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Breast Cancer Cryoablation Fundamentals Past and Present: Technique Optimization and Imaging Pearls

As treatment for breast cancer evolves, cryoablation has come to the forefront among the nonsurgical options, demonstrating efficacy, safety, and feasibility in an outpatient setting with only local anesthetic. This review discusses the long history of cryotherapy, palliative breast cancer cryoablation, and curative breast cancer cryoablation. Also discussed are cryoablation's mechanism of tumor destruction, the immunological benefits, and technical considerations. In studies of curative cryoablation of stage I low-grade breast cancer, past and interim results have shown a 98% overall success rate, with recurrence rates similar to those seen after lumpectomy. The procedure is also useful for patients with refractory disease or disease that recurs after standard breast cancer treatment. "Understanding the indications and optimal technique for breast cancer cryoablation and understanding typical imaging findings after cryoablation are essential to ensure the success of the procedure in carefully selected patients," the authors conclude.

Stereotactic Body Radiation Therapy and Thermal Ablation for Treatment of NSCLC: A Systematic Literature Review and Meta-Analysis

A recent study compared the outcomes of stereotactic body radiation therapy (SBRT) and two image-guided thermal ablation (IGTA) techniques, microwave ablation (MWA) and radiofrequency ablation (RFA), for the treatment of non-small cell lung cancer (NSCLC). The systematic review and meta-analysis included 40 IGTA study arms, with 2,691 patients, and 215 SBRT study arms, with 54,789 patients. Single-arm pooled analyses found local tumor progression (LTP) to be lowest following SBRT at 1 and 2 years and at 1 year in meta-regressions in comparison with IGTA. Additionally, disease-free survival (DFS) was highest among MWA patients in single-arm pooled analyses. DFS was substantially lower for RFA in meta-regressions at 2 and 3 years compared with MWA. In terms of overall survival (OS), rates were similar across treatment methods, timepoints, and analyses. Strong predictors of worse clinical outcomes in the analyses were older age, male patients, large tumor size, retrospective study design, and non-Asian study region. Among high-quality studies (those with a MINORS score of 7 or higher), clinical outcomes were better among MWA patients compared with the main analysis. In a subgroup of patients with stage IA NSCLC, those treated with MWA had lower LTP, increased OS, and overall lower DFS when compared with the overall analysis of all patients with NSCLC. The researchers noted, "[T]he results showed that patients treated with MWA have OS and DFS that is comparable to SBRT and better than RFA." They call for large, high-quality comparative studies to confirm their results and assess other outcomes, including costs and complications.

Effect of Previous Transarterial Chemoembolization (TACE) on Survival and Toxicity After 90Y Transarterial Radioembolization of Hepatocellular Carcinoma in the RESiN Registry

For patients with hepatocellular carcinoma (HCC) refractory to transarterial chemoembolization (TACE), radioembolization with resin 90Y microspheres is an acceptable treatment option, according to new research. The prospective, observational study included 262 U.S. adults with HCC: 93 had previously been treated with chemoembolization (TACE+) and 169 were TACE-naive (T-N). After undergoing transarterial radioembolization (TARE), median overall survival — which was assessed using Kaplan-Meier analysis from the date of TARE — was 22.3 months for TACE+ patients and 21.5 months for T-N patients. Six months after treatment, objective response was 49% for those in the TACE+ group and 60% for T-N patients. Predictors of OS for all patients were Barcelona Clinic Liver Cancer Class A index tumor diameter of <5 cm, and Child-Pugh Class A cirrhosis; previous chemoembolization and solitary tumors were not predictors. For the 156 patients for whom 6-month +/- 2-week imaging was available, a partial or complete response was seen in 49% (27/55) of the TACE+ group and 64% (65/101) of the T-N group. An analysis of 6-month toxicities found that attributable grade 3 or higher liver function toxicities were similar between the TACE+ and T-N groups. Journal of Vascular and Interventional Radiology (09/23) HC Hund; L Du; L Matsuoka; et al.

ACR Appropriateness Criteria Management of Vertebral Compression Fractures: 2022 Update

For the 2022 update of the ACR Appropriateness Criteria Management of Vertebral Compression Fractures, a multidisciplinary expert panel reviewed evidence-based guidelines for specific clinical conditions in the management of vertebral compression fractures (VCF). There are many causes of VCFs, including trauma and osteoporosis. However, the metastasis of some cancers to the bones can lead to malignant VCFs, with the spine the third most common site of metastases. Another cause of malignant VCFs are primary tumors of bone and lymphoproliferative diseases. For the updated guidelines, experts in neurological imaging, interventional radiology, and musculoskeletal imaging conducted a comprehensive analysis of current peer-reviewed medical literature. In addition, the review included the use of established methodologies, such as the RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation (GRADE), to evaluate the appropriateness of imaging and treatment procedures in specific clinical settings. The experts note, "In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment."

Phase II Trial of Lung Chemoembolization

Researchers launched a Phase II trial to evaluate local progression-free survival with lung chemoembolization. A Phase I study of chemoembolization of lung metastases using Lipiodol — the first such trial in the United States — found the procedure treated large and multifocal lung tumors safely, with no serious adverse events and a metabolic response rate of 40%. The high intratumoral drug concentration after chemoembolization, with an initial tumor-to-plasma mitomycin concentration ratio of 380, enabled treatment of systemic chemotherapy-refractory tumors. The new study includes 30 patients with non-small cell lung cancer whose tumors were progressing on systemic therapy and could not be treated with resection, thermal ablation, or ablative radiation therapy. Patients will be treated with bronchial or pulmonary artery chemoembolization using Lipiodol, mitomycin, and Embospheres, with up to four procedures allowed per individual. The primary endpoints in the study are local progression-free survival — the time from the initial transarterial chemoembolization procedure to progression in a completely treated territory, or death from any cause — at 6 months and safety. Safety will be assessed 3 months after the last chemoembolization, and any changes in oxygen saturation, forced vital capacity, forced expiratory volume before and after the procedure will be assessed. Among the common adverse effects of lung chemoembolization are cough, dyspnea, nausea and vomiting, fever, pain, and fatigue. Spinal cord injury and esophageal necrosis are more serious and rare potential complications of the procedure.

Segmental Yttrium-90 Radioembolization Using Glass Microspheres Greater than 400 Gray for the Treatment of Intrahepatic Cholangiocarcinoma: A Preliminary Experience

When treating intrahepatic cholangiocarcinoma (iCCA), segmental transarterial radioembolization at a dose of >400 Gy using Yttrium-90 (90Y) glass microspheres is safe and effective, according to new research. Previous research has demonstrated the feasibility of a >190 Gy dose, but researchers raised the dose higher, noting its use in hepatocellular carcinoma. All 13 of the tumors treated (100%, median size, 5.3 cm) with >400-Gy segmental radioembolization achieved an objective response. One of the 10 iCCA patients studied had a grade 3 or higher major adverse event, with stroke and hepatic decompensation; one patient was bridged to transplant, with >95% pathologic necrosis; and another patients underwent resection, with >99% necrosis. Additionally, all six of the patients treated with modified lobectomy dosing had contralateral hypertrophy; functional liver reserve increased to a median of 57.1% from 31.5%.

The Society of Interventional Oncology presents an opportunity to share key findings from interesting patient cases within the interventional oncology community. Access to these cases and engaging in the discussion surrounding their content is a benefit of SIO membership. New cases will be released in the SIO Insider.

September Case Spotlight - Boosting the Beta Effect

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