radiation therapy) are very promising and will continue to showcase improvements in the upcoming years.

Chen MS, Li JQ, Zheng Y et al. A prospective randomized trial comparing percutaneous local ablative therapy and partial hepatectomy for small hepatocellular carcinoma. Ann Surg 2006;243:321–328. CrossRefMedline

 

[duckie99]

John Hunter said that patient management should be done strategically rather than by brute force. If surgery isn't absolutely necessary, it shouldn't be done.

Thanks for the answer. Someday, Lord knows how considering my situation essentially forces me into being an IMG, I will become an IR and research nonoperative cancer treatments that will make surgical oncology equivalent to tuberculosis surgery, done only as a last resort.

surg onc will just start doing the procedures if their work starts being taken away on any large scale. Vascular surgery already has done so with PAD. There will be the argument that they will be less biased in giving the patient all the options because they could do either interventional or surgery. It also wouldn't surprise me to learn there are surg onc people already performing these procedures.

also it is extremely difficult to design trials that would have patients with cancer avoid the standard of care (surgery) to a largely unproven therapy (RFA, etc). From what I have seen interventional therapy is reserved mostly for patients with inoperable cancers.

 

[Gvataken]

Yes. I do think that it is hard to randomize patients when the standard of care is surgical resection. I do think that regardless of who does it , less invasive techniques will continue to improve . The options are growing and this includes noninvasive techniques such as HIFU.

I treated a patient today with cryoablation. I met her a little over a year ago and she had originally presented with adrenal cortical carcinoma (right ) and this was resected several years ago. However, she had recurrence and underwent a repeat resection. Then at that point about a year ago she presented with recurrence and was referred to me for ablation. I went ahead and treated her with cryoablation in the suprarenal fossa . I admitted her overnight for pain control and she did well. She developed a sympathetic right pleural effusion (but no dyspnea) that ultimately resolved. I was continuing to follow her for a couple of sub centimeter drop metastases from the original surgery that were located in a lower location. These ultimately grew to about 2 cm each and I was able to perform cryoablation on her this afternoon. She recovered quite well and I sent her home today. I will call to see how she is doing tomorrow and have ordered a 3 month follow up imaging study (triphasic kidney CT) and will follow her for recurrence.

The key to ablative therapy is good imaging and clinical follow up and realize you may need to do some touch up work. But, what I find critical is for the IR physician to review the subsequent imaging and discuss this with the patient.

 

[MossPoh]

By all means, read away, but please do me a favor. When you start medical school, don't be that guy that asks these questions in the lectures. Your classmates will hate you for it. Normally, I'm joking or being sarcastic but they will seriously loathe these questions and think of you as the a-hole that likes showing how much he reads (whether justified or not).

Kudos to you though. Its good to have interests and be passionate about things. I just hope you are having standard undergrad fun too.

 

[ImmunoDude]

By all means, read away, but please do me a favor. When you start medical school, don't be that guy that asks these questions in the lectures. Your classmates will hate you for it. Normally, I'm joking or being sarcastic but they will seriously loathe these questions and think of you as the a-hole that likes showing how much he reads (whether justified or not).

Kudos to you though. Its good to have interests and be passionate about things. I just hope you are having standard undergrad fun too.

I most assuredly am not that guy! I only ask these kind of questions after lecture, or when I have some one-on-one time with the prof. Or here, LOL.

I have no intention of making all my fellow students at RCSI hate me!

And I just discovered something interesting that relieves me, knowing that PGY-1 postions for USIMGs and FMGs will be in a crunch by the time I have my MD. Ireland is hurting for doctors since all their grads go overseas for training. If I complete my radiology training in Ireland and get Fellowship of the Royal College of Radiologists and registered with the GMC-I, North Dakota, Maine, and Oklahoma accept that in lieu of the residency requirement for licensure. And, assuming the ABR Alternate Pathway is still open by then, if I do a fellowship and spend three years as a faculty member, I can take the ABR exam.

There's a urologist in Maine who did just that.

 

[shark2000]

I tried a lot not to give a comment, but I could not stop myself.

Radiology as a field is really great, but not for the reasons people think about. One day I read here that somebody wants to do radiology because he wants to do colonoscopies, the other day I read here that someone wants to do it to make 7 figures income, then a premed wants to do it because he wants to do TACE or Y-90 or RFA without even knowing what are these or what Cancer is at all. Then some high school student wants to do it because he likes his physics classes and thinks radiologists are doctors who solve physics problems.
The more you restrict your options early in your education, the more you will be miserable later. Radiology is one of the greatest fields in medicine, but choose it for right reasons. It is one of those fields that is different and you may easily hate it.

 

[Raygun77]

I've been reading a lot about RFA and its cousin, IRE, and I'm now wondering why it hasn't completely replaced surgical resection for solid tumor patients (other than brain tumors, because it doesn't relieve mass effect).

