MWA utilizes electromagnetic waves (1 to 2 GHz) to oscillate the dipole water molecule resulting in increased temperature and cell death. CT guidance is utilized for placement of the microwave antenna and the technical details are similar to RFA procedure. MWA effectively delivers heat energy over a larger tumor volume within a shorter time.70 As opposed to RFA, there are no limitations regarding interelectrode interference and multiple probes can be used at once for a synergistic effect. In addition, issues related to electrode impedance and complications from use of electric current are not seen with MWA. There is less concern for perfusion-mediated heat loss or heating sink effect due to a larger zone of microwave-related active heating as opposed to the passive thermal conduction seen in RFA. MRI monitoring is not possible due to the interference from electromagnetic radiation. In a retrospective analysis of 82 lung parenchymal lesions, MWA resulted in a 1-year local control rate of 67% with mean time to recurrence of 16.2 months. The survival rates were 83%, 73%, 61% at 1, 2, and 3 years, respectively.71 Another prospective study reported MWA of 130 lung metastatic lesions with 73.1% complete ablation and minimal procedural complications. The 1- and 2-year survival rates were 91.3% and 75%, respectively.72 MWA is gaining wide recognition, and is currently the procedure of choice at some institutions. Predominant advantages include a more effective ablation, shorter treatment times, and better safety profile from relative sparing of nontarget tissues.
In LITT, the monochromatic optical fibers deliver laser light that interacts with the tissues resulting in heating and coagulative necrosis.11 The resulting cell death and histologic changes are similar to that of other hyperthermal ablations.73 LITT is MRI compatible, which provides excellent anatomic detail and topographical accuracy. Another theoretical possibility with MRI monitoring is utilization of thermal-susceptible MRI sequences to monitor real-time temperature changes. MRI thermometry is noninvasive and provides real-time temperature changes throughout the area of interest compared with embedded temperature sensors, which are limited by positioning and provide data only at discrete points. Larger caliber devices and longer treatment times may increase complication rates and may limit its role in the treatment of lung malignancies. A prospective study by Rosenberg et al74 reported 1-, 2-, 3-, 4-, and 5-year survival rates of 81%, 59%, 44%, 44%, and 27%, respectively, with a median progression-free interval of 7.4 months after laser ablation of lung lesions. The clinical use of laser ablation is not yet widespread in the current practice.
Cryoablation is performed as a freeze-thaw cycle and delivers freezing temperatures (−20 to −40°C) with crystallization and cellular dehydration resulting in mechanical and vascular injury. It is performed under CT or MRI guidance, and the technical details are similar to other ablative procedures. The ability to monitor treatment changes in real time and visualize the ice ball provides the opportunity to treat lesions selectively and accurately, such as lesions near vital structures. Cryotherapy is less susceptible to heat sink effect and lesions near vascular structures can be effectively treated. Recent initial studies on the role of cryoablation of inoperable lung tumors seem to be promising.75–77 Niu et al78 reported 1-, 2-, and 3-year survival rates of 64%, 45%, and 32%, respectively, for cryoablation in NSCLC. Cryoablation has a relatively similar toxicity profile but less pain complications compared with other ablative therapies.10
Stereotactic ablative radiotherapy involves precise delivery of high-dose radiation therapy to the tumor fractionated over a few sessions. Poststereotactic radiation tumor response is encouraging and a retrospective exploratory analysis in select populations demonstrated outcomes similar to surgery.79 Complications include pneumonitis, chest wall pain, and rib fractures. Stereotactic radiation is advantageous in treating lesions not accessible from a percutaneous approach. A prospective comparison clinical trial using stereotactic body radiotherapy, sublobar resection, and RFA in high risk and inoperable patients with stage-I lung cancer demonstrated no difference in early morbidity and mortality.80 Two recent meta-analysis studies reported better 5-year local control rate, improved overall and cancer-specific survival rates, and decreased postprocedural morbidity after stereotactic radiation compared with other nonsurgical treatment modalities.81,82 However, the authors state that the published evidence is limited and further blind, prospective randomized controlled studies are needed. Currently, the treatment needs to be tailored to individual patients based on local availability, institutional expertise, and risk factors.
