The newest nccn guidelines for nsclc has a page for IGTA or IR ablation for stage 1 lung cancer. What the heck. Is this new or have the nccn guidelines always had this. IGTA the little clinical data I can find for it has poor local control and elevated morbidity risk. I’ve never actually seen IR ablation for nsclc in real life so that’s encouraging. Seems like another reason to refer to pulmonology for ebus or robotic bronchoscopy.
Nsclc IR ablation
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There's always been a mention of it in the guidelines. Did they put a category next to it?
ENB is better for the pt anyways if the lesion is accessible
ENB is better for the pt anyways if the lesion is accessible
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If memory serves, thermal ablation has always been listed on NCCN guidelines as a non-preferred option for medically inoperable stage I non-small cell lung cancer but having a separate Principles of Image-Guided Thermal Ablation Therapy seems new. On that new page, there is no mention of efficacy only 18.7% to 45.7% risk of pneumothorax - I believe SBRT is 0.0%.
That being said, there are lots of technological developments in this space and we know that non-radiation oncologists are willing and able to push their technologies despite lack of data. This represents a threat to monitor.
That being said, there are lots of technological developments in this space and we know that non-radiation oncologists are willing and able to push their technologies despite lack of data. This represents a threat to monitor.
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Been there a while in NCCN.
They (IR) started doing some of them at our center but the whole lung cancer working group pushed back HARD against it and it stopped. We are willing to support a trial, but off trial no way I want this going on in my cancer center.
Once the interventional pulm got very skilled with navigational bronch, it stopped anyway. They can do that and EBUS in same procedure and it's amazing what they can get to with less chance for PTX than a CT guided biopsy.
I think the biggest threat to non operative stage I is some technology via bronchoscope, not via IR....and when/if that happens it will be IMO a HUGE threat because it will be analogous to urology - both able to diagnose, treat, follow up, and manage complications themselves.
They (IR) started doing some of them at our center but the whole lung cancer working group pushed back HARD against it and it stopped. We are willing to support a trial, but off trial no way I want this going on in my cancer center.
Once the interventional pulm got very skilled with navigational bronch, it stopped anyway. They can do that and EBUS in same procedure and it's amazing what they can get to with less chance for PTX than a CT guided biopsy.
I think the biggest threat to non operative stage I is some technology via bronchoscope, not via IR....and when/if that happens it will be IMO a HUGE threat because it will be analogous to urology - both able to diagnose, treat, follow up, and manage complications themselves.
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Well Mr. Smith, we can use a sophisticated 3D treatment planning system to treat your lung cancer very accurately and with a very favorable side effect profile. This is completely non-invasive and doesn't require incisions or cuts, fasting, or a hospital visit. This treatment is supported by literally decades of high-quality clinical data.
. . . or we could shove a hot poker into your chest and burn out the cancer . . .
. . . or we could shove a hot poker into your chest and burn out the cancer . . .
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Not much of one IMO. IR doesn't necessarily manage all of their complications like empyema and pulmonary runs the ship around us
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“we will biopsy and treat at the same time” IR guy
"You can do that, but the control rates are so low I will be treating afterwards anyway" - my response
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They'll bypass pulmonary, CT surgery and us and tell the patients that
You won't see them in the hospital rounding though when their patients are admitted with complications
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The greater threat is interventional pulmonary doing these procedures bronchoscopically since they are involved with diagnosis also. Lots of industry funding in this space with technologies beyond thermal ablation or cryotherapy such as focused ultrasound, pulsed electric field, etc.
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If this happens I am out of a job - my current position's strength relies on a very good, very high volume pulmonary program and tons of lung cancer
"You can do that, but the control rates are so low I will be treating afterwards anyway" also works in these situations. I pushed back VERY hard on a pulmonologist with data, etc, and all he could muster in the end is "well, you're a radonc so of course you're going to say that."
He's no longer in the market, but being aggressive with the data (which is CLEARLY in our favor) in tumor boards was easy to do and prevented him from gaining any traction whatsoever. He got the Big Mad at me, because he was trying to build a Big Program at the hospital, but fortunately I simply did not (and still do not) care and my referring MedOncs understand how to interpret basic medical literature.
This brings up another point. When the data is NOT in our favor (recently, for example, neoadjuvant chemo vs chemoRT for aca of the esophagus), it's important to push just as hard for a non-radiation pathway. I let a medonc know, soon after the trial was published, that the patient which was referred would benefit from neoadjuvant chemotherapy alone rather than chemoRT, and the medonc was happy to get the updated info and move forward with chemo alone.
Honesty with respect to data goes a long way in the long term and dramatically improves one's ability to influence treatment patterns when new data arrives.
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I said something similar on the liver discussions recently. Explaining why you support non radiation approaches when there is something better will earn folks trust. Some new IR guy that wants to MWA everything tried to pull the “you would say that, your a rad onc line” in HPB tumor board a while back and the transplant surgeon who runs it politely told him my opinion meant more than his ever would. It was a good day.
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I don't think the data will pan out to be better than sbrt.
Conceptually it's the same thing IR is doing to these pts and is likely oncologically inferior to SBRT. The RFA control rates drop precipitously above 1-2 cm in the lung
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I’m not IR so I don’t have a dog in this fight but one that I happen to know claims that ablation is better in patients with interstitial lung disease. Is this true or hogwash? Is radiation unsafe in a patient who has say UIP or NSIP?
It isn’t intuitive to me in either direction.
It isn’t intuitive to me in either direction.
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No data to support that afaik. Not sure I want to be subjecting those pts to a PTX risk either for what is likely a substandard TX vs sbrt which carries no such risk
I am not aware of any data to support this. I am never excited about treating someone with ILD, even with SBRT, but I get the sense that all local therapies would likely be more risky in these patients. If anyone has data to show something like ablation is more tolerable, please share
That's utter nonsense.
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No patient who had a clear understanding of their options would choose an IR ablation over SBRT.
The entire premise of these therapies relies on them fooling patients and referrings.
The entire premise of these therapies relies on them fooling patients and referrings.
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ILD portends for increased risk of toxicity from SBRT, yes. As does ILD portend for increased risk of toxicity from surgical resection (hence why we still SBRT so many ILD patients)
To suggest that stabbing the lung is a better option than SBRT is a statement that would require SIGNIFICANT evidence.
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I don’t have any compelling evidence myself. I know he’s a big advocate of cryoablation. This particular person has papers on the topic.
I just read the pets and am curious to know if this dude is crazy.
All the data we have shows that SBRT is superior to cryoablation. Across all tumor sites.
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His entire career is based in this. He cannot fathom potentially being wrong. It doesn't matter if he's wrong, he will continue to believe it. If he was to be wrong and admit it, he would experience an existential crisis having tied his worth to this modality. He is a zealot to cryoablation.
And not criticize Rads as a field. Every field has theri bad apples. Urology has the HI-FU zealots. A similar statement could be made about zealots in Rad Onc who are such big believers in their niche thing, say protons as one immediate example. Unfortunately, these niche things don't actually help patients in any manner, rather just the physician's career.
Sucks for the patients, though. At least proton zealots don't actively worsen a patient's oncologic outcomes.
I think the narrative on potential reduced toxicity of ablation for ILD is not crazy but a little outdated. There were some papers years backing saying SBRT was associated with really excess fatal toxicity. More recently David Palma or whoever ran a prospective trial of SBRT for ILD patients and the toxicity ended up being really underwhelming compared to the retrospective data.