Based on what I've been reading in journals, a patient with a tumor > 5 cm could have DEB-TACE or SIRT to shrink the tumor until it's amenable to RFA or IRE, all the while taking sorafenib.

One could take a percutaneous tru-cut biopsy of the ablation margins to confirm success intraoperatively, and follow that up with a PET scan.

Another thing I was reading was about the 5-aminofluorescein-albumin dye neurosurgeons use for contrast while resecting gliomas, since they take up massive amounts of albumin. I wonder why anyone hasn't tried to conjugate Y-90 to albumin, and use that to internally irradiate the glioma? .

Another interesting thing: since oxygen is a radiosensitizer, perhaps mixing the SIRT microspheres with perfluorocarbon polymer would increase their effect, since perfluorocarbons can transport huge amounts of oxygen.

And I was reading a few articles on clostridial oncolysis. Apparently, since tumors are hypoxic, and Clostridium spp. are obligate anaerobes, they can, and have been shown to, specifically lyse tumors. And there is this Clostridium oncolyticum species that doesn't produce the dangerous alpha-toxin, and is essentially apathogenic. So perhaps embolizing a tumor with a mixture of clostridial spores and acrylic microspheres to permanently occlude the feeding vessels, thus making the tumor even more hypoxic, could be useful. Perhaps adding the cytosine deaminase gene to the bacteria, and also giving capecitabine would increase the effect.

Obviously periop allopurinol and IV fluids are a must in IO practice, in case of TLS.

I'm just an undergrad now, but I love reading about medicine, especially radiology, specifically nuclear and interventional. I wish I could become a member of RSNA; I'd love to attend one the annual meetings. I'm already a member of SNM. Hopefully during my senior undergrad immunology project I can contribute in some small way to advancing the field. Maybe make a novel tracer or something. Leeds has a medphys and molecular imaging department, so I could make the antibody, link it to DOTA-chelated Tc-99m, and then test it out in a mouse model.

Firstly, i'll echo some others in saying- really like your enthusiasm and innovative thinking. You really want to hold on to this (though not necessarily be too vocal about it, especially to be a sycophant as someone else mentioned ). But medicine needs people like you, so good luck with everything.

You mention RFA as first line for solid tumours...but you have to understand surgery is the standard of care for a lot of practical reasons. First of all, an operation allows for 'surgical staging'- i.e. direct camera visualisation and sampling of nearby lymph nodes or lesions, to gauge the stage of the cancer better than any imaging. For example, you may do an FDG-PET/CT of a pancreatic cancer patient and only see the hot primary in their pancreas, however when you actually open them up you see the small metastases peppering their peritoneum.

Second of all, by taking out the tumour you have tissue to do lots of histopath and genetic testing on, which i anticipate will have a larger and larger role in guiding cancer management. For example, with modern techniques you still need a sizeable chunk of say, the glioma you mentioned, to actually test whether the cancer is 'MGMT promoter methylated' or not- which actually effects how treatment resistant it is. It's more than simply diagnosing cancer with a small biopsy- the more tissue, the better for more advanced testing, in general.

And finally, you talked about implantation therapies (for example the gliadel wafers or gliasite brachytherapy used in glioma, going back to that example). Being 'physically' in the brain, surgeons are perfectly positioned to try these therapies, thus far unsuccessfully.

As Wagy has mentioned, lots of things are theoretically plausible...however frustratingly, the data often suggest they are no better than the standard of care, and it's important to be objective and be guided by well designed trials. For example, it may have been plausible and intuitive to give heart failure patients adrenaline in the 70s and 80s, to make their heart work faster. In hindsight we know this worsens outcomes by overworking a damaged heart, (and actually B-blockers improve survival) but we only know this thanks to objective randomized trials. If people just went with their guts, we may still be following this maxim, sometimes a problem in medicine!

 

[Gvataken]

I do think that the evolution of medicine is progressing towards less invasive diagnosis and minimally invasive or non-invasive treatments. If you look at the diagnosis of hepatocellular carcinoma as an example (it is now primarily an imaging diagnosis). Look at Lirads/OPTN/AASLD guidelines. Also, the bulk of patients have poor liver reserve or excessive portal hypertension and thus resection is not a great option. Staging of hepatoma is done primarily by imaging (Chest CT/perhaps a bone scan/ and a look at the adrenals on the CT as well as looking for major vascular invasion on CT). The treatments usually do not require a biopsy and in fact there can be false negatives with biopsy in this situation. There are potential complications of hepatoma biopsy including bleeding and seeding. Lovett et al published a potential of 12 % seeding (though this is controversial and with coaxial techniques seems to be much lower) for this tumor type.