IRE is a new minimally invasive treatment modality wherein probes positioned surrounding the tumor delivers brief and controlled electrical pulses resulting in increased cellular permeability, apoptosis, and cell death. The mechanism of action differs from other ablative therapies as it is not associated with either hyperthermal or cryothermal damage. Noncellular tissue elements such as collagen and elastin fibers, basal membranes, and interstitial matrix are preserved with IRE. Relative preservation of the anatomic “scaffolding” allows for reepithelialization of the vascular and bronchial structures after ablation and recovery of function. Nerve fibers also demonstrate relative preservation. Heat sink effect is not associated with IRE and tumors adjacent to large blood vessels can be effectively treated. ECG gating is necessary to ensure that the electrical pulses are delivered during the refractory period of the cardiac cycle, reducing the risk of cardiac arrhythmias. In addition, these patients are required to be paralyzed and under general anesthesia during the procedure to prevent severe muscular contractions. IRE probes must be placed in a parallel alignment and can often be technically challenging in certain locations, particularly in the thorax when one must work around the ribs. Low density of the lung tissues and surrounding air limit homogenous and efficient energy deposition, which may increase the risk of incomplete ablation and treatment failure with IRE. Extended procedural time, limited expertise and availability, and lack of efficacy studies are current drawbacks for adoption of this procedure. The safety and feasibility are established in the initial studies and efficacy studies are pending.83,84 IRE is a promising novel technology, although evidence from current literature is limited for treatment of lung tumors.85
CT-guided percutaneous approach is the current preferred method for ablation therapy due to ease of accessing the target lesion and placement of required applicators, in addition to the procedural imaging guidance and widespread availability. Other ablative approaches that have been described include intraoperative RFA and bronchoscopic-guided ablation treatments.78,86 Linden et al87 reported use of intraoperative RFA approach for lesions near vital structures that are difficult to access percutaneously, in situations when ablation needs to be performed in conjunction with limited resection, or if resectability can be determined only at the time of surgery.
Percutaneous ablation procedures have complications similar to those that occur after percutaneous needle biopsies, as described. Ablations performed through a bronchoscope may theoretically have fewer procedure-related complications as the pleura are not transgressed.86 The electrode is placed into the lesion from an endobronchial approach and CT imaging is then performed to confirm adequate position of the probe within the target lesion. Tsushima et al88 reported initial use of an internally cooled electrode introduced through the fiberoptic bronchoscope for ablation of sheep lung tissue. Virtual and electromagnetic navigation techniques facilitate access of difficult lung lesions compared to conventional bronchoscopy and aid in administration of thermal ablative therapies.89,90 Technical developments in improved designs of ablation probes are ongoing to facilitate easier endoscopic placement. Although therapeutic bronchoscopic-guided thermal ablation is a promising and novel therapeutic tool, there is need for further studies to establish the extent of ablation, clinical efficacy, and selection of optimal lesions for this treatment modality.
Surgical resection is the standard of care for early-stage lung cancer. Image-guided percutaneous ablative therapies are utilized as alternative treatments for patients with unresectable malignancy or nonsurgical candidates with improved overall survival rates and prolonged time to disease progression. These procedures are available, technically feasible, and effective for localized tumor control in carefully selected populations with NSCLC or metastatic disease. RFA is an established modality for treatment of smaller and peripheral lung tumors located distant from vital structures or large vessels. The safety profile for ablation therapy has been well established with easily manageable common complications including pneumothorax, pleural effusions, and pneumonia. Close imaging follow-up is mandatory after ablation therapy to confirm expected treatment changes and monitor for subsequent response or recurrence. The comparative role of percutaneous or endobronchial ablative therapies, stereotactic radiation, IRE, limited surgical resection, and combined modality treatments warrants further larger and randomized studies.
The authors thank Laura Miller, MD, and Scott Williams, MD, Department of Radiology, Bridgeport Hospital, Bridgeport, CT, for help with topic research and proof reading.
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