Cryo for bone met, lung tx, etc?

[Soapcat]

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A local IR apparently reached out to my colleagues recently re: 'collaboration' of using radiation and cryo for bone mets, lung ca tx, etc.
I am not aware of robust data for using cryo - just some small studies here and there -- e.g. bone met: https://pubs.rsna.org/doi/full/10.1148/rycan.2021200101; unresectable early stage lung: Percutaneous imaging-guided cryoablation for lung cancer - PMC

The examples given above seem to be a pretty straight forward RT cases (and we don't put those needles!). Even the lung case that claims to have achieved a good local control, I would probably attribute it to the Tagrisso she was on for the EGFR+ disease.

Since we do rely on our IR colleagues for biopsies, fiducials, etc. we do want to be cordial/work well together, but I do not feel comfortable with the prospect of them gradually taking over our potential SBRT cases. What's your experiences have been like?

 

[fiji128]

A local IR apparently reached out to my colleagues recently re: 'collaboration' of using radiation and cryo for bone mets, lung ca tx, etc.
I am not aware of robust data for using cryo - just some small studies here and there -- e.g. bone met: https://pubs.rsna.org/doi/full/10.1148/rycan.2021200101; unresectable early stage lung: Percutaneous imaging-guided cryoablation for lung cancer - PMC

The examples given above seem to be a pretty straight forward RT cases (and we don't put those needles!). Even the lung case that claims to have achieved a good local control, I would probably attribute it to the Tagrisso she was on for the EGFR+ disease.

Since we do rely on our IR colleagues for biopsies, fiducials, etc. we do want to be cordial/work well together, but I do not feel comfortable with the prospect of them gradually taking over our potential SBRT cases. What's your experiences have been like?

IR doesn't send you patients. Say no and push back against this nonsense.

 

[BobbyHeenan]

One of our Neuro IR guys got really enthusiastic on cryo for spine bone mets Showed me some small case series of cryo followed by XRT article about it and how they have FDA approval for it. "compared to historical controls" they have better pain control is the party line from the reps.

We did a couple of cases but it's hard to know if it is helpful or not.

Logistically it's hard to justify IMO unless I see more data. We're often trying to work in between chemo cycles and trips in and out of town and just adding another player and delay to the mix I'm not sure is worth it unless I see stronger data.

 

[seper]

Microwave ablation has been done for bone mets since at least 10 y ago. Can’t see how IR it can be comparable to RT, given that it is invasive

 

[taserlaser]

We’ve pushed back here locally for its routine use for mets. Data just isn’t there. Where we have found cryo helpful moreso has been with desmoids, where the role of non-ionizing local therapy can be more compelling.

 

[NotMattSpraker]

A local IR apparently reached out to my colleagues recently re: 'collaboration' of using radiation and cryo for bone mets, lung ca tx, etc.
I am not aware of robust data for using cryo - just some small studies here and there -- e.g. bone met: https://pubs.rsna.org/doi/full/10.1148/rycan.2021200101; unresectable early stage lung: Percutaneous imaging-guided cryoablation for lung cancer - PMC

The examples given above seem to be a pretty straight forward RT cases (and we don't put those needles!). Even the lung case that claims to have achieved a good local control, I would probably attribute it to the Tagrisso she was on for the EGFR+ disease.

Since we do rely on our IR colleagues for biopsies, fiducials, etc. we do want to be cordial/work well together, but I do not feel comfortable with the prospect of them gradually taking over our potential SBRT cases. What's your experiences have been like?

I am curious if the Osteocool product launched this conversation? I am seeing this pushed more and more so just curious if thats what this is for you.

I work with someone now that likes to do this procedure. I like him so am cordial and even went to his industry dinner for his talk about the device.

My experience kind of matches this study, including basically everyone getting ablation + vertebroplasty. Radiofrequency Ablation for the Palliative Treatment of Bone Metastases: Outcomes from the Multicenter OsteoCool Tumor Ablation Post-Market Study (OPuS One Study) in 100 Patients - PubMed

There is not a strong scientific argument that ablation + vert + RT is better than vert + RT. Patients do get nearly instant pain relief which makes them happy, but this is true in my experience with vert alone as well (when patients have significant mechanical pain). Its possible ablation adds acute pain relief, but no one has asked that question to my knowledge.