I look at the evolution of infrainguinal interventions as another example of how we are progressing to less invasive treatments for limb salvage. It used to be that the only option for limb salvage was bypass surgery. Charles Dotter (father of IR) proved the point of surgery without a scalpel and did the first percutaneous IR recanalization of the SFA. Since his seminal work, there has been a rapid improvement in techniques and technology and with associated improvements being noted in stent and vessel patency. We have subintimal techniques, plain old balloon angioplasty, atherectomy, drug coated balloons (europe) , drug eluting stents( RCT Zilver PTX trial by COOK), Resilient trial (self expanding stent trial by BARD). These are all showing quite promising results and each generation of stents seems to do a better and better job. The key is looking at the outcomes by looking at improvement in Rutherford status and limb salvage rates/amputation free survival/ and overall mortality.

Ultimately in order to have a huge impact on society we may need to shift our focus as physicians to preventative measures and screening processes. Hopefully this will reduce societal costs and improve the overall health and productivity of our society. ie obesity control/diet/exercise/smoking cessation/prevention of communicable diseases etc. But, historically we have not done a great job in overall prevention.

 

[ImmunoDude]

Really, thanks for the comments.

And about Raygun77's comment about biopsies: couldn't the pathologist just extract the DNA from the cells, PCR it, and then do Flow-FISH to look for oncogenes and tumor antigens? And there is methylation-specific PCR. With PCR and FCS, you really don't need a whole lot of cells to make a diagnosis, just a whole lot of primers and fluorophores. The pathologist still needs to look at slides though, to determine anatomic info and what primers and fluorophores to order. So the IR needs to take just two small biopsies, one for making slides, and another for molecular and genomic analysis. Instead of a surgeon taking one big biopsy.

And improvements in CT and MRI are increasing in sensitivity to small tumors; I bet you can see those little tumors in the brand-new 7T MRI scanners. And gamma camera are getting more precise.

And since you can't MWA or Nanoknife every single piece of cancer, just like you can't resect every single piece of cancer, wouldn't you also do heated intraperitoneal chemoinfusion to take care of any oncocytes floating around in the peritoneum, like they do already intraoperatively right before closure?

I just got done doing a few presentations on FISH and FCS; got a first on those (yay!), about equivalent to an A. They're so cool and powerful.

And I'm also wondering why DRs always want to leave it up to clinician to explain scan results, despite the fact the clinician is just re-stating what the DR found. And they complain that the DR is hedging, despite the fact that "clinical correlation required" means the clinician hasn't fully examined the patient and ordered appropriate lab tests. Or has done that, but neglected to inform the DR.

And DRs should do their part in educating their patients on their disease and what they can offer, like sending them an annotated copy of the report, explaining what they found and what it could mean, and what this means for them. There's a pathology group that does just this with path reports. http://www.thedoctorsdoctor.com/f_translating.html

Like this:

Study: Abdominal CT with 3D reconstruction, with and without IV contrast.

Your abdomen was scanned before and after a special dye was injected to make blood flow easier to see. The 2D images were then rendered in 3D to assist in interpretation.

Indication: Referring physician suspects liver disease based on clinical history and findings per radiology request form

This is why your doctor wanted you to have this scan, to determine why you have upper abdominal pain, yellowing of the skin and eyes, and nausea and vomiting

Findings: There is a 500 mL hypodense mass in segment 1 and 4 of the cirrhosed liver. One portocaval lymph node is enlarged. Mild ascites is present. There is cavernous transformation of the thrombosed portal vein. The mass and thrombus are continuous with each other and enhance with contrast. Gastric and esophageal varices are present. Remainder of study is normal.

There is a large mass present in the middle of your liver. The mass has invaded the portal vein, which takes nutrient-rich blood from your digestive system to the liver for processing. The portal vein became obstructed because of this, so your body is bypassing the obstruction with many collaterals to relieve the high pressure in it. But this was not enough, so the blood is backing up in the veins in your esophagus and stomach.The high pressure led to scarring and fluid build up around the liver. A lymph node near the portal vein is larger then normal. After the dye was injected, the mass and obstruction became bright, which shows that the mass is perfused with blood. Otherwise, everything else appears normal.

Impression: Strong likelihood of localized unresectable T3bN1M0 hepatocellular carcinoma. Biopsy of mass and enlarged lymph node highly recommended. GI oncology consult advised if biopsy positive.

I believe that this mass could be stage 4b liver cancer, which is causing your symptoms. Due to the mass's location and the damage to your liver, surgical resection would be dangerous. and I urge your doctor to request me to perform a minimally-invasive image-guided biopsy so my on-site pathologist can examine the cells using advanced molecular and genomic analysis methods to determine whether or not this mass is indeed cancer, so your doctor can refer you to a cancer specialist for appropriate treatment. Hopefully the mass is not cancer, but if it is, I provide a full spectrum of state-of-the-art non-surgical cancer treatment if medication alone is not enough to get you healthy again.

Lymph nodes can be biopsied percutaneously, and positive ones can be ablated. Pre-op embolization would help prevent the heat sink effect of tumor blood flow.

