Interventional Oncology: Other 20 Elizabeth Ryan 20.1 Thoracic Interventional Oncology • Surgical resection is the first line therapy for treating primary and metastatic pulmonary malignancy with curative intent. • Percutaneous ablation is an alternative treatment offering a survival advantage in non-surgical candidates, with benefits over surgery including better preservation of normal lung parenchyma and lower treatment-related morbidity. Furthermore it is not necessary to suspend chemotherapy to undergo ablation. 20.1.1 Indications • Primary-early stage disease (stage I and II disease; International Association for the Study of Lung Cancer IASLC 7th edition). • Metastases-up to 5 less than 5 cm each, ideally less than 3.5 cm. • Medical comorbidities-non-operative candidates. 20.1.2 Technical Considerations Tumours results are best for tumours surrounded by normal lung. Tumours abutting the pleura can be treated but this will cause increased periprocedural pain. Heat sink results are less successful for tumours adjacent to vessels of 3 mm diameter or greater. E. Ryan Department of Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland e-mail: firstname.lastname@example.org © Springer International Publishing AG 2018 H.K. Kok et al. (eds.), Interventional Radiology for Medical Students, DOI 10.1007/978-3-319-53853-2_20 147 148 Air Route E. Ryan aerated lungs has an insulating effect. This results in better heating in the centre of the ablation zone but limits ablation at the periphery, which must be taken into account when planning the ablation zone margin. As for lung biopsy, a route to the tumour should be carefully planned that will be technically feasible without crossing fissures (this increases the risk of pneumothorax), or major vascular structures. 20.1.3 Patient Preparation Clinical Thorough history and examination including indicators of pulmonary function, prior surgery and general medical condition. Many of these patients are smokers with associated cardiovascular comorbidities. The procedure should be discussed fully and informed patient consent given. Labs Full blood count, coagulation status. INR should be less than 1.5, platelet count should be greater than 70 × 109/L. Imaging Contrast-enhanced CT of the chest to evaluate the primary tumour and completion imaging of the abdomen and pelvis for metastatic disease. NPO The patient should be fasting for 6 h pre-procedure. 20.1.4 Contraindications • Uncorrectable coagulopathy. • No safe route to the tumour. • Poor respiratory function or severe bullous emphysema rendering the procedure unsafe with the patient being unable to tolerate a post-procedure pneumothorax. • Other untreatable metastatic disease. 20.1.5 Technique • RFA is the most established technique for percutaneous ablation in the chest but MWA and cryoablation have been proved safe and efficacious and the choice of technique is largely down to operator experience and preference. 20.1.6 Postprocedure Care • The patient should lie supine or procedure-side-down for 4 h following the procedure to reduce the risk of pneumothorax. • Pain relief is administered as required for less painful procedures; whereas patient-controlled opioid analgesia may be of benefit for pleural and chest wall 20 Interventional Oncology: Other 149 ablations. Otherwise postprocedure care is as described previously for abdominal ablation. • A mild postablation syndrome characterised by low-grade fever and malaise is common and self-limiting. 20.1.7 Complications • Pneumothorax is common (11–50%), chest drain required for 6–25%, bronchopleural fistula in 0.6% • Pleural effusion (6–20%) • Haemoptysis (3–9%), all intrathoracic haemorrhage including haemothorax 5–20% • Thermal injury to the chest wall, recurrent laryngeal, phrenic, intercostal and brachial plexus nerves and skin (0.5–1.5%) • Air embolism (<1%) 20.2 Prostate Cancer • Prostate cancer is a common cancer ranging from low-grade low-volume incidental disease to high-grade progressive disease with considerable mortality. • The goal of prostate cancer care is to identify those cancers that require treatment, and to treat with intent to cure while minimising morbidity. • Prostate cancer is often multifocal and focal treatments aim to target the index or dominant lesion as it is taken to represent the most aggressive focus of disease. • Focal treatments include image-guided cryoablation and other new techniques under development including high-intensity focused ultrasound (HIFU), photodynamic therapy, laser ablation. 20.3 Ovarian Cancer • There is a survival benefit with tumour debulking, or “cytoreduction” even in advanced stage ovarian cancer. • As with surgical debulking, IO techniques cannot currently offer a cure for advanced disease but may improve survival via cytoreduction. Very limited studies suggest the safety and efficacy of ablative techniques like RFA, MWA and cryoablation for local control and palliation. 20.4 Benign Bone Lesions • Many benign bone lesions are readily diagnosed on imaging, predominantly plain radiographs, and the majority are incidental asymptomatic findings which do not require management. 150 E. Ryan • For a small number of patients, benign bone lesions may result in pain or pathological fractures. • Percutaneous ablation offers relief of symptoms with the morbidity and recovery associated with surgery. For example, percutaneous ablation is now a curative first-line treatment for osteoid osteomas, a benign bone lesion which presents with pain. 20.5 Musculoskeletal Malignancy • Indications for percutaneous ablation in bone malignancy include pain relief, halting local progression into critical structures and stabilisation of collapsing pathological vertebral fractures. • Previously described ablation techniques may be used for primary and secondary bone tumours, as well as cementoplasty which has benefits for structural support and pain relief. This involves injection of bone cement directly into the tumour via an image-guided percutaneous needle (See chapter on Musculoskeletal intervention). Suggested Reading 1. Clark T, Sabharwal T, editors. Interventional radiology techniques in ablation. Lee and Watkinson (Series Editors). Philadelphia, PA: Springer; 2013. 2. Kee ST, Murthy R, Madoff DC. Clinical interventional oncology. Philadelphia, PA: Elsevier; 2014. 3. Kessel D, Ray CE, editors. Transcatheter embolisation and therapy. Lee and Watkinson (Series Editors). New York/London: Springer; 2010.