Ive seen a few "failures" in our very nascent program, which is not surprising. That shapes my opinion a lot.

If you want to be cordial like I was, Id lobby that all patients getting this procedure get a dual referral to rad onc for monitoring or adding RT.

I do think ablation + vert + 8x1 would be interesting to trial against SBRT if that were ever possible. I suspect some cases are better and/or easier treated with ablation + (even sim free) 3DCRT, especially if they are already getting a vert.

I worked with a very thoughtful and academic IR at WUSTL that did a lot of ablation and felt we had a really nice multi D approach. Never felt like he was "stealing SBRT cases".

Edited: to add that its a totally different story in early stage NSCLC IMO. Unless 100% of your patients are getting a full surgical and SBRT evaluation, there is no discussion to be had today. Ablation should be reserved for rare cases where surgery/re-irradiation is not safe or as a last resort.

Palliation of bone mets and curative therapy for ES-NSCLC are not the same. IRs have a very long way to go to show SBRT or resection level efficacy in large numbers of patients.

 

[BobbyHeenan]

I am curious if the Osteocool product launched this conversation? I am seeing this pushed more and more so just curious if thats what this is for you.

I work with someone now that likes to do this procedure. I like him so am cordial and even went to his industry dinner for his talk about the device.

My experience kind of matches this study, including basically everyone getting ablation + vertebroplasty. Radiofrequency Ablation for the Palliative Treatment of Bone Metastases: Outcomes from the Multicenter OsteoCool Tumor Ablation Post-Market Study (OPuS One Study) in 100 Patients - PubMed

There is not a strong scientific argument that ablation + vert + RT is better than vert + RT. Patients do get nearly instant pain relief which makes them happy, but this is true in my experience with vert alone as well (when patients have significant mechanical pain). Its possible ablation adds acute pain relief, but no one has asked that question to my knowledge.

Ive seen a few "failures" in our very nascent program, which is not surprising. That shapes my opinion a lot.

If you want to be cordial like I was, Id lobby that all patients getting this procedure get a dual referral to rad onc for monitoring or adding RT.

I do think ablation + vert + 8x1 would be interesting to trial against SBRT if that were ever possible. I suspect some cases are better and/or easier treated with ablation + (even sim free) 3DCRT, especially if they are already getting a vert.

I worked with a very thoughtful and academic IR at WUSTL that did a lot of ablation and felt we had a really nice multi D approach. Never felt like he was "stealing SBRT cases".

Edited: to add that its a totally different story in early stage NSCLC IMO. Unless 100% of your patients are getting a full surgical and SBRT evaluation, there is no discussion to be had today. Ablation should be reserved for rare cases where surgery/re-irradiation is not safe or as a last resort.

Palliation of bone mets and curative therapy for ES-NSCLC are not the same. IRs have a very long way to go to show SBRT or resection level efficacy in large numbers of patients.

In our patients, yes, they were a collapsed /path spine fracture and they had vertebroplasty and osteocool in one procedure followed shortly thereafter with xrt.

I think it can make sense in these cases.

Im not just blanket sending all bone mets to them though like they’d suggest.

 

[RickyScott]

I am curious if the Osteocool product launched this conversation? I am seeing this pushed more and more so just curious if thats what this is for you.

I work with someone now that likes to do this procedure. I like him so am cordial and even went to his industry dinner for his talk about the device.

My experience kind of matches this study, including basically everyone getting ablation + vertebroplasty. Radiofrequency Ablation for the Palliative Treatment of Bone Metastases: Outcomes from the Multicenter OsteoCool Tumor Ablation Post-Market Study (OPuS One Study) in 100 Patients - PubMed

There is not a strong scientific argument that ablation + vert + RT is better than vert + RT. Patients do get nearly instant pain relief which makes them happy, but this is true in my experience with vert alone as well (when patients have significant mechanical pain). Its possible ablation adds acute pain relief, but no one has asked that question to my knowledge.

Ive seen a few "failures" in our very nascent program, which is not surprising. That shapes my opinion a lot.

If you want to be cordial like I was, Id lobby that all patients getting this procedure get a dual referral to rad onc for monitoring or adding RT.

I do think ablation + vert + 8x1 would be interesting to trial against SBRT if that were ever possible. I suspect some cases are better and/or easier treated with ablation + (even sim free) 3DCRT, especially if they are already getting a vert.