After I graduate RCSI, I plan on doing my internship and then go on to two years of Basic Surgical Training in the UK, Ireland, or Australia, and pass the MRCS exam, because surgical knowledge and training is critical in radiology, especially IR. Then my 5-6 years of diagnostic and interventional radiology training, hopefully doing research so I can get a MD or PhD, pass the Fellowship of the Royal College of Radiologists exam, get registered with the GMC-UK or GMC-I, and then back here to ME, ND, or OK where this is acceptable for licensure. At every training stage I'm still going to try for radiology residency here, of course. Then once I'm back here, I try to do three years of ACGME-accredited fellowships (most likley VIR, abdominal imaging, and nuclear medicine), plus one year of serving as med school faculty, so I can take the ABR exams and fulfill the postgraduate training reqs to get licensed back in California if they don't let me transfer my ME, ND, and OK licenses.

 

[shark2000]

Good luck!

 

[ImmunoDude]

Good luck!

Thanks! If I'm successful, I'll be the first doctor in my family.

I think I'm just carrying on the tradition of my Dad's side of the family getting educated in the UK instead of our home countries. My Dad was from India, got his Master Mariner's license in the UK, and captained supertankers before he came here. He couldn't sail American-flagged ships because the Coast Guard wouldn't accept his license, but he was going to quit anyway. Unlike Dad, I won't have that problem with my UK license.

Although I may have to end up suing CA's board, because if they deny a license to me, despite the fact that three other states are satisfied that I meet the educational and training standards to be fully licensed to practice medicine without restrictions, they're being idiotic.

And training in UK means I have less hours to work, better pay, and more opportunities to improve my general medical knowledge and decide on a specialty, as they require 1-4 years of clinical training before you're eligible for radiology training.

 

[duckie99]

Good luck!

yeah exactly.

immunodude you are just way off in how medicine is practiced. Do you think you are the first one to suggest that DR should be sending patients letters and then offering advice on the next step in management? Basic limiting principles come in to play such as DR having almost no access to pt records, an extremely large workload that is already too much for them, etc. They also do not have the knowledge required on what the best biopsy method would be. Pts are usually sent to surgeons for such things because that is what surgeons train 5 years for. If it needs CT guidance the pt can then be sent to IR. IR's sole role here is to get tissue. The pt then goes back to heme/onc.

If a person has a new dx of cancer you think the best way for them to find out is with a letter for DR? come on no way.

IR's role at the present time is to do procedures. That's pretty much it. They don't offer much further guidance for a great majority of their work. Example pt with choleangitis needs their gallbladder drained. Normally the best way is ERCP but the risk for bowel perforation is too high since the pt also has pancreatitis so CT guidance is the best and the pt is sent to IR for the procedure and back to the ICU. IR is then done with that pt's management. They do not round on the pt and suggest anything further (unless their is a problem from their procedure) because that is what GI does as they are the experts. And honestly lots of things surgeons do are the same way. A surgeon doesn't manage gallstone pancreatitis. They just remove the gallbladder and the patient is sent back to medicine.

The only thing I think IR can really do is make certain procedures they offer require a consult. Obviously not everything can be made a consult (perm cath for example) but some things could probably work out that way. Otherwise IR will always be a totally procedure based field. I don't think there is a drive within the field to change it much to any degree. There are far too many barriers.

If you want interventional stuff and patient management you should do surgery. Some surgeons do their own CT guided biopsies. Vascular surgeons and cardiologists can basically do anything (with the proper training) that requires endovascular work. That's just the reality of the situation. But IR will always have a role because surg or cards won't do certain things because they are already so busy with their own work.

 

[ImmunoDude]

yeah exactly.

immunodude you are just way off in how medicine is practiced. Do you think you are the first one to suggest that DR should be sending patients letters and then offering advice on the next step in management? Basic limiting principles come in to play such as DR having almost no access to pt records, an extremely large workload that is already too much for them, etc. They also do not have the knowledge required on what the best biopsy method would be. Pts are usually sent to surgeons for such things because that is what surgeons train 5 years for. If it needs CT guidance the pt can then be sent to IR. IR's sole role here is to get tissue. The pt then goes back to heme/onc.

If a person has a new dx of cancer you think the best way for them to find out is with a letter for DR? come on no way.

IR's role at the present time is to do procedures. That's pretty much it. They don't offer much further guidance for a great majority of their work. Example pt with choleangitis needs their gallbladder drained. Normally the best way is ERCP but the risk for bowel perforation is too high since the pt also has pancreatitis so CT guidance is the best and the pt is sent to IR for the procedure and back to the ICU. IR is then done with that pt's management. They do not round on the pt and suggest anything further (unless their is a problem from their procedure) because that is what GI does as they are the experts. And honestly lots of things surgeons do are the same way. A surgeon doesn't manage gallstone pancreatitis. They just remove the gallbladder and the patient is sent back to medicine.

