Radiofrequency Ablation-- how will it affect radiion oncology?

[BraggPeak]

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I heard a great talk today on radiofrequency ablation for treatment of certain tumors (in this case, hepatic tumors). Seems like this is done by surgeons and interventional radiologists. How will this affect Rad Onc and will it take away from some of the stuff that we do (potentially)?

Thanks!

 

[Adawaal]

I really agree with those "powers that be" that evolving modalities such as RFA may well add to the push for novel Rad Onc training tracks. I can envision a fellowship system for "interventional oncology" for procedurally-oriented folks. It might involve a lot of invasive brachytherapy, IR-type procedures for oncology (RFA, etc.), maybe even SBRT.

 

[cdf95cro]

Our institution was a big RFA center with the former radiology chair; essentially they nab all the cases otherwise eligible for liver SBRT (just like the chemoembolization guys). However, the RFA LRs occur in the periphery of the tumor volume, while wiping out the hypoxic core, so I'm surprised someone hasn't done a RFA/EBRT protocol.


As for Rays-Rad Onc combo training, see idea by Zeitman in recent Seminars article:

http://www.ncbi.nlm.nih.gov/pubmed/18513631/

 

[medgator]

I can't say I know the data all that well on RFA, but from what I know for lung RFA, there isn't as much follow-up and/or number of studies compared to using SBRT for peripheral Stage I/II tumors.

 

[qwert]

Anyone knows eligibility criteria for lung RFA?

I can't say I know the data all that well on RFA, but from what I know for lung RFA, there isn't as much follow-up and/or number of studies compared to using SBRT for peripheral Stage I/II tumors.

 

[Ursus Martimus]

Anyone knows eligibility criteria for lung RFA?

Relatively recent paper in Lancet Oncology June 18, 2008 :

Response to radiofrequency ablation of pulmonary tumours:
a prospective, intention-to-treat, multicentre clinical trial
(the RAPTURE study)

Inclusion criteria were: age greater than 18 years; biopsy-proven
NSCLC or lung metastasis; patients rejected for surgery
and considered unfi t for radiotherapy or chemotherapy;
up to three tumours per lung, each 3·5 cm or smaller in
greatest diameter, detected by CT; tumours located at least
1 cm from trachea, main bronchi, oesophagus, aorta,
aortic arch branches, main, right, or left pulmonary artery,
and heart; tumours accessible by percutaneous route;
Eastern Cooperative Oncology Group (ECOG) performance
status of 0, 1, or 2; platelet count greater than 100×109/L;
and international normalised ratio of 1·5 or less.
Exclusion criteria were: previous pneumonectomy;
patients considered high-risk for radiofrequency ablation
because of major comorbid medical conditions (comorbid
conditions have not been listed, because the same
comorbid condition can be associated with diff erent
levels of risk depending on the overall general condition
of the patient); more than three tumours per lung; at
least one tumour more than 3·5 cm in greatest diameter;
tumours associated with atelectasis or obstructive
pneumonitis; renal failure needing haemodialysis or
peritoneal dialysis; active clinically serious infection;
history of organ allograft; history of substance abuse or
any medical, psychological, or social conditions that
might interfere with the patient’s participation in the
study or assessment of the study fi ndings; patients who
were pregnant or breast-feeding; ECOG performance
status of more than 2; platelet counts less than or equal

 

[Palex80]

However, the RFA LRs occur in the periphery of the tumor volume, while wiping out the hypoxic core, so I'm surprised someone hasn't done a RFA/EBRT protocol.

We are planning one at our institution.

 

[qwert]

Thanks that's helpful.

Relatively recent paper in Lancet Oncology June 18, 2008 :

Response to radiofrequency ablation of pulmonary tumours:
a prospective, intention-to-treat, multicentre clinical trial
(the RAPTURE study)

Inclusion criteria were: age greater than 18 years; biopsy-proven
NSCLC or lung metastasis; patients rejected for surgery
and considered unfi t for radiotherapy or chemotherapy;
up to three tumours per lung, each 3·5 cm or smaller in
greatest diameter, detected by CT; tumours located at least
1 cm from trachea, main bronchi, oesophagus, aorta,
aortic arch branches, main, right, or left pulmonary artery,
and heart; tumours accessible by percutaneous route;
Eastern Cooperative Oncology Group (ECOG) performance
status of 0, 1, or 2; platelet count greater than 100×109/L;
and international normalised ratio of 1·5 or less.
Exclusion criteria were: previous pneumonectomy;
patients considered high-risk for radiofrequency ablation
because of major comorbid medical conditions (comorbid
conditions have not been listed, because the same
comorbid condition can be associated with diff erent
levels of risk depending on the overall general condition
of the patient); more than three tumours per lung; at
least one tumour more than 3·5 cm in greatest diameter;
tumours associated with atelectasis or obstructive
pneumonitis; renal failure needing haemodialysis or
peritoneal dialysis; active clinically serious infection;
history of organ allograft; history of substance abuse or
any medical, psychological, or social conditions that
might interfere with the patient’s participation in the
study or assessment of the study fi ndings; patients who
were pregnant or breast-feeding; ECOG performance
status of more than 2; platelet counts less than or equal

 

[davidjones]

saw this while doing a search, has anyone done the comparison study yet? No luck on PubMed

 

[JumpingFrenchmn]

saw this while doing a search, has anyone done the comparison study yet? No luck on PubMed

Comparison of SBRT vs. RFA for lung? Don't know of any randomized data but there is a CEA based on what's published so far:

http://cache.trustedpartner.com/docs/library/Cyberknife2010/articles/PIIS0360301610036849.pdf

 

[VIRads]

Interventional oncology is firmly in the realm of interventional radiology. I think the blossoming of interventional oncology is a definite win for patients. Interventional oncology is now in the 4 (formerly 3) pillars of oncology treatment: Med/Onc, Rad/Onc, Surg/Onc, and interventional oncology.