I worked with a very thoughtful and academic IR at WUSTL that did a lot of ablation and felt we had a really nice multi D approach. Never felt like he was "stealing SBRT cases".

Edited: to add that its a totally different story in early stage NSCLC IMO. Unless 100% of your patients are getting a full surgical and SBRT evaluation, there is no discussion to be had today. Ablation should be reserved for rare cases where surgery/re-irradiation is not safe or as a last resort.

Palliation of bone mets and curative therapy for ES-NSCLC are not the same. IRs have a very long way to go to show SBRT or resection level efficacy in large numbers of patients.

Our IRs are ablating w/all vert. Most the time i am not even consulted

 

[Palex80]

I've sent out a few patients for cryoablation of bone mets with recurrent disease post-RT (following SBRT).
It's not always as atraumatic, as IR may claim.

 

[Gfunk6]

IR doesn’t manage patients or their complications. Pneumothorax? Soft tissue necrosis? Chronic pain? These all get punted to someone else.

 

[medgator]

This garbage only happens in areas with low energy rad oncs.

There. I said it

(Or in inpatient heavy programs where there are hungry IRs and too many Mets to go around).

 

[medgator]

.

Since we do rely on our IR colleagues for biopsies, fiducials, etc. we do want to be cordial/work well together, but I do not feel comfortable with the prospect of them gradually taking over our potential SBRT cases. What's your experiences have been like?

The reality is that they have already lost in early lung CA for upfront management and will likely lose liver soon too

 

[medgator]

IR doesn’t manage patients or their complications. Pneumothorax? Soft tissue necrosis? Chronic pain? These all get punted to someone else.

Yep. Empyema after rfa for lung cancer is a notorious one I've heard about from our local pulms

 

[gmsquid]

Often pain is worse after ablation vert in my experience

 

[gmsquid]

Rt should be principal management with kypho post rt for structural pain

 

[JustAdocInBox]

I'm surprised your IR docs are looking for more work. Our radiology group is swamped and has been struggling to recruit interventionalists.

 

[BobbyHeenan]

I'm surprised your IR docs are looking for more work. Our radiology group is swamped and has been struggling to recruit interventionalists.

Ours are looking for things that reimburse them well. Though busy with ports and G tubes and biopsies, etc....I think they do much better with TARE and RFA.

My biggest "fight" with them is on TARE. The concept of a dmin they selectively ignore. I don't care if you gave a zillion Gy to the middle of the tumor, if the poorly perfused part or a part fed by an adjacent feeder part of the tumor doesnt see dose there it will recur there. And often we have different ideas about what is a "selective" TARE and what isn't.

We really need randomized TARE vs. SBRT for HCC and/or cholangio.

 

[OTN]

Ours are looking for things that reimburse them well. Though busy with ports and G tubes and biopsies, etc....I think they do much better with TARE and RFA.

My biggest "fight" with them is on TARE. The concept of a dmin they selectively ignore. I don't care if you gave a zillion Gy to the middle of the tumor, if the poorly perfused part or a part fed by an adjacent feeder part of the tumor doesnt see dose there it will recur there. And often we have different ideas about what is a "selective" TARE and what isn't.

We really need randomized TARE vs. SBRT for HCC and/or cholangio.

AMEN re: Dmin. I simply cannot get IR docs to understand this concept. I have successfully pushed back against "super selective" TARE, as my medical oncologists are able to understand this concept.

 

[BobbyHeenan]

AMEN re: Dmin. I simply cannot get IR docs to understand this concept. I have successfully pushed back against "super selective" TARE, as my medical oncologists are able to understand this concept.

To their credit ours at least started doing immediate post TARE PET's for post-hoc dosimetry most of the time.

Sure enough, if ever a portion is cold they recur RIGHT there. So hopefully they are slowly learning.

 

[evilbooyaa]

AMEN re: Dmin. I simply cannot get IR docs to understand this concept. I have successfully pushed back against "super selective" TARE, as my medical oncologists are able to understand this concept.

To their credit ours at least started doing immediate post TARE PET's for post-hoc dosimetry most of the time.

Sure enough, if ever a portion is cold they recur RIGHT there. So hopefully they are slowly learning.

*insert Upton Sinclair quote*