The only thing I think IR can really do is make certain procedures they offer require a consult. Obviously not everything can be made a consult (perm cath for example) but some things could probably work out that way. Otherwise IR will always be a totally procedure based field. I don't think there is a drive within the field to change it much to any degree. There are far too many barriers.

If you want interventional stuff and patient management you should do surgery. Some surgeons do their own CT guided biopsies. Vascular surgeons and cardiologists can basically do anything (with the proper training) that requires endovascular work. That's just the reality of the situation. But IR will always have a role because surg or cards won't do certain things because they are already so busy with their own work.

You're right. I would be perfectly happy sitting in the reading room analyzing images, giving my opinion, and waiting to be called on. I just don't want to see a patient get sent for a painful surgery that I could've taken care of in a much less traumatic way because the patient wasn't informed of all their options. Just inform the referrer about what you can do about what you found. "Dr Smith, you have questions about my findings and recommendations? Ok..., and here's what I can do for you."

DR and IR is wonderfully challenging in of itself, and it doesn't need the added complexity of long-term patient management.

And DRs should have access to patient records, because that info can help them in interpretation. A detailed history and account of the encounter that led to the study being ordered should be required on the request form. Saves everyone a lot of phone calls that cut into a DRs reading and a clinician's office or OR time.

Once again, everything you're saying simply lends support for my view that DR residency should require more prior clinical training than just an internship.

Physicians should practice in multispecialty groups based on organ system. Like a HPB surgeon should practice with an IR, a GI, and a pathologist. Then patient care can be coordinated smoothly, because no one has any financial incentive to get in the way of effective patient care. Mayo and Cleveland Clinic work like this. If the surgeon and GI gets lots of referrals, that's great for the IR and pathologist because they share in the fees and get extra work. And vice versa. If the IR gets lots of ablation and biopsy referrals, that's great for the GI, surgeon, and pathologist. Same for the pathologist getting more biopsies referred to read.

And I want to be an academic IR, so patient management would get in the way of my research. Can't develop new IO treatments if all your time is spent rounding.

And isn't the SIR pushing for IRs to become more clinical? To evaluate patients before a procedure and to manage them postop? And isn't that exactly how surgeons run their clinics, just that their postop time is usually longer than 24 hours? I only saw my surgeon once in the hospital, and once outpatient.

IR should run like surgery. http://www.appliedradiology.com/Iss...--Back-to-the-Basics-and-Into-the-Future.aspx

 

[Raygun77]

And about Raygun77's comment about biopsies: couldn't the pathologist just extract the DNA from the cells, PCR it, and then do Flow-FISH to look for oncogenes and tumor antigens? And there is methylation-specific PCR. With PCR and FCS, you really don't need a whole lot of cells to make a diagnosis, just a whole lot of primers and fluorophores. The pathologist still needs to look at slides though, to determine anatomic info and what primers and fluorophores to order. So the IR needs to take just two small biopsies, one for making slides, and another for molecular and genomic analysis. Instead of a surgeon taking one big biopsy.

I defer to your knowledge then because it's been a couple of years since I was involved in research. From then, though, the techniques my hospital's path lab had required a large sample to process for methylation status. And i do stand by- the more tissue the better, because as you know things like sampling error become an issue.

And improvements in CT and MRI are increasing in sensitivity to small tumors; I bet you can see those little tumors in the brand-new 7T MRI scanners. And gamma camera are getting more precise.

A bit pie in the sky, my hospital has no plans of getting a 7T MRI (3T is the standard of care here), think of the costs.

And since you can't MWA or Nanoknife every single piece of cancer, just like you can't resect every single piece of cancer, wouldn't you also do heated intraperitoneal chemoinfusion to take care of any oncocytes floating around in the peritoneum, like they do already intraoperatively right before closure?

Back to the issue on data, is there any evidence on such a 'chemo-irrigant' doing more good than harm for things like peritoneal carcinomatosis, especially with very chemo resistant cancers?

After I graduate RCSI, I plan on doing my internship and then go on to two years of Basic Surgical Training in the UK, Ireland, or Australia, and pass the MRCS exam, because surgical knowledge and training is critical in radiology, especially IR. Then my 5-6 years of diagnostic and interventional radiology training, hopefully doing research so I can get a MD or PhD, pass the Fellowship of the Royal College of Radiologists exam, get registered with the GMC-UK or GMC-I, and then back here to ME, ND, or OK where this is acceptable for licensure. At every training stage I'm still going to try for radiology residency here, of course. Then once I'm back here, I try to do three years of ACGME-accredited fellowships (most likley VIR, abdominal imaging, and nuclear medicine), plus one year of serving as med school faculty, so I can take the ABR exams and fulfill the postgraduate training reqs to get licensed back in California if they don't let me transfer my ME, ND, and OK licenses.