 

[Sheldor]

Interventional oncology is firmly in the realm of interventional radiology. I think the blossoming of interventional oncology is a definite win for patients. Interventional oncology is now in the 4 (formerly 3) pillars of oncology treatment: Med/Onc, Rad/Onc, Surg/Onc, and interventional oncology.

You are absolutely right. However, Personally some areas of interventional onc I think could and should fall in with rad onc. HIFU is an example.

 

[davidjones]

HIFU is actually one of the things that should not fall into rad onc since it uses MR guidance and require image interpretation skills. Its unlikely that you will find any radiologist willing to overdrafts the MRI while someone else collects the procedure fee.

Similar things were tried with y90 where IR would do all the work then radonc would show up inject the beads and peace out. That sort of practice was quickly nipped in the bud.

There are also cases where various surgeons would want to bill for ablation just by virtue of their presence while the probe placement, image interpretation and postprocedure observation

 

[medgator]

HI]

Similar things were tried with y90 where IR would do all the work then radonc would show up inject the beads and peace out. That sort of practice was quickly nipped in the bud.

Isn't that still how it is done in certain centers?

 

[Sheldor]

HIFU is actually one of the things that should not fall into rad onc since it uses MR guidance and require image interpretation skills. Its unlikely that you will find any radiologist willing to overdrafts the MRI while someone else collects the procedure fee.

My thoughts based on talking with a couple IR docs and Rad onc docs were that if the procedure involved percutaneous transluminal access, then it was firmly in the domain of IR. Seed placement seems to be in the middle, but as was mentioned above I know IR still does this. However, HIFU seems different. The systems I've interacted with strike me as very similar to rad onc treatment planning software. They both involve using imaging to define the tumor volume as well as adjacent organs, and then plan treatment that delivers the optimum amount of heat to the tumor while sparing nearby organs. It seems to me, that given Rad Onc's extensive training with computerized treatment planning this could easily fall under their domain.

Also, doesn't all of Rad Onc require image interpretation skills with regard to tumor vs. normal anatomy?

As a disclaimer: I'm suggesting a turf war, more just repeating what i've gathered from those in various fields.

 

[davidjones]

Re y90: I actually do not know of any place right now where rad onc tries to participate /bill for it. I heard wake forest had something like that but was discontinued. I suppose it could be done in places with very weak IR where they are just wire jockeys. Thatr sort of arrangement seems like urorad type stuff to me.

Re image interpretation yes rad onc does a form of image interpretation like normal vs. Tumor, but I was talking about incidental findings that require determination of pathology, also I've enountered scenarios where rad onc had to call radiology to help with identifying anatomy. Not often, but it happens. Ultimately I think hifu will be used by botth specialties, ir for things like fibroids and other conditions we treat and rad onc for tumor stuff.

What I would love to see happen is something like a combined training pathwaybut there are too many egos for that to happen.

 

[JackieG]

Just wondering. I know there are interventional radiology fellowship programs that took applicants with out completing a diagnostic radiology residency. I am wondering can one do that fellowship after a rad onc residency?

And at that point one can be ready to do Interventional oncology producers?

 

[davidjones]

The only way to do IR is to do a radiology residency, the scenario that you heard of is people who are FMGs who completed radiology residency outside of the US, can get a fellowship in any sub-specialty here in the US, but they are limited to only practicing in that institution or can complete 3 more 1 year fellowships to be able to get into rads residency.

IR is extremely competitive now with very strong applicants matching at the bottom of their rank list or going unmatched. So in short, no you cannot do IR after a rad-onc residency.

I have considered doing a rad onc residency after an IR fellowship, but that is also unrealistic, because like any other procedural specialty, if you don't use it you lose it, and the 4 years of rad onc residency will preclude me from doing angio/CT/US interventions at a high enough level where I can do it safely as an attending.

I'm sure someone somewhere may decide to do that; the total training will be 10 years, which is like peds surgery, there are people who have done adult/peds cards and intervetion, and combined other related fields by doing multiple residencies, but those are few and far between, and may not have the same financial pressures as the rest of us.


In a perfect world, since both rad onc and IR are under the ACR/ABR umbrella, some sort of combined training pathway, but realistically that will never happen.

 

[davidjones]

Comparison of SBRT vs. RFA for lung? Don't know of any randomized data but there is a CEA based on what's published so far:

http://cache.trustedpartner.com/docs/library/Cyberknife2010/articles/PIIS0360301610036849.pdf

Good article; the only thing I would criticize about the study is the assumption that a repeat CT is required for the management of a pneumothorax; that is overkill and a plain PA and Lateral will suffice, particularly in a patient with a known PTX. I doubt that would change the cost differential significantly since it's only $276; but unless the patient is being managed by IR, some overzealous internist would order it with contrast (~$500) or get multiple CTs to follow the PTX.

I hope this is at my own institution, but I personally do not see that much collaboration between IR and RadOnc, which is I think is too the patient's detrement; this seems mostly due to paranoia regarding "turf" on both sides;

Anyone on here at an institution where this type of collegiality exists?