You've got it all planned out. Don't forget to stop and smell the roses on the way.

 

[ImmunoDude]

I defer to your knowledge then because it's been a couple of years since I was involved in research. From then, though, the techniques my hospital's path lab had required a large sample to process for methylation status. And i do stand by- the more tissue the better, because as you know things like sampling error become an issue.



A bit pie in the sky, my hospital has no plans of getting a 7T MRI (3T is the standard of care here), think of the costs.



Back to the issue on data, is there any evidence on such a 'chemo-irrigant' doing more good than harm for things like peritoneal carcinomatosis, especially with very chemo resistant cancers?



You've got it all planned out. Don't forget to stop and smell the roses on the way.

Well, by the time I'm in practice 1-2 decades from now, 7T will likely be as common as 3T.

And PET-guided biopsy will help reduce sampling error.

And here's the data on HIPEC: http://jco.ascopubs.org/content/21/20/3737.full

RIT is superior to chemo, because it also opsonizes the oncocytes, so ADCC can take place, as well as irradiating them. Just take a look at the success of Bexxar and Zevalin for NHL. http://www.4-traders.com/SPEC-PHARM...py-Trial-for-Non-Hodgkin-s-Lymphoma-13516060/

IR is the oncologic surgery of the future, and RIT is the chemo of the future. MWA with Y-90-labeled anti-E4-65 mAbs instead of resection and sorafenib for HCC.

Patient comes in with weight loss and abdominal pain, GI finds ascites and caput medusae, and starts propanolol and orders LFTs and a CT. CP determines LFTs are abnormal, and DR finds a liver mass invading the portal vein and a lymph node, and GI requests a biopsy. AP does FACS and finds HCC. GI starts patient on Avastin and Tarceva, and orders a follow-up PET/CT. Patient's ascites is getting worse and no change on PET/CT. GI refers patient to IR for TIPS and IO consult. IR decides to do PVE and SIRT to prepare for MWA and add RIT against a tumor antigen listed in the pathology report. They follow the patient with interval PET/CT until there's enough remnant so IR can MWA the tumor, the lymph node, and the area of the portal vein the tumor invaded.

Good luck to you to!

 

[shark2000]

Well, by the time I'm in practice 1-2 decades from now, 7T will likely be as common as 3T.

And PET-guided biopsy will help reduce sampling error.

And here's the data on HIPEC: http://jco.ascopubs.org/content/21/20/3737.full

RIT is superior to chemo, because it also opsonizes the oncocytes, so ADCC can take place, as well as irradiating them. Just take a look at the success of Bexxar and Zevalin for NHL. http://www.4-traders.com/SPEC-PHARM...py-Trial-for-Non-Hodgkin-s-Lymphoma-13516060/

IR is the oncologic surgery of the future, and RIT is the chemo of the future. MWA with Y-90-labeled anti-E4-65 mAbs instead of resection and sorafenib for HCC.

Patient comes in with weight loss and abdominal pain, GI finds ascites and caput medusae, and starts propanolol and orders LFTs and a CT. CP determines LFTs are abnormal, and DR finds a liver mass invading the portal vein and a lymph node, and GI requests a biopsy. AP does FACS and finds HCC. GI starts patient on Avastin and Tarceva, and orders a follow-up PET/CT. Patient's ascites is getting worse and no change on PET/CT. GI refers patient to IR for TIPS and IO consult. IR decides to do PVE and SIRT to prepare for MWA and add RIT against a tumor marker listed in the pathology report. They follow the patient with interval PET/CT until there's enough remnant so IR can MWA the tumor, the lymph node, and the area of the portal vein the tumor invaded.

Good luck to you to!

You are just listing some names without knowing their medical indications.
It is nice that you easily treated the patient with HCC without knowing what you are talking about.
Just FYI, PET-CT does not show increased metabolic activity in many HCCs , is a useless test fot HCC and is not used. TIPS has its own indications and is not done on most of cirrhotic patients.
Cool down. You'd better go to your undergrad school, have fun and see what you are interested in.

Also my humble suggestion: At your level, Saturday night you should go out with friends and have fun, rather than sitting at home and reading about all these BS. You will deal with all these crap later in your life more than enough.

Have fun

 

[ImmunoDude]

You are just listing some names without knowing their medical indications.
It is nice that you easily treated the patient with HCC without knowing what you are talking about.
Just FYI, PET-CT does not show increased metabolic activity in many HCCs , is a useless test fot HCC and is not used. TIPS has its own indications and is not done on most of cirrhotic patients.
Cool down. You'd better go to your undergrad school, have fun and see what you are interested in.

Also my humble suggestion: At your level, Saturday night you should go out with friends and have fun, rather than sitting at home and reading about all these BS. You will deal with all these crap later in your life more than enough.

Have fun

I just was out this night! Had a lot of fun watching the bouncers throw idiots out; one guy exposed himself in the bar, and me and my guard friend were laughing about it for a good while. Then I talked with my friends about what we're going to do over summer; can't wait to get back to CA and see my poor cat who just recovered from whole mouth extraction.

And the reason I'm doing this is because my upcoming genetics class has a lot of cancer genetics in it, as does my physiology and immunology courses. Leeds is a big cancer research center in the UK. Might as well learn this ancillary cancer stuff as well. Some of my recent classes were said by our medical students to be harder then theirs. Like our microbiology ones; the med students get out half-way. Same with the immunology ones. And we take the same physiology class.

And I should learn to like learning this stuff now, so I won't hate it when I'm required to learn these things.

And C-11 acetate PET does image HCC quite nicely. http://www.ncbi.nlm.nih.gov/pubmed/19342249

I never said FDG-PET, just PET, with no specification as to the tracer.

And if the GI tells me the patient's ascites is medically refractory, and he's tried octreotide, and he wants me to place a TIPS, and I find no absolute contraindications to it, I'd do one. TIPS has been done in the setting of PVT successfully. What else would you do, a Denver shunt that does nothing to relieve portal hypertension?

And you guys are being very helpful in showing me the limits of my knowledge.

And do you agree that RIT could be a very useful addition in oncology therapy? Being able to specifically target radiation to cancer and stimulate phagocytosis of the oncocytes, along with interfering with signal transduction.

 

[Raygun77]

Well, by the time I'm in practice 1-2 decades from now, 7T will likely be as common as 3T.

And PET-guided biopsy will help reduce sampling error.

And here's the data on HIPEC: http://jco.ascopubs.org/content/21/20/3737.full

RIT is superior to chemo, because it also opsonizes the oncocytes, so ADCC can take place, as well as irradiating them. Just take a look at the success of Bexxar and Zevalin for NHL. http://www.4-traders.com/SPEC-PHARM...py-Trial-for-Non-Hodgkin-s-Lymphoma-13516060/

IR is the oncologic surgery of the future, and RIT is the chemo of the future. MWA with Y-90-labeled anti-E4-65 mAbs instead of resection and sorafenib for HCC.

Okay, to set a few things straight. 1) We don't know what will be standard of care 10 years from now. At the moment, MRI isn't used for abdominal CA at all. Why would you, when CT has better spatial resolution anyway?!

2) Even from reading the title of your paper supposedly proving HIPEC's worth I can see it doesn't. "Randomized Trial of Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy Versus Systemic Chemotherapy and Palliative Surgery in Patients With Peritoneal Carcinomatosis of Colorectal Cancer"

The abstract states "105 patients were randomly assigned to receive either standard treatment consisting of systemic chemotherapy (fluorouracil-leucovorin) with or without palliative surgery".

Radical excision + HIPEC vs. systemic chemo plus minus palliative surgery (which was either bypass or stoma surgery- no debulking at all).....it should be obvious to you the flaws in your conclusion. There is NO way to conclude anything about HIPEC...in fact the positive prog factor identified was maximal excision of tumour...if anything you made an argument for surgery.

There's a real danger of ultraenthusiasm for new technology. We do -not- know the benefits til they are proved in GOOD trials. You can talk about the theoretical benefits of opsonization or whatever forever, but til outcomes are improved in a good trial it's meaningless. For example, there was huuuuuuge excitement over intra-arterial tPA for stroke patients. IR's pretty much assumed it'd be better than standard IV tPA and that interventional neuroradiology would be the next cardiology. Not so, thus far, recently the IMS-3 trial closed early as it was impossible for the treatment arm to be superior to standard.

I really agree with shark. Focus on ugrad. It IS a massive jump from studying immunology to talking about TIPS like youre an old hand.

 

[cbtk18]

OP, you are going to end up pissing off a lot of your colleagues (both students and attendings) by coming at them with this BS. It is fine to educate yourself here and there and gain some direction for your future. But you are injecting opinions and hypotheses into a field that you have absolutely no business in yet. The individuals that are currently in rads or medicine in general have put in a lot of time, money, effort, etc... in order to be experts in the field. You have not. As a result, to make the claims and assertions at your level IMO is disrespectful. I know it is easy to read some literature, go to some undergrad classes and think that you have all this figured out. You have a long way to go and as you progess you will gain more understand and consequently see that understanding change the way you see all of this. Hell, you may even end up liking a completely different field.

Sent from my ADR6300 using SDN Mobile

 

[duckie99]

And isn't the SIR pushing for IRs to become more clinical? To evaluate patients before a procedure and to manage them postop? And isn't that exactly how surgeons run their clinics, just that their postop time is usually longer than 24 hours? I only saw my surgeon once in the hospital, and once outpatient.

IR should run like surgery. http://www.appliedradiology.com/Iss...--Back-to-the-Basics-and-Into-the-Future.aspx

http://www.ncbi.nlm.nih.gov/pubmed/3966144

that's just a piece from 1985 about how IR should be more clinical. After a quick search it's the earliest I could find.

My point is that people have been pushing this for a long time (at least 27 years) and for the most part not a whole lot has been done. The best part about IR is getting to do cool procedures, help patients quickly with otherwise very minimal contact, and not be bothered with long term management and follow-up. In fact most of the procedures require no follow-up by IR. Also, IR docs are all radiologists. Understand one of the main draws of radiology as a field is very minimal patient contact. At my program just from listening to IR fellows nothing has changed. They argue about who has to consent a patient.


dude, listen to the other people here. It's cool you think IR is interesting but you need to chill out. You just don't have any actual or practical knowledge of medicine. You can't because you're not even a medical student and as an upper level one I would say even my knowledge is pretty limited. What they teach in undergrad bears no relation to the real world.

 

[ImmunoDude]

I'm going to stop pretending I know things on here, all it does is make me rightfully look like an arrogant idiot and disrespects your years of training and experience. I hope you guys will still allow me to ask questions though.

A lot of my seniors have said I have just the right type of mind to be an excellent medical researcher. Maybe I should reconsider med school, and get a PhD and work as a researcher for a company like Immunomedics.

Please permit me to ask these questions, because I'd really like to know what you think:

1. EBRT+TACE vs RIT via isolated tumor perfusion: This study showed RIT was much less toxic, and produced greater 4-year survival rates in HCC patients. http://www.ncbi.nlm.nih.gov/pubmed/12458401

Do you think it could be useful for other types of cancer, like gliomas? Give the cancer, and only the cancer, continuous irradiation, rather than splitting the dose up into dozens of fractions, which could give time for the cancer to recover. And the patient only needs to see the radiologist thrice: once for evaluation, once for imaging with the cold dose, and once for treatment with the hot dose. Beats having to lie in a bomb shelter multiple times a week. But this is just my useless opinion, so make of it what you will.

2. What do you think of this idea which stemmed from reading this incredibly interesting case report (which could only be described as a miracle masquerading as a tragedy): http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0404.2005.00459.x/abstract

Integrate MR/PET into a 3D cerebral angiogram, and embolize the arteries supplying the regions that show hypometabolism, so they infarct. Exact same principle as the MR-guided stereotactic laser ablation (very successful: http://www.aesnet.org/go/publicatio.../display/st/*/sy/2011/sb/all/page/10/id/15300), without requiring risky burr holes.

3. Since the body eventually reabsorbs dead tissue, do you think superselective alcohol injection could be a viable alternative to resections? I know this has been done to do in-situ nephrectomies several times, with very little side-effects and resolution of the patients' situations prompting the need for nephrectomy. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429847/

Thanks for educating me, I really appreciate it. Maybe I will indeed become an IR, maybe I'll pick a different field like surgery, interventional cardiology, or surgical pathology, maybe I won't go into clinical medicine at all, and be a researcher. Hell, maybe I'll become a biotech and medical device patent attorney, and make loads of cash interfering with medical progress

 

[medgator]

Anyone noticing aggressive IR folks in practice who want to offer RFA for malignant lesions after they are referred for a simple CT-guided biopsy.

I had a pt with locally-advanced N2c BOT scc with a few lung nodules that I sent for a biopsy. Came back as scc. Was getting ready to make a med onc referral for upfront chemo alone when the pt tells me the radiologist wants to set him up for an RFA. Had to get on the phone and tell him NO.

It's amazing these guys think that 1) they're oncologists and 2) rfa is any kind of upfront standard of care in lung, mets or otherwise

 

[tco]

It's amazing to me that you'd bump a 4 year old thread to vent your frustrations about one IR guy offering treatment to a patient.

 

[medgator]

It's amazing to me that you'd bump a 4 year old thread to vent your frustrations about one IR guy offering treatment to a patient.

Didn't check the date, and not sure why it is relevant anyways. I was curious whether this was happening in other markets.

Should I have just made a new thread and crowded the forums up some more?

 

[badasshairday]

If it is appropriate treatment to ablate. I would ablate, and be aggressive about getting it done.

 

[medgator]

If it is appropriate treatment to ablate. I would ablate, and be aggressive about getting it done.

ablation is rarely appropriate front line. Surgery or XRT upfront for early-stage lung CA is SOC. Liver, the jury is out between ablation and SBRT....

 

[badasshairday]

ablation is rarely appropriate front line. Surgery or XRT upfront for early-stage lung CA is SOC. Liver, the jury is out between ablation and SBRT....

Yes I know when ablation is appropriate. Thank you for the comment. Sorry that there is a doc out there not doing the appropriate therapy, although that is not unique to our specialty as there are surgeons, rad oncs, med oncs, etc who do the same.